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MODERN  SURGERY 

GENERAL  AND  OPERATIVE 


JOHN  CHALMERS  DA  COSTA,  M.D. 

PROFESSOR    OF    SURGERY    AND   CLINICAL    SURGERY     IN    JEFFERSON    MEDICAL    COLLEGE, 
PHILADELPHIA;    SURGEON    TO    THE    PHILADELPHIA    GENERAL    HOSPITAL;    CON- 
SULTING    SURGEON    TO    ST.     JOSEPH'S     HOSPITAL,     PHILADELPHIA; 
FELLOW  OF  THE  AMERICAN   SURGICAL  ASSOCIATION;    MEMBER 
OF  THE  AMERICAN  PHILOSOPHICAL  SOCIETY;  MEMBRE  DE 
LA  SOCIETK  INTERNATIONAL    DE  CHIRURGIE;  MEMBER 
OF    THE      MEDICAL    RESERVE     CORPS,    U.    S.    A. 


Sixth  Edition,  Thoroughly  Revised  and  Enlarged 

with 

966  Illustrations,  some  of  them  in  Colors 


PHILADELPHIA  AND  LONDON 

W.   B.   SAUNDERS  COMPANY 
1910 


Set  up,  electrotyped,  printed,  and  copyrighted   October,  1894.      Reprinted  March,  1895,  and  August,  1806. 
Revised,  entirely  reset,  reprinted,  and  recopyrighted  June,  1898.      Reprinted  October,  1898,  and 
June,  1899.     Revised,   reprinted,  and  recopyrighted  August,  1900.      Reprinted  August, 
1901  :  August,  1902,  and  November,  1902.     Revised,  entirely   reset,  reprinted,  and 
recopyrighted,  August,  1903.     Reprinted  July,  1904  ;   October,  1905  ;   Sep- 
tember, 1906,  and  October,  1906.      Revised,  reprinted,  and  recopy- 
righted  January,  1907.      Reprinted  April,   1907;    March, 
1908,    and   July,    1909.       Revised,    reprinted, 
and  recopyrighted  January,  1910. 


Copyright,  1910,  by  W.  B.  Saunders  Company 


less    OF 


PM  I  l_AOE  t-PI- 


'Yet  each  man,  following  his  sympathies. 
Unto  himself  assimilating  all, 
Using  men's  thoughts  and  forms  as  steps  to  rise. 
Who  speaks  at  last  his  individual  word, 
The  free  result  of  all  things  seen  and  heard, 
Is  in  the  noblest  sense  original. 
Each  to  himself  must  be  his  final  rule, 
Supreme  dictator,   to  reject  or  use, 
Employing  what  he  takes  but  as  his  tool. 
But  he  who,  self-sufficient,  dares  refuse 
All  aid  of  men,  must  be  a  god  or  fool." 

W.  W.  Story  ("  A  Contemporary  Criticism"). 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/modernsurgerygenOOdaco 


THIS    BOOK    IS    DEDICATED  TO  THE  CHIEF  SURGEON  AND  INSPIRA- 
TION  OF    ONE    OF   THE    GREATEST,    MOST    PROGRESSIVE,   AND 
MOST    INFLUENTIAL    SURGICAL  CLINICS  IN   THE   WORLD. 
A    CLINIC     FROM    WHICH    COME    IMPORTANT    FACTS, 
REAL    IDEAS,    AND    BRILLIANT    MEN. 
TO  THE  OPERATOR,   THE   TEACHER,   THE    INVESTIGATOR,   AND  THE 
SURGICAL  PHILOSOPHER.     TO 

DR.    WILLIAM    STEWART    HALSTED, 

THE     DISTINGUISHED     PROFESSOR     OF     SURGERY     IN 
JOHNS    HOPKINS    UNIVERSITY. 


PREFACE  TO  THE  SIXTH  EDITION 


Less  than  three  years  ago  the  fifth  edition  of  this  book  was  published,  yet 
a  revised  edition  is  now  necessary.  The  work  of  revision  has  proved  an 
arduous  task.  It  has  been  found  most  difiicult  to  select  from  the  large  num- 
ber of  books  and  reports  and  the  great  mass  of  periodic  literature  those  matters 
which  appear  to  be  genuine  advances.  It  has  often  been  a  matter  of  embarrass- 
ing uncertaint)'  to  choose  what  should  go  in  the  new  edition  and  what  should 
be  removed  from  the  text  of  the  forrner  edition.  New  things  are  not  always 
true  things,  and  even  long  accepted  \iews  may  happen  to  be  wrong.  In  investi- 
gating alleged  discoveries  and  advances,  I  have  endeavored  to  bear  in  mind  the 
thought  of  Victor  Hugo  that  new  things  may  be  either  constellations  of  pro- 
fundity or  stars  made  by  duck's  feet  in  the  soft  mud  of  the  pond.  Further, 
in  tr}-ing  to  estimate  the  worth  of  recent  views,  one  must  always  be  on  the 
lookout  for  what  Junius  calls  false  facts.  Many  procedures  are  still  on  irial 
and  their  real  value  has  not  as  yet  been  determined.  The  real  test  of  all 
views  is  experience,  and  ample  experience  can  come  only  after  considerable 
time. 

In  spite  of  these  critical  deductions,  a  reading  of  the  literature  of  the  last 
three  years  impresses  one  with  the  reality  and  magnificence  of  the  progress 
that  is  being  made  in  Surgery.  Almost  every  section  of  this  book  has 
been  altered  or  added  to  for  the  sixth  edition.  Particular  mention  has  been 
made  of  arteriorrhaphy,  a  procedure  which  is  founded  on  the  investiga- 
tions of  ^Murphy,  Carrel,  and  Matas;  Crile's  arteriovenous  anastomosis  for 
affecting  transfusion  of  blood;  Brewer's  tubes  for  transfusion;  the  use  of 
Halsted's  aluminium  "bands  in  the  treatment  of  aneurism;  the  operative  treat- 
ment of  recent  fractures;  Horsley's  operation  for  chronic  spinal  meningitis; 
the  use  of  positive  and  negative  air  pressure  in  intrathoracic  surger}-;  ^Murphy's 
method  of  treating  acute  peritonitis;  Cushing's  operation  of  decompression 
for  brain  tumors;  Bier's  intravenous  local  anesthesia;  the  parath\Toid  glandules; 
the  intraglandular  extirpation  of  goiter,  which  is  favored  by  Halsted  and  the 
Mayos;  the  Lorenz  treatment  of  hip  disease  by  weight  bearing  and  fixation; 
cystoscopy  and  catheterization  of  the  ureters;  gunshot- wounds  in  war; 
Bier's  treatment  of  inflammation;  Wright's  views  on  inflammation;  Rosen- 
berger's  method  of  diagnosticating  tuberculosis  by  finding  the  bacilH  in  the 
blood;  immunity  with  a  sketch  of  antibodies,  of  opsonins,  and  of  phagocytosis; 

9 


lo  Preface  to  the  Sixth  Edition 

bacterial  vaccines;  untoward  effects  of  sera;  tuberculin  in  diagnosis;  fat 
embolism;  erysipeloid;  human  glanders;  Wassermann's  reaction  for  syphilis; 
the  serum  diagnosis  of  cancer;  tumors  in  general;  syphilis;  acute  dilatation 
of  the  stomach,  mesenteric  cysts,  congenital  idiopathic  dilation  of  the  colon, 
teratoids  and  dermoids  of  the  sacrococcygeal  region;  gonorrhea;  ankylosis; 
radium,  electrical  injuries,  and  the  :x;-rays. 

Unfortunately,  the  book  grows  larger  with  each  edition,  and  I  view  this 
growth  with  regret  and  apprehension,  feeling  somewhat  Hke  the  elder  Weller 
when  he  saw  the  woman  drink  nine  and  a  half  breakfast-cups  of  tea  and  noticed 
her  "swellin'  wisibly"  before  his  "wery  eyes." 

In  the  preparation  of  this  edition  I  received  valuable  help  in  the  chapters 
on  Fractures  and  Dislocations,  from  Dr.  T.  Turner  Thomas,  of  the  University 
of  Pennsylvania;  in  the  chapter  on  Orthopedic  Surgery,  from  my  colleague, 
Dr.  H.  Augustus  Wilson,  Professor  of  Orthopedic  Surgery  in  the  Jefiferson 
Medical  College;  in  the  chapter  on  the  ic-rays,  from  Dr.  W.  F.  Manges,  Chief 
of  the  x-ra-Y  Department  of  the  Jefferson  Hospital;  in  the  sections  on  Cysto- 
scopy and  Catheterization  of  the  Ureters  and  Gonorrhea,  from  Dr.  Thomas 
C.  Stellwagen,  Chief  of  the  Genito-urinary  Out-patient  Department  of  the 
Jefferson  Hospital,  in  the  section  on  Cleft  Palate,  from  Dr.  Wm.  J.  Roe, 
Chief  Assistant  in  the  Department  of  Oral  Surgery;  and  from  my  Assistant, 
Dr.  George  J.  Schwartz,  in  a  number  of  important  things.  I  return  my 
cordial  thanks  to  Dr.  Corben  J.  Decker,  U.  S.  Navy  (retired),  for  the  multi 
tude  of  efficient  services  he  has  rendered  so  constantly  and  \\ith  such  unfail- 
ing cheerfulness. 

John    Chalmers    Da  Costa. 
2045  Walnut  Street,  Philadelphia. 
January,  19 10. 


PREFACE  TO  THE  FIRST  EDITION 


The  aim  of  this  Manual  is  to  present  in  clear  terms  and  in  concise  form 
the  fundamental  principles,  the  chief  operations,  and  the  accepted  methods 
of  modern  surgery.  The  work  seeks  to  stand  between  the  complete  but 
cumbrous  text-book  and  the  incomplete  but  concentrated  compend. 

Obsolete  and  unessential  methods  have  been  excluded  in  favor  of  the 
living  and  the  essential.  There  has  been  no  attempt  to  exploit  fanciful  theories 
nor  to  defend  unprovable  hypotheses,  but  rather  the  effort  has  been  to  present 
the  subject  in  a  form  useful  alike  to  the  student  and  to  the  busy  practitioner. 

The  opening  chapter  is  devoted  to  Bacteriolog}-  because  the  author  pro- 
foundly believes  that  without  some  knowledge  of  the  \-ital  principles  of  this 
branch  of  science  the  vast  importance  of  its  truths  will  be  ill-appreciated,  and 
there  will  be  inevitable  failure  in  the  application  of  aseptic  and  antiseptic 
methods. 

Ophthalmology.  g}-necology.  rhinology,  otolog}-,  and  laryngolog}-  have 
not  been  considered,  because  of  the  obvious  fact  that  in  the  advanced  state  of 
.specialized  science  only  the  specialist  is  competent  to  write  upon  each  of  these 
branches. 

In  Orthopedic  Surger}-  are  discussed  those  conditions  which  must  in  the 
very  nature  of  things  often  be  cared  for  by  the  surgeon  or  the  general  prac- 
titioner (such  as  hip-joint  disease,  club-foot,  Pott's  disease  of  the  spine,  flat- 
foot,  etc.).  The  limited  space  at  command  precluded  the  introduction  of  a 
special  di\'ision  on  diseases  of  the  female  breast.  A  large  amount  of  space 
has  been  devoted  to  Fractures  and  Dislocations,  the  enormous  practical  im- 
portance of  these  subjects  caUing  for  their  full  discussion.  Operative  Sur- 
gery is  considered  in  separate  sections,  the  most  important  procedures  being 
fully  described,  giving  also  th^  instruments  necessar}-,  and  the  positions  as- 
sumed by  patient  and  operator.  This  method  has  been  adopted  to  fit  the 
work  for  use  in  surgical  laboratories. 

Many  systems,  manuals,  monographs,  lectures,  and  journal  articles  have 
been  consulted,  and  credit  has  been  given  in  the  text  for  statements  and  quota- 
tions. Special  acknowledgment  is  due  to  the  American  Text-Book  oj  Surgery, 
edited  by  Keen  and  White;  to  the  surgical  works  of  Ashhxirst,  Agnew,  the 
elder  Gross,  Duplay  and  Reclus,  Esmarch,  Albert,  Koenig,  Wyeth,  and 
Bryant;  to  the  Manual  oj  Surgery,  edited  by  Treves;  to  the  International 
Encyclopcedia  oj  Surgery,  edited  by  Ashhurst;  to  the  Surgical  Pathology  of 
Billroth  and  of  Bowlby;  to  the  Diagnosis  of  A.  Pearce  Gould;  to  the  Surgical 
Dictionary  of  Heath ;  to  the  Rest  and  Pain  of  Hilton ;  to  the  works  on  opera- 
tive surger}-  of  Barker,  Jacobson,  Treves.  Stephen  Smith,  and  Joseph  Bell 
to  the  Minor  Surgery  of  \\Tiarton;  to  the  dictionar}-  of  Foster  and  of  Gould 
to  the  Principles  oj  Surgery  of  Senn;  to  the  orthopedic  writings  of  Sa_\Te 


12  Preface  to  the  First  Edition 

to  the  work  on  Diseases  oj  the  Male  Generative  Organs  of  Jacobson;  to  the 
System  oj  Genito-urinary  Diseases,  edited  by  Morrow;  and  to  the  treatises  on 
Fractures  and  Dislocations  of  Sir  Astley  Cooper,  Malgaigne,  Hamihon,  Stim- 
son,  and  T.  Pickering  Pick. 

The  Author  returns  his  thanks  to  the  numerous  writers  who  courteously 
authorized  the  reproduction  of  special  illustrations,  and  particularly  to  Pro- 
fessors Keen  and  White  for  their  free  permission  to  draw  upon  the  American 
Text-Book  oj  Surgery,  from  which  a  number  of  pictures  have  been  taken, 
distinctively  those  referring  to  Bandaging;  to  Mr.  John  Vansant  for  the 
great  amount  of  labor  so  ably  and  cheerfully  performed;  and  to  Dr.  Howard 
Dehoney  for  the  preparation  of  the  Index. 


\ 


CONTENTS 


PAGE 

I.  Bacteriology 17 

II.  Asepsis  and  Antisepsis 55 

III.  Inflammation 79 

IV.  Repair 1 20 

V.  Surgical  Fevers 133 

VI.  Suppuration  and  Abscess 137 

VII.  Ulceration  and  Fistula 167 

VIII.  Mortification  or  Gangrene 1 79 

IX.  Thrombosis  and  Embolism 199 

X.  Septicemia  and  Pyemia 209 

XI.  Erysipelas  (St.  Anthony's  Fire) 215 

XII.  Tetanus  or  Lockjaw 219 

XIII.  Tuberculosis 229 

XIV.  Rickets 255 

XV.  Contusions  and  Wounds 259 

XVI.  Syphilis 312 

XVII.  Tumors,  or  Morbid  Growths 340 

XVIII.  Diseases  and  Injuries  of  the  Heart  and  Vessels 401 

Hemorrhage  or  Loss  of  Blood 434 

Operations  on  the  Vascular  System 459 

Ligation  of  Arteries  in  Continuity 469 

XIX.  Diseases  and  Injuries  of  Bones  anq  Joints 500 

Diseases  of  the  Bones 500 

Fractures 517 

Diseases  of  the  Joints 625 

Luxations  or  Dislocations 664 

Operations  upon  Bones  and  Joints 698 

XX.  Diseases  and  Injuries  of  Muscles  and  Tendons 726 

Operations  upon  Mu§cles  and  Tendons 748 

XXI.  Orthopedic  Surgery 752 

XXII.  Diseases  and  Injuries  of  Nerves 763 

Diseases  of  Nerves 763 

Wounds  and  Injuries  of  Nerves 764 

Operations  upon  Nerves 775 

XXIII.  Diseases  and  Injuries  of  the  Head 786 

Diseases  of  the  Head 786 

Injuries  of  the  Head 797 

XXIV.  Surgery  of  the  Spine   852 

XXV.  Surgery  of  the  Respiratory  Organs 881 

Diseases  and  Injuries  of  the  Nose  and  Antrum 881 

Diseases  and  Injuries  of  the  Larynx  and  Trachea 882 

Operations  on  the  Larynx  and  Trachea 886 

Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs 888 

Operations  on  Pleura  and  Lungs 901 

13 


14  Contents 

PAGE 

XXVI.  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 908 

XXVII.  Diseases  and  Injuries  of  the  Abdomen 936 

Stomach  and  Intestines 949 

The  Peritoneum 1002 

The  Liver,  Gall-bladder,  and  Bile-Ducts 1014 

The  Pancreas 1038 

The  Spleen 1046 

Operations  upon  the  .\bdomen 1048 

XXVIII.  Diseases  and  Injuries  of  the  Rectum  and  Anus 1160 

XXIX.  Anesthesia  and  Anesthetics 1 187 

XXX.  Burns  and  Scalds 1217 

XXXI.  Diseases  of  the  Skin  and  Nails 1222 

XXXII.  Diseases  and  Injuries  of  the  Thyroid  Gland 1226 

XXXIII.  Diseases  and  Injuries  of  the  Lymphatics 1244 

XXXIV.  Bandages 1250 

XXXV.  Plastic  Surgery 1259 

XXXVI.  Diseases  and  Injuries  of  the  Genito-urinary  Organs 1264 

Diseases  and  Injuries  of  the  Kidney  and  Ureter 1271 

Diseases  and  Injuries  of  the  Bladder 1306 

Diseases  and    Injuries  of  the  Urethra,  Penis,  Testicles,  Prostate, 

Seminal  Vesicles,  Spermatic  Cord,  and  Tunica  Vaginalis 1332 

XXXVII.  Amputations 1396 

Special  Amputations 1401 

XXXVIII.  Diseases  of  the  Mammary  Gland 1419 

XXXIX.  Skiagraphy,  or  the  Employment  of  the   Rontgen    Rays;   The 

FiNSEN  Light;  Becquerel's  Rays;  Radium  Rays 1443 

XL.  Injuries  by  Electricity 146 1 


INDEX 1467 


MODERN   SURGERY 


MODERN  SURGERY. 


I.    BACTERIOLOGY. 

Bacteriology  is  the  science  of  micro-organisms.  Though  a  science  in 
the  youth  of  its  years,  bacteriology  has  not  only  profoundly  altered,  but  it 
has  also  revolutioRized,  pathology,  and  our  views  of  surgery  would  be  in- 
complete, misleading,  and  erroneous  without  its  aid. 

Micro=organisms,  or  microbes,  are  minute  non-nucleated  vegetable 
cells  closely  connected  with  fungi  and  algae,  many  of  them  being  ^•isible  only 
bv  means  of  a  highly  powerful  microscope  and  after  they  have  been  brightly 
stained.  The  contents  of  these  cells  are  protoplasm  and  nuclear  chromatin 
enclosed  by  a  structure  containing  cellulose.  There  is  considerable  evidence 
that  some  diseases  are  caused  by  bacteria  so  minute  as  to  escape  detection  even 
by  the  most  powerful  microscope.  The  French  Yellow  Fever  Commission 
asserted  that  the  yellow  fever  micro-organism  passes  through  a  porcelain  filter 
("Annals  of  the  Pasteur  Institute,"  Nov.,  1903).  The  micro-organism  of 
rabies  probably  does  the  same  thing. 

Even  in  the  most  remote  times  some  have  beheved  that  "the  mysterious 
cause  of  contagious  and  epidemic  diseases  must  be  sought  in  hving  entities" 
(Alonti  on  "  Modern  Pathology  ") .  Bacteria  were  discovered  by  Leeuwenhoek 
in  1675,  but  definite  knowledge  of  these  minute  bodies  and  of  their  actions 
dates  from  the  study  of  fermentation  by  the  celebrated  Frenchman  Pasteur, 
who  in  1858  asserted  that  every  fermentation  has  invariably  its  specific 
ferment;  that  this  ferment  consists  of  Hving.cells;  that  these  cells  produce 
fermentation  by  absorbing  the  oxygen  of  the  substance  acted  upon;  that 
putrefaction  is  caused  by  an  organized  ferment;  that  all  organized  ferments 
are  carried  about  in  the  air;  and  that  entirely  to  exclude  air  prevents  putre- 
faction or  fermentation. 

In  1S60  Pasteur  published  the  observation  that  sterile  Uquids  will  not 
be  contaminated  by  air  if  the  air  gains  entry  only  through  a  long  curved 
tube,  the  reason  being  that  dust  and  growths  fall  from  the  entering  air  by 
gravity  ("Comptes  rendus,"  i860). 

In  1863  Pasteur  published  his  experiments  which  proved  that  beer  cannot 
ferment  without  yeast  and  that  wine  received  in  sterile  vessels  and  kept 
from  external  contamination  will  not  undergo  ammoniacal  change. 

The  views  of  Pasteur,  which  were  radical  departures  from  accepted  belief, 
inaugurated  a  bitter  controversy,  and  in  that  controversy  were  born  the 
microbic  theory  of  disease,  the  doctrine  of  preventive  inoculation,  antiseptic 
surgery,  and  serum-therapy. 

The  word  microbe,  which  signifies  a  small  living  being,  was  introduced 

in  1878  by  the  late  Professor  Sedillot,  of  Paris.     At  that  time  the  nature  of 

these  bodies  was  in  doubt;    some  thought  them  animal,  and  called  them 

microzoaria;  others  thought  them  vegetable,  and  called  them  microphyta;  the 

2  17 


Bacteriology 


designation  "microbe"  does  not  commit  us  to  either  view.     We  now  know 
them  to  be  vegetable,  but  the  term  "microbe"  has  remained  in  use. 

The  micro-organisms   connected   with  disease  in  man  are  divided  into: 

1.  Yeasts,  Saccharomyces,  or  Blastomycetes; 

2.  Moulds,  or  Hx'phomycetes; 

3.  Bacteria,  or  Schizomycetes. 

Yeasts  or  budding  fungi  include  most  of  those  fungi  which  can  cause 
alcoholic  fermentation  in  saccharine  matter.  They  consist  of  small  cells 
which  can  live  without  free  oxygen,  and  which  multiply  by  gemmation  or 
budding.  Definite  nuclei  are  not  demonstrable  in  the  cells.  When  a  cell 
multii)lies  a  small  bud  of  protoplasm  projects  from  or  near  the  end  or  buds 
project  from  or  near  both  ends  of  the  cell.  Buds  increase  progressively  in 
size  and  a  constriction  appears  between  each  bud  and  the  parent-cell.  Each 
constriction  deepens  as  the  corresponding  projection  enlarges,  until  the  bud 
attains  a  considerable  size  and  is  cast  off  as  a  daughter-cell.  In  some  cases 
buds  are  not  cast  off,  but  remain  attached,  a  chain  or  series  of  rounded  yeast- 
cells  being  formed.  These  cells  contain  spores  when  nourishment  is  insut^- 
cient.  Under  certain  conditions  yeast  fungi  can  form  interwoven  threads 
called  mycelial  threads. 

Moulds  or  filamentous  fungi  consist  of  filaments,  each  filament  being 
composed  of  a  single  row  of  cells  arranged  end  to  end,  and  all  filaments 
springing  from  a  germinal  tube  which  grows  from  a  germinating  spore.  The 
yeast  fungi  are  the  common,  but  not  the  only  cause  of  fermentation.  Mould 
fungi  are  connected  with  processes  of  decomposition.  Putrefaction  is  due 
to  bacteria  and  retards  the  growth  of  yeasts  and  moulds. 

Most  yeasts  and  moulds  grow  best  upon  dead  organic  matter,  some  attack 
plants,  a  few  the  lower  animals,  and  a  ver)-  few  grow  upon  or  in  the  tissues 
of  the  human  body. 

The  oidiiim  albicans  is  a  mould  fungus  which  by  growing  in  the  mucous 
membrane  produces  the  disease  known  as  thrush.  This  disease  attacks 
especially  the  mucous  membrane  of  the  mouth  and  pharynx,  but  occasionally 
the  growth  takes  place  upon  the  esophagus,  the  vocal  cords,  the  stomach, 
the  vagina,  the  respirator)'  tract,  and  the  areola  of  the  breast  of  a  nursing 
woman.  The  proliferating  fungus  presents  the  appearance  of  milky  white 
spots  which  by  thickening  and  coalescence  form  curd-like  masses,  the  super- 
ficial layer  of  epitheUum  being  raised  and  cast  off.  Thrush  is  particularly 
common  in  infants  suffering  from  marasmus,  but  it  may  occur  in  adults. 

Blastomycetes  dermatitis  is .  an  inflammation  of  the  skin  due  to  yeast 
fungi  and  bearing  a  resemblance  to  tuberculosis  or  sj-philis.     Sanfelice  and 

others  maintain  that  yeasts  are  responsible 
for  the  growth  of  malignant  tumors.  It  is 
certain  that  yeasts  may  exist  in  a  carcinoma 
and  can  be  cultivated,  but  proof  is  entirely 
lacking  that  they  are  anything  but  a  con- 
tamination.    Manv  skin  diseases  are  due  to 


fungi;  among   them   should  be  mentioned: 


Actinomyces  fZiegler). 


Favus,  pityriasis  versicolor,  herpes  tonsurans, 
parasitic  sycosis,  and  eczema  marginatum. 
Actinomycosis  is  due  to  the  ray-fungus  (Fig.  i;  see  page  310).     It  is  un- 
certain in  which  group  the  ray-fungi  should  be  placed;  it  is  quite  certain  that 


Schizomycetes  or  Bacteria  19 

more  than  one  variety  exists,  and  they  seem  to  occupy  a  place  between  moulds 
and  Ixicteria.     Madura-foot,  or  mycetoma,  is  due  to  the  streplolhrix  Madura. 

Schizomycetes  or  bacteria  chiefly  claim  our  attention.  It  is  important 
to  remember  that  the  term  "  bacteria,"  though  applied  to  the  class  schizomycetes^ 
has  also  a  more  restricted  application — that  is,  to  a  division  of  the  class;  it 
may  mean  either  schizomycetes  in  general,  or  rod-shaped  schizomycetes,  whose 
length  is  not  more  than  twice  their  breadth.  In  this  work  it  is  employed  to 
designate  schizomycetes  as  a  class. 

Bacteria  are  minute,  unbranched,  non-nucleated,  vegetable  cells,  free 
from  chlorophyl,  varying  in  shape  and  occasionally  presenting  locomotive 
fiagella.  The  cell  consists  of  a  cell  membrane,  a  layer  of  protoplasm,  and  some 
central  fluid.  No  true  nucleus  has  yet  been  demonstrated,  but  granules 
are  found  within  the  cells  which  some  call  metacJiromatic  bodies  (Babes) 
and  others  nuclei  (Ernst).  The  cell  membrane  varies  greatly  in  thickness, 
and  when  it  is  very  thick  the  cell  is  said  to  have  a  capsule.  The  round  cells 
have  a  smooth  outer  surface,  but  some  of  the  rod-shaped  cells  show  many 
fiagella  or  at  the  end  a  single  flagellum  (Fig.  2).  Fiagella  enable  some 
bacteria  to  move  (motile  bacteria),  but  all  organisms  which  possess  them 
are  not  motile,  and  under  certain  conditions  bacteria  without  fiagella  may 
develop  them,  or  organisms  which  possess  fiagella  may  lose  the  power  to 
develop  them. 


^ii 


Fig.  2. — Types  of  fiagella.  a,  \'ibrio  cholerae,  one  flagellum  at  the  end — monotrichia  type  ;  d, 
Bact.  syncyaneuni  tuft  of  fiagella  at  the  end,  rarely  at  the  side — Lophotrichia  type;  c,  Bact.  vulgare, 
fiagella  arranged  all  about — Peritrichia  type  (Lehmann  and  Neumann). 

Some  bacteria,  known  as  non-pathogenic,  cannot  grow  and  produce  poison 
either  in  the  tissues,  in  wound-fluid,  or  in  the  fluid  moistening  a  mucous  surface. 
Others  grow  upon  dead  organic  matter,  but  are  not  able  to  invade  living 
tissues.  They  can  live  and  multiply  in  the  discharge  from  a  wound  or  in  the 
fluid  covering  a  mucous  surface  and  are  called  saprophytes,  saprophytic 
microbes,  or  putrefactive  bacteria.  Obligate  saprophytes  only  live  in  dead 
matter  and  never  become  parasites.  Facultative  saprophytes  can  be  parasites 
and  can  also  grow  in  dead  organic  matter.  Bacteria,  knowTi  as  the  pathogenic, 
under  certain  conditions  invade  living  tissue  and  cause  various  diseases. 
Parasitic  bacteria  can  grow  on  or  in  the  tissues  of  the  body.  Obligate  parasites 
are  those  which  have  not  been  cultivated  outside  of  the  bodv  (as  the  bacilli  of 
leprosy) .  Facultative  parasites  usually  live  outside  the  body,  but  may  enter  into 
the  body  and  produce  disease.  The  schizomycetes  vary  much  in  shape,  size, 
color,  arrangement,  mode  of  growth,  and  action  upon  the  body.  One  form  can- 
not be  transformed  into  another,  but  each  maintains  its  specific  identity.  Every 
organism  comes  from  a  pre-existing  organism,  this  being  true  of  all  forms. 
Pasteur  proved  that  spontaneous  generation  is  impossible.     The  protoplasm 


20  Bacteriology 

of  these  cells  can  be  stained  with  anilin  colors,  and  the  cell-wall  is  more  readily 
detected  after  treating  it  with  water,  which  causes  it  to  swell. 

Many  bacteria  are  colored;  others  are  colorless.  Some  move  (motile 
bacteria);  others  do  not  move  (ajnotile  bacteria).  The  bacilli  of  anthrax 
and  tuberculosis  and  all  cocci  are  amotile.  Most  bacteria  can  change  from 
motile  to  amotile,  or  from  amotile  to  motile,  when  subjected  to  certain  changes 
of  soil  and  environment.  The  oscillations  of  cocci  are  physical  in  nature, 
not  vital;  they  are  Brunonian  or  Brownian  movements,  movements  due  to 
alterations  in  equilibrium  because  of  currents  or  changes  of  level  in  the  fluid 
in  which  the  micro-organisms  are  contained.  Bacteria  seem  to  possess  the 
power  of  attracting  elements  necessary  for  their  nutrition  (positive  chemiotaxis 
or  chemotaxis)  and  of  repelling  harmful  elements  (negative  chemiotaxis  or 
chemotaxis). 


Fig.  3.— Micrococci.  Fig.  4.— Bacilli.  Fig.  5.— Spirilla. 

Forms  of  Bacteria. — The  three  chief  forms  of  bacteria  are — 

1.  The  Coccus  or  Micrococcus — the  berry-shaped,  oval,  or  rotmd  bacterium 

(Fig.  3); 

2.  The  Bacillus — the  rod-shaped  bacterium  (Fig.  4) ; 

3.  The  Spirillum  or  Vibrio — the  corkscrew-shaped  or  spiral  bacterium 
(Fig.  5).     A  short  spiral  organism  is  called  a  comma  bacillus. 

De  Bary  compares  these  forms,  respectively,  to  the  bilh'ard-ball,  the  lead- 
pencil,  and  the  corkscrew. 

Cocci  and  Bacilli. — As  surgeons  we  have  to  do  only  with  cocci  and  bacilli. 
Cocci  may  be  designated  according  to  their  arrangement  with  one  another; 


\ 


Fig.  6.— Sarcinas    forming  [bales  of    pack-  Fig.  7.— Ascococcus  Billrothil  Colin  (after  F. 

ets.      Single    packets  regularly    grouped  to-  Cohn). 

getber  (Lehmann  and  Keumann). 

namely,  when  existing  singly  they  are  called  monococci  (Fig.  3) ;  in  pairs  they 
are  called  diplococci  (Fig.  8,  a)  ;  arranged  end  to  end  in  a  chain  they  are  called 
streptococci  (Fig.  8,  c) ;  in  group  side  by  side  clustered  like  a  bunch  of  grapes 
they  are  called  staphylococci  (Fig.  8,  b);  in  groups  of  four  they  are  called 
plate  cocci,  or  tetracocci;  in  cubical  groups  they  are  called  sarcince  or  wool-sack 
cocci  (Fig.  6).  Irregular  masses,  resembling  frog-spawn,  constitute  zobglea 
masses  (Fig.  9).  The  gelatinous  matter  in  such  a  mass  is  formed  by  a  trans- 
formation in  the  walls  of  the  bacteria.  The  term  ascococci  is  applied  to  a 
group  of  cocci  enclosed  in  a  capsule  (G.  S.  Woodhead)  (Fig.  7). 


Multiplication  of  Bacteria 


21 


The  cocci  are  often  named  according  to  their  function,  as,  for  example, 
"pyogenic  "  or  pus-forming.  Cocci  may  be  named  according  to  the  color  of 
the  culture.  The  name  may  embody  the  form,  arrangement,  color,  and 
function;  for  instance,  Staphylococcus  pyogenes  aureus  signifies  a  round, 
golden-yellow  micro-organism,  which  arranges  itself  with  its  fellows  in  the 
form  of  a  bunch  of  grapes,  and  which  produces  pus. 


^^^ 


5«  iI^fViMJlSS* 


Fig.  8. — Forms  of  cocci. 


-■'■  \^ 


Fig.  9.— Zooglea  (Ball). 


The  bacilli  are  long,  staff-shaped  organisms.  Long,  delicate,  jointed 
bacilli  having  wavy  outlines  are  known  as  leptothrix  forms.  Chain-like  bacilli 
are  called  streptohacilli.     Bacilli  give  origin  to  many  surgical  diseases. 

Dichotomy  or  Branching. — It  is  very  seldom  that  a  side  bud  appears  upon 
bacteria  except  in  the  bacteria  of  tuberculosis  and  diphtheria. 

Pseudodichotomy  is  by  no  means  unusual.  It  occurs  when  one  end  of  a 
bacillus  grows  by  the  end  of  the  adjacent  bacillus  or  when  a  bacillus  in  a  chain 
divides  in  a  line  parallel  to  the  chain  and  thus  begins  another  chain  (Fig.  10). 


D   B   II 
II   Lff 


B 


I  5 


J' 


o 

8 


Fig.  10. — Pseudodichotomy.    a.  In  bacilli;  b,  in  streptococci  (Lehmann  and  Neumann). 


JVluIti plication  of  Bacteria. — Bacteria  multiply  with  great  rapidity 
when  placed  under  suitable  conditions.  They  can  multiply  by  transverse 
fission  or  by  spore-formation.  Some  bacteria  multiply  by  both  methods.  In 
fission,  or  segmentation,  a  bacillus  undergoes  an  increase  in  size  and  length ; 
a  coccus  does  not  increase  in  size  but  slightly  elongates.  In  either  case  about 
the  middle  of  the  cell  a  transverse  constriction  begins,  which  deepens  until  the 
cell  has  divided  into  two  parts,  each  of  which  soon  grows  as  large  as  its  parent 
(Figs.  11,12).  As  a  rule,  the  micro-organisms  separate  after  division  of  the 
cell;  but  they  may  not  do  so;  and  if  they  do  not  separate,  the  special  grouping 
receives  a  particular  name  (diplococci,  streptococci,  etc.).  If  the  division  is  in- 
variably in  the  same  direction,  and  if  the  new  cells  remain  in  contact,  strepto- 


22 


Bacteriology 


cocci  or  streptobacilli  are  formed.  Tetracocci  and  sarcinae  are  formed  when  a 
number  of  cocci  "  divide  in  two  or  three  successively  vertical  directions'^"  Clin- 
ical Bacteriology,"  by  Levy  and  Klemperer),  forming  four  quadrants  {tetra- 
cocci) or  eight  octants  {sarcincB).    All  cocci  and  some  bacilli  multiply  by  fission. 


Fig.  II. — Divisions  of  a  micrococcus  (after  Mace). 


f  ^;:^ «,  / 1 


\.^^--"^^'-^^  vC<!$y  / 


Fig.  12. — Divisions  of  a  bacillus  (after  Mace;. 

If  segmentation  of  a  single  cell  and  the  growth  to  maturity  of  its  products  re- 
quire one  hour  (it  really  takes  place  in  less  time,  the  cholera  bacillus  requiring 
but  twenty  minutes  to  divide),  a  single  cell  in  a  single  day,  if  the  conditions  for 
increase  were  ideally  favorable,  would  have  16,000,000  descendants,  and 
in  three  days  the  mass  of  new  cells  would  weigh  7500  tons  (Cohn).  In  order, 
however,  for  such  enormous  multiplication  to  occur  conditions  would  have  to 
be  absolutely  favorable  to  the  cells,  and  conditions  are  never  absolutely  favor- 
able. Were  it  otherwise,  all  other  forms  of  life  would  be  destroyed.  During 
growth  in  a  culture  medium  inhibitory  substances  are  formed,  and  these 
substances  are  detrimental  to  the  bacteria  themselves  and  to  all  bacteria  of  the 
same  type.  Such  substances  are  known  as  autotoxins  (Conradi  and  Kurp- 
juweweit,  in  "Muenchen.  med.  Woch.,"  No.  32,  September  12,  1905).  In  a 
culture  of  cholera  baciUi  the  number  of  U\-ing  microbes  begins  to  lessen  after 
twent)'-four  hours,  and  after  forty-eight  hours  the  diminution  is  distinct. 
Spores. — A  spore  is  a  germ,  and  corresponds  with  the  seed  of  a  plant. 

Some  bacilli,  a  few  spirilla,  and  it  may 
be  sarcina.',  multiply  by  spore-formation. 
Cocci  do  not  undergo  spore-formation 
after  the  manner  of  baciUi,  though 
some  observers  maintain  that  cocci 
occasionally  undergo  an  alteration  that 
makes  them  very  resistant  to  any 
destructive  influences.  When  spore- 
formation  is  about  to  occur  in  a  bacillus, 
a  point  of  cloudiness  or  an  area  of 
bright  refraction  appears  in  the  proto- 
plasm and  the  cell  generally  elongates. 
When  a  row  of  cells  sporulate,  the  seg- 
ments, each  of  which  contains  a  lustrous 
area  or  a  region  of  cloudiness,  look  like 
parts  of  a  necklace  of  beads  (Fig.  13). 
The  spore  enlarges,  the  cell  membrane  bursts,  and  the  young  bacillus  emerges 


Fig.  13. — Sporulation  (after  De  Bar>-). 


Life-conditions  of  Bacteria  23 

through  the  opening.  A  cell  usually  contains  but  one  spore,  which  may  be 
situated  at  the  end  of  the  cell  {ends pore)  or  in  the  middle  of  the  cell  (endospore). 
Sometimes  a  single  cell  contains  several  spores.  If  an  endspore  exists,  the 
end  of  the  cell  containing  the  spore  is  swollen  or  club-shaped  (drumstick 
bacterium).  If  an  endospore  exists,  the  cell  becomes  spindle-shaped  (Clostri- 
dium). When  multiplication  is  by  a  single  endospore,  the  bacillus  does  not 
elongate.  When  multiplication  takes  place  by  a  process  of  combined  spore- 
formation  and  fission,  the  mother-cell  divides  into  a  number  of  daughter-cells, 
which  are  called  arthrospores.  Organisms  which  when  active  multiply  by 
fission  take  on  spore-formation  when  subjected  to  certain  conditions. 

Spore-formation  tends  to  occur  when  bacilli  are  about  to  die  for  want 
of  nourishment  or  when  there  is  an  excess  of  oxygen  present.  The  spore 
has  a  dense  envelope  or  covering  which  is  very  resistant  to  destructive  agents. 
So  resistant  is  the  covering  that  twice  the  amount  of  heat  is  necessary  to  kill 
a  spore  as  to  kill  an  active  adult  cell.  Spores  when  placed  under  conditions 
unfavorable  for  development  may  remain  inactive  for  an  indefinite  period, 
just  as  seeds  remain  inactive  when  unplanted.  When  spores  encounter  favor- 
able conditions,  they  at  once  develop  into  adult  cells,  just  as  seeds  develop  when 
planted.  It  seems  probable  that  spores  occasionally  remain  dormant  in  the 
human  body  for  long  periods,  and  finally  awaken  into  activity  because  of 
injury  or  disease  of  the  tissue  in  which  they  lie. 

Chemical  Composition  of  Bacteria. — The  protoplasm  of  bacteria 
consists  of  water,  salts,  albuminous  material,  extractives  soluble  in  alcohol, 
and  extractives  soluljle  in  ether. 

Life=COnditions  of  Bacteria.— In  order  to  grow  and  to  multiply, 
bacteria  require  a  suitable  soil  and  the  favoring  influences  of  heat  and  moisture. 
The  soil  demanded  consists  of  highly  organized  compounds  rather  than  crude 
substances,  and  slight  modifications  in  it  may  prove  fatal  to  some  forms  of 
bacterial  life,  but  highly  advantageous  to  others.  Some  organisms  require 
albuminous  matter,  others  need  carbohydrates ;  they  all  require  water,  carbon, 
nitrogen,  oxygen,  hydrogen,  and  certain  inorganic  materials,  especially  lime 
and  potassium  (Woodhead).  All  organisms  require  water.  If  dried,  no 
micro-organisms  will  multiply,  and  many  forms  will  die.  The  fluids  and 
tissues  of  the  individual  may  or  may  not  afford  a  favorable  soil  for  the  germs 
of  a  disease,  or,  in  the  same  person,  may  afford  it  at  one  time  and  not  at 
another.  Some  individuals  seem  to  possess  indestructible  immunity  from, 
and  others  are  especially  prone  to,  certain  bacterial  diseases,  and  these  im- 
munities and  predispositions  may  be  hereditary.  The  Japanese  show  high 
immunity  to  scarlet  fever  and  negroes  to  yellow  fever.  Drunkards  are  pre- 
disposed to  pneumonia.  Some  families  exhibit  high  susceptibility  to  scarlet 
fever.  Negroes  are  very  susceptible  to  tuberculosis  and  small-pox.  Impair- 
ment of  health,  by  altering  some  subtle  condition  of  the  soil,  may  make  a  person 
liable  who  previously  was  exempt.  The  insane  are  predisposed  to  infections. 
Injury  or  disease  of  a  tissue  may  increase  local  liabihty. 

Again,  some  bacteria  which  under  normal  conditions  are  harmless  may 
become  virulent  under  certain  conditions.  Colon  bacilli,  which  under  nor- 
mal conditions  seem  to  be  putrefactive  organisms  inhabiting  the  intestine,  may 
attack  a  point  of  least  resistance  in  the  intestine  itself;  this  point  being  estab- 
lished by  congestion,  strangulation,  inflammation,  or  injury,  and  descendants 


24  Bacteriology 

of  the  bacteria  which  attacked  the  point  of  least  resistance  may  become  so 
virulent  that  they  can  live  and  develop  in  tissues  distant  and  apparently  normal 
and  cause  disease  in  them. 

The  presence  of  oxygen  influences  microbic  growth.  Most  organisms 
thrive  best  when  exposed  to  the  oxygen  of  the  air,  and  they  are  known  as 
aerobic.  The  term  anaerobic  is  employed  to  designate  organisms  that  can 
grow  and  multiply  and  produce  particular  products  only  when  air  is  absent, 
free  oxygen  being  fatal  to  them.  Tetanus  bacilli  and  the  bacilli  of  malignant 
edema  are  anaerobic.  An  organism  which  grows  best  in  air  but  can  grow  when 
free  oxygen  is  excluded  is  called  a  facultative-aerobic  bacterium.  It  may  need 
oxygen;  but  if  it  does,  it  is  able  to  obtain  it  from  the  tissues  when  air  is  ex- 
cluded. A  sensitive  organism  which  dies  when  the  amount  of  oxygen  is  even 
slightly  diminished  is  called  an  obVi gate-aerobic  bacterium.  Most  microbic 
diseases  in  man  are  due  to  facultative-aerobic  bacteria. 

Effect  of  Motion,  Sunlight,  the  X=rays,  Radium,  Cold,  and  Heat. 

— The  majority  of  fungi  grow  best  when  at  rest;  violent  agitation  retards  the 
growth  of  some.  Sunlight  antagonizes  the  growth  of  certain  bacteria,  especially 
tubercle  bacilli  and  the  bacilli  of  typhoid  fever.  It  is  claimed  by  some  that  the 
-v-rays  retard  bacterial  growth.  Radium  rays  are  bactericidal.  Tempera- 
ture influences  bacterial  growth.  Some  organisms  will  grow  only  within 
narrow  temperature  limits,  while  others  can  sustain  sweeping  alterations,  but 
most  grow  best  between  the  limits  of  from  86°  to  104°  F.  Freezing  renders 
bacteria  motionless  and  incapable  of  multiplication,  but  it  does  not  kill  them; 
they  again  become  active  when  the  temperature  is  raised.  Prudden  showed 
that  typhoid  bacilli  can  live  in  ice  one  hundred  and  three  days.  The  absurdity 
of  employing  cold  as  a  germicide  is  evident  when  the  fact  is  known  that  a  tem- 
perature of  200°  F.  below  zero  is  not  fatal  to  germ -life,  cell-activities  by  such 
a  temperature  only  being  rendered  dormant.  Bacteria  have  been  placed  in 
hermetically  sealed  tubes  and  the  tubes  immersed  in  liquid  air  for  seven  days. 
The  germs  were  thus  subjected  to  a  temperature  of  — 190°  C,  but  there  was  no 
change  produced  in  their  virulence  {A..  MacFayden  and  S.  Roland,  in  "Lancet," 
March  24,  1900).  High  temperatures  are  fatal  to  bacteria;  moist  heat  is  more 
destructive  than  dry  heat,  and  adult  cells  are  more  easily  killed  than  spores. 
A  temperature  less  than  212°  F.  will  kill  many  organisms,  and  boiling  will  kill 
every  pathogenic  organism  that  does  not  form  spores.  Some  spores  are  not 
destroyed  after  prolonged  boiling,  and  some  will  withstand  a  temperature  of 
120°  C.  As  a  practical  fact,  however,  boiUng  water  kills  in  a  few  minutes  all 
cocci,  most  bacilli,  and  all  pathogenic  spores;  though  the  spores  of  anthrax, 
tetanus,  and  malignant  edema  are  killed  with  more  difficulty  than  are  the 
spores  of  other  !)acteria. 

Effect  of  Bacteria  upon  Bacteria. — Some  bacteria  are  antagonistic  to 
others,  some  are  synergistic  to  others.  The  streptococcus  of  erysipelas  is 
antagonistic  to  the  baciUus  of  anthrax  and  also  to  syphilis  and  tuberculosis. 
The  growth  of  some  microbes  in  culture  media  makes  a  soil  favorable  or  un- 
favorable for  other  microbes,  and  the  same  process  may  occur  in  the  human 
body.  Influenza  renders  the  lungs  prone  to  infection  with  pneumococci. 
Saprophytes  on  mucous  surfaces  are  antagonistic  to  certain  pathogenic  bacteria. 
We  are  not  yet  able  to  cure  a  microbic  disease  by  inoculating  the  sufferer 
vdth  antagonistic  microbes,  on  the  principle  of  sending  a  thief  to  catch  a  thief. 


Antiseptic  and  Aseptic  Agents  25 

Latent  Bacteria. — Sometimes  pathogenic  organisms  remain  latent  in  the 
body  for  a  considerable  time.  They  are  not  destroyed,  but  produce  no  symp- 
toms, or  only  local  symptoms,  possibly  because  the  individual  is  immune  for 
the  time  being.  Pneumococci,  staphylococci,  and  tyj)hoid  bacilli  may  become 
latent.  Tubercle  baciUi  may  remain  long  latent  in  a  lymph-gland  or  in  any  old 
area  of  caseation. 

Latent  bacteria  may  take  on  active  growth  when  the  tissue  containing 
them  is  damaged  by  injury  or  disease.  I  have  seen  active  disease  arise  in 
an  apparently  cured  and  stiff  tuberculous  joint  as  a  result  of  forcil)ly  breaking 
up  adhesions.  .A.n  attack  of  bronchitis  may  light  up  an  old  and  latent  area  of 
pulmonary  tuberculosis.  The  administration  of  ether  or  chloroform  by  in- 
halation may  render  active  an  inactive  tuberculous  focus  in  the  lung.  A 
partial  or  incomplete  operation  on  a  quiescent  tuberculous  lesion  is  apt  to  be 
followed  by  active  spread  and  may  result  in  wide  dissemination  of  disease. 

Mixed  Infection. — A  fact  of  practical  importance  to  the  surgeon  is 
that  an  area  infected  by  one  form  of  micro-organism  may  be  invaded  by 
another  form.  This  is  known  as  a  mixed  infection,  and  consists  in  a  primary 
infection  with  one  variety  of  organism,  and  a  secondary  infection  with  another, 
or  in  an  infection  at  the  same  time  with  different  micro-organisms.  INIixed 
infection  is  especially  common  on  surfaces  exposed  to  air  and  wound  in- 
fection is  usually  mixed.  Koch  found  both  bacilli  and  micrococci  in  the  same 
lesion  of  tuberculosis.  A  soil  filled  with  pneumococci  favors  the  growth  of  pus 
cocci  and  tubercle  bacilli.  Tuberculous  or  syphilitic  lesions  may  be  attacked 
by  erysipelas.  Chancre  and  chancroid  can  exist  together.  A  syphilitic  ulcer 
is  a  good  culture-soil  for  tubercle  bacilli  (Schnitzler).  Suppuration  in  lesions 
of  tuberculosis  is  due  to  secondary  infection  with  pus  organisms.  Occasionally 
in  empyema  and  other  conditions  due  to  pus  organisms  the  diseased  process 
ceases  to  be  active,  the  pyogenic  bacteria  having  lost  much  of  their  virulence, 
but  a  mixed  infection  with  some  germ  usually  harmless  may  break  down  sur- 
rounding barriers,  intensify  the  virulence  of  bacteria,  and  aggravate  the  disease 
into  an  acute  outburst.  WTien  secondary  infection  occurs  the  primary  in- 
fection may  remain  virulent,  may  be  mitigated  in  intensity,  may  be  destroyed, 
or  may  be  disseminated. 

Intra=uterine  or  Placental  Infection. — The  infection  of  the  embryo 
by  the  diseased  ovum  or  the  diseased  sperm-cell  occurs  only  in  syphilis.  Such 
an  embryo  is  diseased  at  the  first  moment  of  life.  The  direct  transmission  of 
bacteria  from  parent  to  fetus  is  a  problem  still  in  course  of  solution.  Certain 
it  is  that  some  diseases  may  follow  the  transmission  of  the  micro-organism 
through  the  septum  of  separation  between  the  circulations  of  the  mother  and 
child.  Placental  transmission  may  occur  in  syphilis,  scarlatina,  pneumonia,  an- 
thrax, measles,  pyogenic  conditions,  and  tuberculosis  (Hektoen).  Few  cases 
of  congenital  tuberculosis  have  been  reported,  but  Rosenberger  has  recently 
shown  the  bacilli  in  the  umbilical  vein  from  the  placenta  of  a  tuberculous 
mother.  A  child  of  a  tuberculous  parent  may  not  be  born  tuberculous,  but 
may  have  weakened  tissue-cells  that  easily  fall  a  prey  to  the  tubercle  bacillus 
when  it  reaches  them  by  any  avenue.  Placental  transmission  of  bacteria  is 
favored  by  disease  or  injury  of  the  placenta. 

Chemical  Antiseptics  and  Germicides  and  Aseptic  Agents.— It  is 
necessary  to  make  a  distinction  between  deodorizers,  antiseptics,  and  ger- 


26  Bacteriology 

micides,  although  the  two  latter  terms  are  usually  regarded  as  being  interchang- 
able.     In  the  methods  of  antiseptic  surger}-  we  use  germicides. 

A  deodorizer  is  an  agent  which  destroys  an  offensive  odor.  It  is  true  that 
an  offensive  odor  may  be  due  to  microbic  growth.  It  is  also  true  that  nasty 
odors  may  prove  injurious  to  those  who  inhale  them.  But,  nevertheless,  the 
odor  is  the  result  of  microbic  action,  and  destroying  an  odor  does  not  render 
harmless  the  bacteria  which  caused  it.     Charcoal  is  a  well-known  deodorizer. 

An  antiseptic  is  an  agent  which  retards  or  prevents  putrefaction.  It  acts 
by  weakening  or  killing  saprophytic  organisms,  but  is  not  fatal  to  spores. 

A  germicide  or  disinfectant  is  an  agent  which  is  fatal  to  adult  bacteria 
and  spores.  The  destruction  of  the  germs  of  disease  on  the  skin,  in  clothing, 
in  excreta,  in  a  wound,  etc.,  is  known  as  disinfection.  Disinfection  of  the  skin, 
of  a  wound,  of  dressings,  or  of  instruments  is  called  also  sterilization. 

Antiseptics  and  germicides  should  not  be  used  in  surgically  clean  wounds. 
Repair  \\'ill  occur  more  cjuickly  if  they  are  not  used.  Tillmanns  has  pointed 
out  that  when  antiseptics  are  used  cell-di\'ision  begins  late  and  progresses 
slowly.  Germicides  are  not  efficient  in  fatty  tissue,  as  bacteria  surrounded 
with  oil  cannot  be  reached  by  the  drug,  and  the  chemical  is  irritant  and  apt 
to  induce  fat  necrosis  (Haenel,  in  "Deutsch.  med.  Woch.,"  1895,  No.  8). 

Corrosive  Sublimate. — Many  chemical  agents  will  kill  bacteria,  one  of 
the  most  certain  of  them  all  being  corrosive  sublimate.  Koch  showed  that 
corrosive  sublimate  is  an  efficient  test-tube  germicide  when  present  in  the 
proportion  of  only  i  part  to  50,000.  It  is  used  in  surgen,-  in  strengths  of  i 
part  of  the  salt  to  1000,  2000,  3000,  or  more  parts  of  water.  Badly  infected 
wounds  are  occasionally  irrigated  with  solutions  of  a  strength  of  i  to  500. 
Contact  with  albumin  precipitates  from  a  solution  of  corrosive  sublimate  an 
insoluble  albuminate  of  mercury  which  forms  a  white  layer  upon  the  surface 
of  the  wound,  is  not  a  germicide,  and  prevents  deep  diffusion  of  the  mer- 
curial fluid.  In  surgical  operations  by  the  antiseptic  method  the  mercurial  salt 
should  be  combined  with  tartaric  acid  in  the  proportion  of  i  to  5,  which 
combination  prevents  the  formation  of  the  insoluble  albuminate  of  mercurj'. 

But  though  corrosive  sublimate  under  certain  conditions  is  extremely  pow- 
erful, it  is  not  always  absolutely  reliable.  Many  spores  are  ver}'  resistant  to  its 
action.  Even  a  i  per  cent,  solution  of  bichlorid  of  mercur}-  is  not  certainly 
destructive  to  the  spores  of  anthrax.  Geppert  tells  us  that  anthrax-spores 
may  be  active  after  a  twenty-five  hour  immersion  in  a  i  :  100  solution  of 
sublimate  (Schimmelbusch).  In  the  presence  of  hydrogen  sulphid  corrosive 
sublimate  is  useless,  inert  and  insoluble  sulphid  of  mercury  being  precipitated; 
hence  corrosive  sublimate  is  without  value  as  a  rectal  antiseptic;  in  fact, 
Gerloczy  has  proved  that  a  concentrated  aqueous  solution  of  sublimate  will 
not  disinfect  an  equal  quantity  of  feces.  Corrosive  sublimate  contained  in 
dressings  after  a  time  undergoes  decomposition  and  ceases  to  be  a  germicide. 
It  is  not  germicidal  in  fatty  tissues  because  it  is  unable  to  attack  bacteria 
which  are  coated  with  oil.  Corrosive  sublimate  is  ven,^  irritating  to  the  tissues 
and  causes  copious  exudation.  Hence,  if  an  extensive  wound  has  been  irri- 
gated with  this  agent,  drainage  must  be  employed  to  obtain  exit  for  the  wound 
fluid.  In  some  wounds  which  have  been  irritated  by  corrosive  sublimate  the 
tissues  seem  to  lose  to  a  great  extent  their  power  of  resistance  to. bacteria  and 
infection  may  be  actually  facilitated  by  irrigation  with  bichlorid  of  mercury. 


LithiomcrcLiric  lodid  27 

In  rare  instances  corrosive  sublimate  is  aljsorbed  and  produces  poisoning. 
In  spite  of  these  shortcomings  and  drawbacks  it  is  a  valuable  aid  to  the  sur- 
geon and  must  be  frequently  used,  especially  upon  the  skin  of  the  patient 
and  the  hands  of  the  operator  and  his  assistants.  It  should  be  dissolved  in 
disdlled  water.  Ordinary  water  causes  a  ])recipitate  to  form  (common  salt 
prevents  the  formation  of  this  precipitate) . 

Because  of  the  fact  that  corrosive  sublimate  is  poisonous  and  very  irritant, 
it  should  not  be  used  upon  serous  membranes.  It  is  absorbed  quickly  from 
serous  membranes  and  destroys  the  endothelial  cells  and  should  not  be  in- 
troduced into  the  pleural  sac,  into  joints,  or  into  the  peritoneal  cavity.  It 
should  never  be  put  within  the  dura,  and  should  not  be  applied,  in  strong 
solution  at  least,  to  mucous  membranes.  It  should  not  be  introduced  into  the 
rectum  for  three  reasons:  First,  it  is  intensely  irritant  and  causes  pain  and 
inflammation.  Second,  it  is  useless,  being  largely  and  promptly  converted  into 
insoluble  and  inert  sulphid  of  mercury.  Third,  a  poisonous  dose  may  be 
absorbed.  Instruments  cannot  be  placed  in  corrosive  sublimate  without  being 
dulled,  stained,  and  corroded.  It  is  better  to  make  the  solution  at  the  time  it  is 
needed,  so  as  to  have  it  fresh,  for  in  old  solutions  much  of  the  :5bluble  corrosive 
sublimate  has  been  converted  into  soluble  oxychlorid  of  mercury,  and  the  fluid 
has  ceased  to  be  germicidal.  In  order  to  make  up  fresh  solutions  use  tablets, 
each  of  which  contains  about  7^  grains  of  the  drug — one  of  these  tablets  added 
to  a  pint  of  water  makes  a  solution  of  a  strength  of  i  to  1000.  Tablets  which 
also  contain  ammonium  chlorid  are  more  soluble  than  those  which  contain 
corrosive  sublimate  only.  Hot  solutions  of  the  drug  are  more  powerfully 
germicidal  than  cold  solutions.  As  corrosive  subHmate  is  irritant,  leads  to 
profuse  e.xudation,  and  may  produce  tissue-necrosis,  it  should  never  be  in- 
troduced into  an  aseptic  wound.  In  such  a  wound  it  can  do  no  good  and  may 
do  much  harm. 

Griffin,  in  Foster's  "Practical  Therapeutics,"  sets  forth  the  strengths  of 
solutions  appUcable  to  different  regions: 

For  disinfection  of  the  surgeon's  hands  and  the  patient's  skin,  i  :  1000; 
for  irrigating  trivial  wounds,  i  :  2000;  for  irrigating  larger  wounds  and 
cavities,  i  :  10,000  to  i  :  5000;  for  irrigating  vagina,  i  :  10,000  to  i  :  5000; 
for  irrigating  urethra,  i  :  40,000  to  i  :  20,000;  for  irrigating  conjunctiva, 
I  :  5000;  for  garghng,  i :  10,000  to  i  :  5000. 

Corrosive  Sublimate  Poisoning. — Corrosive  sublimate  may  be  absorbed 
from  a  wound,  a  serous  surface,  or  a  mucous  membrane,  ptyalism  and  diar- 
rhea resulting.  The  absorption  of  bichlorid  of  mercury  may  be  followed  by 
cramp  in  the  Umbs  and  belly,  feeble  pulse,  cold  skin,  extreme  restlessness,  and 
even  collapse  and  death.  At  the  first  sign  of  trouble  withdraw  the  drug  and 
treat  the  ptyahsm  (page  334). 

Lithiomercuric  lodid. — This  material  was  prepared  and  tested  by  Dr. 
Rosenberger  and  Mr.  England  ("American  Medicine,"  1904,  p.  1021).  It  is 
asserted  that  the  iodid  of  mercury  and  lithium  is  more  powerfully  germicidal 
than  corrosive  subHmate,  does  not  form  inert  albuminate  when  placed  in  a 
wound,  and  is  not  precipitated  by  alkaUes.  It  is  not  nearly  so  irritant  nor  is 
it  so  poisonous  as  corrosive  sublimate.  I  have  given  it  an  extensive  trial  in 
my  clinic  and  am  satisfied  that  it  is  superior  to  corrosive  subUmate  as  a  germ- 
icide, is  less  irritant,  and  is  less  poisonous.  Its  only  objection  is  that  it  is  more 
expensive. 


28  Bacteriology 

Carbolic  Acid. — Carbolic  acid  is  a  valuable  germicide  in  the  strength  of 
from  1 :  40  to  1 :  20.  It  is  certainly  fatal  to  pus-organisms,  but  weak  solutions 
fail  to  kill  most  bacteria  and  do  not  destroy  spores.  Unfortunately,  this  acid 
attacks  the  hands  of  the  surgeon;  consequently  in  the  United  States  dilute  car- 
bolic acid  is  chiefly  employed  as  a  solution  in  which  to  place  the  sterilized 
operating  instruments,  or  as  a  germicide  to  prepare  the  skin  of  the  patient 
before  the  operation  is  performed. 

Carbolic  acid  is  very  irritant  to  tissues,  and  carbolized  dressings  may  be 
responsible  for  sloughing  of  the  wound  or  dry  gangrene  (p.  197).  Because  of 
its  irritant  properties  wounds  which  have  been  irrigated  with  it  should  be  well 
drained.     Carbolic  acid,  like  corrosive  sublimate,  is  inert  in  fatty  tissues. 

Pure  carbolic  acid  is  a  reliable  disinfectant  for  certain  conditions.  It  is 
used  to  destroy  chancroids,  to  purify  infected  wounds  and  abscess  cavities, 
to  disinfect  the  medullary  cavity  in  osteomyelitis,  to  stimulate  granulation  after 
the  open  operation  for  hydrocele,  or  to  purify  sloughing  burns  or  ulcerated 
areas.  The  pure  acid  rarely  produces  constitutional  symptoms,  but  it  occa- 
sionally causes  sloughing.  Its  application  causes  pain  for  a  moment  only, 
and  then  analgesia  ensues.  Even  dilute  solutions  of  carbolic  acid  greatly 
relieve  pain  when  applied  to  raw  surfaces.  The  local  action  of  carbolic  acid 
can  be  at  once  antidoted  by  the  application  of  alcohol  (Seneca  D.  Powell). 
When  carbolic  acid  is  applied  to  a  wound,  the  area  about  the  wound  should 
first  be  moistened  with  alcohol.  After  the  application  of  pure  carbolic  acid 
to  the  interior  of  a  joint,  a  wound,  the  medullary  canal,  or  an  infected  area, 
the  surgeon  should  wait  about  one  minute  and  then  apply  alcohol. 

Dilute  carbolic  acid  acts  more  slowly  and  less  certainly  than  corrosive  sub- 
limate. It  requires  twenty-four  hours  for  a  5  per  cent,  solution  to  kill  anthrax 
spores.  Pus  or  blood  (albuminous  matter)  greatly  weaken  the  germicidal 
power  of  carbolic  acid,  and  fatty  tissue  cannot  be  disinfected  by  it.  It  is  not 
even  the  best  of  agents  in  which  to  place  instruments,  as  it  dulls  them.  After 
operation  upon  the  mouth  it  may  be  used  as  a  wash  or  gargle,  i  to  2  per  cent, 
being  a  suitable  strength.  It  is  used  sometimes  to  irrigate  the  bladder  and 
often  to  cleanse  sinuses,  but  is  not  employed  in  the  peritoneal  cavity,  the 
pleural  sac,  the  rectvim,  or  the  brain.  It  is  occasionally  injected  into  tubercu- 
lous joints.     Carbolic  solution  should  never  be  used  in  clean  wounds. 

Carbolic  Acid  Poisoning. — Carbolic  acid  is  readily  absorbed,  and  may  thus 
produce  toxic  symptoms.  Absorption  is  not  uncommon  when  the  weaker 
solutions  are  used,  but  seldom  occurs  when  a  wound  has  been  brushed  over 
with  pure  acid,  because  the  pure  acid  at  once  forms  an  extensive  zone  of  co- 
agulated albumin,  which  acts  as  a  barrier  to  absorption.  One  of  the  early  indi- 
cations of  the  absorption  of  carbolic  acid  is  the  assumption  by  the  urine  of  a 
smoky,  greenish,  or  blackish  hue.  This  hue  appears  a  little  time  after  the  urine 
has  been  voided,  whereas  the  smoky  hue  of  hematuria  is  noted  in  urine  at  once 
after  it  has  been  passed.  The  condition  produced  by  carbolic  acid  is  known  as 
carboluria,  and  examination  of  such  urine  shows  a  great  diminution  or  entire 
absence  of  sulphates  when  the  acidulated  urineis  heated  withchlorid  of  barium. 
The  diminution  of  precipitable  sulphates  is  explained  by  the  fact  that  these 
salts  are  combined  with  carbohc  acid,  forming  soluble  sulphocarbolates 
(Griffin).  Such  urine  is  apt  to  contain  albumin.  If  during  the  use  of  car- 
bolized dressing  or  the  employment  of  carbolic  solutions  the  urine  becomes 


Pcroxid  of  Hydrogen  29 

smoky,  the  use  of  the  drug  'n  any  form  must  be  at  once  discontinued,  otherwise 
dangerous  s}-mptoms  will  soon  appear.  These  symptoms  are  subnormal 
temperature,  feeble  pulse  and  respiration,  muscular  weakness,  and  vertigo. 
If  deatli  occurs,  it  is  due,  as  a  rule,  to  respiratory  failure.  The  treatment  of 
slow  poisoning  by  carbolic  acid  consists  in  at  once  withdrawing  the  drug, 
giving  stimulants  and  nourishing  food,  administering  sulphate  of  sodium 
se\'eral  times  a  day  and  atropin  in  the  morning  and  evening. 

Saline  Solution. — Sodium  chlorid  solution  of  normal  strength  (0.7  of  i 
per  cent.)  does  not  damage  the  cells  of  serous  surfaces  or  of  a  wound  hence 
it  is  used  as  an  irrigating  fluid,  and  it  is  the  best  fluid  for  such  a  purpose.  In 
intravenous  infusion,  in  shock  or  hemorrhage  it  is  very  valuable.  It  does  not 
damage  the  blood-corpuscles  as  plain  water  does.  It  is,  however  irritant  to 
the  kidneys,  when  used  by  hypodermoclysis  or  intravenous  infusion;  hence 
if  the  kidneys  are  diseased  saline  fluid  of  one-half  normal  strength  should  be 
used  for  either  of  the  latter  purposes.  Normal  salt  solution  is  prepared  as 
follows:  A  quart  of  water  is  filtered  and  steriUzed  and  in  this  i^  drams 
of  table  salt  are  dissolved,  and  the  fluid  is  again  boiled  (see  pp.  465  and  467). 

Thiersch's  Fluid. — This  fluid  is  used  upon  mucous  and  serous  surfaces 
and  is  employed  to  irrigate  wounds.  It  is  non-toxic  and  non-irritant.  It 
consists  of  I  grain  of  salicylic  acid  and  6  grains  of  boric  acid  to  i  ounce  of  sterile 
water. 

Alcohol. — Alcohol  is  a  germicidal  agent,  which  is  most  powerful  when  of 
the  strength  of  70  per  cent.  It  may  be  used  on  the  hands  or  the  skin  of  the 
patient,  of  a  strength  of  from  70  to  95  per  cent,  and  may  be  used  plain  or 
mixed  with  corrosive  subUmate,  of  the  strength  of  i  part  of  corrosive  to 
1000  parts  of  alcohol.  Pure  alcohol  is  used  to  arrest  the  local  action  of  pure 
carbolic  acid. 

Boiled  Water. — Is  used  to  dissolve  antiseptic  materials;  to  inject  by 
hypodermoclysis;  to  irrigate  wounds,  mucous  cavities  or  serous  surfaces,  and 
as  a  fluid  in  which  to  keep  instruments  during  the  operation.  It  damages  some- 
what the  tissue-cells  of  the  surface  of  a  wound  and  injures  the  cells  of  serous  sur- 
faces, hence  for  irrigation  salt  solution  is  to  be  preferred. 

Creolin,  which  is  a  preparation  made  from  coal-tar,  is  a  germicide  without 
irritant  or  toxic  effects.  It  is  less  powerful  than  carbolic  acid,  but  acts  similarly 
and  is  used  in  emulsion  of  a  strength  of  from  i  to  5  per  cent.,  and  does  not 
irritate  the  skin  like  carbolic  acid. 

Peroxid  of  hydrogen  is  an  excellent  agent  for  cleansing  a  purulent  or 
putrid  area,  but  it  is  never  applied  to  an  aseptic  wound.  It  is  prepared  in  a 
lo-volume  solution,  which  should  be  diluted  one-half  or  two-thirds  before  using. 
A  30  per  cent,  solution  is  known  as  perhydrol.  It  probably  destroys  the  al- 
buminous element  upon  which  bacteria  live,  and  thus  starves  the  fungi.  When 
peroxid  of  hydrogen  is  applied  to  a  purulent  area  ebullition  occurs,  liberated 
oxygen  bubbling  up  through  the  fluid  and  the  pus  being  oxidized.  The  per- 
oxid reaches  every  cranny  and  diverticulum  containing  pus.  The  peroxid 
of  hydrogen  is  not  fatal  to  tetanus  bacilli;  in  fact,  tetanus  bacilli  can  be  culti- 
vated in  a  strong  solution  of  it.  It  is  very  valuable  as  a  mouth-wash  to  cleanse 
the  mouth  before  and  after  operations  in  the  oral  cavity.  Some  surgeons  use 
it  to  wash  out  appendicular  abscesses  (R.  T.  Morris) .  It  must  not  be  injected 
into  a  deep  abscess  in  any  region  unless  a  large  opening  exists,  as  otherwise  the 


30  Bacteriology 

evolved  gas  may  tear  ajiart  structures,  dissect  uj)  the  cellular  tissue,  ana  spread 
infection.  The  use  of  jKToxid  should  not  be  too  long  continued,  for  if  used  for 
a  considerable  period  it  makes  the  granulations  edematous  and  retards  healing. 
In  fact,  its  continued  use  may  actually  prevent  a  sinus  closing. 

Iodoform. — Iodoform  is  largely  used  by  surgeons  in  spite  of  the  fact  that 
laboratory  workers  have  assured  us  it  is  not  truly  a  germicide  as  bacteria  will 
grow  upon  it.  Clinical  evidence,  however,  is  in  its  favor  and  surgeons  long  ago 
concluded  that  it  at  least  hinders  the  development  of  bacteria,  directly  antago- 
nizes the  action  of  the  toxic  products  of  germ-life,  and  stimulates  the  pro- 
duction of  connective  tissue.  It  is  of  the  greatest  value  when  applied  to  putrid 
foci,  suppurating  areas,  and  tuberculous  processes.  In  putrid  foci  it  probably 
combines  with  toxins  and  renders  them  less  poisonous  or  even  inert. 

It  attenuates  the  virulence  of  pus  cocci  and  organisms  of  putrefaction.  It 
renders  its  greatest  service  in  tuberculous  processes  and  is  infinitely  more 
powerful  when  oxygen  is  excluded  than  when  it  is  present.  The  laboratory 
workers  who  condemn  it  have  in  many  cases  used  nutrient  material  in  which 
it  does  not  dissolve  (P.  F.  Lomry,  "Archiv  fiir  klin.  Chir.,"  1896).  D.  B. 
Heile  ("Proceedings  of  the  German  Surgical  Congress  of  1903")  insists  that 
iodoform  is  a  valuable  germicide  if  oxygen  is  excluded.  He  says,  if  iodoform 
is  mixed  with  tissue  juice,  oxygen  being  excluded,  the  mixture  becomes  power- 
fully germicidal,  even  to  streptococci,  in  from  three  to  five  days,  although,  as  he 
maintains,  neither  constituent  of  the  mixture  when  alone  is  germicidal.  Tissue 
juice  decomposes  iodoform,  Uver  juice  decomposing  it  most  rapidly,  brain  and 
fat  decomposing  it  slowly.  Granulation  tissue  decomposes  it  and  tuberculous 
granulation  tissue  acts  upon  it  most  rapidly. 

The  conclusion  of  Heile  is  that  this  study  confirms  the  cHnical  observation 
that  iodoform  is  valuable  in  cavities  but  not  in  free  surfaces.  My  own 
belief  is  that  it  is  more  valuable  in  cavities  than  upon  free  surfaces,  but 
when  we  are  dealing  with  putrefactive  areas,  even  on  free  surfaces,  it 
is  of  great  value.  Heile  maintains  that  when  iodoform  decomposes  on 
a  free  surface  it  sets  free  I,  which  is  not  a  powerful  germicide.  When  it 
decomposes  in  tissue  juice  it  forms  a  powerful  germicide  which  is  rendered 
inert  by  oxygen.  Clinically,  no  real  substitute  for  iodoform  has  yet  been 
found.  It  can  be  rendered  sterile  by  several  washings  with  a  solution  of 
corrosive  sublimate.  It  need  not  be  appUed  to  clean  wounds,  but  the  powder 
is  very  useful  when  dusted  into  infected  wounds.  It  prevents  wound  dis- 
charges from  decomposing  and  distinctly  allays  pain.  Gauze  impregnated 
with  iodoform  is  used  to  keep  abscesses  open  after  evacuation,  to  drain  the 
belly  after  certain  operations,  to  pack  aside  the  intestines  and  prevent  their  in- 
fection during  some  abdominal'  operations,  and  as  packing  to  arrest  intra- 
cranial hemorrhage.  Iodoform  gauze  will  drain  serum  well,  but  will  not  drain 
pus.  In  fact,  it  blocks  up  a  pus-cavity,  and  if  retained  long  leads  to  the  col- 
lection of  purulent  matter  behind  and  about  the  supposed  drain.  If  used  in  an 
abscess,  it  must  be  removed  in  twenty-four  or  thirty-six  hours.  Tuberculous 
joints  and  cold  abscesses  are  injected  with  iodoform  emulsion,  which  is  made 
by  adding  the  drug  to  sterile  glycerin  or  olive  oil.  The  emulsion  contains  10 
per  cent,  of  iodoform.  A  solution  in  ether  of  a  strength  of  10  per  cent, 
may  be  used  to  inject  the  cavity  of  a  cold  abscess,  but  it  is  dangerous,  may 
rupture  the  wall,  and  is  more  apt  to  produce  poisoning  than  is  the  emulsion. 
Iodoform  wax  is  used  to  fill  cavities  in  bone  (p.  509). 


Acetanilid  31 

Iodoform- poisoning. — The  druu;  must  be  used  with  some  caution.  Ab- 
sorption from  a  wound  sometimes  happens,  producing  toxic  symptoms. 
These  symptoms  are  frequently  misinterpreted,  being  usually  attributed  to 
infection.  R.  T.  Morris  has  pointed  out  that  in  iodoform-poisoning  the 
wound  seems  to  be  in  excellent  condition,  whereas  in  sepsis  the  wound  is  un- 
healthy. The  symptoms  in  some  cases  are  acute  and  arise  suddenly,  and 
consist  of  hallucinatory  delirium,  nausea,  feyer,  watery  eyes,  contracted  pupils, 
metallic  taste  in  mouth,  yellowness  of  the  skin  and  eyes,  an  odor  of  iodoform 
upon  the  breath,  the  presence  of  the  drug  in  the  urine,  the  outbreak  of  a  skin 
eruption  resembling  measles  or  one  which  is  erythematous,  yesicular,  bullous, 
or  petechial.  There  is  often  nephritis  and  always  excessiye  loss  of  flesh  and 
strength.  Patients  with  such  acute  S}'mptoms  usually  pass  into  coma  and  die 
within  a  week.  Such  attacks  are  most  apt  to  arise  in  those  beyond  middle  life 
(see  Gerster  and  Lilienthal,  in  Foster's  "Practical  Therapeutics").  lodin  can 
be  recognized  in  urine  by  adding  a  few  drops  of  commercial  nitric  acid  and  a 
little  chloroform.  When  the  mixture  is  shaken  the  chloroform  will  take  up  the 
free  iodin  and  become  purple,  and  on  standing  the  purple  layer  will  settle  to  the 
bottom  of  the  tube.  Another  method  is  as  follows :  Put  a  little  urine  in  a  saucer, 
add  a  little  calomel,  and  stir.  If  the  urine  contains  iodoform  a  brown  color  will 
be  noted  (R.  T.  Morris).  The  finding  of  iodin  in  the  urine,  however,  is  not 
proof  that  the  patient  is  poisoned.  We  may  find  it  when  no  sign  of  poisoning 
exists.  In  chronic  cases  of  iodoform-poisoning  the  first  symptoms  usually 
observed  are  moroseness,  bewilderment,  and  irritability,  followed  by  depression, 
with  unsystematized  persecutory  delusions,  delirium,  coma,  and  even  death. 

In  systemic  poisoning  by  iodoform,  discontinue  the  use  of  the  drug,  sus- 
tain the  strength  of  the  patient,  and  favor  the  ehmination  of  the  poison. 

Iodoform  sometimes  produces  greal  local  irritation  of  the  cutaneous  sur- 
face, the  dermatitis  being  eczematous  or  else  being  manifested  by  crops  of 
vesicles  filled  with  turbid  yellow  serum  or  even  bloody  serum.  These 
vesicles  rupture  and  expose  a  raw  oozing  surface,  looking  not  unlike  a  burn. 
The  dermatitis  usually  exists  only  in  the  region  with  which  iodoform  was  in 
contact,  but  in  some  cases  it  spreads  widely.  The  use  of  the  drug  must  be  at 
once  abandoned,  for  to  continue  it  will  not  only  increase  the  dermatitis,  but  may 
produce  constitutional  symptoms.  Wash  the  vesiculated  area  with  a  stream 
of  normal  salt  solution  to  remove  iodoform,  open  each  vesicle,  and  dress  the 
part  for  several  days  with  gauze  w^et  with  normal  salt  solution.  After  acute 
inflammation  ceases  apply  zinc  ointment  or  cosmoHn. 

Aristol  is  an  odorless  iodin  compound  used  by  some  as  an  antiseptic 
dusting-powder. 

Loretin  is  an  antiseptic  powder  which  is  odorless,  germicidal,  non-irritant, 
and  which  is  said  to  be  non-toxic. 

Europhen  is  a  powder  containing  iodin,  and  the  iodin  separates  from 
it  slowly  when  the  powder  is  apphed  to  wounds  or  burns.  It  does  not  produce 
toxic  symptoms  readily,  if  at  all,  and  is  a  valuable  substitute  for  iodoform. 
It  is  used  especially  in  the  treatment  of  ulcers  and  burns. 

Nosophen  is  a  pale  yellow  powder  containing  60  per  cent,  of  iodin.  Its 
bismuth  salt  is  known  as  antinosin.  Nosophen  is  not  toxic,  is  free  from 
odor,  and  is  the  best  of  the  substitutes  for  iodoform. 

Acetanilid  is  frequently  used  as  a  substitute  for  iodoform.     It  is  of  value 


32  Bacteriology 

when  applied  to  suppurating,  ulcerating,  or  sloughing  areas,  but  it  does 
not  benefit  tuberculous  conditions.  Sometimes  absorption  takes  place  to  a 
sufi&cient  extent  to  cause  cyanosis,  sweating,  and  weakness  of  the  pulse  and 
respiration.  If  cyanosis  arises,  suspend  the  administration  of  the  drug  and 
administer  stimulants  by  the  stomach. 

Airol  is  a  substitute  for  pure  iodoform,  and  is  composed  of  gallic  acid, 
bismuth,  and  iodoform.     It  is  non-irritant  and  non-toxic. 

Among  other  powders  we  may  mention  iodol,  amyloform,  subiodid  of 
bismuth,  and  dermatol  or  subgallate  of  bismuth. 

Silver  is  a  valuable  antiseptic.  Halsted  and  Bolton  have  shown  that 
metallic  silver  exerts  an  inhibitive  action  upon  the  growth  of  micro-organisms 
and  does  not  irritate  the  tissues.  Crede  has  also  demonstrated  the  same  facts. 
These  statements  indicate  one  great  reason  why  silver  wire  is  such  a  useful 
suture-material.  Halsted  is  accustomed  to  place  silver  foil  over  wounds 
after  they  have  been  sutured,  and  Crede  employs  as  a  dressing  a  fabric  in 
which  metallic  silver  is  intimately  incorporated. 

Crede  considers  silver  lactate  (actol)  an  admirable  antiseptic.  It  does 
not  form  an  insoluble  albuminate  when  introduced  into  the  tissues  and  is 
not  an  irritant.  Silver  citrate  (itrol)  is  said  to  be  even  a  better  preparation 
than  silver  lactate,  and  it  is  a  useful  dusting-powder.  A  preparation  of 
metallic  silver,  known  as  colloidal  silver  or  collargolum,  is  made.  This  prepa- 
ration is  soluble  in  water  and  in  albuminous  fluids.  It  is  said  to  remain  as 
metalHc  silver  when  in  solution  and  to  be  powerfully  germicidal.  It  certainly 
seems  to  cause  temporary  leukocytosis,  but  so  do  some  other  drugs  which  are 
not  antagonistic  to  infections.  It  comes  put  up  in  i-  and  2 -grain  tablets.  A 
solution  of  the  strength  of  from  i  to  5  per  cent,  is  used.  In  severe  cases  of  sepsis 
some  advocate  injecting  this  solution  into  a  vein  which  has  been  rendered  promi- 
nent by  applying  a  bandage  above  the  elbow.  The  dose  is  from  i  to  2  grains 
of  the  drug.  One  injection  or  more  may  be  given.  I  have  never  seen  it  do  the 
slightest  good  and  I  beUeve  that  intravenous  injections  are  dangerous.  Some 
have  given  it  subcutaneously,  some  by  the  mouth,  others  by  enema.  Sub- 
cutaneous injections  are  often  very  irritant  and  it  is  doubtful  if  the  drug  is 
absorbed  from  either  the  stomach  or  rectum.  The  most  extraordinary  claims 
have  been  put  forth  regarding  the  therapeutic  value  of  collargolum.  Its  use 
has  been  advocated  in  the  most  diverse  general  infections.  I  believe  it  is  of 
no  real  value.  Its  claims,  in  my  opinion,  have  been  shattered  by  the  majority 
report  of  the  committee  of  the  American  Medical  Association  ("  Jour.  Am.  Med. 
Assoc,"  March  13,  1909).  Crede's  ointment  of  silver,  I  beheve,  is  of  use  in 
infections -of  the  skin  and  lymphatic  vessels.  I  have  used  it  repeatedly  in  such 
cases.  In  a  child,  15  grains,  in  an  adult,  45  grains  of  the  ointment  are  rubbed 
in  the  skin  at  one  time,  and  the  rubbing  should  be  kept  up  from  ten  to  thirty 
minutes.  There  is  said  to  be  no  risk  of  argyria.  Protargol  is  a  silver  salt 
much  used  in  gonorrhea.  A  solution  in  water  is  made.  It  is  not  precipitated 
by  albumin,  alkalies,  nor  acids.  In  gonorrhea  a  i  to  5  per  cent,  solution  is 
used.  Argyrol  is  a  new  and  valuable  preparation  of  silver  which  I  have  used 
frequently  with  much  satisfaction.  It  is  known  as  silver  vitelline,  is  not  irritant, 
and  contains  30  per  cent,  of  metalHc  silver.  It  is  not  precipitated  by  albumin. 
In  a  strength  of  5  per  cent,  it  is  a  very  useful  injection  for  gonorrhea,  as  it  has 
powerful  gonococcidal  properties.     In  some  types  of  chronic  cystitis  several 


Nucleins  t,t, 

drams  of  a  3  per  cent,  solution  may  be  injected  into  the  bladder  from  time  to 
time,  and  much  stronger  solutions  can  be  used  \\'ith  safety.  Intlamed  mucous 
membranes  may  be  painted  wnth  a  solution  of  a  strength  of  from  20  to  50  per 
cent.  A  sinus  or  a  sluggish  area  of  granulation  may  be  stimulated  by  touching 
with  a  solution  of  a  strength  of  from  25  to  50  per  cent.  I  have  found  it  of  much 
service  in  sinuses. 

Formaldehyd,  or  formic  aldehyd,  has  valuable  antiseptic  properties. 
Formalin  is  a  40  per  cent,  solution  of  the  gas  in  water.  Solutions  of  this 
strength  are  very  irritant  to  the  tissues,  but  i  per  cent,  solutions  can  be  used 
to  disinfect  wounds.  A  solution  of  a  strength  of  0.5  per  cent,  is  used  to 
irrigate  sinuses,  tuberculous  areas,  abscess-cavities,  and  suppurating  joints. 
A  strong  solution  is  used  to  asepticize  chancroids  and  other  ulcers.  A  2 
percent,  solution  disinfects  instruments.  The  vapor  of  formahn  can  be  so 
apphed  as  to  disinfect  wounds,  and  Wood  suggests  its  employment  in  septic 
peritonitis  as  a  means  of  disinfection  after  the  abdomen  has  been  opened. 
The  vapor  of  formalin  thoroughly  disinfects  catheters. 

Formalin-gelatin  was  introduced  by  Schleich  as  an  antiseptic  powder. 
The  commercial  preparation  is  known  as  glutei.  When  applied  to  a  clean 
wound  it  gives  off  formalin  and  keeps  the  wound  aseptic.  When  it  is  applied 
to  a  sloughing  surface  it  will  not  give  off  formalin  unless  it  is  mixed  with 
pepsin  and  hydrochloric  acid.  Formalin-gelatin  has  been  used  to  replace 
bone-defects. 

Lysol  is  a  clear,  brownish,  oily  fluid  with  an  odor  like  creasote.  It  is  a 
valuable  germicidal  agent.  It  is  saponified  phenol  and  is  used  in  a  solution 
of  a  strength  of  from  i  to  3  per  cent.  It  does  not  attack  the  hands  like  carbolic 
acid  and  is  much  less  poisonous. 

Mustard  is  an  excellent  emergency  germicide.  Its  value  has  been  demon- 
strated by  Roswell  Park,  who  uses  a  mixture  of  soap,  cornmeal,  and  mus- 
tard flour  to  scrub  the  surgeon's  hands  or  the  patient's  skin.  I  have 
used  it  repeatedly  with  entire  satisfaction.  Mustard  removes  the  odor  of 
decay  at  once. 

Commercial  gasolene  is  used  by  Riordan  and  others  to  clean  wounds 
and  ulcers,  and  to  prepare  the  field  of  operation.  Its  vapor  is  so  inflammable 
that  the  material  must  not  be  used  when  an  artificial  light  is  necessary,  and 
it  is  used  only  in  the  daytime  and  on  free  surfaces  where  evaporation  is  rapid. 
It  is  sterile,  non-irritant,  and  on  evaporation  leaves  a  dry,  clean  surface. 

lodin. — This  drug  was  strongly  endorsed  by  the  late  Prof.  Nicholas  Senn 
("Surgery,  Gynecolog)^  and  Obstetrics,"  July,  1905).  He  regarded  it  as  the 
most  powerful  and  the  safest  of  antiseptics,  and  claimed  that  in  solutions  of  a 
strength  of  i  per  cent,  it  is  non-irritant  and  causes  a  protective  phagocytosis. 
It  may  be  used  in  great  dilution  or  the  tincture  may  be  applied  to  an  infected 
wound  in  the  same  manner  as  is  pure  carboUc  acid;  a  method  advocated  by 
Carl  Beck.  In  dilute  solution  it  is  used  to  irrigate  sinuses.  The  proper  dilu- 
tion for  irrigation  of  a  sinus  is  obtained  when  the  tincture  is  diluted  to  the  color 
of  sherrv'  wine. 

Nucleins,  especially  protonuclein,  possess  germicidal  powers.    Nuclein  is 

composed  of  nucleinic  acid  and  proteid  material.    When  injected  hj-podermat- 

ically  and  to  a  less  degree  when  taken  by  the  mouth  it  increases  the  germicidal 

power  of  the  blood-serum,  causes  leukocytosis  and  increased  phagocytosis  and 

3 


34  Bacteriology 

thus  prevents  or  opposes  infection.  Mikulicz  has  used  nucleinic  acid  to  in- 
crease vital  resistance  as  a  preliminary  to  ojjeration  (page  42).  A  i  per  cent, 
solution  of  nucleinic  acid  is  on  the  market.  This  acid  is  made  from  yeast. 
The  dose  of  this  preparation  is  from  TTLx  to  Ix,  hypodermically,  once  or 
several  times  a  day.  Protonuclein  probably  contains  nucleinic  acid  and  is 
of  some  value  when  applied  locally  to  areas  of  infection,  particularly  when 
sloughing  exists. 

Heat. — The  best  germicide  is  heat,  and  the  best  form  in  which  to  apply 
heat  is  by  means  of  boiling  water  (which  is  even  better  than  steam) .  One  can  use 
boiling  water  upon  instruments  and  dressings,  but  seldom  upon  a  patient. 
Jeannel,  of  Toulouse,  uses  boiling  salt  solution  in  abscess-cavities,  and  some 
other  surgeons  employ  steam  or  boiling  water  to  disinfect  the  medullary  canal 
in  osteomyelitis.  Nevertheless,  boiling  water  is  seldom  applied  to  a  patient, 
and  in  many  cases  a  chemical  germicide  must  be  used. 

Among  other  antiseptics  and  germicides  of  more  or  less  value  we  may 
mention  trichlorid  of  iodin,  chlorid  of  zinc,  chlorid  of  iron,  salol,  oxycyanid  of 
mercury,  fluorid  of  sodium,  argonin,  sugar,  lannaiol,  bichlorid  of  palladium 
(in  very  dilute  solution),  thymol,  potash  soap,  salicylic  acid,  boric  acid,  sul- 
phate of  copper,  arsenite  of  copper,  camphor,  eucalyptol,  cinnamon,  bromin, 
chlorin  (as  gas  or  as  chlorin- water) ,  cinnamic  acid,  permanganate  of  potassium 
or  of  calcium,  chlorate  of  potassium,  and  oxaUc  acid.  The  surgeon  before 
operating  should  always  scrub  his  hands  in  a  germicidal  solution. 

Distribution  of  Bacteria. — Microbes  are  very  widely  distributed  in 
nature.  They  are  found  in  all  water  except  that  which  comes  from  very 
deep  springs;  in  all  soil  to  the  depth  of  three  feet;  and  in  air,  except  that  over 
the  desert,  over  the  open  sea,  and  that  about  lofty  mountains.  Dust-free  air 
does  not  contain  them;  the  more  dust,  the  more  microbes,  hence  they  are  present 
in  greatest  number  in  the  air  of  towns.  There  are  more  in  narrow  courts 
than  in  broad  highways,  more  in  crowded  attics  than  in  roomy  apartments. 
Bacteria  are  present  on  and  in  the  skin,  in  the  alimentary  canal,  in  the  nose, 
mouth,  and  pharynx,  and  in  the  blood  and  lymph.  As  Adami  points  out,  under 
normal  conditions  the  bacteria  which  enter  the  blood  are  very  quickly  killed. 

Microbes  may  be  useful.  Some  of  them  are  scavengers,  and  clean  the 
surface  of  the  earth  of  its  dead  by  the  process  known  as  "putrefaction,^^  in 
which  complex  organic  matter  is  reduced  to  harmless  gases  and  to  a  mineral 
condition.  The  gases  are  taken  up  from  the  air  by  vegetables,  and  the 
mineral  matter  is  dissolved  in  rain-water  and  passes  into  the  soil  from  which 
it  came,  there  again  to  be  food  for  plants,  which  plants  will  become  food 
for  animals.  Other  organisms  purify  rivers;  others  cause  bread  to  rise; 
still  others  give  rise  to  fermentation  in  liquors.  Microbes  may  be  harmful. 
They  may  poison  rivers  and  soils;  they  may  be  parasites  on  vegetable  life; 
they  cause  diseases  of  the  growing  vine,  and  also  of  wine;  they  produce  the 
mould  on  stale,  damp  bread;  they  occasionally  form  poisonous  matter  in 
sausages,  in  ice-cream,  and  in  canned  goods;  and  they  produce  many  diseases 
among  men  and  the  lower  animals. 

With  so  universal  a  distribution  of  these  fungi,  man  must  constantly  take 
them  into  his  organism.  They  are  upon  the  surface  of  his  body,  he  inhales 
them  with  every  breath,  and  he  swallows  them  with  his  food  and  drink. 
jMost  of  them,  fortunately,  are  entirely  harmless;    others  cannot  act  on  the 


Disease  Production 


35 


living  tissues;  but  some  are  virulent,  and  these  are  generally,  but  not  always, 
destroyed  by  the  cells  of  the  human  body.  The  alimentary  canal  always 
contains  bacteria  of  putrefaction,  which  act  only  upon  the  dead  food,  and  not 
upon  the  living  body;  but  when  a  man  dies  these  organisms  at  once  attack 
the  tissues,  and  post-mortem  putrefaction  begins  in  the  abdomen.  Even 
pathogenic  bacteria  may  ])ersist  for  long  periods  in  the  tissues  without  causing 
illness  in  the  host,  but  when  such  bacteria  do  persist,  they  may  at  any  dme 
and  from  a  variety  of  causes  become  active  in  producmg  disease  or  when  they 
pass  from  the  host  they  may  perhaps  infect  other  people  (see  Typhoid  Carriers, 

page  37)- 

Welch  long  ago  pointed  out  that  the  human  skin  normally  contains  the 
staphylococcus  epidermidis  albus,  even  after  the  most  careful  surgical  cleans- 
ing. Dudgeon,  in  the  Horace  Dobell  Lecture  for  1908  ("Lancet,"  Dec.  5, 1908, 
"  Latent  Persistence  and  the  Reactivation  of  Pathogenic  Bacteria  in  the  Body") , 
says  that  healthy  organs  may  contain  various  bacteria,  that  the  tissues  of  the 
fetus  are  sterile,  but  in  childhood  and  adult  life  "bacteria  are  found  in  various 
parts  of  the  human  body;  that  staphylococcus  albus  can  be  cultivated  from  the 
human  omentum  in  cases  in  which  the  peritoneal  cavity  is  apparently  healthy  " ; 
that  pus  cocci  may  persist  for  long  periods  in  a  scar;  that  virulent  diphtheria 
bacilli  may  be  "found  in  the  throats  of  persons  who  have  come  in  contact  with 
diphtheria  patients,  but  show  no  signs  of  the  disease  " ;  that  the  bacillus  proteus 
is  frequently  found  in  the  urine;  that  colon  bacilli  normally  inhabit  the  in- 
testinal tract  and  appendix  and  frequently  exist  in  the  urinary  tract  without 
giving  rise  to  inflammation  or  symptoms  of  disease,  and  that  typhoid  bacilli 
tend  notably  to  persist  (page  37). 

Koch's  Circuit. — To  prove  that  a  microbe  is  the  cause  of  a  disease  it 
must  fulfil  Koch's  circuit.  It  must  always  be  found  associated  with  the 
disease;  it  must  be  capable  of  forming  pure  cultures  outside  the  body;  these 
cultures  must  be  capable  of  reproducing  the  disease;  and  the  microbe  must 
again  be  found  associated  with  the  artificially  produced  morbid  process. 

Disease  Production. — Pathogenic  organisms  cannot  enter  through  the 
sound  skin  and  the  unbroken  skin  without  causing  the  formation  of  lesions 
at  the  point  of  entrance.  The  sound  skin  is  the  very  best  antiseptic  covering 
for  tissue,  as  ordinary  bacteria  cannot  pass  it  at  all.  Some  bacteria  by  entering 
the  ducts  of  cutaneous  glands  may  cause  disease.  Disease-producing  organ- 
isms which  enter  the  body  may  reach  the  focus  in  which  they  act  from  outside 
of  the  body,  entering  by  inoculation,  inhalation,  or  ingestion.  In  most  in- 
stances organisms  which  enter  the  body  from  without  are  rapidly  destroyed. 
When  they  enter  in  large  numbers,  or  when  they  are  very  virulent,  or  when  the 
vital  resistance  of  the  individual  is  at  a  low  ebb  they  cause  disease.  Bacteria 
may  reach  the  region  in  which  they  become  active  from  some  other  part  of  the 
body.  Bacteria  seldom  dwell  in  the  body  long  without  inducing  disease,  but 
spores  can  lie  dormant  in  the  system  for  years.  When  bacteria  or  spores  from 
some  other  part  of  the  body  reach  a  region  of  injury  or  disease  they  may  be- 
come active;  this  area  is  a  damaged  and  weakened  part,  in  it  the  circulation 
is  abnormal,  it  is  a  so-called  point  of  least  resistance  (a  locus  minor-is  resistentice) 
which  affords  a  nest  for  them  to  develop  and  to  multiply,  the  cellular  activities 
of  the  weakened  part  being  unable  to  cope  with  the  activities  of  the  germs.  Even 
large  numbers  of  pathogenic  organisms  may  induce  no  trouble  in  a  healthy 


36  Bacteriology 

man;  but  let  them  reach  a  damaged  spot,  and  mischief  is  apt  to  arise.  Kocher 
established  subcutaneous  bone-injuries  in  dogs,  and  these  injuries  pursued 
a  healthy  course  until  the  animal  was  fed  upon  putrid  meat,  whereupon  suppu- 
ration took  place.  This  experiment  proves  that  micro-organisms  can  reach 
a  damaged  area  by  means  of  the  blood,  and  it  enables  us  to  understand  how 
a  knee-joint  can  suppurate  when  we  merely  break  up  adhesions,  and  how 
osteomyelitis  can  follow  trauma  when  the  skin  is  intact.  A  given  number 
of  organisms  might  produce  no  effect  on  a  healthy  man,  whereas  the  same 
number  might  produce  disease  in  an  individual  who  was  weak  or  ill-nourished, 
suffering  from  depression  or  fear,  or  debilitated  by  the  habitual  use  of  alcohol. 
The  personal  equation  plays  a  great  part  in  disease-production.  Some  indi- 
viduals seem  to  be  immune  to  certain  diseases;  and  these  immunities  and 
liabilities  may  be  hereditary  or  acquired,  temporary  or  permanent. 

Enzymes. — Bacteria  contain  and  excrete  ferments,  and  these  ferments 
are  known  as  enz^Tnes.  Bacterial  ferments  resemble  pepsin  and  trypsin,  the 
digestive  ferments.  The  digestive  ferments  convert  albumin  into  peptone, 
starch  into  sugar,  and  break  up  fat.  When  microbic  infection  of  the  tissues 
occurs  the  enz}Tnes  of  the  bacteria  act  upon  the  tissues  just  as  the  digestive 
ferments  act  upon  the  food,  and  form  microbic  albumoses.  The  enzymes 
are  the  weapons  of  micro-organisms.  By  means  of  these  ferments  bacteria 
not  only  prepare  substances  for  assimilation,  but  seek  to  destroy  antagonists 
and  cell  enemies.  It  is  probable  that  enz}-mes  when  absorbed  are  frequently 
productive  of  toxemia. 

Toxins. — The  action  of  pathogenic  bacteria  upon  the  tissues  is  of  great 
importance.  In  the  first  place,  they  abstract  from  the  blood,  the  lymph, 
and  the  cells  certain  elements  necessary  to  the  body, — as  water,  oxygen, 
albumins,  carbohydrates,  etc., — and  thus  cause  body- wasting  and  exhaustion 
from  want  of  food.  In  the  second  place,  bacteria  produce  a  vast  number 
of  compounds,  some  harmless  and  others  highly  poisonous.  The  symptoms 
of  a  microbic  disease  are  largely  due  to  the  absorption  of  poisonous  materials 
from  the  area  of  infection.  These  poisons  may  be  formed  from  the  tissues 
by  the  action  upon  them  of  the  bacteria  (true  toxins  and  peptones)  or  may  be 
liberated  from  the  bodies  of  degenerating  microbes  (bacterial  proteid  or  endo- 
toxins). Bacteria  contain  and  secrete  ferments;  and  as  albumoses  are  formed 
in  the  alimentary  canal  b)'the  action  of  digestive  ferments  upon  proteids,  sugars, 
and  starches,  so  microbic  albumoses  are  formed  by  the  action  of  microbic 
ferments  upon  tissues.  Just  as  the  albumoses  formed  in  digestion  are  poisonous 
when  injected,  so  the  albumoses  of  microbic  action  are  poisonous  when  ab- 
sorbed. The  albumoses  of  microbic  action  are  called  toxalbumins,  and  these 
albumoses  often  operate  as  virulent  poisons  to  the  body-cells. 

A  number  of  compounds  formed  by  the  microbic  destruction  of  tissue  are 
alkaloidal  in  nature.  These  poisonous  alkaloids  are  readily  diffusible  and, 
many  of  them,  very  virulent.  It  is  probable  that  ever\-  pathogenic  organism 
has  its  own  special  toxin  which  produces  its  characteristic  effects,  although 
the  effects  are  modified  by  the  nature  of  the  soil — that  is  to  say,  by  the  condi- 
tion of  the  tissues.  Again  one  micro-organism  may  produce  several  toxins. 
The  absorption  of  toxins  may  be  ver}'  rapid;  for  instance,  the  toxins  of  cholera 
mav  kill  a  m^n  before  the  bacilli  have  migrated  from  the  intestine.  Brieger 
uses  the  term  toxin  to  designate  all  of  the  poisonous  products  of  bacterial  action. 


Immunity  37 

He  divides  toxins  into  alkaloidal  or  crystallizable  and  amorphous,  the  latter 
being  called  toxalbumins. 

Ptomains. — By  many  writers  the  term  "  ptomai'n"  is  used  to  designate 
these  toxins,  but  in  reality  a  ptomain  is  a  form  of  toxin  produced  by  the 
action  of  saprophytic  bacteria.  A  ptomain  is  a  putrefactive  alkaloid  and  a 
toxin  is  any  poison  of  microbic  origin.  Among  these  putrefactive  alkaloids 
may  be  mentioned  tetanin,  typhotoxin,  sepsin,  putrescin,  tyrotoxicon,  muscarin, 
and  spasmotoxin.  The  poison  which  occasionally  forms  in  cheese,  ice-cream, 
sausage,  and  canned  goods  is  composed  of  ptomains.  Poisoning  by  any 
putrid  food  is  called  ptomain-poisoning. 

Leukomains  must  not  be  confounded  with  the  above-mentioned  bodies. 
Leukomains  are  alkaloidal  substances  existing  normally  in  the  tissues  and  not 
produced  by  bacteria,  but  arising  from  physiological  fermentations  or  ret- 
rogade  chemical  changes.  They  are  natural  body  constituents,  in  contrast 
to  toxins,  which  are  morbid  constituents.  Leukomains  are  found  in  ex- 
pired air,  saliva,  urine,  feces,  tissues,  and  the  venom  of  serpents.  If  not 
excreted,  these  bodies  may  induce  illness,  and  when  injected  may  act  as 
poisons.  Ordinary  colds  and  some  fevers  result  from  leukomains;  they 
play  a  great  part  in  uremia,  and  when  excretion  is  deficient  the  retained 
leukomains  make  the  system  an  hospitable  host  for  pathogenic  bacteria. 
Sickness  due  to  the  retention  and  absorption  of  leukomains  is  known  as 
auto-intoxication.  Among  leukomains  may  be  mentioned  adenin,  hypoxan- 
thin,  and  xanthin,  aUied  to  uric  acid,  and  other  substances  allied  to  creatin 
and  creatinin.  The  surgeon  should  never  forget  the  possibiUty  of  harm  being 
done  by  retained  leukomains,  and  should  endeavor  to  prevent  auto-intoxication 
in  all  cases  by  keeping  the  skin,  the  bowels,  and  the  kidneys  active. 

Immunity. — If  a  person  cannot  be  infected  with  a  certain  disease,  he  is 
sSid  to  be  immune  to  it.  Some  persons  seem  naturally  immune  to  certain  dis- 
eases {natural  immunity) .  Immunity  to  some  diseases  may  be  produced  arti- 
ficially. When  the  body  itself  produces  the  materials  which  render  it  immune 
the  immunity  is  called  active.  When  immunity  is  produced  by  the  introduc- 
tion of  substances  artificially  produced  the  immunity  is  called  passive.  It  has 
long  been  knowTi  that  w^hen  a  person  recovers  from  certain  diseases  he  has  be- 
come immune  to  the  disease  from  which  he  suffered  {acquired  immunity).  Im- 
munity may  be  transitory,  prolonged,  or  permanent.  Acquired  immunity  may 
be  compared  to  fermentation.  When  fermentation  ceases,  the  addition  of 
more  ferment  is  without  result.  When  a  person  recovers  from  certain  diseases, 
the  addition  to  his  blood  of  more  of  the  causative  bacteria  is  also  void  of  result. 

Immunity  w'as  long  beUeved  to  arise  from  the  exhaustion  of  some  unknown 
constituent  of  tissue  necessary  to  the  life  of  the  bacteria.  This  theory  w^as 
advanced  by  Pasteur.  It  has  been  abandoned  because  of  the  demonstration 
that  though  an  animal  may  become  immune  to  certain  bacteria,  these  bac- 
teria may  continue  to  Hve  in  the  host.  It  is  true  that  w^hen  recovery  ensues 
upon  infections,  as  a  rule,  the  causative  bacteria  disappear,  but  there  are  enough 
exceptions  to  this  rule  to  invalidate  the  theor}'  of  Pasteur.  It  is  well  known  that 
even  for  years  after  an  attack  of  typhoid  fever  the  bacilli  may  exist  in  the  gall- 
bladder or  the  bone-marrow,  or  be  passed  in  urine.  A  person  apparently 
well,  yet  holding,  for  instance,  in  his  gall-bladder  infectious  bacteria,  is  called 
a  "  bacterial  carrier."     From  i  to  2  per  cent,  of  persons  who  have  had  typhoid 


38  ■    Bacteriology 

fever  years  ago  pass  bacilli  in  tlie  stools,  and  sucli  carriers  are  often  responsible 
for  the  spread  of  the  disease.  Gregg  ("Boston  Medical  and  Surg.  Jour.," 
July  16,  1908)  reported  the  case  of  a  typhoid  carrier  fifty-two  years  after 
recovery  from  typhoid.  A  theory  proposed  by  Chauveau  is  known  as  the 
"retention  theory,"  and  is  the  opposite  of  Pasteur's  "exhaustion  theory.'' 
According  to  Chauveau,  bacteria  growing  within  the  body  leave  as  a  legacy 
excrementitious  material,  and  the  accumulation  and  retention  of  excrementi- 
tious  products  produce  immunity. 

Until  very  recently  one  set  of  investigators  maintained  that  immunity  de- 
pends upon  the  activity  of  certain  body-cells  which  attack,  consume,  and  destroy 
bacteria,  this  is  the  theory  of  phagocytosis  (page  41),  The  other  theory  is 
founded  on  the  claims  of  Nuttal  and  Buchner,  that  normal  fresh  blood-serum 
is  germicidal,  the  power  varying  for  different  bacteria  and  being  Hmited. 
A  fixed  amount  of  serum  is  capable  of  destroying  a  fixed  number  of  bacteria  of 
a  certain  variety.  Vaughan  and  -others  stated  that  the  germicidal  agent  is 
probably  a  nuclein  furnished  chiefly  by  the  white  cells  and  held  in  solution  by 
the  alkaline  serum.  This  germicidal  agent  Buchner  called  "alexin''^  or  de- 
fensive proteid,  and  explained  immunity  by  its  presence.  This  theory  is  known 
as  the  "humoral  theory.^^  According  to  this  theory  as  originally  maintained, 
when  an  animal  is  naturally  immune  to  a  bacterial  disease  it  is  assumed  that  the 
blood-serum  and  body  fluids  contain  enough  of  this  alexin  to  dissolve  or  destroy 
the  bacteria.  Neither  method  of  defense  is  the  only  one.  In  all  probability 
both  phagocytosis  and  bacterial  solution  are  occurring  in  the  same  patient  at  the 
same  time,  phagocytosis  being  im[)ossible  but  for  the  serum  and  bacteriolysis 
being  impossible  without  leukocytes. 

Since  the  above  theories  were  set  forth  it  has  been  found  that  when  an  ani- 
mal recovers  from  some  bacterial  diseases  the  blood-serum  and  body  fluids  con- 
tain new  protective  materials  called,  in  genersil,  antibodies.  The  toxin  of  l)acteria 
stimulates  body  cells  to  the  production  of  antibodies  and  antibodies  bring  the 
disease  to  an  end  and  secure  immunity.  It  is  thus  seen  that  the  very  poisons 
produced  by  bacteria  cause  the  body  cells  to  produce  poison  antidotes.  The 
bacteria  may  be  so  virulent  or  the  patient  so  susceptible  that  poison  overwhelms 
the  cells,  antibodies  are  not  formed  in  sufficient  quantity,  and  death  ensues. 
The  cells  may  be  badly  poisoned  and  the  patient  may  become  very  ill,  and  yet 
after  a  time  the  cells  may  regain  enough  vitality  to  furnish  antibodies  in  suffi- 
cient quantity  to  bring  about  cure  and  to  secure  immunity.  The  bacteria  may 
be  so  few  in  number  or  so  attenuated  in  virulence  or  the  cells  of  the  patient  may 
be  so  active  that  quantities  of  antibodies  are  quickly  formed  under  mild 
stimulation,  and  the  individual  does  not  take  the  disease  at  all  or  takes  it  very 
mildly. 

The  lytic  or  bacteriolytic  antibodies  or  lysins  destroy  and  dissolve  bac- 
teria. All  bacteria  are  not  susceptible  to  lysis,  for  instance,  streptococci,  tubercle 
bacilli,  and  pneumococci.  When  recovery  ensues  the  causative  bacteria  usu- 
ally but  not  always  disappear  (page  37).  These  lytic  bodies  are  formed  by 
the  leukocytes,  bone-marrow,  spleen,  and  lymph-glands  (Wasserman  in  "  Berlin 
klin.  Woch.,"  No.  4,  1898;  and  Levaditi  in  "  Annales  de  I'lnst.  Pasteur,"  1904). 

Agglutinins  and  precipitins  gather  in  the  blood-serum  of  an  animal  when 
the  animal  has  been  injected  with  bacteria  or  certain  cells.  When  these  anti- 
bodies appear  in  blood  after  an  animal  has  been  injected  with  bacteria  they 


Agglutinins  and  Precipitins  39 

agglutinate  and  precipitate  the  bacteria  injected.  It  is  probable  that  agglu- 
tinins and  precipitins  are  formed  by  the  endothelium  of  vessel  walls  (Kraus 
and  Schiffman  in  "  Annales  de  I'lnst.  Pasteur.,"  1906).  These  materials  only 
appear  after  certain  infections. 

Opsonins  are  materials  which  by  attaching  themselves  to  certain  bacteria 
so  alter  the  bacteria  that  they  easily  become  the  victims  of  phagocytosis  (see 
Phagocytosis,  page  41). 

Anlitoxins  are  specific  bodies  secreted,  as  Roux  says,  by  the  body  cells. 
They  pass  into  the  serum  and  body  tluids.  They  fix  and  neutralize  the  bac- 
terial toxin  by  combining  with  it,  but  do  not  dissolve,  kill,  precipitate,  or  ag- 
glutinate the  bacteria.  The  first  antitoxin  to  be  discovered  was  that  of  diph- 
theria. The  discovery  was  made  by  Behring  in  1890.*  He  found  that  if  an 
animal  is  injected  with  gradually  larger  amounts  of  toxin  of  diphtheria  the 
serum  comes  to  contain  an  antitoxic  material.  Very  soon  after  this  discovery 
was  announced  Behring  and  Kitasato  made  a  like  discovery  in  regard  to  tetanus 
toxin.  It  was  pointed  out  by  Kitasato  and  Behring  that  animals  can  be  rendered 
immune  to  tetanus  by  artificial  means  and  that  the  blood-serum  of  immune  ani- 
mals will,  if  injected  into  other  animals,  render  them  immune,  or  perhaps  cure 
the  disease  if  injected  into  animals  suffering  from  tetanus.  The  same  state- 
ments were  also  proved  to  be  true  of  diphtheria.  Now  many  experimenters 
are  endeavoring  to  find  the  antitoxin  of  each  microbic  disease  for  the  purpose 
of  using  it  therapeutically  and  also  as  a  preventive  agent. 

In  some  infections  soluble  toxins  are  not  formed  and  the  body  resistance 
depends  largely  on  the  formation  by  the  bacteria  of  substances  which  finally, 
when  present  in  sufficient  amounts,  destroy  bacteria. 

Certainly  one  of  the  most  important  of  modern  discoveries  is  that  certain 
substances  introduced  into  the  body  cause  a  reaction  which  results  in  the  forma- 
tion of  antibodies.  Any  material  which  causes  antibodies  to  form  is  called 
an  antigen.  In  the  preceding  section  we  have  spoken  of  bacterial  products  as 
the  antigens.  But  other  antigens  exist,  for  instance,  blood-corpuscles  and 
other  cells,  blood-serum,  some  vegetable  poisons,  and  some  animal  poisons. 
Thought  is  now  directed  to  treating  bacterial  diseases  by  the  introduction  of  the 
proper  antigen  to  produce  lysins,  opsonins,  antitoxins,  as  the  case  may  be. 
Streptococci  produce  no  antigen  which  leads  to  lysin  formation,  but  do  produce 
antigens  which  lead  to  antitoxin  and  opsonin  formation. 

The  subject  is  of  enormous  importance  and  is  vastly  complicated. 

Ehrlich's  Theory  of  the  Mechanism  of  Immunity  by  Antitoxins. — Ehrlich's 
theory  was  advanced  in  1898  and  is  generally  accepted  at  the  present  time. 
"Ehrlich's  theory  of  the  mechanism  of  immunity  is  based  upon  Weigert's 
teaching  of  the  process  of  tissue  repair.  It  is  a  matter  of  universal  observation 
that  nature  is  prodigal  in  her  attempts  to  repair  an  injury.  This  is  shown 
in  the  healing  process  in  an  ordinary  wound.  A  much  larger  amount  of  mate- 
rial is  thrown  out  to  bridge  the  chasm  than  is  really  utilized  in  the  formation  of 
new  tissue.  The  presence  of  an  excessive  amount  of  new  material  is  shown  by 
the  fact  that  the  part  is  raised  above  the  level  of  the  surrounding  sound  tissue, 
and  this  excess  is  removed  gradually  as  the  new-formed  tissue  becomes  stronger 
and  stronger,  until  finally  the  wound  is  marked  by  a  line  of  white  scar-tissue, 
the  excess  gradually  passing  into  the  blood-current. 

*  "Deutsche  Med.  Wochenschrift,"  1890,  Nos.  49  and  50. 


40  Bacteriolog)' 

"Ehrlich  believed  that  the  mechanism  of  immunity  was  explainable  on  a 
similar  basis.  It  had  become  e\-ident  from  the  experiments  of  Wasserman 
with  the  tetanus  bacillus  that  its  toxin  had  an  especial  affinity  for  the  cell> 
of  the  central  nen'ous  system.  Experiments  with  other  bacteria  pointed  to 
the  fact  that  the  toxins  of  different  species  of  bacteria  had  an  especial  affinity 
for  the  cells  of  different  organs  of  the  body.  When  the  amount  of  poison 
entering  the  body  is  sufficient  to  destroy  the  cells  which  have  an  especial 
affinity  for  it,  these  cells  may  be  injured  only  to  such  an  extent  as  to  permit 
subsequent  repair.  In  order  to  comprehend  Ehrlich's  hj-pothesis  it  is  neces- 
sary- to  conceive  the  cells  of  the  body  as  ha\ing  a  complex  structure  which 
may  be  stated  diagrammatically  as  consisting  of  a  central  mass  or  nucleus 
from  which  radiate  a  number  of  '  lateral  chains,'  or  bonds,  each  of  which 
serves  to  bind  the  cell  to  other  substances.  In  the  case  of  the  cells  of  the 
central  ner\-ous  system  one  of  these  lateral  bonds  has  an  especial  affinity  for 
tetanus  toxin  and  sutt"ers  destruction.  The  cell  now  finds  itself  in  unstable  equi- 
librium, and  at  once  proceeds  to  repair  the  damage  wTought.  As  in  the  case 
of  tissue  repair,  the  new  material  produced  is  far  in  excess  of  the  required 
amount.  The  excess  finds  its  way  into  the  blood-current.  This  material 
now  circulating  in  the  blood-current  has  the  same  affinity  for  tetanus  toxin  as 
when  united  \\'ith  the  central  mass  of  a  cell  as  its  lateral  bond,  and  can,  there- 
fore, combine  with  tetanus  toxin  floating  in  the  blood-current,  thus  preserving 
other  cells  from  injur\\  The  union  formed  between  the  lateral  bond  of  the 
cell  (which  is  really  the  antitoxin)  and  the  tetanus  toxin  results  in  the  forma- 
tion of  a  compound  which  is  physiologically  inert.  According  to  Ehrlich's 
idea,  therefore,  the  antitoxin  is  simply  the  excess  of  lateral  bonds  floating 
in  the  blood-current.  This  substance  can  neutralize  the  effect  of  the  tetanus 
toxin  in  a  test-tube  just  as  readily  as  it  does  within  the  body  "  (D.  H.  Bergey, 
"American  ^ledicine,"  October  ii,  1902). 

PhagOC}  tes. — -It  was  generally  believed  after  Metchnikoff's  important 
discoveries  that  leukocytes  were  the  agents  which  protected  the  body  from 
infection.  When  other  obser%'ers  found  that  in  blood-serum  is  material  that 
damages  or  destroys  bacteria,  opinion  swung  to  the  \'iew  that  the  blood-serum 
contains  the  protective  element,  and  that  the  leukocytes  are  simply  scavengers 
and  remove  dead  bacteria,  but  do  not  destroy  living  ones.  It  has  recently  been 
shown  that  under  some  circumstances  leukocytes  destroy  liNing  bacteria  and 
under  other  circumstances  they  do  not,  and  that  the  presence  or  absence  of 
this  property  depends  in  most  instances  upon  the  presence  or  absence  in  the 
blood-serum  of  substances  which  act  upon  bacteria  and  render  them  susceptible 
to  the  phagocytic  action  of  leukocytes.  We  say  in  most  instances,  not  in  all 
instances,  because  certain  bacteria,  for  instance,  influenza,  bacilli  are  phago- 
cytable  without  the  presence  of  opsonic  serum  (Lud\ig  Hektoen,  address  in 
"  Section  of  Physiolog}-  and  Experimental  Medicine,  American  Assoc,  for 
.\dvancement  of  Science,"  1908;  "Science,"  Feb.  12,  1909).  The  existence  of 
substances  in  the  serum  provocative  of  phagocytosis  was  demonstrated  by 
Wright  and  Douglas  in  1903,  and  they  named  them  opsonins.  If  opsonins 
are  present,  they  act  upon  bacteria,  and  render  the  bacteria  susceptible  to 
phagocytosis.  (See  Lud\ig  Hektoen  in  '*Jour.  Am.  Med.  Assoc,"  May  12, 
1906).  Opsonins  act  upon  bacteria  and  alter  them,  and  the  altered  bacteria 
are  easily  eaten  up  by  leukocytes.     \ery  virulent  bacteria  resist  phagocytosis 


The  Process  of  Phagocytosis 


41 


because  they  have  little  affinity  for  opsonin  (Hektoen),  and  such  virulent  bac- 
teria may  grow  in  opsonic  serum.  The  source  of  opsonins  is  not  known,  but 
serum  normally  contains  "opsonins  for  many  different  bacteria"  (Hektoen, 
in  "Jour.  Am.  Med.  Assoc,"  May  12,  1906).  When  experiment  determines 
the  fact  that  an  individual's  leukocytes  are  highly  phagocytic  toward  particular 
bacteria,  we  believe  that  a  quantity  of  opsonin  for  that  variety  of  bacteria  is 
present,  and  we  may  say  the  individual  has  a  high  opsonic  index  as  regards 
them.  Under  opposite  conditions  we  say  he  has  a  low  opsonic  index.  "The 
opsonic  index  of  Wright  with  respect  to  a  given  bacterium  is  obtained  by 
comparing  the  number  of  the  bacteria  taken  up  under  the  influence  of  the  serum 
of  the  person  or  animal  in  question  with  the  number  taken  up  under  the  influ- 
ence of  the  corresponding  standard  of  normal  serum  under  conditions  that 
are  as  comparable  as  they  possibly  can  be  made"  (Ludvig  Hektoen,  address  in 
"  Section  of  Advancement  and  Physiolog}^  and  Experimental  Medicine  in  Am. 
Assoc,  for  Science,"  1909;  "  Science,"  Feb.  12,  1906). 

The  Process  of  Phagocytosis. — We  have  just  seen  how  opsonins 
stimulate  phagocytosis.  The  process  of  destruction  of  bacteria  by  cells  is 
known  as  phagocytosis,  and  the  destroying  cells  are  called  phagocytes.  The 
cells  active  in  phagocytosis  are  the  endothelial  cells  of  the  blood-vessels, 
lymph-channels  and  lymph-spaces,  and  particularly  the  leukocytes.  When 
infection  occurs,  the  white  blood-cells  gather  in  enormous  numbers  at  the  seat 
of  disease,  encompass  and  sur- 
round the  bacteria,  and  build 
a  barrier  to  prevent  dissemi- 
nation of  the  microbes  and 
general  infection  of  the  organ- 
ism. The  force  which  draws 
leukocytes  to  a  region  of  infec- 
tion also  tends  to  draw  them  to 
an  area  where  there  is  cellular 
degeneration  or  death.  This 
force  is  called  positive  cliemio- 
taxis  and  is  greatly  stimulated 
by  opsonins.  In  very  virulent 
infections  the  leukocytes  may 
fail  to  collect  and  may  actu- 
ally be  repelled  and  scattered 

under  the  influence  of  what  has  been  called  negative  chemiotaxis.  Phagocytes 
at  the  seat  of  infection  try  to  eat  up,  carry  away  to  a  gland,  and  there  digest 
and  destroy  bacteria.  A  battle  royal  occurs,  the  microbes  fighting  the  body- 
cells  with  most  active  ferments  and  destroying  the  opsonic  power  of  the  blood- 
liquor;  the  body-cells  endeavoring  to  devour  and  destroy  the  bacteria  (Fig.  14), 
in  which  effort  opsonins  give  them  aid.  In  some  cases  the  bacteria  win  abso- 
lutely and  the  patient  dies.  In  other  cases  they  \vin  for  a  time  and  over- 
whelm the  system;  but  presently  the  body-cells,  whose  movements  were 
inhibited  by  the  poison,  regain  their  acti\ity  and  are  then  immune  to  the 
bacterial  poison.  It  is  probable  that  the  materials  thrown  out  by  the  white 
cells  during  the  combat  with  the  microbes  tend  to  destroy  bacterial  products 
and  to  neutralize  toxic  products  of  tissue  destruction.    These  materials,  which 


Fig.  14. — Phagocytosis: 


A,  Successful; 
(Senn). 


B,  Unsuccessful 


42  Bacteriology 

neutralize  toxic  products,  are  known  as  antitoxins  (page  39) .  After  the  attack 
of  disease  has  passed  away  the  body-cells  have  been  educated  to  withstand  this 
poison,  and  new  cells  in  the  future  retain  this  capacity;  the  weak  cells  were 
killed,  the  fittest  survived,  and  the  body  fluids  contain  antitoxin.  The  new 
cells  formed  in  the  body  are  insusceptible  to  the  poison  and  the  individual  is 
said  to  be  insusceptible  or  immune.  The  theor}'  of  phagocytosis  immunity 
assumes  an  educated  white  corpuscle  and  body-cell.  This  view  originated 
with  Sternberg,  but  it  is  usually  accredited  to  Metchnikoff.  Lankester  gave 
us  the  term  "educated  corpuscle." 

Artificial  Stimulation  of  Phagocytosis.— When  active  hyperemia  is 
induced  by  heat,  when  irritants  are  applied  to  an  inOamed  surface,  or  when 
an  inflamed  joint  is  treated  by  Bier's  method  of  passive  h}^eremia,  local 
leukocytosis  is  stimulated  and  phagocytosis  becomes  more  active.  Some  ten 
years  ago  Issaefl"  affirmed  that  the  introduction  of  certain  materials,  as  salt 
solution,  into  the  peritoneal  cavity,  leads,  for  a  time,  to  great  increase  in  the  re- 
sistance to  abdominal  infection.  This  period  of  increased  resistance  he  called 
the  resistance  period.  It  begins  a  few  hours  after  the  injection  and  terminates 
by  the  end  of  the  fifth  day.  During  this  period  the  great  increase  in  intra- 
peritoneal leukocytes  saves  the  animal  from  infection  \\\i\\  bacteria,  which 
would  otherwise  cause  a  dangerous  or  fatal  inflammation.  Mikulicz  beheved 
it  possible  to  establish  this  resistance  period  before  abdominal  operations  and 
was  working  on  the  problem  just  before  his  lamented  death.  Mikulicz  used 
diluted  nucleinic  acid  injected  twenty-four  to  forty-eight  hours  prenous  to 
operation  (Mikuhcz,  "Verhandl.  d.  33.  Congress  d.  Deutsch.  Ges  f.  Chir.," 
1904).  Some  surgeons  have  injected  fresh  warm  horse-serum  for  the  same 
purpose  (Petie,  Jayle,  and  Federmann ;  see  "  Le  Presse  Medicale, ' '  1 905) .  The 
agents  used  must  not  be  of  a  nature  to  damage  opsonins,  for  leukocytosis 
without  {)lenty  of  opsonins  would  do  no  good. 

Vital  Resistance. — It  is  learned  from  the  above  that  the  vital  resistance 
to  infection  depends  in  part  upon  germicidal  and  opsonic  blood-liquor  and  in 
part  upon  active  leukocytes. 

Vital  resistance  is  increased  by  agents  which  cause  active  phagocytosis 
(see  nucleinic  acid,  page  34)  without  destruction  of  opsonins. 

Anything  that  lessens  the  germicidal  and  opsonic  power  of  blood-serum  or 
the  phagocytic  activity  of  corpuscles  lessens  vital  resistance.  Among  these 
causes  are  ill  health,  worry,  unhygienic  life,  chronic  drug  intoxications,  chronic 
visceral  diseases,  diabetes,  Bright's  disease,  gout,  rheumatism,  violent  and 
sudden  fluctuations  of  temperature,  and  the  creation  of  points  of  least 
resistance  (page  35). 

Protective  and  Preventive  Inoculations. — Our  knowledge  of  pro- 
tective inoculations  for  contagious  diseases  dates  from  Jenner's  discovery 
of  vaccination  against  smallpox  in  1798.  Preventive  inoculations  with  attenu- 
ated virus  are  due  to  the  experiments  of  Pasteur.  This  observer  discovered 
the  cause  of  chicken-cholera,  and  cultivated  the  micro-organism  of  this  disease 
outside  the  body.  He  found  that  by  keeping  his  cultures  for  some  time  they 
became  attenuated  in  virulence,  and  that  these  attenuated  cuUures,  inoculated 
in  fowls,  caused  a  mild  attack  of  the  disease,  which  attack  was  protective,  and 
rendered  the  fowl  immune  to  the  most  virulent  cultures.  Cultures  can  be 
attenuated  by  keeping  them  for  some  time,  by  exposing  them  for  a  short  period 


Orrhotherapy,  or  Serum-lhcrapy  43 

to  a  temperature  just  below  that  necessary  to  kill  the  organisms,  or  by  treating 
them  with  certain  antiseptics.  It  has  further  been  shown  that  injection  of  the 
blood-serum  of  an  animal  rendered  immune  by  inoculation  is  capable  of  mak- 
ing a  susceptible  animal  also  immune. 

A  most  important  fact  is  that  animals  may  be  rendered  immune  to  certain 
diseases  by  inoculating  them  with  filtered  cultures  of  the  microbes  of  the  dis- 
ease, the  filtrate  containing  microbic  products,  but  not  living  microbes.  By 
this  method  animals  can  be  rendered  immune  to  tetanus  and  diphtheria. 
Pasteur's  protective  inoculations  against  hydrophobia  owe  their  power  to 
microbic  products,  and  Koch's  lymph  contains  them  as  its  active  ingredients. 
The  chief  feature  in  acquired  immunity  is  the  presence  in  the  blood  and 
tissues  of  elements  which  can  neutralize  the  toxic  products  of  bacteria.  These 
elements  are  "antitoxins "  (page 39).  Microbic  products  are  dead  and  cannot 
multiply  as  can  living  bacteria,  hence  the  human  organism  is  not  overwhelmed 
unless  the  dose  is  too  large,  but  the  microbic  products  cause  the  development 
of  antitoxin  as  certainly  as  do  the  living  microbes.  The  above  facts  are  of 
immense  importance,  for  on  these  lines  may  be  solved  the  problems  of  the 
prevention  and  treatment  of  microbic  maladies. 

Orrhotherapy,  or  serum=therapy,  is  an  attempt  to  utilize  therapeu- 
tically the  germicidal  properties  of  blood-serum.  It  is  believed  that  when 
a  person  recovers  from  an  infectious  disease  the  alkaline  blood-serum  is 
saturated  with  protective  materials,  particularly  with  antitoxin.  If  this  belief  is 
true,  it  is  a  proper  deduction  that  blood-serum  containing  protective  material 
should  cure  the  disease  if  injected  into  a  patient  suffering  from  an  attack. 
Instead  of  using  the  blood-serum  itself,  some  observers  have  precipitated  the 
supposed  curative  material  from  the  serum,  have  dissolved  this  material,  and 
have  administered  the  solution  in  fixed  amounts.  Instead  of  using  the  serum 
of  persons  rendered  immune  by  an  attack  of  the  disease,  many  physicians  have 
employed  the  serum  of  animals  rendered  artificially  immune  by  injections  of 
attenuated  cultures  of  the  bacteria  or  injections  of  bacterial  products.  Some 
experimenters  have  even  employed  the  serum  of  animals  naturally  immune 
to  the  disease.  In  some  cases  the  serum  is  given  hypodermatically,  in  some 
intravenously,  in  some  by  lumbar  puncture,  in  some  by  intracerebral,  and 
in  others  by  intraneural,  injection.  Claims  have  been  made  that  serums  are 
eflicient  when  given  by  the  mouth  or  by  the  rectum.  Paten,  of  Melbourne, 
claimed  in  igo6  that  the  oral  administration  of  immune  serum  raises  the  opsonic 
index  ("Med.  Press  and  Circular,"  Jan.  31  and  Feb.  7,  1906). 

Latham  ("Lancet,"  Feb.  15, 1908)  and  others  claim  that  chnical  and  bac- 
teriologic  evidences  are  in  favor  of  the  view  that  serums  are  efficient  when  given 
by  the  mouth.  If  these  views  are  proved  to  be  true  serum-therapy  will  receive 
an  enormous  impetus.  Calmette  has  perfected  an  antivenomous  serum  (anti- 
venene)  for  use  after  cobra  bites.  Pasteur  has  devised  a  method  which  will  usu- 
ally prevent  hydrophobia  (page  306).  That  Murri,  of  Bologna,  has  apparently 
cured  a  case  of  hydrophobia  seems  proved  (page  307).  Hosts  of  observers 
believe  in  the  utility  of  diphtheria  antitoxin  and  many  are  convinced  of  the  value 
of  tetanus  antitoxin.  The  earlier  in  the  disease  the  injection  of  antitoxin  is 
practised  and  the  larger  the  dose  the  more  apt  it  is  to  prove  curative.  When 
the  toxin  has  not  yet  combined  with  cells,  antitoxin  may  keep  it  from  doing  so, 
and  when  it  has  recently  combined  and  the  combination  is  still  unstable,  anti- 


44  Bacteriology 

toxin  may  cause  disassociatifm  of  the  combination.  When  the  disease  is  well 
established  the  cell  combination  of  toxin  is  firm  and  antitoxin  will,  in  all  prolja- 
bility,  fail  to  cure.  In  order  to  make  diphtheria  antitoxin  a  horse  is  immunized 
to  diphtheria  toxin  by  inoculating  it  first  with  attenuated  and  then  with  virulent 
bacteria.  The  blood  containing  antitoxin  is  withdrawn  by  bleeding,  the  serum 
is  separated  from  the  clot,  and  its  antitoxic  potency  is  determined  by  complicated 
methods.  We  signify  the  degree  of  potency  of  a  serum  by  saying  that  it  is  of 
so  many  "immunizing  units,"  a  unit  being  an  arbitrary  standard.  The  average 
dose  for  a  child  is  looo  units  and  for  an  adult  2000  units.  (Tetanus  antitoxin 
is  considered  on  page  225 ;  antivenene  is  considered  on  page  301.) 

Inconclusive  experiments  have  been  made  in  the  treatment  of  syphilis 
by  the  serum  of  dog's  blood  and  by  the  blood-serum  of  men  laboring  under 
tertiary  syphiUs;  in  the  treatment  of  pneumonia  with  the  blood-serum  of 
persons  convalescent  from  pneumonia;  and  in  the  treatment  of  sufferers 
from  septic  diseases  with  antistreptococcic  serum — blood-serum  of  horses 
rendered  immune  to  virulent  streptococci.  The  real  value  of  antistreptococcic 
serum  is  yet  uncertain.  Occasionally  it  seems  to  do  great  good;  at  other 
times  it  appears  to  produce  no  benefit  whatever.  In  several  cases  of  7)hleg- 
monous  erysipelas  and  in  two  cases  of  malignant  endocarditis  I  thought  it  was 
of  benefit.  Tavel,  in  an  elaborate  research  ("Klinische-therapeutische 
Wochenschrift,"  Vienna,  August,  1902),  states  that  he  obtained  brilliant 
results  in  some  cases,  but  no  results  in  others.  He  does  not  undertake  to 
explain  this  variability  of  action.  He  thinks  the  serum  benefits  staphylo- 
coccus as  well  as  streptococcus  infections,  .\ntistreptococci  serum  often  fails 
completely.  This  is  supposed  to  be  due  to  the  fact  that  there  are  many  difterent 
families  of  streptococci.  It  was  hoped  that  a  polyvalent  serum  would  prove 
efficient,  but  the  hope  is  still  but  a  hope.  Tavel  and  Closer  prepare  serum  by 
using  cultures  of  streptococci  obtained  from  a  number  of  cases  of  scarlet  fever. 
Van  de  Velde  uses  cultures  of  streptococci  ol:)tained  from  various  streptococcic 
infections.  According  to  Burkard  antistreptococcic  serum  destroys  neutro- 
philes  in  the  blood.  This  destruction  is  not  harmful  if  leukocytosis  follows 
the  injections,  and  it  does  follow  them  in  all  cases  when  the  body  is  able  to 
react  to  the  serum  ("Archiv.  f.  Gynak.,"  Ixxx.,  Xo.  3).  Before  removing  a 
tongue  or  an  upper  jaw  it  is  my  custom  to  give  antistreptococcic  serum,  and  I 
believe  that  it  lessens  the  tendency  to  toxemia  and  to  septic  bronchopneumonia. 
Malignant  tumors  (both  sarcomata  and  carcinomata)  have  been  treated  with 
the  blood-serum  of  dogs,  which  animals  had  been  injected  with  fluid  expressed 
from  malignant  growths  (Richet  and  Hericourt).  Von  Leyden  and  Blumen- 
thal  obtain  a  serum  by  compression  of  a  recent  cancerous  growth  and  treat 
human  victims  of  cancer  with  it.  They  claim  that  the  results  are  encouraging 
("Deutsche  medicinische  Wochenschrift,"  Sept.  4,  1902).  Many  claims  made 
for  serum-therapy  in  surgical  diseases  are  exaggerated,  sensational,  and  un- 
scientific. It  does  not  seem  possible  to  obtain  an  antitoxin  for  each  bacterial 
malady,  and  the  bacteria  of  most  specific  diseases  are  potent  for  harm  for  more 
reasons  than  because  they  form  crystalloidal  toxic  matter.  That  there  is  truth 
in  the  method  seems  highly  probable,  but  how  much  truth  there  is,  is  not  yet 
definitely  ascertained.  It  is  our  duty  to  study,  experiment,  and  obsen-e,  and  to 
reach  a  conclusion  only  after  honest,  careful,  and  thorough  investigation.  A 
little  skepticism  is  as  yet  a  safe  rule. 


Treatment  of  Infections  by  Bacterial  Vaccines  45 

Untoward  Effects  of  Serum  Injections. — It  has  been  known  for  a  consid- 
erable lime  that  guinea-pigs  which  had  been  injected  with  antitoxin  frequently 
died  when  injected  with  the  serum  again  some  time  later;  the  curious  fact  is 
that  the  first  dose  does  no  harm,  but  the  second  dose,  given  after  several  days, 
produces  the  trouble.  In  man  unpleasant  or  other  dangerous  effects  may  follow 
the  injection  of  any  serum.  They  occur  in  certain  hypersensitive  individuals. 
They  may  occur  from  a  first  dose,  but  are  far  more  apt  to  arise  from  the  second, 
the  third,  or  some  later  injection. 

The  symptoms  may  be  trivial  and  not  arise  for  several  hours.  The  most 
common  ones  are  joint  pains,  weakness,  depression,  dyspnea,  urticaria  or 
erythema,  cough,  itching,  sneezing,  edema  of  the  face,  and  swelling  of  the 
tongue  ("Progressive  Medicine,"  Dec.  i,  1908). 

The  symptoms  may  be  serious  and  arise  in  a  few  minutes.  In  such  a 
condition  any  of  the  previously  mentioned  symptoms  may  exist,  but  the  dysp- 
nea is  urgent,  the  face  is  often  cyanosed,  and  collapse  occurs.  In  some  cases 
death  occurs  in  a  few  minutes  after  an  injection.  When  untoward  results 
follow  a  first  injection  the  condition  is  regarded  as  hypersusceptibil ity  to  serum. 
When  it  follows  a  later  injection  it  is  called  serum  disease.  We  fear  fatality 
from  an  initial  dose  when  there  is  hypersusceptibihty.  Serum  disease  is 
usually  made  manifest  by  minor  symptoms  developing  from  eight  to  thirteen 
days  after  a  first  injection  or  almost  at  once  after  an  injection  given  from  four- 
teen days  to  four  months  after  the  first  one.  There  is  no  way  of  knowing 
beforehand  that  a  person  is  hypersensitive  or  that  he  is  liable  to  serum  disease, 
except  that  asthma  is  ominous  and  makes  us  fear  some  untoward  effect.  In 
using  diphtheria  antitoxin  or  tetanus  antitoxin  the  serum  should  be  given  at 
close  intervals  and  not  at  intervals  of  several  days. 

Treatment  of  Infections  by  Bacterial  Vaccines.*— The  studies 
of  Wright  and  Douglas  upon  opsonins  lead  to  the  adoption  of  this  plan  of 
treating  certain  infections. 

By  the  injection  of  an  antitoxic  serum  we  seek  to  directly  neutralize  toxic 
products.  By  the  injection  of  the  bacterial  vaccines  we  seek  to  stimulate  the 
body  cells  to  produce  antibodies  and  particularly  opsonin.  Bacterial  vaccine 
consists  of  dead  bacteria  and  their  toxins.  Each  individual  has  his  own 
response  to  such  an  injection,  but  this  response  varies  at  different  times. 
An  antitoxic  serum  contains  other  antibodies  besides  antitoxin.  Bacterial 
vaccine  is  made  up  with  salt  solution  and  is  truly  specific.  A  vaccine  made 
up  from  a  certain  variety  of  organisms  is  valuable  only  in  infections  from 
that  variety  of  organism.  In  some  cases  stock  cultures  are  used,  but  it  is 
better  whenever  possible  to  obtain  the  bacteria  from  the  infected  person  and 
obtain  our  cultures  from  them  (autogenous  vaccine) .  In  some  cases,  how- 
ever, we  cannot  wait  for  the  development  of  a  culture  and  must  then  use 
stock  vaccines.  In  a  mixed  infection  it  is  sometimes  uncertain  which  or- 
ganism is  the  main  factor  in  causing  the  trouble  and  danger,  and  yet  it  is 
the  main  factor  against  which  the  vaccine  must  be  levelled.  Until  recently 
it  was  believed  that  the  dose  must  be  determined  by  the  opsonic  index.  This 
plan  is  now  seldom  followed.     Each  cubic  centimeter  of  Wright's  stock  vaccine 

*  In  this  connection  see  particularly  article  by  Roger  J.  Lee  and  article  by  H.  F. 
Hartwell  and  Roger  J.  Lee  in  "  Publications  of  Mass.  General  Hosp.,"  October,  1908.  I 
have  used  these  articles  freely. 


46  Bacteriology 

contains  600,000,000  dead  bacteria.  The  first  does  is  ^  cc.  and  the  second 
dose  is  I  cc.  Hartwell  and  Lee  repeat  the  full  dose  every  fourth  or  fifth  day 
until  the  lesions  are  cleared  up  ("Publications  of  Mass.  General  Hosp.," 
Oct.,  1908).  Each  injection  is  made  in  the  subcutaneous  tissue,  the  skin  hav- 
ing been  previously  scrubbed  with  soap  and  water  and  washed  with  alcohol. 
In  many  cases  there  is  a  trivial  reaction  after  injection.  This  reaction  is  not 
febrile,  is  of  brief  duration,  and  is  manifested  by  headache,  backache,  and 
languor. 

There  is  much  testimony  as  to  the  value  of  this  plan  of  treatment.  It  is 
particularly  serviceable  in  superficial  infections  from  the  staphylococcus 
aureus  (boils  and  carbuncles) .  In  many  cases  pain  and  tenderness  begin  to 
abate  a  few  hours  after  the  first  injection,  a  profuse  discharge  flows  from  the 
lesion  if  it  is  open,  and  gathers  in  the  tissues  if  there  is  no  opening.  If  the  focus 
of  infection  is  closed  it  should  be  incised,  but  Wright  insists  that  antiseptics 
must  not  be  used,  as  they  destroy  the  activity  of  opsonins.  The  treatment  is  of 
uncertain  value  in  abscess,  pyemia,  septicemia,  and  mixed  infections. 
Tuberculin. — See  page  235. 

Special  Surgical  Microbes.— Suppuration  (seepage  137).— Suppura- 
tion is  caused  by  microbes.  Does  it  ever  exist  without  them  ?  The  answer  is, 
"Practically  no."  Injection  of  a  sterile  fluid  containing  dead  organisms,  or 
the  injection  of  the  sterile  products  of  the  growth  of  pyogenic  cocci,  will  form  a 
limited  amount  of  pus;  injection  of  an  irritant  forms  a  thin  fluid  which  may  re- 
semble pus,  but  which  is  not  pus.  In  surgery  pus  is  very  seldom  met  with  with- 
out the  actual  presence  of  micro-organisms  (page  138),  and  the  presence  of  pus 
proves  the  presence  of  micro-organisms. 

Pyogenic  Bacteria. —Pm.s  microbes,  or  pyogenic  microbes,  are  strongly 
proteolytic,  that  is,  they  possess  the  property  of  peptonizing  albumin,  and 
thus  forming  pus.  The  peptonizing  action  is  brought  about  by  bacterial 
products.  Some  believe  that  pus  is  not  formed  by  a  peptonizing  action  of 
the  bacteria  but  that  the  bacteria  furnish  a  poison  (leukolysin)  which  breaks 
up  the  leukocytes,  and  that  the  breaking  up  of  leukocytes  liberates  an  enzyme 
which  dissolves  albumin.  The  inflammation  which  surrounds  an  area  of 
pyogenic  infection  is  caused  by  the  irritant  products  of  bacterial  action  (tox- 
albumins,  ammonia,  etc.).  In  the  presence  of  the  pyogenic  peptones  the 
coagulation  of  inflammatory  exudate  is  retarded  or  prevented.  Bacteria 
which  ordinarily  cause  suppuration  may  not  cause  it  but  produce  non-sup- 
purative  inflammation  if  they  are  present  in  small  numbers  or  if  the  tissue  re- 
sistance is  at  a  high  level,  or  if  their  virulence  has  been  modified  by  adverse 
antecedent  conditions.  Bacteria  which  ordinarily  do  not  cause  suppuration 
may  do  so  under  certain  conditions  of  increased  bacterial  virulence  or  lessened 
tissue  resistance.  The  typhoid  bacillus  is  at  times  pyogenic,  but,  as  a  rule, 
it  is  not  pyogenic.  The  usual  causes  of  suppuration  are  the  foflowing  micro- 
organisms. 

The  term  micrococcus  pyogenes  (Fig.  15)  includes  the  staphylococcus 
aureus,  the  staphylococcus  albus,  and  the  staphylococcus  citreus.  These 
forms  are  deviations  from  one  form  and  are  not  specifically  different. 
The  albus  and  citreus  may  be  grown  from  the  aureus  and  they  may 
remain  white  and  yellow  or  may  revert  in  part  to  the  aureus  form  ("Atlas  of 
Bacteriology,"  by  Lehmann  and  Neumann).     Some  observers  maintain  that 


pyogenic  Bacteria  47 

these  forms  vary  greatly  in  virulence  and  hence  are  specifically  different,  but 
the  varying  virulence  has  been  disputed  and  it  seems  to  have  been  proved  that 
virulence  may  be  lessened  greatly  even  when  the  color  does  not  change.  Sev- 
enty-seven per  cent,  of  acute  abscesses  are  due  to  staphylococci  (\V.  Watson 
Cheyne).  Staphylococci  are  found  also  in  osteomyelitis,  in  a  carbuncle,  in  a 
boil,  in  acne,  in  pemphigus,  in  periostitis,  in  septicemia,  and  in  pyemia,  and 
in  some  cases  of  empyema  and  peritonitis.  Some  toxic  products  of  staphylococci 
destroy  leukocytes.     All  of  the  staphylococci  are  non-motile. 

Staphylococcus  pyogenes  aureus  (Plate  i,  Fig.  i,  and  Fig.  15),  the  golden- 
yellow  coccus.  When  grown  in  the  air  it  produces  orange-yellow  pigment. 
This  is  the  most  usual  cause  of  abscesses  (circumscribed  suppurations) .  The 
staphylococcus  pyogenes  aureus  grows  best  in  air,  but  can  grow  when  air  is  ex- 
cluded. As  it  can  thus  grow  it  is  a  facultative,  aerobic  parasite.  It  is  widely 
distributed  in  nature,  and  is  found  in  the  soil,  the  dust  of  air,  water  the  ali- 
mentary canal,  under  the  nails,  on  and  in  the  superficial  layers  of  skin,  espe- 
cially in  the  axillae  and  perineum,  in  the  mouth,  the  nasal  ca\'ities,  the  vagina, 
and  human  milk.  It  forms  the  characteristic  color  only  when  it  grows  in  air 
(Plate  I,  Fig.  i).  It  is  killed  in  ten  minutes  by  a  moist  temperature  of  58°  C. 
and  is  instantly  killed  by  boihng  water.  Carbolic  acid  (i :  40)  and  corrosive 
sublimate  (i:  2000)  are  quickly  fatal  to  this  coccus. 


Fig.  15.— Micrococcus  pyogenes  aureus  IX  looo).  Y\g.  i6. — Streptococcus  pyogenes  (X  700). 

(Lehmann  and  Neumann.)  (Lehmann  and  Neumann.) 

Staphylococcus  pyogenes  alhus  (Plate  i.  Fig.  2),  the  white  staphylococcus, 
acts  like  the  aureus,  but  is  usually  more  feeble  in  power.  When  this  organism 
is  found  upon  and  in  the  skin  it  is  called  the  staphylococcus  epidermidis  albus, 
an  organism  which  Welch  proved  to  be  the  usual  cause  of  stitch-abscesses. 

Staphylococcus  pyogenes  citreus,  the  lemon-yellow  coccus,  is  found  occa- 
sionally in  acute  circumscribed  suppurations,  but  less  often  than  are  the 
other  two  forms.     Its  pyogenic  power  is  even  weaker  than  that  of  the  albus. 

The  staphylococcus  cereus  albus  and  the  staphylococcus  cereus  flavus  are 
found  occasionally  in  acute  abscesses,  but  these  forms  cannot  be  sharply  dif- 
ferentiated from  the  micrococcus  pyogenes  and  the  names  should  be  abandoned. 

Staphylococcus  flavescens  is  occasionally  found  in  abscesses.  It  is  inter- 
mediate between  the  aureus  and  albus  (Senn). 

Micrococcus  pyogenes  tenuis  rarely  takes  the  form  of  a  bunch  of  grapes. 
It  is  occasionally  found  in  the  pus  of  acute  abscesses. 

The  micrococcus  tetragenus  is  thought  to  be  the  bacterium  chiefl}'  respon- 
sible for  the  suppuration  of  tuberculous  pulmonary  lesions. 


48  Bacteriology 

Streptococcus  pyogenes  (Fig.  16). — This  coccus,  known  as  the  chain  coccus, 
grows  best  in  air  and  can  also  grow  when  air  is  excluded.  It  is  non-motile  and 
does  not  bear  spores.  It  is  found  in  the  healthy  human  body  in  the  nasal 
cavities,  urethra,  mouth,  vagina,  and  on  the  skin.  It  has  been  found  in  spread- 
ing inflammation  and  suppuration,  erysipelas,  pneumonia,  otitis,  puerperal 
fever,  pyemia,  septicemia,  lymphangitis,  some  very  acute  abscesses,  and  some 
cases  of  meningitis,  empyema,  peritonitis,  ulcerative  endocarditis,  pericarditis, 
osteomyelitis,  diarrhea,  and  in  certain  sore  throats.  It  varies  very  greatly 
in  virulence  and  the  intensity  of  its  action  is  strongly  influenced  by  the  nature 
of  the  soil  in  which  it  is  implanted.  Not  only  do  streptococci  produce  virulent 
toxins  but  they  also  produce  a  non-toxic  material  called  hemolysin,  which  dis- 
solves red  corpuscles.  Woodhead  tells  us  (Treves'  "System  of  Surgery")  that 
six  organisms,  each  of  which  bears  a  separate  name,  are  discussed  under  this 
designation.  Three  of  these  organisms  he  places  in  one  group,  two  in  another, 
and  says  the  sixth  may  be  a  separate  species. 

ist  Group. — Streptococcus  pyogenes  (Fig.  16),  found  especially  in  spreading 
suppuration.  Such  suppurations  spread  because  streptococci  only  feebly 
attract  leukocytes  and  also  prevent  the  coagulation  of  exudate.  Streptococci 
are  also  found  in  very  acute  abscesses.  Cheyne  says  that  16  per  cent,  of  acute 
abscesses  contain  streptococci.  The  streptococcus  pyogenes  is  easily  killed 
by  boiling,  and  can  be  destroyed  by  carbolic  acid  and  corrosive  sublimate. 
These  organisms  are  normally  present  in  the  nasal  passages,  vagina,  mouth, 
and  urethra. 

Streptococcus  pyogenes  malignus,  an  uncommon  organism  found  in  splenic 
abscess. 

Streptococcus  septicus  has  a  strong  tendency  to  break  up  into  diplococci. 

2d  Group. — Streptococcus  of  erysipelas  is  found  in  the  capillary  lymph- 
spaces  in  erysipelas.  Many  bacteriologists  beheve  it  to  be  identical  with  the 
streptococcus  pyogenes.  These  bacteria  tend  particularly  to  gather  in  the 
lymph-spaces.  They  rarely  produce  pus  and  when  they  do  it  is  usually  watery. 
When  ordinary  thick  pus  forms  there  is  a  mixed  infection  with  staphylococci. 

Streptococcus  of  Septicemia  and  Pyemia. — Most  observers  maintain  that 
it  is  identical  with  the  streptococcus  pyogenes  and  the  streptococcus  of  ery- 
sipelas. 

3d  Group. — Streptococcus  articulorum,  found  in  the  false  membrane  of 
diphtheria  (see  the  article  by  Woodhead  in  the  "System  of  Surgery"  by  Sir 
Frederick  Treves). 

Other  Pyogenic  Organisms. — The  various  forms  of  colon  bacillus,  the 
typhoid  bacillus,  the  streptococcus  intracellulosis,  the  micrococcus  tetragenus, 
and  the  pneumococcus,  are  at  times  pyogenic.  Pneumococci  may  ]jroduce 
arthritis  (page  647),  peritonitis  (page  1012),  cholecystitis,  empyema,  necrosis  of 
bone,  or  wound  infection.  A  case  of  wound  infection  due  to  pneumococci  was 
recently  reported  by  J.  H.  Beaty  ("Northwestern  Lancet,"  July  i,  1907).  In 
many  persons  pneumococci  exist  in  the  mouth.  A  common  form  of  colon 
bacillus  is  the  bacillus  pyogenes  fetidus:  it  is  found  in  stinking  peritoneal  pus 
and  in  the  pus  of  ischiorectal  abscesses.  The  gonococcus  is  also  pyogenic. 
Blue  pus  is  produced  by  the  bacillus  pyocyaneus  (Ernst). 

The  bacillus  pyocyaneus  forms  chains  and  may  produce  suppuration 
itself.     Usually,  however,  when  it  appears  it  constitutes  a  secondary  infection 


BACTERIOLOGY. 


Plate  i. 


1.  Staphylococcus  pyogenes  aureus. 

2.  Staphylococcus  pyogenes  albus. 

3.  Bacillus  tuberculosis  on  glycerin-agar, 

(Warren's  Surgical  Pathology.^ 


Other  Surgical  Microbes  49 

in  a  suppurating  area.     It  causes  a  blue  or  blue-green  hue  in  pus  and  wound 
discharges. 

It  is  normally  found  in  water  and  e.xists  in  the  mouth,  intestine,  and  in  the 
skin. 

Other  Surgical  Wicrobes.—S/replococais  of  erysipelas  (Fehleisen's 
coccus),  as  stated  before,  is  thought  by  many  to  be  identical  with  the  strepto- 
coccus pyogenes.  Their  difference  in  action  is  believed  by  Sternberg  to  be 
due  to  difference  in  virulence  induced  by  external  conditions  and  by  the  state 
of  the  tissues  of  the  host.  The  coccus  of  erysipelas  is  somewhat  larger  than 
the  ordinary  form  of  streptococcus  pyogenes.  Infection  takes  place  by  a 
wound,  often  a  very  trivial  wound  of  the  skin  or  mucous  membrane.  The 
cocci  multiply  in  the  small  lymph-channels.  This  coccus 
will  cause  puerperal  fever  in  a  woman  in  childbed  when 
it  gains  access  to  "an  absorbing  surface  in  the  genital  ^^^ 

tract"  (Senn).     The  streptococcus  may  cause  suppura-  9^ 

tion  in  er\-sipelas,  mixed  infection  not  being  necessan,-  to  ^^   ^^ 

induce  pus-formation.  Fi-.  i7.-Micrococci 

The  gonococciis,  or  the  micrococcus  gonorrhcecE  (the  gonorrhceae,  highly 
bacillus  of  Xeisser)  (Fig.  18),  is  the  diplococcus  which  "^^^^^^^  and^^Xeu- 
causes  gonorrhea.  Xeisser,  in  1879,  observed  this  bacil-  mann.) 
lus  in  pus  from  gonorrheal  ophthalmia  and  urethral  gonor- 
rhea. Bumm,  in  1887,  proved  the  causative  influence  of  the  gonococcus.  He 
reproduced  the  disease  in  a  healthy  female  urethra  by  inoculation  with  the 
twentieth  generation  in  descent  from  a  pure  culture.  These  diplococci  are  in 
pairs  and  each  member  of  a  pair  is  kidney  shaped  (Fig.  17).  Gonococci  grow 
■  best  in  air,  but  can  grow  w'hen  air  is  excluded  (facultative  aerobic) .  Diplococci 
are  found  often  in  the  secretions  of  apparently  healthy  mucous  membranes,  and 
simulate  very  closely  gonoccoci,  but  genuine  gonococci  are  not  so  found.  The 
gonococcus  is  a  pure  parasite  and  is  not  found  outside  of  the  organism  except 


=  *'^  ...,^  :;  ^^ 

*'H.  .  ..   .  '^  ^ 

Fig.  18. — Gonococci  from  gonorrheal  pus. 

upon  articles  contaminated  with  gonorrheal  discharge.  In  male  gonorrhea  the 
gonococci  are  in  the  urethra  and  prostate;  in  female  gonorrhea  they  are  in  the 
urethra,  glands  of  BarthoUn,  and  cer\-ix  uteri.  These  cocci  may  cause  gonor- 
rheal conjunctivitis,  lymphangitis,  lymphadenitis,  rhinitis,  otitis,  proctitis,  endo- 
metritis, salpingitis,  oophoritis,  cystitis,  peritonitis,  bursitis,  thecitis,  pleuritis, 
malignant  endocarditis,  arthritis,  periostitis,  abscess,  and  parotitis.  In  chronic 
urethral  gonorrhea  the  gonococci  may  at  times  be  absent  from  the  discharge, 
returning  when  there  has  been  sexual  or  alcoholic  excess,  traumatism,  or  con- 
4 


50  Bacteriology 

tact  with  an  irritant  secretion.  In  such  a  case  a  very  few  gonococci  must  have 
multipUed  and  the  majority  of  the  bacteria  must  have  quickly  died,  so  that 
there  were  never  many  in  the  urethra  at  one  time,  and  the  discharge  must  have 
l)een  kept  up  by  their  irritant  toxins.  If  a  part  in  such  a  condition  is  irritated, 
active  multipHcation  begins  and  the  cocci  reappear  in  the  discharge.  Gonococci 
cannot  be  cultivated  upon  ordinary  media,  but  grow  best  upon  human  blood  or 
human  blood-serum.  In  gonorrhea  the  organisms  are  found  both  within  and 
outside  of  pus-cells  and  on  mucous  cells  (Fig.  i8).  The  gonococci  infect  a 
surface  covered  with  cylindrical  epithelium  much  more  readily  than  a  surface 
covered  with  pavement-epithelium.  They  pass  into  the  submucous  tissue, 
cause  inflammation,  and  spread  by  way  of  the  lymph-paths.  It  seems  certain 
that  the  gonococcus  is  pyogenic,  although  mixed  infection  with  other  pyogenic 
organisms  may  exist  in  this  disease.  Their  presence  inside  of  pus-cells  means 
phagocytosis.  Gonococci  stain  easily  by  methylene-blue  and  are  readily 
decolorized  by  Gram's  method. 


Fig.  19. — Bacillus  of  tetanus,  witli  spores. 

In  noma  streptococci  are  found.  No  specific  organism  has  been  isolated 
for  traumatic  spreading  gangrene  or  hospital  gangrene. 

The  bacillus  of  tetanus  or  the  Bacillus  tetani  (Nicolaier's  bacillus)  (Fig. 
19)  was  discovered  by  Nicolaier  in  1884.  In  1889  Kitasato  obtained  a  pure 
culture.  It  is  an  anaerobic  organism.  In  recent  cultures  at  least  it  ceases 
to  grow  in  the  presence  of  oxygen.  It  grows  witJiin  the  tissues  of  the  animal 
body.  In  a  wound  to  which  air  has  access  the  bacilli  may  lie  so  surrounded 
by  fluid  that  air  is  excluded.  Pyogenic  or  saprophytic  bacteria  may  consume 
the  air  or  the  bacilli  may  lie  in  a  laceration  of  the  tissue  the  outlet  of  which 
is  sealed  by  exudate  or  blood.  It  is  a  facultative  saprophyte,  that  is,  under 
certain  conditions  it  can  grow  in  dead  organic  material.  It  is  possible  to 
develop  by  cultivation  bacilli  which  will  live  in  air. 

The  bacilli  of  tetanus  are  widely  distributed.  They  are  found  in  hay,  in 
the  soil  of  gardens,  in  the  dust  of  old  buildings,  in  street  dust  and  dirt,  and 
in  the  sweepings  of  stables.  The  feces  of  healthy  horses,  cattle,  and  men  may 
contain  the  bacilli.     Tetanus  develops  after  a  wound  and  the  bacilli  remain 


Other  Surgical   Microbes  51 

in  the  wound  and  do  not  enter  the  blood.  They  furnish  deadly  toxins  which 
are  absorbed.  The  symptoms  are  due  to  intoxication,  not  to  infection.  The 
toxin  of  tetanus  is  alkaloidal,  not  albuminoid.  These  bacilli  stain  by  Gram's 
method.  Cultures  are  made  on  sugar-agar  plates,  the  air  being  excluded. 
These  bacilli  when  placed  under  somewhat  unfavorable  conditions  sporulate 
with  great  rapidity,  and  the  spores  are  seen  at  the  ends  (Fig.  19).  The  spores 
are  far  more  resistant  than  the  adult  bacilli,  and  it  is  difficult  to  kill  them  in  a 
wound.     The  drug  which  is  most  certainly  fatal  to  tetanus  bacilli  is  bromin. 


Fig.  20. — Tubercle  bacilli  in  sputum  (Ziegler). 

The  Bacillus  tuberculosis  (Koch's  bacillus)  (Fig.  20).  This  bacillus  is 
the  cause  of  all  tuberculous  processes.  It  was  discovered  and  cultivated  by 
Koch  in  1882. 

It  is  non-motile  and  requires  oxygen  in  order  to  grow,  but  may  obtain  this 
from  the  body-cells  or  fluids.  It  stains  by  Gram's  method  and  by  fuchsin. 
These  bacilli  are  cultivated  upon  glycerin-agar  or  solid  blood-serum  (Plate  i. 
Fig.  3).  They  are  found  in  dust  containing  the  dried  sputum  of  victims  of 
phthisis  and  dried  discharges  and  secretions  of  tuberculous  patients.     This 


Fig.  21.— Bacillus  anthracis  (X  looo).  Fig.  22.— Bacillus  of  malignant  edema 

(Lehmann  and  Neumann.)  (Lehmann  and  Neumann). 

infected  dust}-  air  is  the  chief  means  of  conve}ing  infection  (inhalation  tuber- 
culosis) .  Infection  can  also  be  conveyed  by  inoculation  of  bacilli  (inoculation 
tuberculosis)  and  by  eating  the  meat  and  drinking  the  milk  of  tuberculous 
animals  (ingestion  tuberculosis).     Tuberculin  is  discussed  on  page  235. 

Bacillus  anthracis  or  the  bacillus  of  anthrax  (Fig.  21)  was  first  obsen-ed 
by  Pollender  in  1849  and  its  causal  influence  was  first  demonstrated  by  Davaine 
in  1863.  It  is  the  cause  of  malignant  pustule  or  splenic  fever.  It  is  non- 
motile.     Tissue  containing  it  is  stained  bv  Gram's  method.     Cover-glass  prepa- 


52  Bacteriology 

rations  are  stained  with  a  watery  solution  of  an  aniline  dye.  It  will  grow  without 
oxygen,  but  grows  best  in  air.  In  the  presence  of  air  sporulation  occurs,  but 
it  does  not  occur  in  the  infected  animal.  It  grows  upon  or  in  gelatin  or  agar. 
Only  outside  of  the  diseased  body  are  spores  found,  and  they  exist  in  the  hides 
and  hair  of  infected  animals  and  in  stalls  and  pastures  in  which  diseased  ani- 
mals were  kept. 

Bacillus  mallei  or  the  bacillus  of  glanders  is  the  cause  of  glanders.  It  was 
discovered  by  Lofifler  and  Schutz  in  1882.  It  is  non-motile  and  grows  best  in 
air,  growing  with  great  difficulty  when  air  is  excluded.  It  grows  well  upon 
glycerin-agar  and  does  not  stain  by  Gram's  method.  It  is  never  found  except  in 
the  body  of  a  diseased  man  or  other  animal.  It  is  best  cultivated  in  solid  blood- 
serum.     Under  certain  circumstances  some  few  of  the  bacilli  contain  spores. 

The  Pneumococcus,  called  also  the  diplococciis  pneumonia,  FrankeP s  bacillus, 
and  the  streptococcus  lanceolatus,  was  discovered  by  Steinberg  in  1880.  It  is 
often  found  in  the  saliva  of  healthy  individuals.  It  is  not  found  outside  of  the 
body.  It  varies  greatly  in  virulence,  but  when  virulent  can  establish  inflamma- 
tion and  even  suppuration,  particularly  of  mucous  and  serous  surfaces.  It  may 
cause  croupous  pneumonia,  catarrhal  pneumonia,  pleuritis,  meningitis,  con- 
junctivitis, arthritis,  peritonitis,  periostitis,  osteomyelitis,  parotitis,  salpingitis, 
empyema,  cholecystitis,  perinephric  and  other  abscesses,  nephritis,  tonsillitis, 
and  septicemia.  In  any  of  these  conditions  it  may  appear  in  the  blood.  It 
grows  best  in  bouillon  cultures  and  in  ascites  glycerin-agar. 

The  Bacillus  coll  communis,  called  also  the  bacterium  coll  commune,  the 
colon  bacillus,  or  the  bacillus  of  Escherich  (Fig.  23),  was  discovered  in  feces  by 
Emmerich  in  1885.  Under  ordinary  conditions  this  is  a  putrefactive  bacillus 
inhabiting  the  intestinal  canal  and  feces  invariably  contain  it.  It  is  found  in  the 
mouth,  nose,  and  vagina,  on  the  skin,  and  under  the  nails.  The  bacillus  is 
normally  found  in  water,  even  in  water  regarded  by  the  users  as  })ure.  It  has 
already  been  stated  that  this  ordinarily  harmless  organism  may,  under  certain 
conditions,  acquire  pathogenic  power  and  enter  the  circulation.  This  bacterium 
grows  best  in  air,  but  it  can  also  grow  when  air  is  excluded.  It  is  not  stained 
by  Gram's  method  and  has  pyogenic  power.  It  stains  with  anilin  dyes  and 
is  decolorized  by  iodin  solution.  There  are  numerous  forms  of  colon  bacilli, 
and  some  of  them  are  motile,  some  are  amotile.  This  bacillus  may  be  respon- 
sible for  appendicitis,  peritonitis,  inflammation  of  the  genito-urinary  tract, 
pneumonia,  inflammation  of  the  intestine,  leptomeningitis,  perineal  ab.scess, 
cholangitis,  cholecystitis,  myelitis,  puerperal  fever,  wound  infection,  and 
septicemia.  It  is  the  cause  of  many  abscesses  about  the  intestine,  and  is 
responsible  for  many  ischiorectal  abscesses.  From  the  pus  of  an  appendiceal 
abscess  we  may  perhaps  obtain  a  pure  culture  of  Escherich's  bacillus,  but  usu- 
ally find  also  streptococci,  staphylococci,  or  pneumococci. 

The  Bacillus  a'dematis  maligni,  the  bacillus  of  malignant  edema,  or  the 
vibrione  septique  of  Pasteur  (Fig.  22),  was  discovered  by  Pasteur  in  1875. 
This  baciflus  is  found  especially  in  stagnant  water  and  certain  varieties  of  soil 
and  exists  in  putrefying  material.  It  is  sometimes  motile,  but  is  often  amotile 
and  multiplies  by  spore  formation.  It  is  anaerobic  and  in  its  growth  produces 
bubbles  of  gas.  In  the  disease  known  as  mahgnant  edema  there  is  usually  a 
mixed  infection  with  the  bacilli  of  malignant  edema  and  saprophytic  organisms, 
and  the  latter  also  form  considerable  quantities  of  gas  in  the  tissues.     The 


Other  Surgical  Microbes  53 

bacilli  of  malignant  edema  may  cause  either  spreading  bloody  edema  contain- 
ing gas  bubbles  or  spreading  emphysematous  gangrene.  The  bacilli  enter  the 
blood  and  produce  septicemia.  The  bacillus  is  grown  in  the  interior  of  a  stab 
in  gelatin  agar-agar  or  solid  blood-scrum  when  the  mouth  of  the  stab  has  been 
sealed  up. 

The  Bacillus  aerogenes  capsulatus  of  Welch  was  described  by  Welch  and 
Nuttal  in  1892.  This  bacillus  is  found  sometimes  in  aljscesses  containing  gas. 
It  is  causative  of  some  cases  of  gangrenous  cellulitis,  which  is  a  spreading  gan- 
grene with  gas  formation. 

It  has  a  capsule  and  very  seldom  forms  spores.  It  stains  by  Gram's 
method  and  grows  well  upon  blood-serum. 

As  pointed  out  by  Lehmann  and  Neumann,  there  are  occasionally  encount- 
ered "gaseous  phlegmons  and  similar  diseases  of  internal  organs,  in  which  are 


>* 


r 


r 


)r''        <^   ^    -     ' 

Fig.  23. — Bacillus  coli  communis. 

found  the  bacterium  coli  alone  or  usually  in  combination  with  other  varieties, 
but  without  any  anaerobes  being  present "  ("Atlas  and  Principles  of  Bacte- 
riology," Vol.  II.,  edited  by  Geo.  H.  Weaver). 

The  Bacterium  typhi,  the  typhoid  bacillus,  or  Eberth's  bacillus,  was  dis- 
covered by  Eberth  in  1880.  It  is  sometimes  found  in  water  or  soil  contaminated 
by  typhoid  fecal  matter.  It  never  exists  in  the  healthy  human  body.  It 
causes  typhoid  fever  and  in  this  disease  can  be  obtained  and  cultivated,  par- 
ticularly from  the  spleen  and  lymphatic  glands  and  frequently  from  the  blood. 
It  has  been  found  in  the  urine,  kidney,  bone-marrow,  and  bile.  It  is  difficult 
to  cultivate  typhoid  bacilli  from  feces  because  of  the  presence  of  multitudes  of 
other  bacteria.  The  bacillus  of  typhoid  is  motile,  does  not  stain  by  Gram's 
method,  and  grows  best  in  air,  but  can  grow  when  air  is  excluded.  It  grows  upon 
all  the  ordinary  nutrient  media.  This  bacillus  is  particularly  apt  to  be  con- 
founded with  the  colon  bacillus,  and  it  is  even  possible  that  the  former  develops 
from  the  latter.  Besides  typhoid  fever  the  typhoid  bacillus  may  cause  peri- 
tonitis, chronic  osteomyelitis,  gangrene,  cholecystitis,  thrombosis,  embolism, 
synovitis,  and  arthritis.  This  bacillus,  under  certain  conditions,  is  pyogenic. 
Typhoid  bacilli  are  agglutinated  and  lose  motion  by  contact  with  a  i  to  50 
dilution  of  the  blood-serum  of  a  patient  with  typhoid  fever  or  convalescent 
from  typhoid  fever  (the  Widal  reaction). 


54  Bacteriology 

Putrefactive  Bacteria.— By  putrefatti<jn  we  mean  the  decomposition 
of  albuminous  matter  with  the  production  of  materials  possessed  of  a  foul  odor. 
The  bacilli  of  putrefaction  act  upon  dead  tissue  exposed  to  air  and  are  most 
active  when  the  supply  of  air  is  somewhat  limited.  The  surgeon  encounters 
these  bacteria  in  areas  of  necrosis  or  in  tissues  previously  destroyed  by  other 
microbes.  In  the  latter  case  they  cause  a  mixed  infection.  An  instance  of  such 
a  mixed  infection  is  putrid  pus.  Some  of  the  products  of  putrefactive  bac- 
teria are  highly  poisonous  (ptomai'ns).  Absorption  of  a  small  amount  of 
[)utrid  toxin  causes  surgical  fever  and  absorption  of  a  large  amount  causes 
putrid  intoxication. 

The  chief  putrefactive  bacteria  are:  The  colon  bacillus  (when  under 
normal  conditions);  the  bacillus  of  malignant  edema;  the  proteus  vulgaris; 
the  proteus  mirabilis;  the  three  forms  of  the  bacillus  saprogenes;  and  the 
proteus  Zenkeri. 

We  may  mention,  in  conclusion,  as  of  occasional  surgical  importance  the 
bacillus  of  influenza,  bacillus  of  diphtheria,  bacillus  of  bubonic  plague, 
bacillus  of  leprosy,  bacillus  of  rhinoscleroma,  bacillus  of  fetid  ozena,  bacillus 
of  hemorrhagic  septicemia,  and  the  bacillus  lactis  aerogenes,  which  is  an  un- 
usual cause  of  peritonitis. 

The  ray-fiingus  is  considered  on  page  310. 

Infections  with  Protozoa.— Protozoa  is  the  name  given  to  the  lowest 
forms  of  animal  life.  This  group  of  organisms  shows  transitions  from  forms 
certainly  animal  toward  forms  certainly  vegetable.  The  protozoa  are  minute 
unicellular  organisms.  The  cell  has  a  definite  nucleus  and  is  composed  of 
protoplasm  and  a  more  or  less  dense  cell-wall.  Many  species  have  organs  of 
locomotion  (cilia  or  flagella) .  Pebrine  or  silkworm  disease  is  due  to  protozoa, 
so  is  tr)'panosomiasis.  Protozoa  are  known  to  cause  malaria  (the  plasmodium 
malariee)  and  tropical  dysentery  (the  entameba  histolytica).  Some  observers 
maintain  that  they  cause  cancer,  others  assert  that  they  are  responsible  for 
hydrophobia,  it  is  almost  certain  that  they  cause  syphilis,  and  it  is  thought 
probable  that  they  may  produce  measles,  smallpox,  yellow  fever,  scarlatina, 
and  spotted  fever. 

The  Spirochccta  Pallida. — .\  bacterial  cause  of  syphilis  has  long  been 
sought  for.  Lustgarten  thought  he  had  found  it  in  a  bacillus  resembling  the 
tubercle  bacillus,  but  this  view  has  not  been  proved.  Schaudinn  and  Hoff- 
mann have  described  an  organism  constantly  present  in  the  initial  lesion  of 
syphilis  and  in  secondarj'  lesions  and  which  they  call  the  spirochaeta  pallida 
(".■\rbeiten  aus  dem  Kaiserlichen  gesundheitsamte,"  Berlin,  April  10,  Heft 
2).  The  studies  of  Schaudinn  and  Hoffmann  were  confirmed  by  Metchnikoft 
("Bull.  .\cad.  de  med.  de  Paris,"  May  16,  1905).  These  organisms  are  found 
in  great  numbers  in  the  juice  of  S}'philitic  glands,  in  condylomata,  and  in 
chancres.  They  are  motile,  are  without  flagella,  cun-e  from  3  to  12  times,  are 
stained  with  difticulty,  and  are  transported  by  the  lymph  and  blood  (Blaschko, 
in  "Berlin  klin.  Woch.,"  No.  11,  1907).  It  is  a  protozoon  and  belongs  with 
the  animal  parasites.  The  spirochaeta  was  originally  discovered  by  Bordet  and 
Geugm  in  1903.  These  obser\'ers  found  them  in  chancres,  but  thought  their 
presence  was  inconstant.  Schaudinn  and  Hoft'mann  show  that  it  is  constant. 
Rosenberger  says  "that  it  plays  some  part  in  the  etiology  of  syphilis  seems 
plausible,  as  it  has  not  been  encountered  except  by  one  or  two  observers  in  any 


Asepsis  and  Antisepsis  55 

other  lesion  than  syphilis"  ("Am.  Jour.  Med.  Sciences,"  Jan.,  1906).  Very 
])()sitive  claims  have  been  made  as  to  the  causal  influence  of  the  pale  spirocha.'ta 
and  it  seems  highly  probable  that  it  is  the  cause  of  the  disease.  It  is  present 
in  primary  syphilis  and  all  early  secondary  lesions  and  in  congenital  syphilis. 
It  is  not  found  in  gummata.  As  yet  it  has  not  been  grown  In  culture.  Ewing 
("N.  Y.  State  Journal  of  Medicine,"  May,  1907)  and  numerous  other  observers 
maintain  that  it  is  the  real  long-sought  cause. 


II.  ASEPSIS  AND  ANTISEPSIS. 

The  effort  in  all  operations  is  to  secure  and  maintain  scrupulous  surgical 
cleanliness.  What  is  known  as  the  antiseptic  method  we  owe  to  the  splendid 
labors  of  Lord  Lister,  and  the  aseptic  method  is  but  a  natural  evolution  of 
the  antiseptic  method.  It  is  true  that  Agostino  Bassi,  over  half  a  century  ago, 
convinced  that  various  maladies  were  due  to  parasites,  treated  wounds  with 
a  solution  of  corrosive  sublimate.  It  is  also  true  that  Semmelweis  in  1847 
demonstrated  the  infectiousness  of  puerperal  fever  and  the  method  of  prevent- 
ing it;  that  Jules  Lemaire  in  1863  published  a  treatise  on  carbolic  acid  and 
advocated  the  use  of  this  drug  in  the  treatment  of  wounds  in  order  to  destroy 
living  germs,  and  that  Bottini  in  1866  employed  carbolic  acid  in  the  treatment 
of  putrid  and  suppurating  wounds  because  he  believed  germs  to  be  responsible 
for  such  conditions  (Monti  on  "Modern  Pathology").  In  spite  of  the  above 
facts,  Lister  is  the  real  father  of  asepsis  and  taught  all  nations  how  to  prevent 
infection.  Monti  says:  "But  Lister,  with  that  practical  spirit  which  forms 
one  of  the  best  characteristics  of  English  genius,  from  the  scientific  studies 
of  Pasteur,  deduced  the  general  laws  of  antisepsis  and  the  rules  for  their 
methodical  application  to  practical  surgery. "  Lister  called  the  attention  of 
the  profession  to  a  new  method  of  treating  wounds,  compound  fractures, 
and  abscesses  in  1867.*  The  processes  first  employed  were  extremely  com- 
plicated, but  have  been  made  in  the  last  few  years  simple  and  easy  of  per- 
formance. Lister  believed  the  chief  danger  to  be  from  air.  It  is  now  believed 
that  the  chief  danger  is  from  actual  contact  of  hands,  instruments,  dressings, 
or  foreign  bodies  with  a  wound.  Air  carries  but  few  micro-organisms  unless 
it  is  filled  with  dust.  Infection  through  air  is  most  apt  to  occur  if  the  air  is 
dusty,  and  is  more  common  after  an  aseptic  than  an  antiseptic  operation. 

Of  course,  some  bacteria  from  the  air  must  settle  in  every  wound,  but 
the  majority  of  the  air  fungi  are  harmless.  Comparatively  few  reach  the  wound 
unless  the  air  is  dusty,  and  these  few  the  tissues  are  usually  able  to  destroy. 
Schimmelbusch  made  experiments  in  v.  Bergmann's  clinic  when  the  stu- 
dents were  present.  He  found  that  "the  number  of  bacteria  which  settle  upon 
the  surface  of  a  wound  a  square  decimeter  in  extent,  in  the  course  of  half  an  hour, 
is  about  60  or  70,"  and  thousands  are  usually  required  to  produce  infection. 

There  is  no  danger  of  infection  being  produced  by  the  breath  of  spectators. 
Air  which  comes  from  the  lungs  is  germ  free,  and  even  a  large  class  will  not 
infect  the  air  by  breathing,  but  will  rather  help  to  free  it  from  bacteria,  for  the 
lungs  are  filters  for  air  laden  with  micro-organisms.  If  a  surgeon  talks  while  he 
is  operating  he  may  spray  droplets  of  sahva  into  the  wound  and  thus  produce 
*  "Lancet,"  March  i6,  1867;  "Brit.  Med.  Jour.,"  August  9,  1867. 


56  Asepsis  and  Antisepsis 

injection.  In  order  to  obviate  this  danger  some  surgeons  wear  masks  of  gauze 
before  the  nose  and  mouth.  A  conversational  assistant  is  a  danger  and  a  sur- 
geon should  direct  his  remarks  away  from  the  wound  and  not  toward  it.  The 
surgeon  and  his  assistant  should  wear  caps  to  keep  hair  from  falling  in  the 
wound.  The  clean  shaven  face  is  not  a  peril  to  the  patient,  the  face  "  bearded 
like  the  pard"  may  be.     A  bearded  man  should  wear  a  mask. 

The  more  simple  the  operative  technic  the  better  and  the  more  certain  is  it 
to  be  carefully  carried  out.  As  Desault  said,  "The  simplicity  of  an  operation 
is  the  measure  of  its  perfection."  The  fewer  assistants  that  are  used  the  better 
and  no  hands  but  the  surgeons  thould  enter  the  wound  unless  others  are  ab- 
solutely required. 

In  performing  any  surgical  operation  cutting  is  better  than  tearing  by 
blunt  dissection.  The  former  method  makes  an  incised  wound,  the  latter  a 
lacerated  wound.  .In  an  incised  wound  there  is  a  minimum  amount  of  dam- 
age and  there  will  be  rapid  repair.  In  a  lacerated  wound  some  necrosis  occurs 
and  there  is  great  lowering  of  tissue  resistance,  hence  a  lacerated  wound  is  much 
more  apt  to  become  infected  than  is  an  incised  wound. 

Surgical  cleanliness  may  be  obtained  by  either  the  aseptic  or  the  antiseptic 
method.  In  the  aseptic  method,  heat,  chemical  germicides,  or  both  are  used 
to  cleanse  the  instruments,  the  field  of  operation,  and  the  hands  of  the  surgeon 
and  his  assistants,  the  surface  being  freed  from  the  chemical  germicide  by 
washing  with  boiled  water  or  with  saline  solution.  After  the  incision  has 
been  made  no  chemical  germicide  is  used,  the  wound  being  simply  sponged 
with  gauze  sterilized  by  heat;  if  irrigation  is  necessary,  boiled  water  or  normal 
salt  solution  is  used,  and  the  wound  is  dressed  with  gauze  which  has  been 
rendered  sterile  by  heat.  The  effort  of  the  surgeon  is  simply  to  prevent  the 
entrance  of  micro-organisms  into  the  tissues.  Some  micro-organisms  must 
enter,  but  the  number  will  be  so  small  that  they  will  be  destroyed  by  healthy 
tissues.  The  aseptic  method  should  be  used  only  in  non-infected  areas.  If 
chemical  germicides  are  not  used,  there  will  be  a  minimum  amount  of  irritation, 
few  cells  will  be  destroyed,  the  amount  of  wound-fluid  will  l)e  small,  the  surgeon 
can  often  dispense  with  drainage,  and  repair  will  be  rapid.  If  a  wound  is 
to  be  closed  without  drainage,  every  point  of  bleeding  must  be  ligated.  Many 
wounds  are  closed  by  interrupted  through-and-through  sutures.  Some  wounds 
are  closed  in  layers.  If  a  wound  is  closed  in  layers,  muscle  being  against  mus- 
cle, fascia  against  fascia,  etc.,  the  skin  may  be  closed  by  interrupted  sutures  or 
by  Halsted's  subcuticular  stitch  (Fig.  273).  If  this  stitch  is_  employed,  the  skin 
staphylococcus  does  not  obtain  access  to  stitch-holes,  and  stitch-abscesses  are 
not  apt  to  arise.  This  suture  may  consist  of  catgut,  silk,  or,  preferably,  silver 
wire,  this  latter  agent  being  capable  of  certain  sterilization  by  heat  and  exercis- 
ing a  powerful  inhibitory  action  on  micro-organisms.  If  a  wound  is  closed 
without  drainage,  firm  compression  is  applied  over  the  wound  to  obliterate  any 
cavity  which  may  exist.  Such  a  cavity  is  called  a  dead  space.  If  a  dead 
space  is  allowed  to  remain  wound-fluid  will  gather,  tissue  resistance  will  be 
lowered,  and  the  wound-fluid,  the  tissue,  or  both  may  become  infected. 
Drainage  must  be  used  if  the  wound  is  very  large,  if  its  shape  or  struc- 
ture prevents  the  obliteration  of  the  cavity  by  pressure,  if  there  is  any 
doubt  as  to  the  perfect  cleanliness  of  the  part,  if  the  patient  is  very  fat,  for 
in  such  individuals  fat  necrosis  predisposes  to  sepsis  and  to  fat  embolism. 


Preparation  for  an  Operation  57 

and  if  the  skin  is  so  thin  that  we  fear  pressure  will  produce  sloughing  ("A 
Manual  of  Surgical  Treatment,"  by  Cheyne  and  Burghard).  In  some 
regions  of  the  body  wounds  are  sealed  with  collodion  or  iodoform-collo- 
dion.  If  irrigation  is  not  practiced  and  the  wound  is  dressed  with  dry  sterile 
gauze,  the  procedure  is  said  to  be  by  the  ^'dry^^  aseptic  inethod.  In  the 
antiseptic  method  the  same  preparations  are  made  for  the  operation  as  in  the 
aseptic  method,  but  during  the  operation  sponges  impregnated  with  a  chemi- 
cal germicide  are  used,  and  the  wound  is  dressed  with  gauze  containing  cor- 
rosive sublimate  or  some  other  chemical  germicide.  If  the  wound  is  not 
flushed  with  a  chemical  germicide,  and  is  dressed  with  dry  antiseptic  gauze, 
the  operation  is  said  to  be  by  the  "dry''  antiseptic  method.  The  antiseptic 
method  is  preferred  in  infected  areas.  Dry  dressings  are  usually  preferable 
to  moist  dressings  in  treating  aseptic  wounds,  because  they  are  more  absorbent 
and  do  not  act  as  poultices,  and  dry  dressings  may  be  used,  even  when  the 
wound  has  been  flushed.  Some  surgeons  question  the  value  of  antiseptic 
irrigation  in  a  septic  wound,  but  I  believe  it  removes  many  bacteria  and 
much  poisonous  matter  and  also  antidotes  toxic  material.  In  suppurating 
areas  it  is  often  best  to  use  moist  dressings  in  the  form  of  antiseptic  fomen- 
tations. Year  by  year  the  aseptic  method  becomes  more  popular.  Surgeons 
have  learned  that  the  most  important  factor  in  asepsis  is  mechanical  cleans- 
ing by  means  of  soap  and  water.  The  chemical  germicide  plays  a  secondary 
rather  than  a  vital  part.  By  mechanical  cleansing  great  numbers  of  micro- 
organisms are  removed  along  with  dkt,  grease,  and  epithelium.  Many 
bacteria  remain,  but  vast  hordes  are  washed  away,  and  the  danger  of  infec- 
tion is  greatly  lessened  by  thus  diminishing  the  number  of  bacteria.  If  a 
chemical  germicide  is  used  without  preliminary  mechanical  cleansing,  it  is 
useless,  because  it  cannot  destroy  bacteria  in  the  epithelium  and  in  masses 
of  oily  matter.  After  mechanical  cleansing  the  germicide  is  active  in  destroy- 
ing the  comparatively  few  bacteria  which  are  naked  on  the  surface.  In  many 
regions  a  strong  chemical  germicide  must  not  be  used  (in  the  abdomen,  in 
the  brain,  in  joints,  in  the  pleural  sac,  and  in  the  bladder),  and  in  other 
regions  (mucous  surfaces  and  fatty  tissue)  it  is  productive  of  harm  rather 
than  good. 

Preparation  for  an  Operation. — If  the  operation  is  to  be  performed 
in  a  hospital  there  is,  of  course,  an  operating  room  always  ready.  If  it  is  to 
be  done  in  a  private  house,  much  careful  preparation  is  desirable.  The 
operating  room  should  be  warm,  but  not  very  warm.  The  desirable  tempera- 
ture is  78°  to  80°  F.  Over  80°  F.  is  too  warm,  causes  vascular  relaxation  in  the 
patient,  and  makes  the  surgeon  perspire  and  wear  out.  The  patient  is  kept 
warm  by  certain  special  methods.  He  may  be  placed  on  a  table  heated  by  hot 
water  or  electricity  or  he  may  be  surrounded  by  hot-water  bags.  Any  large 
raw  surface  is  kept  covered  as  far  as  possible  with  pads  of  gauze  wrung  out  of 
hot  salt  solution  and  frequently  changed.  Protruding  intestines  are  treated  in 
the  same  way.  Every  effort  is  made  to  avoid  soaking  the  patient's  skin  with 
fluids,  because  as  they  cool  they  will  chill  him.  A  room  in.  which  an  operation 
is  to  be  performed  should  be  well  Hghted  and  well  ventilated.  The  northern 
light  is  the  best.  It  is  advantageous  to  have  an  open  grate  in  the  room,  for  then 
a  wood  fire  can  be  quickly  made  to  take  a  chill  off  the  air  and  ventilation  is  im- 
proved.    The  morning  before  the  operation  the  furniture  should  be  removed, 


58 


Asepsis  and  Antisepsis 


the  carpet  taken  up,  and  the  curtains  and  hangings  taken  down.  If  the  ceiling 
and  walls  are  papered,  they  must  be  thoroughly  brushed.  If  they  are  painted, 
they  must  be  washed  with  soap  and  water.  Dust  is  thus  removed  and  the  dan- 
ger of  dust  falling  into  the  wound  is  averted.  The  floor  is  scrubbed  with  soap 
and  water.  The  windows  should  be  opened  for  many  hours  to  thoroughly  dry 
and  freshen  the  room.  On  the  morning  of  the  operation  the  windows  are 
closed  and  newspapers  are  tacked  up  so  as  to  cover  the  lower  half  of  each  win- 
dow. Plenty  of  light  is  admitted  and  the  curiosity  of  neighbors  across  the  street 
cannot  be  satisfied.  The  patient's  bed  is  brought  into  the  room  and  placed 
in  a  position  where  there  will  be  plenty  of  light  for  future  dressings,  and  where 
the  surgeon  will  have  access  from  either  side.  In  order  that  there  may  be 
access  from  each  side  the  bed  must  not  be  in  a  corner  or  against  the  wall. 
Never  use  a  big  broad  bed;  use  a  narrow  bed.  Never  have  a  feather  bed,  but 
insist  on  Treves's  advice  being  followed,  and  employ  a  metal  bed  with  a  wire 
netting  and  hair  mattress. 

A  piece  of  carpet  or  rug  is  spread  upon  a  portion  of  the  floor  and  the  table 
is  set  upon  it.  The  table  should  be  so  placed  that  there  will  be  a  good  light 
on  the  field  of  operation.  There  are  several  tables  which  are  very  satisfac- 
tory. The  best  for  a  private  house  operation  is  Lilienthal's  (Figs.  30  and 
31).  This  table  can  be  folded  into  a  small 
compass,  can  be  carried  in  a  case  with  a 
handle,  and  is  comparatively  light  and 
easily  transportable.     It  can  be  rapidly 


Fig.  24.  —  Plain  d4>uble  wash-stand. 


Fig.  25. — Revolving  wash-stand. 


set  up,  is  firm,  and  it  enables  the  surgeon  to  obtain  the  Trendelenburg  posi- 
tion at  any  moment.  A  kitchen  table  does  very  well.  If  a  kitchen  table  is 
used  and  the  abdomen  is  to  be  opened  a  frame  should  be  at  hand  which, 
when  slipped  under  the  patient,  enables  the  surgeon  to  obtain  the  Trendelen- 
burg position.  Dr.  Joseph  Price  uses,  instead  of  a  table,  two  trestles  and  a 
board  like  an  ironing  board.  In  hospital  work  I  use  Boldt's  table  (Figs.  28 
and  29).  On  the  table  or  board  is  placed  a  folded  comfortable  or  several 
folded  blankets  and  Kelly's  pad  to  catch  fluids  is  laid  upon  the  blankets  and 
is  so  placed  that  fluid  used  in  irrigation  will  flow  into  it  and  will  be  conducted 
by  it  to  a  suitable  receptacle. 

Around  the  operating  table  at  proper  distances  are  arranged  a  table  for 
instruments,  a  table  for  dressings,  a  table  for  sponges  and  a  basin  of  bichlorid, 
and  a  table  for  soap  and  a  basin  of  water.     Ordinary  wooden  tables  may  be 


Preparation  for  an  Operation 


59 


used  if  they  are  covered  with  towels  wet  in  corrosive  sublimate  solution.  In 
a  hospital  special  tables  are  used.  They  are  of  iron  with  glass  tops.  Ordi- 
nary basins  may  be  used,  but  enameled  or  glass  basins  in  stands  (Figs.  24 
and  25)  are  the  most  satisfactory.  A  couple  of  buckets  should  be  placed 
on  the  floor  near  at  hand.  Enameled  buckets  are  the  best  ones  to  use.  The 
nurses  and  assistants  should  have  ready  the  ether  cone,  wrapped  in  a  clean 


Fig.   26. — Porcelain  surgical  tray. 


Fig.  27. — Glass  surgical  tray. 


towel,  sterile  sheets,  sterile  gowns,  sterile  towels,  sterile  gauze  for  sponges  and 
dressings,  trays  for  instruments  (Figs.  26  and  27),  iodoform  gauze,  catgut, 
silk,  silkworm  gut,  hot  normal  salt  solution,  etc.,  according  to  the  nature  of 
the  operation.  The  surgeon  should  pick  out  the  instruments  required.  The 
anesthetizer  should  lay  out  a  mouth-gag,  tongue-forceps,  a  h}^odermatic 
syringe  in  working  order,  ether  or  chloroform,  brandy,  tablets  of  strychnin, 
and  also  of  atropin,  and  a  cylinder  of  oxygen. 


Fig.  28.— Boldt's  operating  table. 

IVIost  surgeons  have  the  operative  field  sterilized  the  day  before  the  opera- 
tion, except  in  an  emergency  case.  Of  late  I  have  been  doing  it  after  the  patient 
has  been  anesthetized  and  find  this  plan  more  comfortable,  less  troublesome, 
and  equally  effective. 

When  the  time  for  the  operation  arrives,  the  surgeon  and  his  assistants 
remove  their  clothing  and  put  on  duck  trousers  and  thin,  short-sleeved  shirts  of 


6o 


Asepsis  and  Antisepsis 


white  muslin.  After  sterilizing  the  hands  and  forearms  they  envelop  their 
bodies  in  aseptic  or  antiseptic  sheets  or  gowTis,  to  protect  the  patient  and  them- 
selves, and  put  on  sterile  muslin  caps.  The  caps  prevent  hair,  dandrutJ, 
and  sweat  falling  into  the  wound.  Mikulicz  and  some  other  operators  wear 
over  the  mouth  and  nose  a  respirator  or  piece  of  gauze  in  order  to  prevent 
saliva  or  mucus  being  projected  into  the  wound  while  the  surgeon  talks. 

Danger  from  the  Hands. — It  is  a  difficult  or  impossible  matter  to  abso- 
lutely sterilize  the  hands,  but  it  is  fortunate,  as  Mikulicz  and  FRigge  say,  that 
most  of  the  bacteria  of  the  skin  are  harmless.  The  staphylococcus  epidermidis 
albus,  however,  is  constantly  present  in  the  epidermis.  The  hands  of  some 
persons  are  more  easily  sterilized  than  those  of  others.  For  instance,  a  hairy, 
creased  hand  is  more  difficult  to  sterilize  than  a  smooth  and  almost  hair- 


Fig.  29. — Boldt's  operating  table. 


less  one;  a  hand  grossly  neglected,  than  one  reasonably  clean.  Germs  abound 
in  the  epidermis,  in  the  fissures  and  creases,  under  and  around  the  nails,  on 
hairs,  and  in  ducts  of  glands.  The  surface  of  the  hands  may  be  thoroughly 
sterile  at  the  beginning  of  an  operation  and  become  infected  later,  because 
germs  in  gland  ducts  are  forced  to  the  surface.  Hence,  in  a  prolonged  opera- 
tion, the  surgeon,  if  he  does  not  wear  gloves,  should  from  time  to  time  stop 
operating  and  wash  his  hands,  first  in  alcohol  and  then  in  corrosive  sublimate 
solution  (Leonard  Freeman). 

In  view  of  the  difficulty  of  cleansing  the  hands,  every  student  must  be 
taught  ho-^v  to  do  it,  and  he  must  become  impressed  with  the  fact  that  the 
surgical  hand  is  to  be  regarded  as  reaching  to  the  elbow.  The  more  hands 
used  in  an  operation,  the  greater  is  the  danger  of  infection  of  the  wound. 
The  surgeon  uses  retractors  and  forceps  whenever  possible,  but  his  fingers 


Mechanical  Clcansin<];  of  Hands  and  Forearms 


6i 


must  enter  the  wound.  The  fingers  of  no  other  person  should  enter  unless 
absolutely  necessary.  The  basis  of  all  plans  of  sterilization  and  the  most 
important  part  of  any  plan  is  mechanical  cleansing  by  scrubbing  with  soap 


Fig.  30. — Lilienthal's  portable  operating  table. 


Fig.  31. — Lilienthal's  portable  operating  table,  folded. 


and  water.     By  this  means  a  quantity  of  loose  epidermis  is  removed  and  with 
it  great  numbers  of  bacteria. 

Mechanical  Cleansing  of  the  Hands  and  Forearms. — The  hands  and 


62 


Asepsis  and  Antisepsis 


forearms  may  be  sterilized  in  several  ways.  Any  method  is  preceded  by 
mechanical  cleansing,  which  is  carried  out  as  follows:  Scrub  for  five  min- 
utes with  soap  and  hot  sterile  water,  giving  special  attention  to  the  nails 
and  creases  in  the  skin.  The  water  should  be  as  hot  as  can  be  borne  with 
comfort,  as  hot  water  stimulates  the  sweat  glands  and  the  flow  of  sweat  washes 
out  the  ducts.  If  the  ducts  are  washed  out  before  the  operation  by  copious 
sweating,  during  the  operation  the  secretion  will  be  slight.  The  brush  is 
rubbed  in  the  long  axis  of  the  extremity  and  also  transversely.  The  creases 
on  the  back  of  the  hands  and  fingers  will  be  partially  opened  by  flexing 
the  fingers,  and  transverse  scrubbing  will  clean  the  furrows.  The  furrows 
on  the  palmar  surface  will  be  opened  by  extending  the  fingers,  and  will  be 
best  cleaned  by  transverse  scrubbing  (George  Ben  Johnston).  An  excellent 
soap  is  the  ethereal  soap  of  Johnston,  which  is  a  solution  of  castile  soap  in  ether. 
Green,  or  castile  soap  can  be  used.  Many  surgeons  use  synol  soap.  It  is 
an  admirable  cleanser  but  there  is  no  particular  advantage  in  using  a  soap 
containing  a  germicide,  as  such  a  soap  is  practically  without  germicidal 
power.  The  brush  employed  should  be  kept  in  a  i  :  looo  solution  of  cor- 
rosive sublimate  or  should  have  been  recently  sterilized  with  steam  and  kept 
in  a  sterile  glass  box  (Fig.  32).     The  nails  are  cut  short,  are  cleansed  with  a 

knife  or,'  better,  with  an  orange-wood 
stick,  which  does  not  scratch  them, 
and  the  hands  are  again  scrubbed. 
Very  prolonged  or  very  rough  scrub- 
bing, especially  with  harsh  agents  like 
marble  dust  or  sand,  is  actually  harm- 
ful as  it  tends  to  crack  the  hands  and 
make  them  rough  and  it  extensively 
loosens  epidermis  which  may  drop  into 
the  wound.  Epidermis  may  contain 
bacteria  within  it  and  may  infect  the 
wound. 
Sterilization  of  the  Hands  and  Forearms.— After  mechanical  cleans- 
ing a  germicide  is  employed  to  render  the  parts  sterile.  Whatever  method 
is  adopted  it  is  desirable  that  it  shall  not  unduly  irritate  the  skin.  An  occa- 
sional operator  may  use  without  injury  tolerably  strong  chemicals,  but  the 
busy  hospital  surgeon,  who  operates  perhaps  several  times  or  many  times  a 
day,  cannot  use  them.  Any  method  which  inflames,  cracks  or  roughens  the 
skin  makes  future  sterilization  difficult  or  impossible,  hence  such  a  method  is 
undesirable.     Four  methods  are  described  here: 

Filrhringefs  Method:  After  washing  off  the  soap  in  sterile  water  the  hands 
are  dipped  in  95  per  cent,  alcohol  and  held  there  for  two  or  three  minutes  while 
the  forearms,  hands,  fingers,  and  nails  are  being  rubbed  with  alcohol.  Alcohol 
removes  the  soap  which  has  entered  into  follicles  and  creases,  removes  desqua- 
mated epithelium,  enters  under  and  about  the  nails,  and  favors  the  diffusion 
of  the  corrosive  sublimate  under  the  nails  and  into  the  follicles,  when  the  hands 
are  placed  later  in  the  mercurial  solution.  Alcohol  also  hardens  epithelium 
and  keeps  it  from  desquamating  into  the  wound.  After  using  the  alcohol 
the  hands  are  then  dipped  in  a  hot  solution  of  corrosive  sublimate  (i  :  1000), 
and  with  the  forearms  are  scrubbed  for  at  least  a  minute,  the  nails  receiving 
especial  care. 


Fig.  32  — Glass  brush-box  wilh  cover 


The  Use  of  Gloves  63 

The  W el ch- Kelly  Method:  After  the  hands  and  forearms  have  been  cleansed 
mechanically  and  have  been  rinsed  in  sterile  water  they  are  immersed  for 
two  minutes  in  a  warm  solution  of  permanganate  of  potassium  (a  saturated 
solution  in  distilled  water).  This  solution  causes  the  cutaneous  surface  to 
assume  a  very  dark  brown  color.  The  hands  and  forearms  are  then  immersed 
in  a  warm  saturated  solution  of  oxalic  acid  and  are  held  there  until  decolor- 
ized. They  are  then  well  washed  in  sterile  water,  are  next  immersed  for 
two  minutes  in  a  i  :  500  solution  of  corrosive  sublimate,  and  finally  are  rinsed 
in  sterile  water  and  dried  on  a  sterile  towel.  The  solutions  for  use  in  the  above 
method  should  be  contained  in  jars  of  the  shape  of  a  druggist's  percolator 
so  that  both  the  hands  and  forearms  can  be  immersed  at  the  same  time.  In 
this  method  the  permanganate  of  potash  is  merely  an  oxidizer  and  the 
oxalic  acid  is  the  active  germicide.  The  skin  of  some  persons  tolerates  the 
plan  very  well,  others,  among  whom  is  the  author,  find  the  oxalic  acid  deci- 
dedly irritant  when  used  several  times  in  a  day. 

The  Weir-Stimson  Method:  This  method  was  suggested  by  Mr,  Rausch- 
enberg,  the  pharmacist  of  the  New  York  Hospital,  and  it  was  practically 
applied  by  Doctors  Weir  and  Stimson.  The  process  is  as  follows:  The  hands 
should  be  cleansed  mechanically  as  previously  directed  or,  as  Weir  prefers, 
by  scrubbing  with  a  brush  and  green  soap  and  in  running  hot  water  and  clean- 
ing under  the  nails  with  a  piece  of  soft  wood.  Place  about  a  tablespoonful 
of  chlorinated  lime  in  the  palm  of  the  hand,  place  upon  the  lime  a  piece  of 
crystalline  carbonate  of  soda  (washing  soda)  one  inch  square  and  half  an 
inch  thick,  add  a  little  water,  and  rub  the  creamy  mixture  over  the  arms  and 
hands  until  the  rough  granules  of  sodium  carbonate  are  no  longer  felt.  This 
requires  from  three  to  five  minutes.  At  first  there  is  a  sensation  of  heat  usually 
followed  by  a  sensation  of  coolness.  Place  the  paste  under  and  around  the 
nails  by  means  of  a  bit  of  sterile  orange-wood.  Wash  the  arms  and  hands 
in  hot  sterile  water.*  Remove  the  odor  of  chlorin  by  washing  the  hands  and 
arms  in  sterile  ammonia  water  of  a  strength  of  from  ^  per  cent,  to  i  per  cent. 
(McBurney,  CoUins,  and  Oastler,  in  " International  Text-Book  of  Surgery"). 
The  combination  of  carbonate  of  sodium  and  chlorinated  lime  is  said  to  set  free 
nascent  chlorin,  a  most  efficient  germicide.  This  method  has  proved  extremely 
efficient  in  the  clinic  of  the  Jefiferson  Medical  College  Hospital,  although 
when  employed  several  times  a  day  it  may  prove  decidedly  irritant.  It  is 
important  that  crystalhne  washing-soda  be  employed.  If  the  bicarbonate 
is  used,  nascent  chlorin  will  not  be  produced,  but  hydrochloric  acid  gas 
will  be  formed,  and  the  latter  gas  irritates  the  skin  and  is  not  a  satisfactory 
germicide. 

The  Sublimate-Alcohol  Method:  This  is  the  method  I  personally  prefer. 
It  is  as  follows :  Cleanse  the  hands  with  soap  and  water  as  previously  directed. 
Use  95  per  cent,  alcohol  as  in  Fiirbringer's  method  (page  62) .  Dip  the  hands 
in  70  per  cent,  alcohol  containing  i  part  to  1000  of  corrosive  sublimate,  and 
rub  the  hands,  forearms,  and  nails  with  a  piece  of  sterile  gauze  wet  with  this 
fluid  for  three  minutes.  Rinse  these  parts  in  the  fluid  and  then  rinse  in 
sterile  water. 

The  Use  of  Gloves. — Some  surgeons  are  so  impressed  with  the  impos- 
sibility of  sterilizing  the  hands  that  they  wear  gloves  in  operations.  Hunter 
*  Medical  Record,  April  3,  1897. 


64 


Asepsis  and  Antisepsis 


Robb  is  said  to  have  suggested  the  use  of  gloves  in  1894,  but  Halsted  began 
to  use  rubber  gloves  in  1889.  MikuUcz  used  white  cotton  gloves.  Lockett 
has  proved  that  cotton  and  silk  are  not  impervious  to  micro-organisms,  but 
that  rubber  is.  The  thin,  seamless  rubber  gloves  which  are  now  made  are 
very  satisfactory.  They  are  sterilized  by  boiling,  are  then  dried,  and  are 
wrapped  in  a  sterile  towel.  In  order  to  insert  the  hand  in  them  the  hand  should 
be  dried,  the  interior  of  the  glove  should  be  dusted  with  sterile  starch  or  talc 
powder,  and  then  the  nurse  should  fold  forward  the  wrist  part  and  hold  the 
glove  open  while  the  surgeon  inserts  his  fingers  into  the  proper  compartments 
and  pushes  the  hand  in.  The  custom  of  filling  the  glove  with  sterile  fluid  and 
then  inserting  the  hand  is  troublesome  and  objectionable,  because  the  fingers 
soon  become  sodden  like  those  of  a  washwoman,  the  sense  of  touch  is  im- 
paired, considerable  discomfort  is  occasioned,  and  the  skin  is  apt  to  crack  open. 


Fig-  33- — Showing  rubber  glove  applied. 


If,  during  an  operation,  a  glove  becomes  infected,  a  clean  one  can  be 
substituted  for  it.  Gloves  somewhat  impair  the  sense  of  touch,  but  a  surgeon 
soon  learns  to  work  with  them.  If  they  are  to  be  used,  the  hands  should  be 
sterilized  just  as  carefully  as  when  they  are  not  to  be  used,  because,  during 
the  operation,  the  gloves  may  tear  or  be  punctured  by  a  needle.  I  always  wear 
gloves,  but  that  it  is  absolutely  necessary  to  wear  gloves  in  all  cases  has  not  been 
proved.  Their  use  does  contribute  to  success  in  brain  operations,  abdominal 
operations,  and  joint  operations.  They  are  of  great  value  in  militar}'  surgen.^, 
for  the  military  surgeon  may  not  have  time  to  prepare  his  hands,  and  sterile 
gloves  can  be  always  kept  ready  prepared. 

When  a  surgeon  is  obliged  to  place  his  fingers  in  an  area  of  virulent  infec- 
tion he  may  be  poisoned.  Gloves  will  save  him  from  this  danger.  Again, 
a  surgeon  should  try  to  avoid  bringing  his  bands  unnecessarily  in  contact 
with  putrid  or  purulent  matter.  Though  it  may  not  poison  him,  it  grossly 
infects  the  surface,  renders  subsequent  cleansing  difl&cult,  and  endangers 
other  patients.      Gloves  will  prevent  this  danger.     A  surgeon  should  wear 


Instruments 


65 


Fig.  34.— Half-long  rubber  glove. 


gloves  if  he  is  making  an  examination  or  performing  an  operation  which  is 
sure  to  infect  the  bare  hands,  and  he  should  wear  gloves  in  an  operation  if  in  a 
previous  operation  his  hands  were  infected.*  A  surgeon  whose  hands  are 
very  hairy  or  sweat  much  will  contribute  to  the  patient's  safety  by  wearing  gloves. 

Gloves  should  be  worn  if  the  surgeon  has  a  wound  or  sore  upon  his  hand 
or  chapped  hands.  When  using  gloves  in  a  prolonged  operation  dip  the 
covered  hands  now  and  then  in  corrosive  subHmate  solution,  because  the 
glove  may  have  been  punctured  or  dust  may  have  settled  upon  it  from  the  air. 

Gloves  make  the  hands  sweat  and  if  one  should  be  punctured  considerable 
sweat  may  emerge  from  the  puncture  and  enter  the  wound  and  sweat  often 
contains  bacteria.  The  entry  of  any  consider- 
able amount  of  sweat  is  more  dangerous  to  the 
patient  than  are  well  cleaned  naked  hands, 
hence  gloves  may  actually  favor  the  infection 
they  are  meant  to  prevent.  When  they  are 
used  the  surgeon  must  take  scrupulous  care 
not  to  puncture  them  with  a  needle,  clip  them 
with  forceps,  or  tear  them  with  a  ligature  or  suture. 

The  closer  they  fit  the  less  the  danger  of  puncture  and  one  should  know 
accurately  what  size  he  requires  to  fit  closely  and  smoothly  without  being  so 
tight  as  to  make  the  fingers  numb. 

Preparation  of  Gloves. — \\'ash  with  soap  and  water  containing  a  little  ammo- 
nia, rinse  in  sterile  water,  boil  for  thirty  minutes  in  a  i  per  cent,  solution  of  car- 
bonate of  soda.  Dry  the  glove  and  wrap  in  a  dry  sterile  towel  and  keep  imtil 
it  is  needed.  A  pair  of  gloves  should  stand  about  20  boilings.  The  surgeon 
should  carry  a  number  of  pairs  of  prepared  gloves  in  his  bag,  for  the  use  of 
himself  and  assistants  in  private  house  operations. 

Instruments  are  disinfected  by  subjecting  them  to  the  action  of  steam 
in  a  special  sterilizer,  or  better  by  boiling  them  for  fifteen  minutes  in  a  i  per 
^  cent,   solution   of   carbonate   of  sodium. 

They  are  wrapped  into  a  bundle  by 
means  of  a  towel  or  piece  of  gauze  and 
are  dropped  into  the  solution.  The 
blades  of  knives  should  first  be  ^Tapped 
in    cotton    to    prevent    scratching    and 


Fig.  35- — iJ,  Schimmelbusch's  gas-heated  apparatus  for  sterilizing  instruments;  b,  wire  basket. 

dulling.     After  boiHng,  the  instruments  should  be  rinsed  in  hot  sterile  water 

*A  review  of  the  literature  of  disinfection  of  the  hands,  by  Martin  B.  Tinker  and  A. 
B.  Craig,  will  be  found  in  the  Phila.  Med.  Journal,  Feb.  15,  1902.  See  also  Edgar  R. 
McGuire,  in  "The  Best  Method  of  Hand  Sterilization,"  in  American  Medicine,  Feb.  28, 
1903;  Robert  T.  Morris,  on  "Rubber  Gloves  in  Surgerv^"  New  York  Medical  Journal, 
Nov.  22,  1902;  and  "Sterilization  of  the  Hands,"  by  Charles  Leedham-Green,  in  the 
Birmingham  Med.  Review,  April,  1904;  Nicholas  Senn,  in  Surgery,  Gynecology,  and 
Obstetrics,  July,  1905  ;  Reverdin  and  ^Slassol,  in  Brit.  Med.  Jour.,  Oct.  7,  1905  ;  K. 
Vogel,  in  Deutsche  Medizinische  Woch.,  Jul\  27,  1905  ;  J.  R.  Williamson,  in  Brit.  Med, 
Jour.,  Alay  14,  1904. 


66  Asepsis  and  Antisepsis 

or  in  a  5  per  cent,  solution  of  carbolic  acid  and  be  kept  until  needed  in  a  pan 
of  sterile  water.  The  carbonate  of  sodium  prevents  rusting.  In  a  clinic 
the  boiHng  is  carried  out  in  a  Schimmelbusch  sterilizer  (Fig.  35).  In  a 
private  house  it  can  be  done  in  a  sterilizer  such  as  that  shown  in  Fig.  36,  or 
in  a  pan,  a  kettle,  or  a  wash-boiler.  A  sterilizer  with  a  tray  is  better  than 
an  ordinary  pan  or  kettle,  because,  when  the  latter  is  used,  the  metal  instru- 
ments lie  in  the  bottom  of  the  \essel,  where  the  heat  is  very  great,  and  the 

temper  may  be  impaired. 
Boiling  unfortunately  destro}^ 
to  some  extent  the  keenness  of 
WJ'^^:^^  ..^ =^  -^-^jf^^l^^  cutting  instruments,  the  ebul- 
lition thro\A"ing  them  about. 
Hence  the  knives  should  be 
A\Tapped  in  cotton  to  preserve 
Fig.  36.-Portabie  sterilizer.  the  edges.     After  Sterilization 

the  instruments  are  placed  in 
trays  containing  boiled  water.  After  the  completion  of  the  operation  the 
instruments  should  be  scrubbed  with  soap  and  water,  boiled  in  soda  solution, 
dried,  and  placed  in  a  closet  with  glass  shelves  so  they  will  not  gather 
dust.  Instruments  can  be  partially  disinfected  by  keeping  them  for  thirty 
minutes  in  a  5  per  cent,  solution  of  carbolic  acid  or  better,  in  a  2  per  cent,  solu- 
tion of  formalin.  Instruments  with  handles  of  wood  must  not  be  boiled.  If 
such  instruments  are  used,  they  can  be  disinfected  by  the  use  of  carbolic  acid' 
or  formalin,  but  they  should  not  be  used.  Metal  instruments,  whenever  pos- 
sible, should  consist  of  one  smooth  piece.  Grooves  and  letters  are  objec- 
tionable, as  dirt  gathers  in  such  depressions.  Ivor}'  handles  cannot  be 
boiled. 

Preparation  of  the  Patient. — Whenever  possible  give  the  patient  some 
days'  rest  in  ijed  before  a  severe  operation.  This  is  not  possible  in  an  emer- 
gency. It  is  seldom  desirable  in  the  case  of  a  highly  nervous  and  excitable 
woman.  Such  a  patient  is  sleepless  and  frightened  and  loses  ground  by  delay. 
In  most  cases  this  preliminar}-  rest  is  advisable.  It  is  particularly  desirable  in 
a  strong  active  working  man  suddenly  translated  from  labor  to  bed.  We  \Aish 
to  prepare  him  to  meet  operative  shock.  During  the  wait  the  patient  is  apt  to 
adjust  himseK  to  his  svuroundings,  he  becomes  accustomed  to  diminished 
acti\ity  and  to  sick-room  routine,  forms  an  acquaintance  with  his  nurses  and 
physicians,  and,  as  a  rule,  becomes  less  nervous  and  more  calmly  confident  of 
the  result.  He  also  learns  to  use  the  bed-pan  and  to  micturate  while  re- 
cumbent. A  patient  while  waiting  is  to  have  a  general  bath  several  times. 
Some  weak  and  emaciated  patients  are  treated  and  built  up  for  weeks  before 
the  operation  is  attempted.  During  this  prehminan-  rest  study  the  disease, 
and  study  the  individual  in  order  to  leam  his  tendencies,  pecuharities.  etc. 
The  condition  of  the  lungs,  the  heart,  the  blood,  and  the  kidneys  should  be 
accurately  determined.  The  amount  of  urine  passed  in  twent}-four  hours 
should  be  ascertained,  and  the  percentage  of  urea  should  be  estimated  from 
a  sample  of  the  twent)--four-hour  urine.  The  urine  is  carefully  examined  for 
sugar,  albumin,  casts,  acetone,  diacetic  acid,  etc.  By  the  above  examinations 
we  may  be  able  to  anticipate  and  provide  against  certain  calamities.     We 


Preparation  of  the  Patient  67 

may  be  led  to  postpone  or  al)and()n  an  operation,  and  we  will  have  the  in- 
formation necessary  in  order  to  intelligently  select  the  proper  anesthetic.  The 
presence  in  the  urine  of  acetone  and  diacetic  acid  forbids  any  but  an  emer- 
gency operation.  Granular  and  fatty  casts  in  the  urine  or  a  considerable 
quantity  of  albumin  make  us  hesitate  to  operate.  A  hemoglobin  percentage 
of  under  50  makes  us  seek  to  avoid  operation  in  most  cases  not  associated 
with  bleeding.  The  anesthetist  should,  during  this  preliminary  period,  ex- 
amine the  heart  and  i)ulse  so  as  to  know  the  natural  character  of  each  when 
the  patient  is  free  from  excitement.  Without  this  preliminary  knowledge  he 
cannot  accurately  appreciate  or  intelligently  interpret  some  changes  induced 
by  the  anesthetic.  Constipation  must  be  amended  by  mild  laxatives  or  enemas, 
and  all  fermented  matter  should  be  removed  from  the  alimentary  canal.  Con- 
stipation increases  the  probability  of  wound  infection  and  greatly  impairs  the 
comfort  of  the  patient.  As  previously  shown,  the  putrefactive  bacteria  in 
the  intestinal  canal,  which  are  usually  harmless  and  are  what  Adami  calls 
"potential  parasites,"  may  escape  into  the  tissues.  The  retention  of  fermented 
matter  causes  catarrhal  inflammation  and  bacteria  escape  more  easily.  If  they 
escape  they  may  lead  to  damage  in  the  wound  and  even  if  wound  infection  from 
within  does  not  occur,  constipation  lessens  vital  resistance  and  increases  the 
liability  to  wound  infection  from  without.  Purgatives  must  not  be  violent,  as 
anything  which  greatly  depresses  a  person  lessens  \'ital  resistance,  and  powerful 
purgatives  are  powerful  depressants.  The  diet  should  be  bland  and  nutritious, 
but  not  bulky.  The  night  before  the  operation  give  a  saUne  cathartic,  and  the 
morning  of  the  operation  employ  an  enema.  Not  only  do  we  empty  the  bowel 
to  lessen  the  UabiUty  to  wound  infection,  but  we  wish  the  rectum  empty  at  the 
time  of  operation  for  another  reason.  It  is  desirable  that  the  rectum  be  empty 
because  in  shock  the  absorbing  power  of  the  stomach  is  greatly  diminished  or  is 
even  aboHshed  for  the  time,  and  we  may  wish  to  utiUze  the  absorbing  power  of 
the  rectum  and  give  stimulants  by  enema.  When  a  patient  is  under  the  influence 
of  an  anesthetic  or  when  he  is  profoundly  shocked,  of  course  no  attempt  is  made 
to  give  stimulants  by  the  mouth.  Whenever  possible  give  a  general  warm  bath 
the  day  before  the  operation.  It  is  the  usual  custom  the  evening  before  the 
operation  to  shave  the  region  if  hairy,  scrub  the  entire  field  of  operation,  as  well 
as  the  adjoining  regions,  with  ethereal  soap  and  water;  wash  vrith  alcohol; 
scrub  with  hot  corrosive  subHmate  solution  (i:  1000);  apply  a  layer  of  moist 
corrosive  subHmate  gauze,  and  place  over  this  dry  antiseptic  gauze,  a  rubber 
dam,  and  a  bandage.  Many  surgeons  apply  a  poultice  of  green  soap  for  many 
hours  before  applying  a  chemical  germicide,  in  order  to  separate  masses  of 
epithehum  and  \vith  them  many  germs.  This  method  is  particularly  useful  in 
cleansing  the  scalp.  On  removing  the  dressings  to  perform  the  operation, 
the  part  is  scrubbed  with  soap  and  water,  and  washed  vrith  sterile  water  and 
then  with  alcohol.  I  have  become  convinced  that  the  teachers  in  Johns  Hop- 
kins Hospital  are  right  and  that  this  preliminary  cleansing  is  not  necessary. 
Neither  is  it  desirable,  as  it  often  gives  the  patient  a  resdess  night.  It  is  my 
custom  to  have  a  hairy  region  shaved  before  the  patient  is  brought  into  the 
operating  room.  All  of  the  rest  of  the  cleansing  is  carried  out  as  just  described, 
after  anesthetization.  In  emergency  cases  disinfection  can  only  be  practised  just 
previous  to  the  operation.    When  the  field  of  operation  has  been  prepared,  sur- 


68  Asepsis  and  Antisepsis 

round  it  with  dry  sterile  sheets  and  towels.  Murphy  prevents  infection  from  the 
cutaneous  surface  by  spreading  a  specially  prepared  rubber  solution  over  the 
steriHzed  operation  area.  The  solution  is  sterile  and  sticks  to  the  skin  and  is 
applied  after  the  skin  has  been  washed,  first  with  ether  and  then  with  alcohol. 
The  rubber  is  dissolved  in  acetone  and  is  painted  on  the  skin.  The  incisions 
are  made  through  the  artificial  skin  of  rubber  and  the  rubber  is  removed  when 
the  surgeon  is  ready  to  introduce  the  sutures.  Thus  infection  of  the  wound  with 
contaminated  secretion  of  the  skin  glands  is  prevented,  for,  as  Murphy  says, 
this  elastic  covering  is  "in  reality  a  non-secreting,  sterile,  artificial  derma  for 
the  period  of  operation"  ("General  Surgery,"  edited  by  John  B.  Murphy,  vol. 
ii.,  1905).  The  patient  must  be  carefully  protected  from  cold  by  wrapping  him 
in  blankets  and  often  by  having  him  wear  specially  prepared  drawers  with  feet. 
After  the  completion  of  an  operation  and  the  application  of  the  dressings  the 
patient  is  returned  to  his  room  or  the  ward,  care  being  taken  to  protect  him 
from  cold  or  draughts. 

Disinfection  of  Mucous  Membranes. — It  is  impossible  to  thoroughly 
disinfect  mucous  membranes.  We  must  not  scrub  forcibly  and  we  must  not 
use  powerful  antiseptics,  because  they  are  irritant  and  also  because  they  may 
be  absorbed.  The  best  that  can  be  done  in  the  vagina  is  to  rub  lightly, 
when  possible,  with  a  bit  of  moist  absorbent  cotton  and  irrigate  with  a  solution 
of  boric  acid  or  with  normal  salt  solution.  Another  method  is  to  sponge  the 
vagina  with  creolin  and  Johnston's  ethereal  soap  (i  and  16)  and  irrigate  with 
hot  saline  fluid  or  boric  acid. 

The  rectum  is  prepared  by  washing  out  all  retained  feces  by  the  use  of 
copious  high  injections  and  by  irrigating  with  salt  solution  or  boric  acid. 

The  mouth  is  prepared  by  having  snags  of  teeth  and  tartar  removed  and 
decayed  teeth  removed  or  plugged.  For  several  days  before  the  operation 
scrub  the  teeth  twice  a  day  with  a  soft  brush  and  castile  soap;  and  every  three 
hours,  when  the  patient  is  awake,  rinse  the  mouth  with  peroxid  of  hydrogen 
and  spray  the  nares  and  nasopharynx  with  boric  acid  solution. 

The  urethra  is  prepared  by  the  administration  for  several  days  of  salol  or 
urotropin  and  by  frequent  irrigation  of  the  urethra  and  bladder  with  boric 
acid  solution  or  normal  salt  solution  or  a  solution  of  permanganate  of  potash 
(i  :  6000). 

Preparation  of  a  Patient  for  an  Operation  Upon  the  Stomach. — (See  page 
1063.) 

The  Tinie  of  Day  to  Operate. — A  hard  and  fast  rule  cannot  be  set  as  to  the 
time  of  day  when  operations  should  be  done.  Emergency  operations  must  be 
performed  at  once  without  any  consideration  as  to  time.  It  is  often  necessary, 
because  of  other  professional  obligations,  to  set  an  afternoon  hour  for  an  opera- 
tion. Whenever  possible,  however,  if  the  nature  of  the  case  admits  of  it,  operate 
in  the  morning  and,  preferably,  in  the  early  morning.  By  doing  this  the  patient 
is  saved  some  hours  of  dread  and  worry  and  the  surgeon  is  enabled  to  operate 
when  he  is  fresh,  active,  and  alert;  in  other  words,  when  he  is  at  his  best.  A  tired 
mind,  like  a  tired  hand,  tends  to  become  shaky,  and  a  tired  mind  may  mean  in- 
correct observation,  careless  technic,  impaired  judgment,  disastrous  timidity,  or 
calamitous  recklessness. 

Irrigation  is  often  practised  in  septic  wounds,  but  is  not  required  in 
aseptic  wounds.     In  a  septic  wound  gentle  irrigation  with  a  germicide  is 


Ligatures  and  Sutures  69 

advisable.  It  removes  bacteria  and  toxins  and  antidotes  retained  toxins. 
Irrigation  must  never  be  forcible  for  fear  it  may  disseminate  infection.  Among 
irrigating  fluids  we  may  mention  corrosive  sublimate,  carbolic  acid,  peroxid 
of  hydrogen,  boric  acid  solution,  and  normal  salt  solution.  Hot  normal 
salt  solution  is  the  best  agent  with  which  to  irrigate  the  peritoneal  cavity,  the 
pleural  sac,  the  interior  of  joints,  and  the  surface  of  the  brain.  This  solution 
contains  0.7  per  cent,  of  sodium  chlorid. 

Many  surgeons  employ  Landerer's  dry  method  in  operating  aseptically. 
No  fluid  is  applied  to  the  wound.  As  the  wound  is  enlarged  gauze  sponges 
are  packed  in  to  arrest  hemorrhage.  On  the  completion  of  the  operation  the 
sponges  are  removed,  bleeding  points  are  ligated,  and  the  wound  is  often 
closed  without  drainage. 

Ligatures  and  Sutures. — In  using  sutures  always  remember  that  they 
must  be  tied  firmly,  but  never  tightly.  A  tight  suture  will  cut  when  the 
wound  swells  and  will  thus  fail  of  its  purpose;  further,  it  produces  an  area 
of  tissue  necrosis,  which  is  a  point  of  least  resistance  in  and  about  which 
infection  is  prone  to  occur.  We  would  far  1)etter  use  many  very  fine 
sutures  than  a  less  number  of  thick  ones.  The  individual  suture  is  weak, 
but  in  numbers  they  give  fine  support.  A  fine  suture  cannot  be  tied  too 
tight.  If  we  make  it  too  tight  the  end  is  frustrated  by  the  breaking  of 
the  suture. 

Catgut. — The  favorite  ligature  material  is  catgut.  Catgut  undergoes  ab- 
sorption in  the  tissues.  Years  ago  attempts  were  made  by  Scarpa,  Crampton, 
and  Physick  to  use  absorbable  ligatures.  Sir  Astley  Cooper  tried  catgut. 
These  attempts  failed  because  the  material  employed  was  septic,  suppuration 
ensued,  the  wound  gaped,  and  the  hgature  was  cast  off  prematurely.  Surgeons 
remained  content  with  non-absorbable  ligatures  of  silk  or  linen.  These 
ligatures  were  not  cut  short,  but  a  long  end  was  left  to  each  one,  and  the 
ends  were  allowed  to  hang  out  of  the  wound.  The  ligatures  were  lightly 
pulled  upon  from  time  to  time,  and  when  they  loosened  or  cut  through  were 
removed.  Catgut  is  the  submucous  coat  of  the  intestine  of  the  sheep,  and 
is  the  material  from  which  violin  strings  are  made.  It  was  reintroduced  into 
surgery  by  Lister.  It  is  obtained  in  the  following  manner:  The  small  intestine, 
after  separation  from  the  mesentery,  is  washed  in  water,  laid  upon  a  board, 
and  scraped  with  a  metal  instrument.  Thus  the  mucous  coat  and  the  muscular 
coat  are  scraped  away,  and  the  submucous  coat  only  remains.  The  sub- 
mucous coat  is  cut  into  strips,  and  each  strip  is  twisted  into  a  coil.  Raw  cat- 
gut is  an  infected  material.  It  is  difficult  to  sterilize,  because  in  the  twisting 
many  organisms  get  into  the  interior  of  the  strand,  where  it  is  impossible  for 
antiseptics  to  reach  them.  Raw  catgut  obtained  from  animals  dead  of 
splenic  fever  contains  spores  of  anthrax.  If  not  thoroughly  disinfected,  catgut 
is  dangerous,  and  some  surgeons  consider  its  cleanhness  always  a  matter 
of  grave  question  and  will  not  use  it.  Surgeon's  catgut  can  be  bought  from 
the  dealer  in  skeins  containing  30  yards.  It  should  be  rough  and  yellow. 
The  smooth  white  variety  should  not  be  purchased.  It  has  been  rubbed  smooth 
with  a  piece  of  glass  and  bleached  with  a  chemical,  and  in  consequence  is 
weak  and  unreUable.  The  smallest  size  is  known  as  double  zero,  then  come 
single  zero.  No.  i,  No.  2,  No.  3,  and  No.  4.     The  usual  ligature  size  is  No. 


7©  Asepis  and  Antisepsis 

2.  Nos.  3  and  4  are  only  used  for  tying  thick  pedicles.  Nos.  i  and  2  are  used 
for  suturing  the  dura  and  peritoneum  and  No.  i  for  tying  smiall  vessels  in  the 
brain.  McBurney  and  Collins  state  that  when  catgut  is  used  to  tie  delicate 
tissue  (omental  masses,  intestinal  surfaces,  etc.),  it  must  first  be  softened  by 
immersing  for  half  a  minute  in  normal  salt  solution.  If  this  precaution  is 
neglected  and  wiry  catgut  is  used,  the  ligature  or  suture  will  cut  and  hem- 
orrhage will  occur.*  I  thoroughly  agree  with  this  statement.  The  greater 
the  diameter  of  the  gut  the  more  uncertain  is  the  sterilization.  Nos.  3  and  4  are 
of  doubtful  cleanliness,  no  matter  what  method  of  sterilization  is  employed,  and 
a  strand  though  clean  upon  the  surface  may  be  infected  in  its  interior.  When 
a  strand  which  is  infected  within  is  used  by  the  surgeon  the  tissues  are  not  in- 
fected promptly,  but  after  some  days  when  the  catgut  has  been  partially  ab- 
sorbed and  the  spores  or  bacteria  within  the  strand  have  been  set  free.  Many 
late  infections  are  due  to  catgut  infected  in  the  interior  of  the  strand.  The 
smaller  sizes  I  believe  can  usually  be  satisfactorily  sterilized.  I  am  very  un- 
certain as  to  the  surgical  cleanliness  of  the  larger  sizes. 

If  catgut  is  thoroughly  freed  from  bacteria  and  the  wound  in  which  it 
is  used  is  aseptic,  it  is  a  most  satisfactory  ligature  material,  is  absorbed 
in  the  wound  after  being  cut  off  short,  and  produces  no  trouble,  although  it 
does  increase  wound  secretion  slightly.  The  smaller  sizes  are  absorbed  in 
four  or  five  days.  No.  2  lasts  from  nine  to  ten  days,  Nos.  3  and  4  from  ten 
days  to  three  weeks.  Chromicized  catgut  is  absorbed  far  less  rapidly  than 
plain  gut. 

One  of  the  following  methods  of  preparation  may  be  used: 

Boiling  in  Alcohol. — The  catgut  is  soaked  in  ether  for  twenty- four  hours 
to  remove  fat.  It  is  then  wound  on  glass  spools,  transferred  to  alcohol,  and 
boiled  under  pressure.  The  boiling  is  conducted  in  a  heavy  metal  jar  with 
a  well-fitting  screw-top.  The  jar  is  half  filled  with  alcohol.  The  spools  of 
catgut  are  placed  in  the  jar,  the  lid  of  the  jar  is  screwed  down,  and  the 
apparatus  is  immersed  in  boiling  water  for  half  an  hour.  The  gut  is  kept  in 
this  jar  until  needed.  Fowler's  catgut  is  prepared  by  boiling  in  alcohol.  It 
is  placed  in  hermetically  sealed  U-shaped  glass  tubes.  Each  tube  contains 
alcohol  and  1 2  ligatures.  The  alcohol  is  boiled  by  immersing  the  tube  in  boil- 
ing water. 

The  Cumol  Alethod. — The  cumol  method  is  employed  by  Kelly  in  the 
Johns  Hopkins  Hospital,  and  is  known  as  Kronig's  method.  Cumol  is  a 
fluid  hydrocarbon  which  boils  at  179°  C.  Catgut  is  wound  upon  spools  of 
glass,  and  these  are  placed  in  a  beaker  glass,  the  bottom  of  which  is  covered 
with  cotton.  A  bit  of  cardboard  is  placed  on  top  of  the  beaker,  and  through 
a  small  perforation  in  the  cardboard  a  thermometer  is  introduced.  The 
beaker  is  placed  in  a  sand-bath  and  the  bath  is  heated  by  means  of  a  Bunsen 
burner.  The  temperature  is  gradually  raised  to  80°  C,  and  is  kept  at  this 
point  for  one  hour,  in  order  entirely  to  remove  moisture  from  the  gut.  Cumol, 
at  a  temperature  of  100°  C,  is  poured  into  the  glass,  and  the  heat  is  increased 
until  the  temperature  of  the  cumol  is  a  few  degrees  below  its  boiling-point 
(165°  C).  For  one  hour  this  temperature  is  maintained.  Then  the  cumol 
is  poured  off  and  the  catgut  is  allowed  to  remain  for  a  time  in  the  sand- 

*  International  Text-book  of  Surgery. 


Ligatures  and  Sutures  71 

bath  at  a  temperature  of  100°  C,  in  order  to  dry.     It  is  transferred  for  keeping 
into  sterile  glass  jars  or  test-tubes.* 

The  Claudius  Method. — The  iodin  catgut  is  prepared  by  the  Claudius 
method.  Mr.  Moynihan,  of  Leeds,  makes  Claudius  catgut  as  follows:  In  10 
ounces  of  sterile  water  dissolve  i  ounce  of  crystals  of  iodid  of  potassium. 
When  all  the  crystals  are  dissolved  add  10  ounces  of  sterile  water  and  then 
add  I  ounce  of  iodin  in  crystalline  form.  Dilute  the  mixture  with  4  pints  of 
sterile  water.  The  result  is  a  i  per  cent,  solution  of  iodin  and  potassium 
iodid.  After  the  usual  preliminary  preparation,  place  the  gut  in  the  mixture 
and  keep  it  in  it  for  at  least  eight  days  before  using.  It  can  be  kept  in  it 
without  harm  for  a  number  of  months.  Salkindsohn  has  modified  the  Claudius 
method  as  follows:  Use  i  part  of  tincture  of  iodin  and  15  parts  of  proof  spirit 
and  immerse  the  catgut  for  eight  days  (J.  S.  Riddell,  in  "Brit.  Med.  Jour.," 
April  6,  1907). 

Silver ized Catgut. — Blake  advocates  this  form  of  gut  ("Annals  of  Surgery," 
January,  1907).  He  prepares  it  as  follows:  He  winds  four  coils  of  gut  on 
four  glass  plates,  places  the  plates  in  a  jar  containing  a  2  per  cent,  solution  of 
coUargolum  and  keeps  them  immersed  for  a  week,  the  jar  being  shaken  once  or 
twice  during  the  period  of  immersion.  At  the  end  of  a  week  the  plates  are  • 
removed  from  the  silver  solution  and  are  placed  for  from  fifteen  to  thirty  min- 
utes in  95  per  cent,  alcohol,  then  the  gut  is  wound  on  glass  spools  with  aseptic 
care  and  is  kept  until  wanted  in  95  per  cent,  alcohol. 

The  Formalin  Method. — The  formalin  method  was  advocated  by  the  late 
Prof.  Senn.  The  catgut  is  wound  on  glass  test-tubes  and  is  immersed  in  an 
aqueous  solution  of  formalin  (2-4  per  cent.)  for  twenty-four  to  forty-eight  hours. 
It  is  placed  in  running  water  for  twelve  hours  to  get  rid  of  the  formalin.  It 
is  boiled  in  water  for  fifteen  minutes,  is  cut  in  pieces  and  tied  in  bundles, 
is  placed  in  a  glass-stoppered  jar,  and  is  kept  ready  for  use  in  the  following 
mixture:  950  parts  of  absolute  alcohol,  50  parts  of  glycerin,  and  100  parts  of 
pulverized  iodoform.     Every  few  days  the  mixture  should  be  shaken. 

Senn's  process  is  a  modification  of  Hoffmeister's.  Even  sterile  catgut 
contains  a  toxic  substance  which  increases  wound  secretion,  has  a  poisonous 
effect  on  body-cells,  and  favors  to  some  extent  limited  suppuration.  Senn 
maintains  that  to  counteract  this  influence  gut  should  not  only  be  sterile, 
but  should  be  antiseptic,  to  inhibit  the  growth  of  pyogenic  organisms  which 
reach  the  wound  from  without  during  operation  or  subsequently  by  the  blood. 

Dry  Heat  Method. — Boeckman  wraps  catgut  in  paraffin  paper,  seals  it  in  a 
paper  envelope,  puts  it  in  the  sterilizer,  and  subjects  it  to  dry  heat.  For  three 
hours  it  is  heated  to  a  temperature  of  284°  F.,  and  for  four  hours  to  a  tem- 
perature of  290°  F.  The  envelope  can  be  carried  in  the  pocket  or  the  instru- 
ment bag.  When  the  gut  is  wanted  the  end  of  the  envelope  is  torn  off,  an 
assistant  with  sterilized  hands  unwraps  the  paraffin  paper,  and  the  gut  is 
dipped  for  a  moment  in  sterile  water  to  make  it  pliable. f 

Corrosive  Sublimate  Method. — A  method  which  has  been  largely  used 
is  to  take  raw  catgut,  keep  it  in  ether  for  twenty-four  hours,  soak  it  for  twenty- 

*See  McBurney  and  Collins,  in  "International  Text-Book  of  Surgery,"  and  Clark,  in 
"Johns  Hopkins  Hospital  Bulletin,"  March,  1896. 

t  James  E.  Moore,  in  "Phila.  Med.  Journal,"  June  22,  1898. 


72  Asepsis  and  Antisepsis 

for  hours  in  an  alcoholic  solution  of  corrosive  sublimate  (i  :  500),  wind  it 
on  sterilized  glass  rods,  and  place  it  for  keeping  in  ether  or  in  alcohol. 

Johnston's  quick  method  of  preparing  catgut  is  as  follows:  Place  it  for 
twenty-four  hours  in  ether;  at  the  end  of  this  period  place  it  in  a  solution 
containing  20  grains  of  corrosive  sublimate,  100  grains  of  tartaric  acid,  and 
6  ounces  of  alcohol.  The  small  gut  is  kept  in  this  for  ten  or  fifteeen  minutes, 
the  larger  gut  from  twenty  to  thirty  minutes,  but  never  longer.  It  is  placed 
for  keeping  in  a  mixture  containing  i  drop  of  chlorid  of  palladium  to  8  ounces 
of  alcohol.  This  gut  is  strong  and  reliable.  At  the  time  of  operation  the  gut 
is  placed  in  a  solution  one-third  of  which  is  5  per  cent,  carbolic  acid  solution 
and  two-thirds  of  which  is  alcohol. 

Preparation  of  Chromicized  Catgut. — Chromicized  catgut  is  absorbed 
less  rapidly  by  the  tissues  than  ordinary  catgut.  It  is  used  to  tie  thick 
pedicles  and  large  arteries,  to  suture  nerves  and  tendons,  and  as  a  suture 
material  in  the  radical  cure  of  hernia.  Chromicized  gut.  No.  3  and  No  4, 
will  remain  unabsorbed  in  the  tissues  from  four  to  six  weeks.  The  gut 
should  be  soaked  in  ether  for  twenty-four  hours,  and  be  immersed  for  twenty- 
four  hours  in  a  4  per  cent,  solution  of  chromic  acid  in  water.  The  gut  is 
then  dried  in  a  hot-air  sterilizer  and  is  disinfected  by  one  of  the  several 
methods.     The  cumol  method  is  satisfactory. 

How  to  Tie  Catgut. — Catgut  is  tied  in  a  reef  knot  (square  knot)  and  dis- 
tinct ends  are  left  on  cutting.  The  second  knot,  if  pulled  too  tightly,  may 
break  the  ligature.  Moist  catgut  is  slipper}'  and  is  hard  to  tie.  If  a  large 
vessel  is  tied  by  catgut,  a  third  knot  should  be  used  and  the  ends  cut  close 
to  the  knot.     Really  strong  catgut  can  be  tied  in  a  surgeon's  knot. 

Kangaroo-tendon  and  Its  Preparation. — This  material  is  obtained  from 
the  tail  of  the  great  kangaroo.  It  is  especially  useful  for  buried  sutures  in 
hernia  operations;  it  will  be  absorbed  in  the  tissues,  but  only  after  a  long 
time  (sixty  to  seventy  days).  Kangaroo-tendon  is  not  grossly  infected  as  is 
catgut.  The  material  is  obtained  from  a  recently  killed  animal  and  is  promptly 
dried  in  the  sun.  This  suture  material  was  introduced  by  Dr.  Henr}-  O. 
Marcy.  It  can  be  prepared  in  the  same  manner  as  the  chromicized  catgut, 
and  it  ought  always  to  be  chromicized.  Marcy's  plan  of  preparation  is  as 
follows:  Soak  the  dried  tendon  in  a  solution  of  corrosive  sublimate  (i  :  1000) 
and  separate  the  individual  strands.  The  individual  strands  will  be  of  equal 
diameter  and  from  10  to  20  inches  in  length.  The  diameter  depends  on  the 
size  of  the  animal.  Dry  each  strand  in  an  antiseptic  towel.  Chromicize  the 
tendons  and  keep  them  until  needed  in  boiled  linseed  oil  containing  5  per 
cent,  of  carbolic  acid.  Before  using  the  strands  take  them  out  of  the  oil, 
wipe  off  the  oil  with  a  sterile  towel,  and  immerse  the  tendon  for  half  an  hour 
in  a  I  :  1000  solution  of  bichlorid  of  mercury.  This  immersion  does  not  make 
them  swell  and  soften  and  does  not  weaken  them  as  it  would  catgut. 

The  following  method  of  preparation  is  recommended  by  Charles  Truax 
("Mechanics  of  Surgery"):  Soak  the  dried  tendon  until  it  becomes  supple, 
m  a  I  :  1000  solution  of  corrosive  sublimate.  Separate  the  material  into 
individual  tendons,  place  them  lengthwise  between  two  towels;  dry  them; 
make  them  aseptic  by  soaking  in  a  solution  of  formalin,  as  we  would  do  with 
catgut  (see  above).     After  washing  out  the  formalin  chromicize  the  tendon 


Ligatures  and  Sutures  73 

by  placing  it  in  a  fresh  5  per  cent,  solution  of  carbolic  acid  containing  i  :  4000 
parts  of  chromic  acid.  When  the  tendons  become  "dark  golden  brown"  in 
color,  they  are  removed  from  the  chromic  acid  solution,  dried  between  sterile 
towels,  and  placed  for  keeping  in  10  per  cent,  carbolized  oil.  When  wanted, 
they  are  removed  from  the  oil,  and  wiped  with  a  sterile  towel  saturated  with 
bichlorid  solution  (i  :  1000).     Kangaroo-tendon  is  tied  in  a  reef  knot. 

Silk. — This  material  can  be  used  for  both  ligatures  and  sutures;  many 
sizes  should  be  kept  on  hand.  Silk  is  very  strong,  soft,  extremely  supple, 
and  does  not  swell  or  irritate  the  tissue.  It  can  be  tied  into  very  firm  knots. 
Ordinary  surgical  silk  is  a  form  of  twisted  silk — that  is,  several  or  many  strands 
are  twisted  into  one.  Cable  twist  or  Tait's  silk  is  very  strong  and  is  used  for 
tying  large  pedicles.  Braided  silk  is  extremely  strong  and  is  made  by  plaiting 
together  several  strands  of  twisted  silk.  Floss  silk  is  "  a  straight  fiber  slightly 
twisted"  (Truax).  Silk  is  usually  tied  in  a  reef  knot,  but  occasionally  in  a 
surgeon's  knot.  White  silk  may  be  used,  or  black  silk,  which  is  more  easily 
visible.  Silk  becomes  encapsuled  in  the  tissues.  It  is  not  absorbed  at  all 
or  only  after  a  ver\'  long  time.  It  is  not  a  good  material  for  buried  sutures, 
as  in  the  long  run  it  may  form  a  sinus. 

Preparation  of  Silk. — Sutures  of  silk  should  be  boiled  for  half  an  hour  before 
using  in  a  I  per  cent,  solution  of  carbonate  of  sodium.  Some  surgeons  keep 
the  silk  after  boiling  in  sublimated  alcohol  (i  :  1000)  or  carbolic  solution  (5 
per  cent.),  but  it  is  better  to  prepare  it  just  before  using.  A  convenient  method 
of  preparation  is  to  wind  the  silk  on  a  glass  spool,  place  the  spool  in  a  large 
test-tube,  close  the  mouth  of  the  tube  with  jewelers'  cotton,  introduce  the  tube 
into  a  steam  sterilizer,  and  subject  it  to  a  pressure  of  10  pounds  for  twenty 
minutes,  repeating  the  process  the  next  day.  These  tubes  are  carried  in 
wooden  boxes  sealed  with  rubber  corks. 

Horsehair  and  Its  Preparation. — This  is  used  for  effecting  very  neat  approxi- 
mation where  only  light  sutures  are  required;  for  instance,  in  wounds  of  the 
face.  Its  chief  use  is  for  capillary  drainage.  It  is  prepared  by  washing  and 
then  boiling  for  fifteen  minutes  in  a  4  per  cent,  solution  of  carbonate  of  sodium. 
It  is  kept  until  needed  in  sublimated  alcohol  (i  :  1000). 

Silkworm-gut  and  Its  Preparation. — This  material  contains  fewer  bacteria 
than  catgut  and  does  not  swell  when  introduced  into  a  wound.  It  is  strong, 
solid,  smooth,  non-irritating,  can  be  dra^\Ti  through  the  tissues  with  slight 
force,  and  does  not  tend  to  cut  the  tissue  as  does  a  metallic  suture.  The 
designation  silkworm-gut  is  a  misnomer;  the  material  is  not  gut  at  all  but 
is  obtained  from  the  silk-producing  glands.  Italy  suppHes  most  of  the 
gut  used  by  fishermen  but  the  gut  used  by  the  surgeon  comes  chiefly  from 
Murcia  in  Spain.  When  the  silkworms  are  just  ready  to  spin  they  are 
placed  in  vinegar  and  water  for  a  number  of  hours  and  are  thus  killed.  Each 
worm  is  opened  and  the  silk-producing  glands  are  clearly  exposed  and  each 
gland  is  drawn  by  its  ends  into  a  single  thread.  The  threads  are  dried  in 
the  air  and  assume  a  reddish  color  (M.  J.  Triollet,  in  "Bulletin  des  Sciences 
Pharmacologiques,"  1905,  No.  5.  Quoted  in  "Lancet,"  Feb.  3,  1906). 
"  This  crude  silkworm-gut  is  sold  to  the  manufacturer  and  further  treated.  It  is 
first  boiled  in  alkaline  water  to  remove  fat  and  blood  and  is  then  dried  in  the 
sun,  being  protected  from  dust.  It  is  next  polished  by  means  of  slightly  oiled 
pvumice  stone.     The  gut  is  then  bleached  with  sulphurous  acid  and  rubbed 


74 


Asepsis  and  Antisepsis 


vigorously  with  chamois  leather  to  remove  dust  and  sulphur"  ("  Lancet," 
Feb.  3,  1906).  It  is  a  very  valuable  material,  but  is  not  used  for  ligatures,  as 
it  cannot  be  tied  as  firmly  as  catgut  and  because  when  left  buried  in  the 
tissues  the  sharp  ends  may  stick  and  irritate  and  a  point  of  least  resistance 
may  be  created.  Silkworm-gut  is  prepared  by  placing  it  in  ether  for  forty- 
eight  hours  and  in  a  solution  of  corrosive  Sublimate  (i  :  1000)  for  one  hour, 
or  it  can  be  boiled  in  plain  water  for  half  an  hour.  It  is  carried  in  a  long 
tube  filled  with  alcohol.  A  few  minutes  before  using  the  gut  is  placed  in 
carbolic  acid  and  alcohol  (one-third  of  the  solution  is  a  3  per  cent,  solu- 
tion of  acid,  two-thirds  of  it  is  alcohol).  Silkworm-gut  is  tied  by  the  sur- 
geon's knot. 

Celluloid  Thread  and  Its  Preparation. — This  material  is  warmly  advo- 
cated by  Pagenstecher.     He  calls  it  celluloid  yarn,  and   prepares  it  from 

English  gray  linen  thread.    I  have  used 
r  -       it  with  much  satisfaction.     It  is  strong, 

smooth,  flexible,  and  the  knot  holds 
firmly;  it  can  be  sterilized  by  any 
method  used  for  raw  silk,  and  steril- 
ization by  dry  heat  actually  increases 
its  strength.  Its  one  disadvantage  is 
that  it  absorbs  about  40  per  cent,  of 
fluid,  but  does  not  soften.  The  cel- 
luloid is  added  after  the  thread  has 
been  boiled  in  a  i  per  cent,  solution 
of  carbonate  of  soda,  wiped  or  wrapped 
in  a  sterile  towel,  and  dried  in  hot  air 
or  steam.  It  is  then  dipped  in  a  solu- 
tion of  celluloid  heated  in  a  hot-air 
sterilizer,  and  packed  in  sterile  boxes 
(Schlutius,  in  "  Pacific  Med.  Journal," 
Jan.,  1900;  Keen  and  Rosenberger, 
in  "  Phila.  Aled.  Journal,"  May  10, 
1900).  Celluloid  thread  can  be  used 
for  sutures  or  ligatures. 

Silver  wire  is  prepared  by  boiling. 
It  is  a  very  useful  suture  material,  as 
it  can  be  thoroughly  steriHzed  and  has 
a  mild  inhibitory  efi'ect  on  the  growth 
of  bacteria.  Some  surgeons  use  it  for 
buried  sutures,  but  many  are  opposed 
to  using  it  thus  on  the  ground  that 
it  is  apt  to  lead  to  sinus  formation. 
Copper,  brass,  and  bronze  have  a  very  distinct  inhibitory  efi'ect  on  bacteria 
(C.  L.  Green  in  the  "Practitioner,"  March,  1907),  and  wire  made  of  either 
one  of  these  metals  is  useful.  I  have  used  copper  wire  and  brass  screws  in 
bone  and  have  used  wire  of  aluminum  bronze  for  various  purposes. 

Most  wounds  are  closed  by  interrupted  sutures  of  silkworm-gut,  but  silk, 
catgut,  chromic  catgut,  or  silver  wire  can  be  used.  The  old  continuous 
suture  (glovers'  stitch)  is  rarely  used  except  as  a  buried  suture.     An  admir- 


Fig.  37. — Small  steam-pressure  sterilizer  and 
instrument  boiler  (Fowler). 


Dressings 


75 


able  closure  can  be  effected  by  Halsted's  subcuticular  stitch,  and  scarcely  any 
scar  results  (page  56).  Marcy's  buried  tendon  sutures  are  very  valuable, 
especially  in  hernia  operations  and  in  various  operations  upon  the  abdomen. 

Dressings  are  made  of  cheese-cloth.  In  order  to  make  antiseptic  gauze 
the  cheese-cloth  is  boiled  in  a  solution  of  carbonate  of  sodium,  rinsed  out, 
and  dried;  it  is  then  soaked  for  twenty-four  hours  in  a  solution  containing  i 
part  of  corrosive  subhmatc,  2  parts  of  table  salt,  and  500  parts  of  water.  It 
is  placed  in  clean  jars  with  glass  lids,  and  it  may  be  kept  moist  or  dry. 

Sterilized  or  aseptic  gauze  is  prepared  by  boiling  in  carbonate  of  sodium 
solution,  etc.,  as  described  under  Antiseptic  Gauze.  The  gauze  is  then 
wrapped  in  a  towel  and  is  placed  in  a  steam  sterilizer  (F'igs.  37  and  38)  for 
an  hour.  It  is  kept  until  wanted  in  sterile  glass  jars  with  glass  lids.  The 
pads  for  sponging  are  made  by  rolling  up  portions  of  sterile  gauze.  Ashton^s 
abdominal  pads  are  made  by  taking  several  layers  of  sterile  gauze,  each  piece 


Fig.  38. — Laulenschlager"s  steam  sterilizer  for  dressings:  yl,  Exterior  view;  £,  cross-section. 


about  six  inches  long  and  four  inches  wide,  running  a  stitch  around  the  mar- 
gin, and  sewing  a  piece  of  tape  into  one  corner. 

Sterile  absorbent  cotton  is  prepared  in  the  same  manner  as  gauze.  Cotton 
is  useful  as  a  dressing  to  supplement  gauze,  being  placed  on  the  outside  of  the 
gauze.     It  absorbs  quantities  of  serum,  but  will  take  up  very  little  pus. 

Iodoform  gauze  is  very  useful  for  packing  in  the  brain  and  abdomen,  for 
packing  abscesses  and  tuberculous  areas,  and  for  dressing  foul  wounds.  It 
is  prepared  as  follows :  Make  an  emulsion  composed  of  equal  parts  by  weight 
of  iodoform,  glycerin,  and  alcohol,  and  add  corrosive  sublimate  in  the  pro- 
portion of  I  part  to  1000  of  the  mixture.  This  mixture  stands  for  three 
days.  Take  moist  bichlorid  gauze,  saturate  it  with  the  emulsion,  let  it  drip 
for  a  time,  and  keep  it  in  sterihzed  and  covered  glass  jars  (Johnston) . 

Lister's  cyanid  gauze  (double  cyanid  of  zinc  and  mercury)  is  not  certainly 
antiseptic,  and  must  be  dipped  into  a  corrosive  sublimate  solution  (i  :  2000) 
before  using.  All  forms  of  gauze  can  be  bought  ready  prepared  from  reliable 
firms. 


76  Asepsis  and  Antisepsis 

Some  surgeons  place  silver  foil  upon  a  wound  before  applying  the  gauze 
(Halsted,  page  32).  Small  wounds  in  which  drainage  is  not  employed  may 
often  be  dressed  by  laying  a  film  of  aseptic  absorbent  cotton  over  the  wound 
and  applying,  by  means  of  a  clean  camel's-hair  brush,  iodoform  collodion 
(grs.  xlviij  of  iodoform  to  §  j  of  collodion).  Among  other  materials  sometimes 
used  for  dressing  wounds  the  following  should  be  mentioned:  Wood  wool, 
absorbent  wool,  moose  pappe,  oakum,  jute,  peat,  and  sawdust. 

Protectives. — A  protective  is  a  material  placed  directly  upon  wounds  to 
shield  them  from  irritation  and  infection  and  outside  of  dressings  to  diffuse  and 
prevent  the  escape  of  discharge.  The  commonly  used  protectives  are  Lister's 
oil  silk  protective,  gutta-percha  tissue,  rubber  dam,  waxed  paper,  paraffin 
paper,  mackintosh,  and  silver  foil.  Undoubtedly,  many  antiseptic  agents 
destroy  young  cells  and  in  this  way  hinder  repair.  The  same  is  true  of  certain 
rough  dressings. 

R.  T.  Morris  showed  us  that  gauze  and  particularly  cotton  are  injurious 
to  a  healing  wound.  A  non-irritant  protective  laid  directly  upon  a  wound 
may  be  useful  by  saving  new  cells  from  injury  by  an  irritant  germicide  and 
from  being  pulled  away  at  each  change  of  dressings. 

Among  the  best  protectives  in  common  use  are  Lister's  protective,  gutta- 
percha tissue,  and  silver  foil.  Morris  condemns  gutta-percha  tissue  as  irri- 
tant. He  uses  thin  gold-beaters'  skin  made  from  the  peritoneum  of  the  ox, 
which  material  he  calls  Cargile  membrane,  after  an  Arkansas  physician  who 
introduced  it  into  practice.  The  advantage  of  this  material  is  that  moisture 
cannot  penetrate  and  new  cells  do  not  adhere.  I  have  used  it  with  satisfac- 
tion in  some  cases  but  in  wounds  and  ulcers  prefer  silver  foil  (see  "An  Experi- 
mental and  Histological  Study  of  Cargile  Membrane,"  by  A.  B.  Craig  and 
A.  G.  Ellis,  "Annals  of  Surg.,"  June,  1905). 

Silver  foil.  Lister's  protective,  or  gutta-percha  tissue  is  laid  directly 
upon  a  wound,  the  dressing  being  placed  above  it.  Silver  foil  comes  in  books 
and  is  sterihzed  by  dry  heat.  Gutta-percha  tissue  should  be  steriUzed  by  wash- 
ing with  soap  and  water,  rinsing  in  sterile  water,  and  soaking  in  a  solution  of 
corrosive  sublimate.  Lister's  protective  is  employed  to  save  the  wound  from 
the  irritation  of  carboHzed  dressings.  In  the  United  States,  if  it  is  desired  to 
place  an  impermeable  material  over  a  dressing,  a  rubber  dam  is  usually  em- 
ployed. A  rubber  dam  before  being  used  should  be  washed  with  soap  and 
water  and  soaked  in  a  solution  of  corrosive  sublimate. 

The  use  of  an  impermeable  material  on  the  outside  of  the  gauze  dressing 
is  not  nearly  so  common  as  formerly.  In  an  aseptic  wound  dry  dressing  un- 
covered by  rubber  is  the  most  useful.  When  a  dressing  is  covered  by  an 
impermeable  material  it  becomes  wet,  acts  as  a  poultice,  and  the  discharges 
on  the  dressings  may  undergo  decomposition. 

Drainage. — Drainage  is  used  in  all  infected  wounds,  in  most  very  large 
wounds,  in  wounds  to  which  irritant  antiseptics  have  been  applied,  in  cases 
in  which  large  abnormal  cavities  exist,  in  very  fat  people,  and  in  individuals 
with  such  thin  skin  that  we  dare  not  apply  firm  pressure  (see  page  57). 
Drainage  is  obtained,  when  needed,  by  rubber  or  glass  tubes,  by  strands  of 
horsehair,  silkworm-gut  or  catgut,  by  pieces  of  gauze,  and  occasionally  in 
the  abdomen  by  Mikulicz's  bag  or  tampon  by  which  we  obtain  pressure  to 
arrest  hemorrhage  and  also  secure   drainage    (Fig.  42)-     Rubber  drainage 


Removal  of  Stitches 


77 


C 


^ 


Fig- 39— Drainage-tubes;  A,  Glass;  B,  Rubber. 


tubes  (Fig.  39,  B)  are  rendered  sterile  by  boiling  in  plain  water.  They  are  kept 
until  wanted  in  a  mercurial  solution.  This  solution  should  be  changed  every 
few  days,  because  the  mercury  is 
apt  to  be  precipitated  as  sulphid. 
Glass  tubes  are  sterilized  by  boil- 
ing. A  bit  of  rubber  tissue  is 
sometimes  used  for  drainage. 
Gauze,  catgut,  etc.,  are  known 
as  capillary  drains.  WTaen  moist 
they  drain  serum  excellently,  but 
pus  very  badly  or  not  at  all.     Pus 

requires  tubular  drainage.  Drainage-tubes  or  strands  are  brought  out  at  a 
portion  of  the  wound  which  will  be  dependent  when  the  patient  is  recum- 
bent. 

Change  of  Dressing. — \Mien  a  change  of  dressings  is  determined  upon 
the  surgeon  should  carefully  steriHze  his  hands  and  forearms  and  should  have 
at  hand  a  warm  solution  of  corrosive  sublimate,  common  salt  solution,  an 
irrigator,  iodoform,  iodoform  gauze,  scissors,  forceps,  basins  (Figs.  40  and  41), 

etc.  Dressings  should 
be  moistened  before  re- 
moval with  salt  solution 
or  corrosive  subHmate 
solution.  If  they  stick 
to  the  part  a  spray  of 
hydrogen  dioxid  pro- 
jected from  an  atomizer 
4o.-Smith-s  dressing  basin.  between   the   skin   and 

dressings  will  soon  loosen 
them.  Dressings  must  be  changed  as  soon  as  soaking  %Aith  blood  or  wound- 
fluid  is  apparent.  If  the  w^ound  becomes  uneasy  and  painful  or  if  con- 
stitutional S}-mptoms  of  wound  infection  arise  the  dressings  must  be  removed 
to  permit  of  inspection  of  the  wound.  A  change  of  dressings  must  be 
effected  mth  all  of  the  aseptic  care  employed  in  a  surgical  operation. 
Dressings  are  not  dispensed  with  until  the  wound  is  soundly  healed. 

Removal  of  Stitches. — Buried 
stitches  of  animal  material  are  not 
removed  by  the  surgeon  but  are 
gradually  absorbed  in  the  tissues. 
Buried  stitches  of  silk  or  silver  wire, 
which  are  used  by  some  surgeons, 
although  they  are  not  absorbed  in 
the  tissues,  may  never  require  re- 
moval   but    in    some    cases    cause 

sinuses  to  form  and  a  sinus  from  a  suture  or  hgature  will  not  heal  until  the 
sutiure  or  Ugature  is  removed. 

If  a  catgut  stitch  is  passed  through  the  skin  and  tied  externally  the  loop 
in  the  tissue  is  absorbed  but  the  knot  and  remainder  of  the  loop  is  on  the 
surface  and  is  not  absorbed  but  remains  adherent  to  the  wound  and  the  stur- 
geon need  only  hft  it  off  with  forceps.     Catgut  is  used  as  a  material  for  cuta- 


Fi£ 


Fig.  41.— Plain  dressing  basin. 


78 


Asepsis  and  Antisepsis 


neous  suturing  in  the  operation  of  circumcision.  When  a  skin  wound  is 
closed  by  unabsorbable  sutures,  as  it  usually  is,  the  surgeon  at  the  proper 
time  takes  forceps  and  scissors  and  removes  the  stitches.  Stitches  may 
usually  come  out  from  the  sixth  to  the  eighth  day,  although  if  there  is 
much  tension  on  the  edges  of  the  wound  they  are  allowed  to  remain  several 
days  longer.     In  large  wounds,  half  of  the  stitches   are  taken  out  at  one 

time,  the  remainder  being  allowed  to  remain 
for  a  couple  of  days  longer.  When  a  stitch 
begins  to  cut,  it  is  doing  no  good,  and  it  should 
be  removed,  no  matter  how  short  a  time  it  has 
been  in  place.  If  it  is  allowed  to  remain,  it  will 
cut  into  the  wound,  make  a  stitch-abscess,  and 
cause  an  irregular  suture-line.  In  order  to 
remove  a  stitch  pick  up 
an  end  distal  from  the 
knot  with  forceps,  lift  it 
lightly,  cut  one  side  of 
the  suture  close  to  the 
skin  by  scissors,  and  re- 
move it  by  puUing  in  the 
direction  of  the  side  on 
which  the  suture  was 
cut  (Fig.  43). 
Bits  of  gauze  should  be  used,  each  piece  being 
with   blood   or    tissue  fluid.      Gauze 


Fig.  42. — Mikulicz's  bag;  a,  Ab- 
dominal sutures;  b,  gauze  bag;  c, 
abdominal  wound;  d,  loops  in  the 
abdominal  wall;  f,  gauze  strip. 


Fig-  43- — Method  of  ex- 
traction of  a  suture  (Es- 
march  and  Kowalzig). 


Artificial  Sponges. 

thrown  away  as  soon  as  it    is  soaked 

pads  can  be  used,  soaking  them  in  an  antiseptic  solution  and  squeezing  them 

out  from  time  to  time  during  an  operation. 

Preparation  of  Marine  Sponges. — Marine  sponges  are  seldom  used. 
Gauze  pads  are  preferred.  Marine  sponges  absorb  admirably,  but  they 
are  hard  to  clean  when  new  and  cannot  be  certainly  sterilized  in  their  inte- 
riors after  becoming  infected.  They  may  be  prepared  as  follows:  Beat  out 
the  dust;  place  them  for  forty-eight  hours  in  a  solution  of  hydrochloric  acid 
(15  per  cent.);  wash  them  with  water;  place  them  for  one  hour  in  a  solution 
of  permanganate  of  potassium  ( 5  iij  to  5  pints  of  water) ;  soak  for  four  hours 
in  a  solution  containing  10  ounces  of  hyposulphite  of  sodium,  5  ounces  of 
hydrochloric  acid,  and  3  pints  of  water;  wash  with  running  water  for  six 
hours.  Keep  the  sponges  in  a  jar  containing  corrosive  sublimate  solution 
(i  :  1000).  After  using,  wash  in  hot  water,  soak  for  half  an  hour  in  a  solution 
of  sodium  carbonate  (i  :32),  wash  again  in  hot  water,  and  replace  in  cor- 
rosive sublimate. 

Senn's  Decalcified  Bone-chips. — Take  the  shaft  of  the  tibia  or  femur 
of  a  recently  killed  ox,  saw  it  into  portions  two  inches  in  length,  remove  the 
marrow  and  periosteum,  and  place  the  fragments  of  bone  in  a  15  per  cent, 
solution  of  hydrochloric  acid.  Change  the  solution  every  twenty-four  hours. 
In  from  two  to  four  weeks  the  bone  will  be  decalcified.  Wash  in  distilled 
water,  place  the  pieces  of  decalcified  bone  for  a  few  minutes  in  a  dilute  solu- 
tion of  potash  to  neutralize  the  acid,  and  then  immerse  for  twenty- four  hours 
in  distilled  water.  The  portions  of  bone  are  cut  into  strips  in  the  direction 
of  the  long  axis  of  the  segments.     Each  strip  is  three-quarters  of  an  inch  wide 


Active  Hyperemia  79 

and  should  be  sliced  into  bits  one  millimeter  thick.     These  chips  are  kept  in 
an  alcoholic  solution  of  corrosive  subhmate  (i  :  500). 

Bandages. — For  retaining  dressings  upon  wounds  the  unbleached  muslin 
bandage  may  be  used,  but  in  most  cases  the  gauze  bandage  is  employed.  The 
gauze  bandage  soaked  in  corrosive  sublimate  solution  is  antiseptic;  it  does  not 
partly  seal  the  dressing  and  act  like  protective;  it  can  be  applied  firmly,  evenly, 
and  rapidly,  and  is  very  comfortable. 


III.  INFLAMMATION. 

Definition. — When  the  tissues  are  injured  they  react  or  respond,  and 
this  reaction  or  response  is  known  as  inflammation.  The  process  of  inflam- 
mation was  defined  by  the  late  Sir  John  Burdon-Sanderson  as  "the  succession 
of  changes  which  occur  in  a  living  tissue  when  it  is  injured,  provided  that  the  in- 
jury is  not  of  such  a  degree  as  at  once  to  destroy  its  structure  and  vitality. ' '  Pro- 
fessor Adami,  in  his  article  upon  inflammation  in  Allbutt's  "System  of  Medi- 
cine," points  out  that  this  definition  really  includes  too  much.  He  alludes 
to  the  hemorrhage  which  occurs  in  the  liver  after  a  traumatism,  and  the  sub- 
sequent changes  in  the  extravasted  corpuscles,  and  points  out  that  these 
changes  are  not  inflammatory  phenomena.  This  definition,  however,  includes 
all  inflammatory  conditions,  is  largely  employed,  is  very  useful,  indicates  the 
cause,  and,  as  Burdon-Sanderson  says,  makes  clear  that  inflammation  is  a 
process  and  not  a  state  (Adami).  Adami's  definition  is  as  follows:  "The 
series  of  changes  constituting  the  local  manifestation  of  the  attempt  at  repair 
of  actual  or  referre4  injury  to  a  part,  or,  briefly,  the  local  attempt  at  repair  of 
actual  or  referred  injury."  The  changes  alluded  to  in  Burdon-Sanderson's 
definition  comprise  (i)  changes  in  the  vessels  and  the  circulation,  (2)  depar- 
ture of  fluids  and  solids  from  the  vessels,  and  (3)  changes  in  the  perivascular 
tissues. 

Vascular  and  circulatory  changes  were  formerly  thought  to  be 
absolutely  essential  to  inflammation  in  both  vascular  and  non-vascular  tissues. 
In  the  former  they  occur  in  the  inflamed  tissues;  in  the  latter  (cornea  and 
cartilage)  they  are  manifest  in  neighboring  tissues  from  which  the  non-vascular 
area  derives  its  nutritive  material.  As  a  matter  of  fact,  in  inflammation, 
vascular  changes  are  almost  always  present;  but  in  a  rather  trivial  corneal 
inflammation  the  episcleral  vessels  may  not  dilate,  and  the  only  white  corpus- 
cles which  gather  in  the  damaged  area  are  those  which  come  from  the  lymph- 
spaces  of  the  cornea.  Inflammation  in  any  tissue  will  not  be  accompanied 
by  vascular  dilatation  unless  the  process  reaches  a  certain  stage  of  severity. 

Active  Hyperemia. — When  an  irritant  is  applied  to  tissue  there  may 
be  a  momentary  arterial  contraction  due  to  irritation  of  the  nerves,  but  this 
contraction  is  transitory,  and  is  not  an  inflammatory  phenomenon.  The 
first  vascular  phenomenon  is  dilatation  of  all  the  vessels, — capillaries,  venules, 
and  arterioles, — appearing  first  and  being  most  pronounced  in  the  small 
arteries.  As  a  result  of  the  dilatation  there  are  increased  rapidity  of  circula- 
tion and  increased  determination  of  blood  to  the  part,  and  the  area  of  hyper- 
emia becomes  warmer  than  is  normal.  This  condition  of  increased  circulatory 
activity  is  known  as  "active  hyperemia"  (Fig.  45). 


8o 


Inflammation 


Active  hyperemia  is  an  increase  in  the  amount  of  moving  blood  in  a  part. 
Passive  hyperemia  is  an  increase  in  the  amount  of  blood  in  a  part,  but  not  of 
moving  blood,  as  passive  hyperemia  or  congestion  is  due  to  venous  obstruction, 
and  the  blood  is  stagnated.  Diminution  in  the  amount  of  blood  in  a  part  is 
ischemia.  Local  anemia  is  the  complete  cutting-off  of  the  blood-supply  of  a 
part. 

In  active  hyperemia  more  blood  goes  to  the  part  and  more  blood  passes 
through  it,  an  increased  amount  of  venous  blood  comes  from  the  hyperemia 
area,  the  venous  tension  is  increased,  and  the  veins  may  even  pulsate.  The 
capillaries,  vv^hich  under  ordinary  circumstances  contain  but  few  blood-cells 
(Fig.  44),  become  filled  with  corpuscles  (Fig.  45),  and  even  the  smallest  capil- 
laries pulsate.  The  blood  in  the  veins  adjacent  to  the  area  of  inflammation 
is  of  a  much  lighter  red  than  in  health.     Many  capillaries  which  were  invisible 

under  normal  conditions  become  visible 
when  active  hyperemia  exists.  The  capil- 
laries contain  no  muscle-fiber,  and  hence 
these  tubes  cannot  actively  contract,  except 
so  far  as  the  caliber  of  the  tubes  is  altered 
by  the  contraction  or  expansion  of  the 
endothelial  cells  of  the  capillary  wall. 
Contraction  and  dilatation  of  the  capilla- 
ries depend  chiefly  on  the  amount  of 
blood  sent  to  or  retained  in  them.  In 
active  hyperemia  the  increased  amount 
of  blood  sent  to  the  part  causes  capillary 
dilatation.  As  a  result  of  the  dilatation 
the  endothelial  cells  become  thinner  than 
before,  the  cells  as  a  result  of  irritation  lose 
some  of  their  power  to  restrain  exudation, 
and  some  observers  assert  that  openings 
are  formed  between  the  cells  or  that  pre- 
viously existing  openings  enlarge  (page 
83) .  Fluid  elements  rarely  leave  the  blood- 
vessels during  active  hyperemia,  but  they 
occasionally  do.  The  wheals  of  urticaria  are  thus  formed  (Warren).  Active 
hyperemia  is  often  the  first  stage  of  an  inflammation,  but  it  is  not  of  neces- 
sity followed  by  other  inflammatory  changes,  and  it  can  be  caused  by  nerve 
section  or  nerve  stimulation. 

The  duration  of  active  hyperemia  is  variable.  If  the  irritation  was  brief, 
the  hyperemia  is  very  transitory.  In  some  cases  dilatation  with  accelerated 
circulation  is  scarcely  more  than  momentary,  giving  way  almost  immediately 
to  dilatation  with  retardation.  If  the  irritation  is  prolonged,  hyperemia  may 
last  some  time  before  giving  way  to  retardation.  In  the  web  of  a  frog's  foot, 
if  an  irritant  is  applied,  hyperemia  lasts  from  one-half  hour  to  two  hours 
before  it  is  replaced  by  retardation. 

Clinical  Signs  of  Active  Hyperemia. — A  hyperemia  part,  if  on  or  near 
the  surface,  is  red  in  color,  imparts  a  sense  of  heat  to  the  examining  hand, 
the  color  quickly  disappears  on  pressure  and  quickly  returns  when  pressure 
is  released.     In  a  congested  part  the  temperature  is  diminished,  the  surface 


Fig.  44.— Normal  vessels  and  blood-stream. 


Oscillation  and  Stagnation 


is  purple,  the  congested  veins  are  visible,  there  are  edema  and  a  sensation  of 
coldness  and  numbness.  When  congestion  is  purely  local,  the  lividity  dis- 
appears quickly  when  pressure  is  applied  and  returns  quickly  when  pressure 
is  removed,  WTien  due  to  disease  of  the  heart  or  lungs,  it  disappears  and 
returns  slowly.  When  a  local  congestion  is  about  to  give  way  to  gangrene, 
the  lividity  disappears  very  slowly  on  pressure  and  crawls  back  slowly  when 
pressure  is  released. 

Retardation. — After  active  hyperemia  has  existed  for  a  variable  time 
the  blood-current  begins  to  lessen  in  velocity,  until  it  becomes  more  tardy  than 
in  health.  This  is  known  as  "retardation  of  the  circulation."  Retardation 
is  first  noted  in  the  venules,  next  in  the  capillaries,  and  last  in  the  arterioles; 
but  arterial  pulsation  continues.  The  red  cells  take  the  center  of  the  blood- 
stream, which  is  known  as  the  axial  current.  The  white  corpuscles  settle  out 
of  the  central  stream,  separate  from  the  red,  and  float  lazily  along  near  the 
vessel- wall,  and  they  are  accompanied  by  many  third  corpuscles.  The  white 
cells  show  a  strong  tendency  to  adhere  to  the  venule- walls,  and,  as  a  result, 
accumulate  against  the  inside  of,  and  stick  to,  these  walls  and  to  one  another, 
until  the  venules  are  entirely  hned  with  layers  of  leukocytes  (Fig.  46).  The 
third  corpuscles  act  in  a  similar  man- 
ner and  take  the  peripheral  current.  In 
the  capillaries  some  leukocytes  gather, 
but  not  many.  In  the  arterioles  they 
adhere  during  cardiac  dilatation,  but 
are  swept  away  by  the  force  of  the 
heart's  contractions.  Retardation  is 
believed  to  be  chiefly  due  to  paresis  of 
the  muscular  walls  of  the  arterioles. 
This  causation  seems  probable  when 
we  recall  Lord  Lister's  experiments 
upon  the  pigment-cells  of  the  frog's 
foot.  Lister  proved  that  inflammation 
paralyzes  the  pigment-cells,  and  con- 
cluded that  dilatation  at  the  focus  of 
an  inflammation  is  due  to  the  paralyz- 
ing action  of  an  irritant.  Dilatation 
at  a  distance  from  the  focus  is  a  reflex 
phenomenon  (W.  Watson  Cheyne). 
When  the  vessels  are  weakened  or 
paralyzed,  the  contractions  of  the  arte- 
rioles are  feeble  or  absent,  and  the  blood  is  no  longer  urged  forward  by  arterial 
power.  The  endothelial  cells  of  the  small  vessels  enlarge  distinctly  diu-ing 
retardation  and  develop  a  condition  of  stickiness,  which  leads  the  white  cells 
to  adhere  to  them,  and  thus  increases  resistance  to  the  current  of  blood  and 
adds  to  retardation.  Fluids  pass  through  the  wall  of  a  vessel  in  this  con- 
dition more  readily  than  through  a  healthy  vessel,  and  white  corpuscles 
leave  the  vessel  in  large  numbers. 

Oscillation    and    Stagnation.- — By    this    accumulation    of    leukocytes 
the  blood-stream  is  progressively  narrowed  and  the  axial  current  is  impeded. 
The  red  blood-cells  begin  to  stick  to  one  another,  forming  aggregations  like 
6 


Fig.  45 — Dilatationof  the  vessels  in  inflammation. 


82 


Inflammation 


rouleaux  of  coin,  which  masses  increase  the  difficulty  the  axial  current  has  to 
contend  with,  until  progressive  movement  ceases  and  the  contents  of  the  vessels 
sway  to  and  fro  with  each  heart-beat.  This  is  the  stage  of  oscillation.  In  a 
short  time  oscillation  ceases  and  the  vessels  are  filled  with  blood  which  does 
not  move,  and  the  vessel-walls  become  irregular  in  outline  or  even  pouched. 
This  stage  is  known  as  "stasis"  or  "stagnation."  Stasis  is  chiefly  due 
to  paralysis  and  damage  of  the  vessel-walls.  Migration  ceases  when  stasis 
takes  place.  If  stasis  persists,  coagulation  occurs,  because  the  vessel-walls 
have  been  so  injured  by  the  irritant  as  to  be  practically  dead  material,  and  they 
are  no  longer  able  to  prevent  clotting  of  their  contents.  Finally,  in  persisting 
stasis  the  vessel-walls  rupture  or  are  entirely  destroyed. 

Resume  of  the  Vascular  Changes  of  Inflammation. — We  can  sum  up 
the  vascular  changes  of  inflammation  by  stating  that  they  consist  in  a  dilatation 
of  the  small  vessels  and  a  primary  acceleration,  a  secondary  retardation,  and  a 
subsequent  stagnation  of  the  blood-current,  exudation  of  blood-Hquor,  adhe- 
sion of  leukocytes  to  the  walls  of  veins  and  capillaries,  migration  of  leukocytes, 
the  aggregation  of  the  red  blood-cells  into  intravascular  masses,  and  coagulation 

of  the  material  remaining  in  the  vessel. 
Exudation  of  Fluids. — It  is  to 
be  remembered  that  in  the  process 
of  nutrition  blood-liquor  and  also  white 
cells  pass  into  the  tissues  through  the 
walls  of  veins  and  capillaries,  and  dur- 
ing this  process  certain  other  materials 
are  passing  from  the  tissues  into  the 
vessels.  Hence,  a  diffusible  irritant 
in  the  vessels  may  pass  into  the  tissues 
and  a  diffusible  irritant  in  the  tissues 
may  pass  into  the  vessels,  ^^^leneve^ 
retardation  of  the  circulation  arises, 
there  is  an  increase  in  the  amount  of 
/  "iGBsif^^' '  ~fg'M\  \^'  V^^\WB  plasma  which  passes  out  of  the  vessels, 

I  '(^^^^^^^^^m^)  V^^®^  "'^  but    in    inflammation    the    exudation 

into  the  lymph-spaces  is  vastly  greater 
in  amount  and  is  different  in  com- 
position. In  a  slight  inflammation, 
and  in  the  early  stage  of  any  in- 
flammation, there  is  an  increase  in  the 
fluid  exudate,  and  we  speak  of  the  con- 
dition as  "serous  inflammation."  This  fluid  is  really  not  serum,  but  is  liquor 
sanguinis.  We  find  true  serum  in  passive  congestion,  not  in  active  inflam- 
mation. The  fluid  in  a  serous  exudation  contains  very  few  white  cells,  and 
hence  little  or  no  fibrin  can  form  in  it,  and  coagulation  does  not  take  place  in 
the  perivascular  tissues ;  and  if  the  inflammation  goes  no  further,  the  exudate 
is  absorbed  by  the  lymphatics.  A  blister  is  an  example  of  serous  inflamma- 
tion. If  the  inflammation  continues  to  intensify,  the  exudation  is  altered 
in  character — it  becomes  thicker,  turbid,  and  very  coagulable  and  exhibits 
a  greatly  increased  bactericidal  power.  It  contains  many  white  cells  and 
fibrin  elements,  and  coagulates  in  the  tissues,  because  some  of  the  leukocytes 


Fig:.46. — Retardation  of  blood  and  migration  of 
white  corpuscles  in  inflammation. 


Exudation  of  Fluids  83 

break  up  and  set  free  fibrin  ferment,  and  fibrin  ferment  causes  the  union  of 
calcium  and  fibrinogen  and  the  formation  of  fibrin.  This  fluid  exudate  is 
known  as  "lyniph,^'  or  plastic  exudation,  and  when  it  is  present  we  speak  of  the 
condition  as  "plastic  inflammation."  Lymph  can  be  seen  in  the  anterior 
chamber  of  the  eye  in  cases  of  plastic  iritis.  Coagulated  fibrin  in  a  recent 
wound  causes  the  edges  to  adhere  or  glazes  the  raw  surface.  In  inflammation 
of  a  mucous  surface  it  may  a}:)pear  as  a  false  membrane.  In  inflammation  of 
serous  surfaces  it  may  glue  the  surfaces  together  and  lessen  motion,  the  fibrin- 
ous masses  which  effect  the  gluing  being  called  fibrinous  or  plastic  adhesions. 
These  adhesions  within  the  abdomen  may  seal  a  perforation,  may  cover  a  raw 
spot,  or  may  encompass  an  area  of  infection  and  prevent  fatal  diffusion. 
Further  fibrin  surrounds  and  entangles  bacteria  and  retards  their  diffusion. 
Pyogenic  cocci  lessen,  retard,  or  prevent  fibrin  formation  or  destroy  fibrin  previ- 
ously formed.  The  fibrinous  adhesions  may,  of  course,  do  harm.  They  may 
retard  or  prevent  the  absorption  of  exudate;  they  may  narrow  and  obstruct 
important  structures  (bowel,  urethra,  larynx),  they  may  bind  up  and  cripple  an 
important  viscus  (liver,  heart  or  brain) .  Fibrinous  adhesions  may  be  succeeded 
by  dense  contracting  and  constricting  bands  of  fibrous  tissue.  The  lymphatics 
endeavor  to  absorb  the  fluid  exudate  in  inflammation,  but  become  occluded 
by  coagulation,  and  the  area  they  drain  becomes  swollen,  hard,  and  "brawny." 
The  slighter  the  inflammation,  the  less  albuminous  is  the  fluid;  the  more  in- 
tense the  inflammation,  the  more  albuminous  is  the  fluid.  The  focus  of  an 
inflammation  usually  feels  brawny  because  of  coagulation  of  a  highly  albumin- 
ous exudate;  the  periphery  of  an  inflammation  is  soft  and  edematous  because 
of  the  presence  there  of  thin  and  non-coagulable  exudate.  Inflammatory 
lymph  contains  proteids  and  other  substances.  "Of  these  the  more  important 
are  ferments,  the  results  of  proteolysis  (notably  fibrin  and  its  precursors  and 
peptones),  and  in  many  cases  mucin, together  with  bactericidal  substances,  and, 
where  bacteria  are  present,  the  products  of  their  growth."  *  The  amount  of 
the  exudation  varies  with  the  violence  of  the  irritation,  the  nature  of  the  irri- 
tant, the  general  condition  of  the  organism,  and  the  state  of  the  tissues  which  are 
involved.  In  dense  tissue  (bone,  periosteum,  etc.)  the  exudation  is  scanty. 
In  loose  tissues  (subcutaneous  tissue)  it  is  profuse.  Profuse  exudation  may 
take  place  into  a  joint,  the  pleural  sac,  the  peritoneal  cavity,  or  the  peri- 
cardium. In  such  cases  the  exudation  is  profuse  because  the  serous  mem- 
brane has  a  thin  covering  of  endotheUum,  contains  quantities  of  vessels,  and  the 
vessels  receive  but  a  thin  covering  and  obtain  but  a  scant  support  towards  the 
cavity. 

Does  the  plasma  leave  the  vessels  as  a  simple  filtrate?  Some  maintain 
that  it  does.  Heidenhain  and  others  claim  that  it  does  not,  and  beHeve  that 
the  endothehal  cells  play  an  active  part  in  the  process.  Heidenhain  Ukens 
exudation  to  secretion,  because  some  materials  from  the  plasma  pass  out 
and  others  do  not.  Adami  is  inclined  to  agree  with  Heidenhain,  that  the 
epithelium  plays  "not  a  passive,  but  an  active  role."  Are  there  spaces  between 
the  endothelial  cells  of  the  capillary  ?  It  was  long  taught  posidvely  that  there 
are  no  open  spaces  between  the  endothehal  cells  of  the  vessel-wall,  and  that 
these  cells  are  held  close  together  by  a  cement  substance.  It  is  now  believed 
by  some  observers  that  spaces  exist  between  the  protoplasmic  strands  which 
*  Adami,  in  Allbutt's  "System  of  Medicine." 


84 


Inflammation 


hold  the  cells  together,  these  spaces  being  closed  when  the  vessel  is  contracted 
and  open  when  the  vessel  is  dilated.  When  these  spaces  are  open  fluid  passes, 
and  through  these  doorways  leukocytes  emerge. 

Migration  and  Diapedesis. — Even  early  in  an  inflammation  some  few 
white  corpuscles  pass  through  the  vessel- walls;  but  when  the  inflammation 
is  well  established,  large  numbers,  and  when  it  is  severe  vast  hordes,  pass  into 
the  perivascular  tissues.     This  process  is  known  as  "  migration  "  (Figs.  46  and 


Ftg.47. — Stages  of  the  migration  of  a  single  white  blood-corpuscle  through  the  wall  of  a  vein  (Caton). 


47).  The  leukocytes  throw  out  protoplasmic  arms,  insert  themselves  between 
the  ceUs  of  the  walls  of  the  vessel,  and  puU  themselves  through  by  their  power 
of  ameboid  movement  (Fig.  48) .  Some  observers  claim  that  they  do  not  pass 
through  existing  open  doors,  but  form  openings  which  close  after  them.  This 
is  readily  accomplished,  because  the  vessel-waU  is  itself  damaged,  weakened, 
and  convoluted.     Others  claim  that  stomata  exist  between  the  endothelial 

cells,  the  vessel-wall  being 
porous  like  a  filter  (page  83). 
The  escape  of  leukocytes 
takes  place  chiefly  from  the 
venules,  though  some  mi- 
grate through  the  capillaries 
and  even  the  arterioles  (Fig. 

46). 

The  leukocytes  are  in- 
fluenced to  move  toward  the 
damaged  tissue  by  the  at- 
tractive force  known  as  posi- 
tive "  chemiotaxis"  a  force 
which  draws  them  toward 
invading  bacteria,  to  regions  of  irritation,  and  to  areas  of  tissue  death. 
Leukocytes  may  move  from  very  virulent  organisms,  influenced  by  what  is 
known  as  negative  "  chetniotaxis."  The  migration  of  a  leukocyte  requires 
but  a  short  time.  Fig.  47  shows  the  migration  of  a  white  blood-cell  through  a 
vein-wall,  the  process  requiring  one  hour  and  fifty  minutes.  In  very  acute 
inflammations  red  corpuscles  also  pass  into  the  tissues.     Red  corpuscles  are  not 


Fig.  48.— Ameboid  movements  of  a  leukocyte  (Warner). 


Changes  in  the  Perivascular  Tissues  85 

capable  of  ameboid  movements,  and  if  they  do  escape  from  the  vessels  the 
process  is  passive  on  their  part  and  not  active.  This  passive  escape  happens 
because  the  capillary  walls  have  been  destroyed  or  because  stomata  have  been 
greatly  enlarged  by  vascular  dilatation.  If  red  corpuscles  do  pass  into  the 
exudate,  as  happens  in  pneumonia,  the  inflammation  is  a  very  severe  one  and 
is  called  a  hemorrhagic  inflammation.  The  escape  of  corpuscles  by  a  passive 
process  is  known  as  "diapedesis,"  in  contra-distinction  to  the  escape  of 
leukocytes  by  active  ameboid  movements,  a  process  known  as  "migration." 
The  white  corpuscles  usually  greatly  increase  in  number  in  the  blood  of  a 
person  who  has  an  acute  inflammation,  and  the  blood-making  organs,  such  as 
the  spleen  and  lymphatic  glands,  are  often  enlarged.  An  increase  of  white 
corpuscles  in  the  blood  of  an  individual  is  called  leukocytosis. 

Blood  Plaques. — Blood  plates,  blood  plaques,  or  third  corpuscles,  may  be 
discovered  in  freshly  drawn  blood,  but,  unless  they  are  present  in  unusual  num- 
bers, they  will  rarely  be  seen  in  specimens  prepared  in  the  usual  way.  The 
third  corpuscles  can  be  seen  by  a  high  power  microscope  in  the  moving  blood 
of  the  web  of  a  frog's  foot.  In  blood  outside  of  the  body  they  are  destroyed  as 
soon  as  coagulation  begins,  and  in  order  to  see  them  coagulation  must  be 
prevented.  Some  observers  maintain  that  the  third  corpuscles  are  the  real 
fibrin-formers.  The  blood  plaques,  or  third  corpuscles,  are  found  to  be  present 
in  increased  numbers  in  inflammation.  In  health  their  usual  proportion  to 
red  cells  is  as  i  to  20.  They  are  especially  numerous  at  the  height  of  fever 
processes  and  during  convalescence  from  an  extensive  abscess. 

Changes  in  the  Perivascular  Tissues.— The  cells  of  the  peri- 
vascular tissue  are  phagocytes  and  when  stimulated  they  enlarge,  become 
more  actively  phagocytic,  and  undergo  reproduction.  The  liquor  sanguinis 
which  exudes  during  an  acute  inflammation  coagulates  unless  prevented  by 
virulent  bacteria.  It  has  often  been  asserted  that  exudation  is  Nature's 
method  of  supplying  nutriment  to  the  cells  of  the  damaged  region.  Adami 
points  out  the  apparently  contradictory  observation  that  the  amount  of  exu- 
date is  in  direct  proportion  to  the  rapidity  of  cell-destruction,  but  nevertheless 
concludes  that  exudation  stands  in  close  relation  with  cell-proliferation.* 
From  whatever  cause,  tissue-cells  multiply,  and  this  process  is  known  as 
"  cell- proliferation." 

When  a  tissue  is  injured  it  inflames,  and,  as  Adami  points  out,  the  reaction 
we  call  inflammation  is  an  attempt  to  repair  injury. 

Irritation  may  lead  to  degeneration  and  death  of  cells;  it  may  lead  to 
growth  and  multiplication.  In  many  cases  both  processes  are  active  in  the 
acute  stage,  the  cells  at  the  focus  of  the  inflammation  undergoing  degeneration 
and  destruction,  and  those  at  the  boundary  undergoing  growth  and  prolifera- 
tion.f 

If  tissue-cells  have  been  seriously  damaged,  they  perish,  and  new  cells  are 
required  to  replace  them.  The  inflammatory  process  has  led  to  exudation 
of  plasma  and  migration  of  leukocytes  into  the  perivascular  tissues.  The 
connective-tissue  cells  multiply  and  produce  young  cells,  which  are  known 
as  "  fibroblasts,"  and  which  eat  up  many  leukocytes.  Early  in  an  inflammation 
polynuclear  leukocytes  preponderate,  later  mononuclear  phagocytic  cells 
♦Adami,  in  Allbutt's  "  Svstem  of  Medicine." 


86  Inflammation 

predominate  (Opie).  The  leukocytes  contain  two  enzymes.  One  is  derived 
from  bone  marrow  and  digests  proteid  in  an  alkaline  medium ;  the  other  is  de- 
rived from  lymph-glands  and  digests  proteid  in  an  acid  medium  (Opie).  The 
migrated  leukocytes  in  part  surround  the  inflamed  region  and  retard  diffusion 
of  the  process.  Many  enter  the  diseased  area  and  attack  bacteria.  Some 
undergo  degenerative  changes  and  liberate  fibrin  ferment  which  makes  the 
exudate  clot.  Some  move  out  of  the  inflamed  area,  each  one  carrying  within 
it  tissue  debris,  and  many  are  eaten  up  by  the  fibroblasts.  There  is  no  real 
proof  that  leukocytes  proliferate  and  help  directly  to  form  new  tissue.  This 
mass  of  young  cells,  taking  origin  from  the  fixed  cells,  has  been  called  em- 
bryonic tissue,  because  of  a  fancied  resemblance  to  the  cells  of  the  embr}^o. 
John  Hunter  called  it  juvenile  tissue.  It  has  also  been  called  indifferent  tissue, 
because  of  the  belief  that  it  could  be  converted  indifferently  into  various  tissue 
according  to  circumstances.  It  is  also  spoken  of  as  inflammatory  new  for- 
mation. 

An  exudation  may  be  absorbed  by  the  lymphatics.  It  may  be  converted 
into  pus  if  infected  with  pyogenic  bacteria,  or  be  replaced  by  cells  from  the 
proliferation  of  fixed  tissue-cells,  the  cellular  mass  being  subsequently  vascu- 
larized by  the  extension  into  it  of  capillary  loops  derived  from  adjacent  capil- 
laries. When  embryonic  tissue  is  filled  with  blood-vessels, — that  is  to  say, 
when  it  is  vascularized, — it  is  called  granulation  tissue.  Granulation  tissue 
is  finally  converted  into  fibrous  tissue.  The  above  complicated  processes, 
vascular  and  perivascular,  are  not  accidents  nor  haphazard  freaks,  but  are 
Nature's  efforts  to  bring  about  a  cure. 

Dilatation  is  due  to  the  direct  effect  of  the  irritant  upon  the  muscle  or  its 
nerve-elements.  Retardation  and  stasis  are  due  to  paralysis  of  the  vessel- 
wall,  which  paralysis  causes  resistance  to  the  passage  of  the  blood-stream 
and  adhesion  of  the  leukocytes  to  the  vessel-wall.  The  blood-liquor  exudes 
and  the  leukocytes  migrate.  Often  these  efforts  of  Nature  succeed.  Accel- 
eration of  the  circulation  may  succeed  in  washing  away  an  irritant  from  the 
vessel-wall.  By  bringing  quantities  of  blood  to  the  part  it  secures  copious 
exudation  of  plasma.  The  exudation  may  wash  and  remove  irritants  from 
the  tissues,  and  the  germicidal  blood-liquor  may  destroy  bacteria  in  the 
damaged  area.  The  migration  of  corpuscles  may  prove  of  great  service. 
The  leukocytes  surround  an  area  of  infection  and  tend  to  limit  its  spread. 
Leukocytes  have  phagocytic  properties,  and  energetically  attack  and  often 
destroy  bacteria,  and  they  furnish  enzymes  which  may  digest  proteids  and 
antitoxins  which  antagonize  and  may  neutralize  the  poisons  produced  by 
micro-organisms.  Leukocytes  aid  in  forming  fibrin.  Fibrin  formation  is  of 
service  by  helping  immobilization  and  by  hindering  the  spread  of  bacteria. 
Leukocytes  also  aid  in  separating  dead  tissue  from  living,  and  they  remove 
tissue  debris  from  the  area  of  inflammation.  The  multiplication  of  the  fixed 
connective-tissue  cells  leads  to  the  formation  of  fibroblasts,  and  fibroblasts  are 
converted  into  fibrous  tissue,  which  effects  permanent  repair  (these  changes 
will  be  alluded  to  again  in  the  section  on  Repair). 

Nature  may  fail  in  her  efforts.  For  instance,  an  enormous  exudate  in- 
creases stasis  and  may  cause  such  tension  that  gangrene  results. 

Inflammation  in  Non=vascular  Tissue.— A  type  of  non-vascular 
tissue  is  the  cornea,  and  the  cornea  can  inflame.     The  healthy  cornea  contains 


Classification  of  Inflammations  87 

no  blood-vessels.  It  is  formed  of  many  layers  of  fibers,  each  layer  running 
parallel  with  the  corneal  surface  and  forming  angles  with  the  fibers  of  the 
adjacent  layers.  Between  the  layers  are  communicating  lymph-spaces  con- 
taining connective-tissue  cells  known  as  corneal  corpuscles.  It  obtains  its 
nourishment  in  part  from  the  vessels  of  the  conjunctiva,  but  chiefly  from  the 
vessels  of  the  ciliary  body  and  sclera.  When  the  cornea  inflames,  the  epi- 
scleral, conjunctival,  and  ciliary  vessels  usually  dilate  and  pour  out  exudate, 
and  the  fluid  exudate  and  the  leukocytes  enter  into  the  coineal  lymph-spaces. 
The  exudate  coagulates  and  cell-multiplication  ensues  as  in  any  other  in- 
flammation. In  mild  inflammations  the  vessels  about  the  cornea  may  not  dilate. 
Leukocytes,  from  the  lymph-spaces,  reach  the  seat  of  injury  in  small  numbers, 
and  the  fixed  cells  multiply.  Nancrede  points  out  that  in  trivial  inflammation 
which  injures  but  does  not  destroy  the  epithelium  leukocytes  may  not  go  to 
the  seat  of  inflammation,  the  only  change  being  enlargement  and  multipli- 
cation of  corneal  corpuscles.  If  new  formation  takes  place,  a  permanent 
opacity  mars  the  cornea  as  a  consequence. 

Cartilage  has  no  blood-vessels  except  in  regions  where  growth  is  very  activ^e 
or  where  ossification  is  taking  place.  Cartilage  has  no  spaces,  like  the  cornea, 
for  a  free  circulation  of  honph.  In  man  canals  have  not  been  demonstrated 
and  it  is  thought  that  fibrils  conduct  nutritive  fluids,  the  nutritive  plasma  flow- 
ing between  the  cells,  but  there  is  no  direct  connection  with  blood-vessels.  The 
plasma  is  furnished  by  the  vessels  at  the  margin  of  the  perichondrium.  Carti- 
lage can  inflame  and  an  inflammation  of  this  structure  is  slow  in  evolution  and 
of  long  duration.  When  inflammation  occurs,  the  cartilage  cells  enlarge  and 
their  nuclei  proliferate,  the  intercellular  substance  softens  and  cartilage  cells 
may  be  cast  off.  After  a  long  time  vessels  may  invade  the  inflamed  cartilage 
and  fibrous  tissues  form  from  the  perichondrium,  but  in  some  cases  aloss  of  sub- 
stance is  not  repaired. 

Inflammation  of  Mucous  Membrane.— It  may  be  catarrhal,  suppura- 
tive, croupous,  or  diphtheritic.  In  a  catarrhal  hfflammation  the  increased 
blood-supply  causes  an  excessive  flow  of  mucus.  The  submucous  tissues 
present  the  ordinary  changes  of  inflammation  and  quantities  of  epithelial 
cells  are  cast  off  from  the  surface.  Fibrous  tissues  may  form  in  the  sub- 
mucous tissue  and  thus  cause  permanent  thickening  (stricttu-es,  etc.). 

Suppurative  inflammation  is  usually  preceded  by  catarrhal  inflammation. 
In  this  condition  the  discharge  is  mucopurulent  and  ulcers  are  apt  to  form. 
A  trivial  loss  of  substance  permits  of  regeneration,  but  a  considerable  loss  is 
repaired  by  fibrous  tissue  which  by  its  bulk  and  by  contracting  may  interfere 
greatly  with  the  functional  usefulness  of  an  organ  or  a  canal. 

A  croupous  inflammation  is  one  in  which  quantities  of  epithelial  cells  are 
cast  oft"  the  surface  and  there  forms  upon  the  surface  a  highly  fibrinous  ex- 
udate (false  membrane). 

In  diphtheritic  inflammation  the  mucous  membrane  is  destroyed  and  the 
false  membrane  invades  the  submucous  tissue.  Diphtheritic  inflammation 
is  due  to  a  specific  bacillus. 

Classification  of  Inflammations. — The  various  forms  of  inflamma- 
tions are — {1)  Simple  or  cowwow,  that  which  is  due  to  any  ordinary  traumatic, 
chemical,  thermal,  or  actinic  cause,  and  not  to  bacteria,  such  as  traiunatic 
periostitis  or  sun  dermatitis.     It  does  not  tend  particularly  to  spread.     As  a 


88  Inflammation 

rule,  the  cause  of  a  simple  inflammation  is  momentary  in  action;  (2)  infec- 
tive or  specific,  that  which  is  due  to  micro-organisms,  as  the  streptococcus  of 
erysipelas.  An  unsuccessful  attempt  has  been  made  to  charge  all  inflamma- 
tions to  bacteria.  It  is  true  that  bacteria  can  generally  be  found  in  inflamma- 
tory areas,  but  that  they  are  the  only  causes  of  inflammation  is  accepted  by 
few.  Infective  inflammations  often  tend  to  spread  widely;  (3)  traumatic, 
which  is  due  to  a  blow  or  an  injury;  (4)  idiopathic,  which  is  without  an  ascer- 
tainable cause.  There  is  certainly  a  cause,  even  if  it  cannot  be  pointed  out, 
and  the  term  "idiopathic"  means  that  we  do  not  know  the  cause;  (5)  acute, 
which  is  rapid  in  course  and  violent  in  action;  (6)  chronic,  which  follows  a 
prolonged  course;  (7)  subacute,  which  is  intermediate  in  violence  and  dura- 
tion between  acute  and  chronic;  (8)  sthenic,  characterized  by  high  action. 
Occurs  in  strong  young  subjects;  (9)  asthenic  or  adynamic,  occurring  in  the 
old,  the  debilitated,  and  the  broken-down.  In  such  an  inflammation  there 
is  no  certain  limitation  of  the  inflammation  by  leukocytes,  and  there  is  an 
indisposition  on  the  part  of  the  tissue-cells  to  form  fibroblasts;  (10)  paren- 
chymatous, affecting  the  "parenchyma,"  or  active  cells  of  an  organ;  (11) 
interstitial,  affecting  the  connective-tissue  stroma  of  an  organ;  (12)  serous, 
characterized  by  profuse  non-coagulating  exudation  (as  in  pleuritis)  or  by 
marked  inflammatory  edema;  (13)  plastic,  adhesive,  or  fibrinous,  character- 
ized by  an  exudation  which  glues  together  adjacent  surfaces,  as  in  peritonitis; 
(14)  purulent,  phlegmonous,  or  suppurative,  when  pyogenic  cocci  are  present 
and  multiply;  (15)  hemorrhagic,  when  the  exudate  contains  many  red  blood- 
cells,  as  in  strangulated  hernia  and  in  the  pustules  of  black  smallpox;  (16) 
croupous,  when  an  inflammation  produces  upon  the  surface  of  a  tissue  a 
fibrinous  exudate  which  cannot  be  organized  into  tissue,  and  which  is  due  to 
the  action  of  micro-organisms.  An  exudate  of  this  character  was  called  by 
the  older  surgeons  ^'aplastic  lymph.'''  It  occurs  most  usually  on  mucous 
membrane;  (17)  diphtheritic,  which  differs  from  croupous  in  the  fact  that 
the  false  membrane  is  in  the  tissue  rather  than  upon  it;  (18)  gangrenous,  an 
inflammation  resulting  in  death  of  the  part,  the  gangrene  being  due  to  the 
tension  of  the  exudate  or  the  virulence  of  the  poison;  (19)  healthy,  when  the 
tendency  is  to  repair;  (20)  unhealthy,  when  the  tendency  is  to  destruction; 
(21)  latent,  an  inflammation  which  for  some  time  does  not  announce  itself  by 
any  obvious  symptoms,  as  the  inflammation  of  Peyer's  patches  in  typhoid 
fever;  (22)  contagious,  when  its  own  secretions  can  propagate  it;  (23)  dry, 
without  exudation;  (24)  hypostatic,  arising  in  a  region  of  passive  congestion 
(as  a  bed-sore);  (25)  malignant,  due  to  a  malignant  growth;  (26)  catarrhal, 
affecting  a  mucous  membrane;  (27)  neuropathic,  due  to  impairment  of  the 
trophic  functions  of  the  nervous  system,  as  in  perforating  ulcer;  and  (28) 
sympathetic  or  refiex,  due  to  disease  or  injury  of  a  distant  part,  as  when  orchitis 
follows  mumps. 

Extension  of  Inflammation. — Inflammation  extends  by  continuity 
of  structure,  by  contiguity  of  structure,  by  the  blood,  and  by  the  lymphatics. 
Extension  by  continuity  is  seen  in  phlebitis.  Extension  by  contiguity  is 
seen  when  a  cutaneous  inflammation  advances  and  attacks  deeper  struc- 
tures. Extension  by  the  blood  is  seen  in  the  formation  of  the  smallpox 
exanthem.  Extension  by  the  lymphatics  is  witnessed  in  a  bubo  following 
chancroid. 


Terminations  of  Inflammation  89 

Terminations  of  Inflammation.— Inflammation  may  be  followed  by 
a  return  of  the  tissues  to  health,  and  this  return  may  take  place  by  deUtes- 
cence,  by  resolution,  or  by  new  growth.  By  delitescence  is  meant  abrupt 
termination  at  an  early  stage,  as  when  a  quinsy  is  aborted  by  the  administra- 
tion of  quinin  and  morphin,  and  the  production  of  a  sweat;  resolution  means 
the  gradual  disappearance  of  the  symptoms  when  inflammation  has  passed 
through  its  regular  stages;  and  new  growth  means  that  an  inflammation  has 
lasted  a  considerable  time,  with  ample  blood-supply,  and  without  suppuration 
and  has  gone  on  to  the  formation  of  fibroblasts,  granulation  tissue,  and  fibrous 
tissue.  Inflammation  may  be  followed  by  death  of  the  inflamed  part,  or 
necrosis.  Death  of  the  part  may  be  due  to  suppuration,  ulceration,  or  gan- 
grene. 

The  causes  of  inflammation  are — predisposing,  or  those  residing  in 
the  tissues,  and  rendering  them  liable  to  inflame;  and  exciting,  or  those  which 
directly  awake  the  process  into  activity.  The  first  may  be  thought  of  as 
furnishing  inflammable  material;  the  second  may  be  regarded  as  sparks  of 
fire. 

Predisposing  causes  are  those  which  impair  the  general  vigor,  injure  the 
blood,  weaken  the  tissues,  or  lower  nutritive  activities.  Among  these  causes 
are  shock,  hemorrhage,  nervous  irritation,  gout,  rheumatism,  diabetes, 
Bright's  disease,  alcohohsm,  and  syphilis.  Plethora  renders  a  person  liable 
to  sthenic  inflammations  (those  characterized  by  high  action).  Tissue 
debility  renders  one  prone  to  adynamic  or  asthenic  inflammations.  Nerve 
injury  predisposes  to  inflammation,  either  from  damage  to  trophic  nerves  and 
consequent  failure  in  tissue  nutrition  and  resistance  or  because  analgesia  exists 
and  irritants  which  reach  the  region  are  not  recognized  and  are  allowed  to 
remain.  For  instance,  if  the  conjunctiva  is  in  a  condition  of  analgesia,  the 
presence  of  foreign  bodies  is  not  noticed  and  destructive  inflammation  may 
result  from  their  non-removal. 

After  removal  of  the  Gasserian  ganglion  the  cornea  is  devoid  of  sensation, 
the  flow  of  tears  is  lessened,  dust  gathers  in  the  eye,  and  if  not  removed  by 
irrigation  or  kept  out  by  a  shield  inflammation  and  disastrous  ulceration  will 
ensue. 

Exciting  Causes. — The  exciting  causes  of  inflammation  are — traumatic^ 
as  blows  and  mechanical  irritation;  chemical,  as  the  stings  of  insects,  the 
rubefacient  effects  of  mustard,  venom  of  serpents,  products  of  bacteria, 
ivy  poison,  etc.;  thermal,  heat  and  cold;  specific,  the  micro-organisms,  caus- 
ing, for  instance,  tuberculous  peritonitis  or  erysipelas;  and  nervous,  nerve  stimu- 
lation certainly  being  capable  of  producing  hyperemia  and  sometimes  even 
inflammation.  Inflammation  due  to  nerve  stimulation  is  seen  in  herpes  zoster 
and  in  the  swollen  and  discolored  skin  over  an  inflamed  joint  ( Adami) .  Inflam- 
mation may  also  be  induced  by  electric  currents,  by  the  ^-rays,  by  radium 
rays,  and  by  the  actinic  rays  of  sunlight  and  of  electric  light. 

Some  writers  insist  that  every  inflammation  is  due  to  the  action  of  micro- 
organisms, but  this  statement  lacks  proof.  They  maintain  that  inflammation 
is  a  destructive  microbic  process  which  cannot  bring  about  repair,  and  that 
repair  beg'ns  only  when  inflammation  ends.  As  Adami  points  out,  the  advo- 
cates of  this  view  argue  that  swelling,  pain,  and  discoloration  point  to  the 
existence  of  inflammation;  that  repair  can  take  place  when  these  phenomena 


90  Inflammation 

are  absent,  hence  inflammation  is  not  present  when  repair  begins.  As  a  matter 
of  fact,  swelHng,  discoloration,  and  pain  are  phenomena  often  but  not  inva- 
riably associated  with  inflammation;  and  in  inflammation  one  or  all  of 
these  phenomena  may  be  absent.  Because  these  signs  are  not  discovered  is 
no  proof  that  inflammation  does  not  exist.  I  believe  that  inflammation  is 
not  always  due  to  microbes  and  is  not  always  a  destructive  process,  but  may 
be  from  the  start  conservative  and  reparative.  It  is  the  reaction  of  the  tissue 
to  injury  and  is  the  first  step  on  the  road  to  repair.* 

Symptoms  of  Acute  Inflammation. — Inflammation,  if  at  all  severe, 
announces  its  presence  by  symptoms  which  are  both  local  and  constitutional. 
The  local  symptoms  are  heat,  pain,  discoloration,  swelling,  disordered  function, 
and  in  some  regions  muscular  rigidity;  the  chief  constitutional  symptom  is  fever. 

Local  Symptoms  of  Inflammation. — The  most  prominent  local  symp- 
toms were  known  centuries  ago  to  the  famous  Roman,  Celsus,  who  stated  them 
as  "rubor,  color  cum  tuniore  et  dolore" — redness  and  heat  with  swelling  and 
pain.  As  set  forth  to-day,  the  local  symptoms  are — (i)  heat;  (2)  pain;  (3) 
discoloration;  (4)  swelling;  (5)  disordered  function;  and  (6)  muscular 
rigidity,  which  is  noted  in  inflammation  of  certain  regions  and  structures. 

Heat  is  due  to  the  passage  of  an  increased  quantity  of  blood  through  the 
damaged  area  and  to  the  arrival  at  the  surface  of  the  body  of  warm  blood 
from  internal  parts.  Although  an  inflamed  part  may  be,  and  usually  is, 
warmer  than  the  surrounding  parts,  its  temperature  is  never  greater  than  the 
temperature  of  the  blood.  This  increase  of  heat  is  especially  noticeable  when 
we,  for  instance,  touch  an  arm  affected  with  erysipelas  and  contrast  the  sensa- 
tion obtained  with  that  obtained  by  placing  the  hand  on  the  sound  arm. 
The  diseased  arm  feels  much  warmer  to  the  examining  hand  than  does  the 
sound  arm,  but  its  temperature  is  not  above  the  general  body-temperature. 
An  extremity  in  health,  as  is  well  known,  shows  on  the  surface  a  temperature 
below  that  of  the  blood;  in  an  inflamed  state  the  temperature  may  nearly  equal 
that  of  the  blood.  Heat  is  always  present  in  inflammation  of  a  superficial 
part.  The  surgeon  examines  for  heat  by  placing  his  hand  upon  the  suspectfed 
area  and  then  placing  it  upon  a  corresponding  portion  of  the  opposite  side 
of  the  patient  in  order  to  note  the  contrast.  If  great  accuracy  is  desired,  a 
surface  thermometer  is  used. 

Pain  is  a  constant  and  conspicuous  symptom.  It  is  due  to  stretching 
of  or  pressure  upon  nerves  from  exudate;  to  irritation  of  nerves;  or  to  inflam- 
mation of  the  nerves  themselves,  producing  cellular  changes.  Pain  is  asso- 
ciated with  tenderness  (pain  on  pressure),  it  is  aggravated  by  motion  and  by 
a  dependent  position  of  the  part,  and  it  varies  in  degree  and  in  character.  In 
serous  membranes  it  is  acute  and  lancinating,  like  dagger-thrusts;  in  connec- 
tive tissue  it  is  acute  and  throbbing;  in  large  organs  it  is  dull  and  heavy;  in 
the  bone  it  is  gnawing  or  boring;  in  the  skin  and  mucous  membrane  it  is 
itching,  burning,  smarting,  or  stinging;  in  the  urethra  it  is  scalding;  in  the 
testicle  it  is  sickening  or  nauseating;  in  the  teeth  it  is  throbbing;  and  in  in- 
flammation under  dense  fascia  it  is  pulsatile.  Pain  in  inflammation  after 
presenting  itself  in  one  form  may  change  in  character.  If  a  pain  becomes 
markedly  throbbing,  suppuration  may  be  anticipated.  Pain  does  not  always 
occur  at  the  seat  of  trouble,  but  may  be  felt  at  some  distant  point.  This  is 
*  See  Adami's  masterly  article  in  Allbutt'*  "  System  of  Medicine." 


Local  Symptoms  of  Inflammation  91 

known  as  a  "sympathetic  "  pain,  and  is  due  to  the  fact  that  the  area  to  which 
pain  is  referred  receives  its  nerve-supply  from  the  same  spinal  segment  as  does 
the  inflamed  area,  in  other  words,  there  is  a  nervous  communication  between 
the  inflamed  part  and  a  distant  area.  In  most  cases  of  sympathetic  pain  a 
nerve-trunk  refers  the  sense  of  pain  to  its  peripheral  distribution  but  some- 
times pain  is  referred  to  an  adjacent  nerve,  a  distant  nerve,  or  even,  perhaps, 
to  a  nerve  on  the  opposite  side  of  the  body.  Tenderness,  however,  is  de- 
tected at  the  seat  of  trouble  and  not  at  the  seat  of  referred  pain. 

Pain  of  hepatitis  is  often  felt  in  the  right  shoulder.  Pain  at  the  point  of 
the  shoulder  or  in  the  shoulder-blade  is  felt  also  in  gall-stones  and  in  cancer 
of  the  liver.  The  pain  arises  in  filaments  of  the  pneumogastric  from  the 
hepatic  plexus,  which  filaments  reach  the  spinal  accessory,  pain  being  ex- 
pressed in  the  branches  of  the  spinal  accessory  which  supply  the  trapezius 
and  communicate  with  the  third  and  fourth  cervical  nerves.* 

Pain  of  coxalgia  is  often  felt  on  the  inside  of  the  knee,  because  the  obturator 
nerve,  which  sends  a  branch  to  the  ligamentum  teres,  also  sends  a  branch  to 
the  interior  and  to  the  inner  side  of  the  knee-joint. 

Inflammation  of  an  eye  with  increased  tension  causes  browache.  In- 
flammation of  the  neck  of  the  bladder  causes  pain  in  the  head  of  the  penis. 
Inflammation  of  a  testicle  cause  pain  in  the  groin.  Renal  calcidus  and  pyelitis 
cause  pain  in  and  retraction  of  the  testicle,  and  pain  in  the  loin,  groin,  or  thigh. 

If  the  covering  of  an  organ  is  involved,  pain  becomes  more  violent;  for 
instance,  hepatitis  becomes  much  more  painful  when  the  perihepatic  structures 
are  attacked.  Inflammation  without  pain  is  known  as  "latent"  (as  the  in- 
flammation of  Peyer's  patches  in  typhoid).  The  sudden  disappearance  of 
inflammatory  pain,  when  not  due  to  the  administration  of  opiates,  suggests 
the  possibility  of  gangrene,  because  analgesia  exists  in  gangrene.  The 
characteristics  of  inflammatory  pain  are  that  it  comes  on  gradually,  has  a  fixed 
seat,  is  continuous,  is  attended  by  other  inflammatory  symptoms,  and  is 
increased  by  motion,  by  pressure,  and  by  a  dependent  position  of  the  part. 
If  there  be  no  tenderness  in  a  part,  the  source  of  the  pain  is  not  local  inflam- 
mation; but  tenderness  may  exist  when  there  is  no  local  inflammation,  as  in 
pain  referred  from  a  distant  part.  Pain  of  inflammation  does  not  correspond 
to  an  exact  nervous  distribution.  If  pain  corresponds  exactly  to  the  area  of 
a  nerve's  distribution,  the  cause  of  it  is  acting  on  the  nerve-trunk  or  on  its 
roots.  If  the  cutaneous  surface  is  involved,  the  lightest  touch  causes  pain. 
If  touching  the  skin  produces  no  pain,  but  deep  pressure  does  produce  it, 
the  deeper  structures  are  the  source.  Pain  in  muscle  and  ligament  is  devel- 
oped by  motion;  in  muscle,  by  contraction,  but  not  by  passive  movements 
with  the  muscle  relaxed;  in  ligament  pain  is  developed  by  active  or  passive 
movements  which  stretch  the  ligament.  If,  for  example,  a  man  with  a  stiff 
neck  has  pain  on  the  right  side  of  the  back  of  his  neck  on  voluntarily  turning 
his  face  toward  the  left  shoulder,  but  is  without  pain  when  his  face  is  turned 
by  the  surgeon,  who,  conversely,  induces  pain  by  turning  the  patient's  face  far 
to  the  right,  this  condition  indicates  the  trouble  to  be  muscular.  If,  however, 
no  pain  arises  on  turning  the  face  to  the  right,  but  it  is  manifest  on  turning  the 
face  actively  or  passively  to  the  left,  the  pain  is  in  those  ligaments  which  stretch 

*Embleton's  view  in  Hilton  on  "  Rest  and  Pain,"  a  book  every  student  should  read. 


92  Inflammation 

when  the  face  is  turned  to  the  left.*  In  inflammation  of  the  synovial  mem- 
brane gentle  passive  motion  in  any  direction  causes  pain. 

The  pain  of  colic  differs  from  that  of  inflammation.  It  is  sudden  in  onset, 
intermits,  recurs  in  paroxysms,  and  is  relieved  by  pressure.  The  pain  of 
inflammation  is  gradual  in  onset,  is  continuous,  and  is  made  worse  by  pressure. 
The  pain  of  neuralgia  is  often  preceded  by  cutaneous  anesthesia  of  the  skin 
of  the  part,  is  very  paroxysmal,  comes  on  suddenly,  darts  through  recognized 
nerve-areas,  the  attack  lasts  some  hours,  and  is  apt  to  recur  at  a  certain  hour. 
It  presents  no  general  tenderness,  as  does  inflammation,  but  we  may  find 
serveral  points  which  are  acutely  sensitive  to  pressure  (Valleix's  points  dou- 
loureux). The  tender  spots  of  Valleix  are  met  with  in  inveterate  neuralgia, 
and  occur  at  points  where  nerves  "  pass  from  a  deeper  to  a  more  superficial 
level,  and  particularly  where  they  emerge  from  bony  canals  or  pierce  fibrous 
fasciag."! 

Pain  is  often  of  great  value  by  calling  attention  to  parts  diseased;  but  it 
may  be  a  terrible  evil,  racking  the  organism  and  even  causing  death.  If  pain 
continues  long,  it  becomes  in  itself  formidable:  it  prevents  sleep,  it  destroys 
appetite,  and  it  deteriorates  the  mind,  and  one  of  the  surgeon's  highest  duties 
is  to  relieve  it.  The  physiognomy  or  expression  of  physical  pain  presents  the 
following  characteristics:  Heavy  fulness  about  the  eyes,  and  dropping  of  the 
angles  of  the  mouth,  added  to  appearance  due  to  anemia,  widespread  tremor, 
etc.  The  absence  of  the  physiognomy  of  pain  in  a  person  who  complains  of 
great  agony  is  a  strong  indication  that  the  patient  exaggerates  the  gravity  of 
his  sufferings  or  deliberately  deceives. 

Discoloration  arises  from  determination  of  blood  to  the  part;  hence  the 
more  vascular  the  tissue,  the  greater  the  discoloration.  A  non-vascular  tissue 
presents  no  discoloration,  though  we  usually  find  discoloration  adjacent  in  the 
zone  of  blood-vessels  which  furnish  the  tissue  with  nutriment.  Discoloration 
is  most  intense  at  the  focus  or  center  of  inflammatory  action.  Discoloration 
varies  in  tint  and  in  character  according  to  the  tissue  implicated  and  the  nature 
of  the  inflammation.  It  may  be  circumscribed  or  diffuse.  Arborescent 
redness  means  a  distribution  in  dendritic  lines.  Linear  discoloration  signifies 
redness  running  in  straight  fines,  as  in  phlebitis.  Punctiform  discoloration 
occurs  in  points,  and  is  due  to  vascular  rupture.  Maculiform  redness  re- 
sembles an  ecchymosis  or  blotch.     Dusky  discoloration  points  to  suppuration. 

Inflammation  of  the  throat  and  skin  produces  scarlet  discoloration;  in- 
flammation of  the  sclerotic  coat  of  the  eye  and  of  the  fibrous  coat  of  muscle 
produces  lilac  or  bluish  discoloration;  inflammation  of  the  iris  produces  brick- 
dust,  grayish,  or  brown  discoloration;  erysipelas  causes  a  yellowish-red  dis- 
coloration; secondary  syphilis  causes  a  copper-hued  discoloration;  and  ton- 
sillitis causes  a  livid  discoloration.  A  tuberculous  ulcer  is  of  a  purple  color 
on  the  edge.  Gangrene  is  shown  by  a  black  discoloration.  A  scorbutic  ulcer 
is  surrounded  by  an  area  of  violet  color. 

Redness  as  a  sign  of  inflammation  must  be  permanent  and  joined  with 
other  symptoms.  Redness  due  to  inflammation  disappears  on  pressure,  but 
returns  as  soon  as  the  pressure  is  removed.  If  redness  is  due  to  staining  of 
the  surface  by  dye,  pigmentation,  or  extravasation  of  blood,  pressure  will  not 

*  "  Surgical  Diagnosis,"  by  A.  Pearce  Gould. 

f  Anstie,  "  Neuralgia  and  Diseases  which  Resemble  It." 


Impairment  of  Special  Function  93 

blanch  the  spot. '  If  on  taking  off  pressure  the  redness  of  inflammation  rapidly 
returns,  the  circulation  is  active;  if,  on  the  contrary,  it  very  slowly  reappears, 
the  circulation  is  very  sluggish  and  gangrene  is  threatened.  Subcutaneous 
hemorrhage  gives  rise  to  a  purple-red  color  which  does  not  fade  when  sub- 
jected to  pressure.  Stains  of  the  surface  by  dyes  fail  to  disappear  on  pressure, 
are  distributed  over  a  considerable  surface,  show  a  hue  which  is  uniform 
throughout,  are  obviously  superficial,  are  not  associated  with  other  signs  of 
inflammation,  and  can  be  washed  away. 

A.  Pearce  Gould,  in  his  excellent  little  work  upon  "  Surgical  Diagnosis," 
tells  us  that  the  color  of  a  hyperemic  surface  may  furnish  important  informa- 
tion. Lividity  may  mean  failure  of  the  heart  and  lungs,  or  simply  venous 
congestion  in  the  part.  In  lividity  from  obstruction  of  the  lungs  or  heart  the 
color  slowly  returns  after  pressure  has  driven  it  out.  In  lividity  due  to  local 
congestion  the  color  quickly  returns  when  pressure  is  released  and  the  dilated 
veins  are  often  distinctly  visible.  Of  course,  in  a  local  trouble,  when  the 
circulation  becomes  impaired  to  such  a  degree  that  gangrene  is  threatened, 
the  lividity  fades  very  slowly  on  pressure  and  reappears  very  slowly  on  the 
release  of  pressure. 

Swelling  or  tumefaction  arises  in  small  part  from  vascular  distention,  but 
chiefly  from  effusion  and  cell-multiplication.  The  more  loose  cellular  mate- 
rial a  part  contains,  the  more  it  swells;  hence  the  eyelids,  scrotum,  vulva, 
tonsils,  glottis,  and  conjunctivae  swell  very  largely  when  inflamed.  A  swelling 
is  soft  or  edematous  when  due  to  uncoagulable  eft'usion;  is  brawny  and  doughy 
when  due  to  coagulated  effusion;  is  hard  and  elastic  when  produced  by  pro- 
liferating cells.  Swelling  may  do  good  by  unloading  the  vessels  and  acting 
like  a  blister  or  local  bleeding,  or  it  may  do  great  harm  by  pressing  upon  the 
vessels  and  cutting  off  the  blood-supply.  Swelling  of  the  conjunctiva,  or 
chemosis,  may  cause  sloughing  of  the  cornea,  and  swelling  of  the  prepuce 
may  cause  gangrene.  A  swelling  may  do  harm  by  obstructing  a  natural 
passage,  as  in  edema  of  the  glottis,  when  the  larynx  becomes  blocked;  or  by 
compression  of  a  normal  channel,  as  in  the  swelling  of  the  perineum,  when 
the  urethra  is  compressed.  A  swollen  area  may  be  covered  with  blisters  or 
blebs.     This  condition  is  noted  particularly  in  burns  and  fractures. 

Disordered  junction  is  always  present  in  inflammation.  It  may  be  mani- 
fested by  increased  tenderness  or  sensibility,  a  slight  touch,  it  may  be,  pro- 
ducing torturing  pain.  Parts  almost  or  entirely  destitute  of  feeling  when 
healthy  (as  tendons,  ligaments,  and  bones)  become  highly  sensitive  when 
inflamed.  It  may  be  manifested  by  increased  irritability.  In  dysentery  the 
colon  repeatedly  contracts  and  expels  its  contents;  the  stomach  does  likewise 
in  gastritis;  and  the  bladder  acts  similarly  in  cystitis.  Spasmodic  twitching 
of  the  eyelids  occurs  in  conjunctivitis,  and  twitching  of  the  muscles  of  a  limb 
in  fracture  and  after  amputation. 

Impairment  of  Special  Function. — In  inflammation  of  the  eye,  when  an 
attempt  is  made  to  look  at  objects,  the  lids  close  spasmodically,  and  even  a 
little  light  causes  great  pain  and  lachrymation  (photophobia).  In  inflamma- 
tion of  the  ear  noises  cause  great  suffering,  and  even  when  in  a  quiet  room  the 
patient  has  subjective  buzzing  and  roaring  in  his  ears  (tinnitus  aurium). 
In  coryza  the  sense  of  smell,  in  glossitis  the  sense  of  taste,  in  dermatitis  the 
sense  of  touch,  and  in  laryngitis  the  voice  may  be  lost.     In  inflammation  of 


94  Inflammation 

the  brain  the  mind  is  affected;  in  arthritis  the  joints  can  scarcely  be  moved; 
and  in  myositis  it  is  difficult  and  painful  to  employ  the  muscles. 

Derangement  0}  Secretions. — In  dermatitis  the  sweat  is  not  thrown  off;  in 
hepatitis  bile  is  not  properly  secreted;  and  in  nephritis  urea  is  not  satisfac- 
torily removed.  The  secretions  may  undergo  important  changes  of  compo- 
sition. The  sputum  in  pneumonia  is  rusty,  and  dysentery  causes  a  discharge 
of  bloody  mucus  (Gross). 

Derangement  0}  Absorbents. — In  the  height  of  an  inllammation  the  absor- 
bents are  blocked  and  clogged  by  coagulated  exudate,  and  they  cannot  perform 
their  offices. 

Muscular  rigidity  is  sometimes  an  important  sign  of  inflammation.  If 
a  joint  is  inflamed  the  muscles  which  move  the  joint  are  rigid  and  the  joint 
is  more  or  less  immobile.  In  inflammation  of  the  peritoneum  the  abdominal 
muscles  are  rigid  and  the  respirations  become  shallow,  frequent,  and  thoracic. 
In  pleuritis  the  intercostal  muscles  of  the  inflamed  side  become  rigid  and  the 
respiratory  excursion  of  the  chest  is  limited.  Rigidit}'  serves  to  lessen  motion, 
prevent  pain,  protect  the  part,  and  so  give  physiological  rest. 

Constitutional  symptoms  of  acute  inflammation  may  be  absent,  and 
often  are  in  moderate  or  limited  inflammations;  but  in  severe,  extensive,  or 
infective  inflammations  the  symptom  group  known  as  fever  is  certain  to  exist. 
This  is  known  as  symptomatic,  or  inflammatory  fever,  and  it  arises  in 
non-septic  cases  from  the  absorption  of  aseptic  pyrogenous  exudate  and  in 
microbic  inflammations  from  the  absorption  of  pyrogenous  toxic  products 
of  bacterial  action.  In  young  and  robust  individuals  an  acute  non-microbic 
inflammation  causes  a  fever  characterized  by  full,  strong  pulse,  flushed  face, 
coated  tongue,  dry  skin,  nausea,  constipation,  and  possibily  acute  delirium  (the 
sthenic  type  of  the  older  authors).  In  broken-down  and  exhausted  indi- 
viduals an  ordinary  inflammation,  and  in  any  individual  a  bacterial  inflam- 
mation, may  cause  a  fever  with  typhoid  symptoms  (the  typhoid,  asthenic,  or 
adynamic  type).  Fibrin  ferment  is  obtained  from  the  white  corpuscles;  it  is 
liberated  as  the  corpuscles  break  up  in  the  exudate,  and  acting  on  the  liquor 
sanguinis  cause  the  union  of  calcium  and  fibrinogen  and  the  formation  of 
fibrin.  The  absorption  of  fibrin  ferment  many  believe  causes  aseptic  fever 
(page  134).  Inflammatory  blood  contains  an  increased  amount  of  albumin 
and  salts.  If  a  person  with  inflammatory  fever  is  bled,  the  blood  coagulates 
rapidly,  the  clot  sinks,  and  there  is  found  on  the  surface  a  cup-shaped  coat, 
made  up  of  liquor  sanguinis  and  white  cells,  known  as  the  "buffy  coat";  but 
this  is  not  really  a  sign  of  inflammation,  and  occurs  normally  in  the  blood  of 
the  horse.  The  buffy  coat  forms  when  blood  contains  a  great  number  of  leu- 
kocytes, because  these  leukocytes  sink  more  slowly  than  do  the  red  corpuscles. 
Cupping  occurs  because  the  white  corpuscles  sink  more  slowl}^  by  the  side 
of  the  tube  than  far  from  the  sides. 

Letikocytosis. — In  many  inflammatory  and  infectious  diseases  leukocy- 
tosis is  noted.  It  probably  indicates  an  attempt  on  the  part  of  the  organism 
to  protect  itself  from  noxious  materials.  Leukocytosis  is  usually  much  more 
marked  if  pus  exists  than  if  the  exudation  is  serous  or  fibrinous. 

"The  degree  of  leukocytosis  may  be  considered  a  general  index  to  the  in- 
tensity of  the  infection  and  to  the  strength  of  the  individual's  resisting  powers 
in  reacting  against  it.     If  follows,  therefore,  that  intense  infections  occurring 


Chronic  Inflammation  95 

in  individuals  whose  resisting  powers  are  strong,  produce  a  decided  increase; 
but  the  presence  of  an  infection  of  Uke  intensity  in  one  whose  resisting  powers 
are  greatly  crippled  fails  to  cause  leukocytosis,  for  in  such  an  instance  the  organ- 
ism is  so  overpowered  by  the  effects  of  the  morbid  process  that  it  is  incapable 
of  reacting"  ("Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.).  We  see  from 
the  above  that  gangrene  or  any  other  virulent  infection  may  be  accompanied 
by  a  low  leukocytic  count,  and  when  pus  is  surrounded  by  a  thick  wall  the  leu- 
kocytes may  be  normal  in  number.  An  increased  proportion  of  polymorpho- 
nuclear leukocytes  strongly  suggests  body  reaction  against  infection,  and  an 
increase  of  eosinophiles  aids  us  in  recognizing  deep-seated  pus  when  the  leuko- 
cyte count  is  normal  or  but  shghtly  increased. 

The  introduction  of  salt  solution  into  the  peritoneal  cavity  leads  to  the 
gathering  of  numbers  of  white  cells  and  the  resistance  of  the  serous  mem- 
brane to  infection  is  increased.  Horse  serum  that  has  t)een  boiled  is  said  by 
Petit  to  be  a  valuable  material  to  draw  polynuclear  leukocytes  to  a  part 
("Med.  Record,"  June  22,  1907).  It  has  been  injected  into  the  peritoneal 
cavity  the  evening  before  an  operation  (30  cc.) ;  it  has  been  poured  into  the 
cavity  at  the  termination  of  an  operation;  the  gauze  used  for  drainage  after 
an  appendicitis  operation  has  been  soaked  in  it. 

There  is  no  fixed  number  of  leukocytes  which  causes  us  to  affirm  the 
presence  or  absence  of  gangrene  or  pus.  Deaver  thinks  that  a  relative  per- 
centage of  polynuclear  cells  below  70  in  blood  showing  any  degree  of  inflam- 
matory leukocytosis  indicates  excellent  tissue  reaction  and  the  absence  of  pus 
and  gangrene  ("N.  Y.  Med.  Jour.,"  Feb.  2,  1907).  Most  serious  inflamma- 
tions show  marked  inflammatory  leukocytosis  and  an  increase  in  the  relative 
proportion  of  polynuclear  cells.  Typhoid  shows  no  leukocytosis  and  even  a 
mixed  infection  shows  comparatively  httle  increase  of  polynuclear  cells.  The 
same  is  true  of  tuberculosis.  The  same  man  should  make  all  the  counts  on  one 
patient;  at  least  500  cells  should  be  counted  and  several  examinations  ought  to 
be  made. 

Chronic  Inflammation. — This  condition  results  from  the  action  on  the 
tissues  of  some  mild  but  long  acting  irritant.  It  progresses  slowly  and  does  not 
produce  symptoms  of  severity  either  in  the  part  or  the  body  at  large. 

Causes. — Blood  diseases,  as  rheumatism  and  gout;  infective  diseases,  as 
tuberculosis  and  S}^hilis;  retained  pus  in  an  ill-drained  abscess;  blocking 
of  the  duct  of  a  gland;  the  retention  of  a  foreign  body  in  a  part;  the  flow  of  an 
irritant  secretion  (as  saliva  from  a  fistula);  repeated  identical  traumatisms 
of  an  occupation,  etc.  \V.  Watson  Cheyne  tells  us  that  chronic  inflammation 
is  not  due  to  the  ordinary  pyogenic  organisms  (see  Cheyne's  article  in  Treves's 
" System  of  Surgery"). 

Tissue-changes. — These  changes  are  practically  the  same  as  in  acute 
inflammation,  but  take  place  far  less  rapidly.  Vascular  dilatation,  exudation, 
and  leukocytic  migration  are  often  trivial.  Cell  proliferation  is  always  con- 
spicuously marked.  It  is  maintained  by  Cheyne  and  others  that  typical  granu- 
lation tissue  does  not  form,  the  tissues  of  the  part  being  replaced  directly  by 
fibrous  tissue.  The  amount  of  fibrous  tissue  produced  is  relatively  very  great. 
This  tissue  may  cause  permanent  thickening,  or  may  contract  and  thus  dimin- 
ish the  size  of  a  part.  Contraction  is  very  considerable  in  cirrhosis  of  the  liver 
and  in  interstitial  nephritis. 


96  Inflammation 

Symptoms. — Pain  varying  in  intensity  and  character;  tenderness;  great 
swelling,  which  in  some  cases  is  followed  by  shrinking,  and  is  usually  indurated 
or  brawny.  As  a  matter  of  fact,  great  swelling  is  the  most  usual  symptom. 
Sometimes  there  is  a  trivial  amount  of  heat.  There  is  rarely  discoloration 
unless  the  skin  is  itself  inflamed,  but  usually  the  surface  veins  are  distinctly 
and  sometimes  they  are  greatly  distended.  There  are  no  constitutional 
symptoms  attributable  purely  to  the  inflammation.  If  there  are  such  symp- 
toms, they  are  due  to  the  disease  which  induced  the  inflammation  or  to  inter- 
ference with  the  function  of  an  organ  because  of  the  fibrous  mass.  (For  the 
treatment  of  chronic  inflammation  see  articles  upon  special  regions  and  par- 
ticular structures.) 

Treatment  of  Acute  Inflammation.— The  first  rule  in  treating  an 
inflammation  must  be  to  remove  the  exciting  cause.  If  this  cause  is  a  splinter 
in  the  part,  take  out  the  splinter;  if  it  is  a  foreign  body  in  the  eye,  remove  the 
foreign  body;  if  urine  is  extra vasated,  open  and  drain;  take  off  pressure  from 
a  corn;  pull  out  an  ingrown  nail;  and  remove  microbes  from  an  infected  area 
by  exposing,  irrigating,  and  applying  antiseptics.  The  rule,  remove  the  cause, 
applies  to  a  chronic  as  well  as  to  an  acute  inflammation.  If  the  cause  of  an 
inflammation  was  momentary  in  action  (as  a  blow),  we  cannot  remove  it,  for 
it  has  already  ceased  to  exist.  After  removing  the  cause,  endeavor  to  bring 
about  a  cure  by  local  and  constitutional  treatment. 

Local  Treatment  of  Inflammation. — It  must  be  remembered  that  the 
division  of  inflammation  into  stages  is  natural,  and  not  artificial,  and  that  a 
remedy  which  does  good  in  one  stage  may  do  harm  in  another.  Certain  agents 
are  suited  to  all  stages  of  an  acute  inflammation,  namely,  rest  and  elevation.  In 
many  inflammatory  conditions  Nature  seeks  to  immobiHze,  protect,  and  rest 
the  part  by  increasing  the  tension  of  adjacent  muscles.  By  this  muscular 
rigidity  inflamed  joints  are  fixed  and  rested.  Rigidity  of  the  intercostal  mus- 
cles in  pleuritis  limits  chest  motion  and  pain;  rigidity  of  the  abdominal  mus- 
cles in  peritonitis  limits  abdominal  movements  and  lessens  suffering. 

Rest. — Physiological  rest  is  of  infinite  importance,  and  is  always  indicated 
in  acute  inflammation.  In  the  exercise  of  function  blood  is  taken  to  a  part 
and  an  existing  inflammation  is  aggravated.  Further,  as  Billroth  has  pointed 
out,  rest  prevents  the  dissemination  of  infection,  because  motion  exposes 
fresh  surfaces  to  inoculation  and  breaks  down  protective  barriers  of  leuko- 
cytes. Its  principles  were  first  thoroughly  studied  by  Hilton.*  Baron  Larrey, 
the  celebrated  military  surgeon  of  the  Napoleonic  Empire,  anticipated  many 
modern  views  on  this  subject.  He  insisted  on  the  necessity  of  rest  in  the 
treatment  of  wounds;  he  believed  that  rest  permitted  Nature  to  perform 
her  work  unhampered;  he  was  accustomed  to  leave  a  "first  dressing,"  if 
properly  applied,  undisturbed  for  several  or  even  for  many  days.  He  believed 
it  advisable  to  associate  with  rest  well  adjusted  and  judicious  compression 
made  by  bandages,  especially  flannel  bandages.  (The  author  on  Baron 
Larrey,  in  "Johns  Hopkins  Hospital  Bulletin,"  July,  1906.)  The  means  of 
securing  rest  differ  with  the  structure  or  the  part  diseased.  When  rest  is 
used,  do  not  employ  it  too  long.  Rest  in  bed  diminishes  the  amount  of  blood 
sent  to  an  inflamed  part  and  lessens  the  force  of  the  circulation;  hence  it 
antagonizes  stasis.  It  has  been  shown  that  the  heart  beats  at  least  fifteen 
*  "  Lectures  upon  Rest  and  Pain." 


Local  Bleeding  q7 

times  per  minute  less  when  the  patient  is  recumbent  than  when  he  is  erect. 
The  saving  of  strength  and  the  benefit  to  the  local  condition  are  thus  seen  to 
be  enormous.  In  fact,  the  heart  saves  at  least  twenty-one  thousand  beats  a 
day.     In  every  severe  inflammation  insist  on  the  patient  going  to  bed. 

In  cerebral  concussion  rest  must  be  secured  by  quiet,  by  darkness,  by  the 
avoidance  of  stimulants  and  meat,  by  the  application  of  ice  to  the  head,  and 
by  the  use  of  purgatives  to  prevent  reflex  disturbance  and  the  circulation  of 
poisons  in  the  blood.  In  inflamed  joints  rest  must  be  obtained  by  proper 
position,  associated  in  many  cases  with  the  adjustment  of  splints  or  plaster- 
of-Paris,  or  the  employment  of  extension. 

In  pleuritis  partial  rest  can  be  secured  by  strapping  the  affected  side  with 
adhesive  plaster  or  by  using  a  bandage  or  a  binder  to  limit  respiratory  move- 
ments. In  fractures  Nature  procures  rest  by  her  splints — the  callus — and 
the  surgeon  procures  rest  by  his  splints — firm  dressings,  or  extension.  In 
cancer  of  the  rectum  and  intractable  rectitis  a  colostomy  secures  rest  for  the 
inflamed  and  damaged  bowel.  In  enteritis  opium  gives  rest  to  the  bowel  by 
stopping  peristalsis.  In  cystitis  rest  is  obtained  by  the  administration  of  opium 
and  belladonna,  which  paralyze  the  muscular  fibers  of  the  bladder.  The  use 
of  the  catheter  gives  rest  to  the  bladder  by  removing  urine.  A  cystotomy 
allows  complete  rest  by  permitting  the  bladder  to  suspend  its  function  as  a 
reservoir  of  urine.  In  cystitis  from  vesical  calculus  rest  is  obtained  by  incising 
and  draining  the  bladder  or  by  crushing  and  evacuating  the  stone.  In  in- 
flamed mucous  membrane  rest  from  the  contact  of  irritants  is  secured  by  touch- 
ing the  membrane  with  silver  nitrate,  which  forms  a  protective  coat  of  coagu- 
lated albumin.  Opening  an  abscess  gives  its  walls  rest  from  tension.  In 
inflammations  of  the  eye  Ught  must  be  excluded  to  obtain  complete  rest,  but 
tolerably  satisfactory  rest  is  given  in  some  cases  by  the  use  of  glasses  of  a 
peacock-blue  tint.  In  aneurysm  the  operation  of  ligation  cuts  off  the  blood- 
current  and  gives  rest  to  the  sac.  In  hernia  the  operation  gives  rest  from  pres- 
sure.    Instances  of  the  value  of  rest  could  be  multipHed  indefinitely. 

Relaxation  is  in  reality  a  form  of  rest,  and  consists  in  placing  the  part  in  an 
easy  position.  In  synovitis  of  the  knee  semiflexion  of  the  knee-joint  lessens 
the  pain.     In  muscular  inflammations  relaxation  relieves  the  pain. 

Elevation. — Elevation  partly  restores  circulatory  equilibrium.  A  felon 
is  less  painful  when  the  hand  is  held  up  in  a  sling  than  when  it  is  dependent. 
A  congestive  headache  is  worse  during  recumbency.  A  gouty  inflammation 
in  the  great  toe  is  more  painful  with  the  foot  lowered  than  when  it  is  raised. 
A  toothache  becomes  worse  on  lying  down. 

Certain  agents  are  suited  to  the  stage  of  vascular  engorgement,  increased 
arterial  tension,  and  beginning  eft'usion.  These  agents  are — (i)  local  bleed- 
ing or  depletion;  (2)   cutting  oft"  the  blood-supply;  and  (3)  cold. 

Local  Bleeding. — Local  bleeding,  or  depletion,  is  the  abstraction  of  blood 
from  the  inflamed  area.  This  abstraction  relieves  circulatory  retardation 
and  causes  the  blood  to  move  rapidly  onward;  the  corpuscles  clinging  to  the 
vessel-walls  are  washed  away,  the  capillaries  shrink  to  their  natural  size,  and 
the  exudate  is  absorbed.  In  other  words,  local  blood-letting  increases  the 
rate  of  the  circulation,  though  not  its  force. 

The  methods  of  bleeding  locally  are — (a)  puncture;  {b)  scarification;  (c) 
leeching;  and  {d)  cupping. 
7 


98  Inflammation 

Puncture  is  recommended  in  inflammation,  not  only  because  it  abstracts 
blood  locally,  but  also  because  it  gives  an  exit  to  effusion  under  fibrous  mem- 
branes. It  is  very  useful  in  relieving  tension — for  instance,  in  epididymitis. 
It  is  performed  with  a  tenotome  and  with  aseptic  precautions.  If  numerous 
punctures  are  made,  the  procedure  is  termed  "multiple  puncture."  This  is 
very  useful  when  applied  to  the  inflamed  area  around  a  leg-ulcer.  The  late 
Prof.  Joseph  Pancoast  was  very  fond  of  employing  multiple  punctures,  desig- 
nating the  operation  "the  antiphlogistic  touch  of  the  therapeutic  knife." 

Scarification  or  Incision. — By  means  of  scarification  we  bleed  locally, 
evacuate  exudate,  and  relieve  tension.  One  cut  or  many  cuts  may  be  made, 
and  these  cuts  may  be  deep  or  may  not  go  entirely  through  the  skin,  according 
to  circumstances.  Multiple  incisions  are  useful  when  applied  to  inflamed 
ulcers,  ulcers  in  danger  of  gangrene,  and  to  almost  any  condition  of  great  ten- 
sion. Scarification  is  of  notable  value  when  edema  of  the  glottis  exists.  Free 
incision  is  of  great  benefit  in  periostitis  and  in  threatened  gangrene.  In  osteo- 
myelitis the  medullary  canal  must  be  promptly  opened. 

Leeching. — Leeches  must  not  be  applied  to  a  region  plentifully  endowed 
with  loose  cellular  tissue,  as  great  swelling  and  discoloration  are  sure  to  ensue. 
These  regions  are  the  prepuce,  labia  majora,  scrotum,  and  eyelids.  Leeches 
should  never  be  applied  to  the  face  (because  of  the  scar),  near  specific  sores 
or  inflammations,  nor  over  a  superficial  artery,  vein,  or  nerve.  A  leech  is  best 
applied  at  the  periphery  of  an  inflammation  and  between  an  inflammation 
and  the  heart.  To  leech  at  the  inflammatory  focus  only  aggravates  the  trouble. 
Before  applying  leeches,  wash  the  part  and  shave  it  if  hairy.  Place  the  leech 
in  a  test-tube  or  an  inverted  wine  glass,  inserting  the  tail  or  thick  end  first, 
and  invert  the  tube  so  that  the  leech's  head  will  come  in  contact  with  the  pre- 
pared skin.  The  leech  is  restrained  in  the  tube  until  it  "takes  hold"  and 
begins  to  feed,  when  the  tube  is  removed.  If  the  leeches  will  not  bite,  smear 
the  part  with  milk  or  a  Httle  blood.  Never  pull  off  a  leech;  let  it  drop  ofif. 
It  will  usually  drop  off  when  full,  but  if  it  refuses  to  do  so,  sprinkle  it  with  salt. 
After  removing  a  leech,  employ  warm  fomentations  if  continued  bleeding  is 
desired.  Sometimes  the  bleeding  persists,  but  this  may  be  arrested  by  styptic 
cotton  and  pressure.  In  some  rare  cases  the  bleeding  continues  in  spite  of 
pressure.  This  is  due  to  the  fact  that  the  tissue  contains 
a  considerable  quantity  of  a  material  secreted  from  the 
throat  of  the  leech,  which  material  prevents  coagulation 
of  blood.  In  such  a  case  excise  the  bite  and  the  area 
of  tissue  adjacent  to  it,  and  suture  the  wound.  Leech- 
ing leaves  permanent  triangular  scars.  The  Swedish 
leech,  which  is  ])referred  to  the  American,  draws  from 
two  to  four  drams  of  blood.  After  a  leech  has  been  re- 
moved, if  we  desire  to  use  it  again,  place  it  in  salt  water. 
This  causes  it  to  vomit  the  blood  which  it  has  taken  up. 
Leeching  has  both  a  constitutional  and  a  local  effect.  It 
— R  bb  r  b  lb  ^^  ^^  present  used  comparatively  rarely,  but  it  is  employed 
cupper.  by  some  practitioners  over  the  spermatic  cord  in  epi- 

didymitis, on  the  temple  in  ocular   inflammation,  and 
over  the  right  iliac  region  to  relieve  pain  in  mild  cases  of  appendicitis. 

Cupping. — Dry  cups  deviate  blood  from  a  deeply  placed  inflamed  area  to 
the  surface.     Wet  cups  actually  remove  blood. 


Cold  in  Treatment  of  Inflammation 


99 


Dry  Cups. — Dry  cups  are  applied  without  first  incising  the  skin.  One  or 
more  may  be  applied.  A  special  instrument  is  sold  in  the  shops  for  the  per- 
formance of  dry  cupping.  It  consists  of  a  glass  bell,  with  a  globular  and  hollow 
top  of  rubber  (Fig.  49).  The  rubber  bulb  is  emptied  of  air  by  squeezing,  the 
glass  bulb,  the  edges  of  which  have  been  greased,  is  pushed  upon  the  skin,  and 
the  compression  is  relaxed  upon  the  rubber  bulb.  A  partial  vacuum  is  created, 
and  an  area  of  skin  and  subcutaneous  tissue  full  of  blood  rises  into  the  glass  bell. 

Cupping  can  be  easily  performed  by  means  of  a  tumbler.  The  edge  of  the 
glass  is  greased;  a  bit  of  blotting-paper  wet  with  alcohol  is  placed  in  the  bottom 
of  the  tumbler  and  lighted.  After  a  brief  period  the  glass  is  inverted  and  placed 
upon  the  skin,  which  has  been  dampened  with  warm  water.  As  the  air  in  the 
glass  cools,  the  tissues  rise  into  the  partial  vacuum. 

Wet  Cups. — Wet  cups  draw  blood,  and  the  skin  should  be  cleansed  before 
they  are  applied.     In  wet  cupping  apply  a  cup  for  a  moment,  remove  it.  incise 


Fig.  50 — Scarificator. 


Fig.  51.— Heurteloup's  artificial  leech. 


or  puncture  the  skin,  and  replace  the  cup  to  draw  the  requisite  amount  of 
blood.  Incisions  may  be  made  by  an  ordinary  scalpel,  a  lancet,  or  a  scarifi- 
cator, a  cup  being  then  applied.  An  excellent  scarificator  is  shown  in  Fig. 
50.  In  this  instrument  concealed  blades  are  thrown  out  by  touching  a  spring. 
Baron  Heurteloup  devised  an  instrument  (Fig.  51)  in  which  the  incision  is 
made  by  a  scarificator.  The  blood  is  drawn  out  by  a  pump,  the  tube  being 
placed  upon  the  cut  area  and  the  withdrawal  of  the  ])iston  creating  a  vacuum. 
This  instrument  is  known  as  the  ''artificial  leech."  After  scarification  and 
the  application  of  the  cup,  the  partial  vacuum  draws  blood  into  the  cup;  when 
the  surface  ceases  to  bleed,  the  cup  is  removed,  and  if  further  bleeding  is 
thought  desirable,  the  clots  are  wiped  away  and  the  cup  is  again  applied,  and 
after  its  removal  warm  fomentations  are  used  (Cheyne  and  Burghard).  Wet 
cupping  is  of  value  in  pleuritis,  pericarditis,  and  nephritis. 

Cutting  off  the  Blood-supply. — Onderdonk,  of  New  York,  in  1813 
recommended  ligation  of  the  main  artery  of  a  limb  for  the  cure  of  inflamma- 
tion in  important  structures  supplied  by  the  vessel.  The  procedure  was 
warmly  advocated  by  Campbell,  of  Georgia,  for  the  treatment  of  gunshot 
wounds  of  joints.  This  plan  of  treatment  is  now  not  to  be  considered  for  a 
moment;  antisepsis  furnishes  us  with  a  safer  and  more  certain  plan.  Van- 
zetti,  of  Padua,  advocates  digital  pressure  to  cut  off  the  blood-supply  to  an 
inflamed  part. 

Cold. — Cold  is  a  very  powerful  and  useful  agent  if  used  judiciously  and 
applied  at  the  proper  time.     It  is  valuable  because  of  its  reflex  effect  upon  the 


loo  Inflammation 

vessels  of  the  inflamed  area  rather  than  because  of  direct  action  upon  the  cells 
of  a  part.  It  should  be  used  early  in  the  case,  before  stasis  occurs.  It  is  not 
to  be  used  in  the  later  stages  of  inflammation,  for  it  will  then  only  aggravate 
the  existing  state;  in  fact,  when  there  is  considerable  exudation  cold  does  no 
good. 

Cold  acts  by  constricting  the  vessels  of  a  hyperemic  area,  thus  lessening 
the  amount  of  blood  sent  to  the  part,  and  preventing  the  evolution  of  the  pro- 
cess into  the  stage  of  stasis  and  exudation.  Further,  it  prevents  the  migra- 
tion of  leukocytes,  retards  cell-proliferation,  relieves  pain  and  tension,  and 
lowers  temperature.  If  cold  is  too  intense,  if  it  is  kept  too  long  applied,  if  it 
is  used  late  in  an  inflammation,  if  it  is  used  upon  an  old  or  feeble  patient,  or 
if  it  is  employed  when  there  is  much  exudation  or  a  condition  of  tissue  strangu- 
lation, it  does  actual  harm.  It  lessens  the  nutritive  acti^•ity  of  cells,  constricts 
the  lymph-spaces  and  channels,  increases  existing  stasis,  and  hence  lowers  the 
vitality  of  the  tissues.  If  the  parts  are  constricted,  as  in  strangulated  hernia, 
or  if  they  are  compressed  by  a  large  exudate,  or  fed  by  diseased  blood-vessels, 
cold  may  cause  gangrene.  Nancrede,  in  his  "Principles  of  Surgery,"  points 
out  that  in  an  inflammation  stasis  soon  arises  at  the  focus  of  the  inflammation, 
and  there  is  an  area  of  stasis  surrounded  by  a  zone  of  hyperemia.  Cold 
benefits  the  hyperemic  zone  but  aggravates  the  stasis.  Nancrede  cautions  us 
as  follows:  "Judgment  is  therefore  requisite  to  decide  whether  the  evil  at 
the  focus  will  not  outweigh  the  good  exerted  at  the  periphery."  *  Nancrede 
further  points  out  that  cold  must  not  be  used  intermittently;  but  if  employed 
at  all,  must  be  continuously  applied.  If  cold  is  applied  intermittently,  there 
will  be  a  reaction  whenever  it  is  removed,  and  this  reaction  causes  increased 
hyperemia.  Hence,  cold  must  be  "continued  in  action  to  prevent  reaction." 
If  during  the  employment  of  cold  the  skin  becomes  purple  and  congested  and 
the  circulation  feeble,  at  once  discontinue  the  use  of  it,  as  its  continuance  will 
be  dangerous. 

Cold  may  be  used  as  wet  cold  or  as  dry  cold. 

Wet  Cold. — Wet  cold  is  easily  applied,  but  it  is  much  more  depressing  than 
dry  cold,  is  Ukely  to  produce  discomfort,  macerates  the  skin,  and  may  lead 
to  the  formation  of  excoriations,  etc.  A  part  can  be  subjected  to  wet  cold  by 
the  application  of  evaporating  fluids  or  the  use  of  a  siphon.  When  w^et  cold 
is  used  inspect  the  part  at  frequent  intervals,  and  discontinue  the  treatment 
if  evidences  of  stasis  become  positive.  Evaporating  fluids  are  extensively 
employed.  If  such  a  fluid  is  used,  never  cover  the  part  with  a  thick  dressing. 
If  this  should  be  done,  the  fluid  wall  not  evaporate  with  sufficient  rapidity  to 
produce  cold.  A  piece  of  thin  muslin  or  flannel  should  be  moistened  with  the 
fluid  and  laid  upon  the  part,  and  be  kept  constantly  moist  by  the  application 
from  time  to  time  of  smaU  quantities  of  the  liquid.  Lead-water  and  laudanum 
is  used  extensively,  and  probably  owes  its  chief  value  to  the  fact  that  it  pro- 
duces cold  on  evaporation.  Lead-water  and  laudanum  is  composed  of  5j  of 
laudanum,  5j  of  liquor  plumbi  subacetatis,  and  i  pint  of  water.  Liquor 
plumbi  subacetatis  dilutus  may  be  used  without  laudanum.  It  is  thought 
that  the  addition  of  laudanum  tends  to  allay  pain.  A  solution  of  ammonium 
chlorid  may  be  used  in  the  strength  of  §j  of  the  drug  to  2  quarts  of  water.  If 
ammonium  chlorid  is  used  for  more  than  a  short  period  of  time,  it  is  prone  to 

*  "Principles  of  Surgery." 


Cold  in  Treatment  of  Inflammation  loi 

cause  the  formation  of  blisters  which  are  irritable  and  painful.  Cheyne  and 
Burghard  use  the  following  formula:  ^  ounce  of  ammonium  chlorid,  i  ounce 
of  alcohol,  and  7  ounces  of  water.  Plain  spring-water,  iced  water,  or  a  mixture 
of  alcohol  and  water  may  be  used.  The  siphon  is  occasionally  used.  If 
there  is  a  wound,  the  fluid  must  be  aseptic  or  antiseptic.  In  conjunctivitis, 
cold  is  applied  to  the  eye  by  means  of  linen  or  muslin  soaked  in  iced  water  laid 
upon  the  closed  lids,  and  changed  frequently. 

To  apply  wet  cold  by  means  of  a  siphon,  the  part  is  covered  with  one  layer 
of  wet  linen  or  muslin  and  is  laid  upon  a  rubber  sheet  folded  like  a  trough  and 
emptying  into  a  bucket.  A  vessel  filled  with  cold  water  is  placed  upon  a 
higher  level  than  the  bed.  A  wet  lamp-wick  is  now  taken,  one  end  is  inserted 
into  the  water  of  the  vessel,  and  the  other  end  is  laid  upon  the  part.  Capillary 
action  and  gravity  combine  to  keep  the  part  moist.  A  rubber  tube  may  be 
used  instead  of  a  wick.  If  a  tube  is  employed,  tie  it  in  a  knot  or  clamp  it  so 
that  the  fluid  is  dehvered  drop  by  drop  (Fig.  53).  Ordinary  water  or  iced 
water  can  be  used.  If  the  water  be  too  warm,  it  can  be  reduced  to  about  45°  F. 
by  adding  i  part  of  alcohol  to  every  4  parts  of  water.  A  mixture  of  5  parts 
of  nitrate  of  potassium,  5  parts  of  chlorid  of  ammonium,  and  16  parts  of  water 
produces  great  cold. 

Dry  cold  is  more  manageable  and  more  generally  useful  than  wet  cold. 
It  is  applied  by  means  of  a  rubber  bag  or  a  bladder  filled  with  ground  or  finely 
cracked  ice,  several  folds  of  flannel  being  first  laid  over  the  part.  The  flannel 
collects  the  moisture  from  the  "sweating"  bag  and  thus  prevents  maceration 
of  the  skin.  Further,  it  saves  the  tissue  from  being  subjected  to  too  much 
direct  cold  and  enables  us  to  obtain  the  beneficial  reflex  effect.  The  ice-bag 
of  India-rubber  is  widely  used.  We  can  venture  to  apply  by  means  of  the 
ice-bag  a  greater  degree  of  cold  than  it  is  proper  to  apply  by  the  use  of  fluids, 
as  dry  cold  is  not  so  likely  to  induce  gangrene  as  is  moist  cold.  If  there  is 
much  tenderness,  the  weight  of  an  ice-bag  causes  pain,  and  it  is  best  to  suspend 
it  from  a  frame,  so  that  it  lightly  touches  the  part.  The  frame  is  the  same  as  is 
used  to  keep  the  bedclothes  from 
a  fractured  leg,  and  can  be  easily 
made  from  barrel  hoops.  Dur- 
ing the  time  an  ice-bag  is  being 
used  the  part  must  be  inspected 
at  brief  intervals  to  see  that  the 
circulation  is  not  unduly  de- 
pressed.    The  ice-bag    is     fre- 

^,  ,    .       .    •    ,  .    n  Fig.  52.-Ice-bag  (VV.  E.  Ashton). 

quently  used  m  jomt-mflamma-  o  ^^ 

tion,  in  intracerebral  inflammation,  in  the  earliest  stage  of  appendicitis  (see 
page  999),  in  epididymitis,  and  in  acute  myelitis.  If  a  joint  is  sprained,  the 
immediate  application  of  an  ice-bag  is  of  great  service.  A  part  can  be  encircled 
with  a  rubber  tube  through  which  iced  water  is  made  to  flow  (Fig.  54).  Even 
when  this  apparatus  is  used  the  part  should  first  be  wrapped  in  flannel. 
Leiter's  tubes,  which  are  tubes  of  lead  made  to  fit  various  regions  and  which 
carry  a  stream  of  cold  water,  can  also  be  used.  A  piece  of  flannel  must  be 
placed  between  the  tube  and  the  skin.  The  temperature  of  these  tubes  can  be 
lowered  to  any  desired  degree  by  lowering  the  temperature  of  the  circulating 
fluid.     Cheyne  and  Burghard  caution  us  to  use  a  fluid  at  a  temperature  not 


I02 


Inflammation 


under  50°  or  60°  F.,  to  inspect  the  part  every  three  or  four  hours,  and  not  to 
employ  the  tubes  longer  than  twenty-four  hours. 


F'g- S3'— Siphon  (Esmarch). 

Heat  is  employed  by  some  early  in  an  inflammation.     It  is  rarely  beneficial 
at  this  stage,  except  when  appHed  by  a  hot-air  apparatus  for  the  treatment  of 

an  injured  joint.  It  is  true 
that  a  degree  of  heat  which 
does  not  actually  destroy 
the  tissues  will  contract  the 
vessels  as  does  cold;  but 
this  degree  of  heat  will  not 
be  borne  by  the  patient  un- 
less but  a  limited  portion 
of  a  superficial  part  is  in- 
volved. 

Certain  agents  are 
suited  to  the  stage  of  fully 
developed  inflammation, 
when  there  is  a  great  deal 
of  swelling  due  to  effusion 
and  cell-proliferation.  The 
indication  in  this  stage  is 
to  abate  swelling  by  pro- 
moting  absorption.     This 


Fig.  54. — Tiie  Esmarch  cooling  coil. 


is  accomplished  by  (i)  compression;  (2)  local  use  of  astringents  and  sorbefa- 
cients;  (3)  the  douche;  (4)  massage;  and  (5)  heat. 


Astringents  and  Sorbcfacients  103 

Compression. — Compression  is  especially  useful  in  fully  developed  or  in 
chronic  innammation,  but  it  will  do  good  even  in  the  early  stages.  Compres- 
sion is  of  great  usefulness;  it  supports  the  vessels  and  causes  them  to  drink  up 
effusion,  and  it  strongly  rouses  the  absorbents.  This  agent  is  valuable  in 
most  external  inflammations  with  marked  swelling  and  is  particularly  bene- 
ficial in  chronic  inflammation.  In  erysipelas  of  an  extremity  the  part  should 
be  elevated  and  the  extremity  bandaged  from  the  periphery  to  the  body.  In 
ulcers,  especially  those  with  hard  and  blue  edges,  the  use  of  Martin's  elastic 
bandage  or  of  straps  of  adhesive  plaster  gives  decided  relief.  In  chronic  in- 
flajnmation  0}  a  joint  elastic  compression  is  of  great  value.  In  epididymitis, 
after  the  acute  stage,  the  testicle  may  be  strapped  with  adhesive  plaster.  In 
lymphadenitis  compression  by  a  weight  or  by  a  bandage  is  very  generally 
employed.  In  jractiires  compression  not  only  antagonizes  spasm,  but  often 
combats  the  swelling  and  pain  of  inflammation.  Compression  must  be  judici- 
ous; it  must  never  be  forcible,  and  it  must  not  be  applied  to  a  limb  without 
including  the  distal  portion  of  the  extremity  (never,  for  instance,  strongly 
compress  the  elbow  without  including  the  hand,  nor  the  palm  without  band- 
aging the  fingers).  Injudicious  compression  causes  severe  pain  and  great 
edema,  and  may  produce  gangrene. 

Astringents  and  Sorbefacients. — Astringents  may  have  direct  value  in 
inflammation  of  the  skin,  but  it  is  not  likely  that  they  have  any  effect  on  deep- 
seated  inflammation.  When  used  in  evaporating  lotions  in  an  earlier  stage 
of  inflammation  the  cold  does  good  rather  than  the  drug.  Lead-water  and 
laudanum  is  extensively  employed  and  it  is  thought  to  somewhat  allay  in- 
flammatory pain.  The  mixture  certainly  gives  comfort  in  cutaneous  ery- 
sipelas. It  is  very  doubtful  if  lead-water  is  of  any  service  at  any  stage  of  a' 
deep-seated  inflammation  or  in  any  fully  developed  inflammation.  If  used 
after  the  first  stage  it  must  not  be  applied  as  an  evaporating  lotion,  because 
cold  will  do  harm.  Pieces  of  Hnt  are  soaked  in  the  fluid  and  placed  upon  the 
part,  and  a  bandage  is  applied.  The  wet  lint  which  has  been  placed  upon 
the  part  is  covered  with  oiled  silk  or  a  rubber  dam  before  the  bandage  is 
applied.  If  used  in  the  latter  manner,  the  body-heat  is  retained  in  the  part. 
If  greater  heat  is  required,  a  hot-water  bag  can  be  placed  outside  of  the 
bandage.  Lead-water  is  not  used  in  treating  wounds  and  hot  lead-water 
should  not  be  applied  to  a  cutaneous  inflammation. 

Saturated  watery  solution  of  Epsom  salt  is  of  real  value  in  inflammation. 
It  is  applied  as  a  wet  compress  covered  with  rubber  dam.  It  is  moistened 
every  two  or  three  hours  and  renewed  in  twenty-four  hours,  the  skin  being 
washed  at  the  time  of  renewal.  In  many  cases  it  allays  pain  and  abates  swelling 
(Tucker  in  "Jour.  Experimental  Med.,"  May  25,  1907). 

Tincture  of  iodin  is  astringent,  sorbefacient,  counterirritant,  and  anti- 
septic. It  must  not  be  used  pure.  For  application  to  adults  it  should  be 
diluted  with  an  equal  amount  of  alcohol,  and  for  children  with  3  parts  of 
alcohol.  In  using  iodin,  paint  it  upon  the  part  with  a  camel's-hair  brush  and 
fan  it  dry,  applying  one  or  more  coats.  The  repeated  application  of  iodin 
to  the  skin  is  of  great  benefit  in  inflammation  of  the  glands,  muscles,  tendons, 
joints,  and  periosteum.  Iodin  is  apt,  after  a  time,  to  vesicate,  and  must  not 
be  used  in  full  strength,  because  it  is  irritant.  It  is  of  special  value  in  chronic 
inflammation.     In  deep-seated  inflammation  it  acts  as  a  counterirritant. 


I04  Inflammation 

Nitrate  oj  silver  is  a  non-irritating  astringent  of  considerable  value  in 
inflammation  of  mucous  membranes.  It  forms  a  protective  coat  of  coagu- 
lated albumin,  and  is  much  used  in  treating  the  throat,  mouth,  and  genital 
organs.  In  urethral  inflammation  a  proteid  compound  of  silver  known  as 
protargol  may  be  used. 

Ichthyol  is  a  drug  of  decided  efftciency  in  reducing  inflammatory  swelling. 
It  is  usually  employed  in  ointments,  the  strength  being  from  25  to  50  per  cent. 
It  is  best  exhibited  with  lanolin.  When  rubbed  in  over  inflamed  glands, 
joints,  and  lymphatic  enlargements,  it  is  of  great  value.  In  children  a  25  per 
cent.,  and  in  adults  a  50  per  cent.,  ointment  should  be  rubbed  in  thoroughly 
twice  a  day.  In  inflammatory  skin-disease,  synovitis,  thecitis,  frost-bite, 
bubo,  chilblain,  and  in  many  other  conditions,  acute  or  chronic,  the  use  of 
ichthyol  is  indicated.  The  odor  of  ichthyol  is  highly  disagreeable,  and  when 
ordered  for  a  refined  person  it  should  better  be  deodorized.  For  this  purpose 
Hare  uses  oil  of  citronella,  n^xx  to  Sj  of  ointment. 

Mercurials. — Blue  ointment,  pure  or  diluted  to  various  strengths,  is  ex- 
tremely valuable.  It  is  spread  upon  lint  and  kept  applied  over  areas  of  fully 
developed  inflammation.  It  is  especially  useful  in  acutely  or  chronically 
inflamed  joints,  glands,  tendons,  etc.  Blue  ointment  is  strongly  irritant,  and 
will  soon  blister  or  excoriate  a  tender  skin.  It  is  very  beneficial  in  periostitis, 
and  is  employed  largely  in  chronic  inflammations. 

The  Douche.— The  douche  consists  of  a  stream  of  water  falling  upon  a 
part  from  a  height.  The  water  may  be  poured  from  a  receptacle  or  may  run 
through  a  tube,  and  may  be  either  hot  or  cold.  Alternating  hot  and  cold 
streams  are  very  popular  in  inflammations  of  joints  and  tendons,  especially  in 
chronic  inflammation.  This  mode  of  application  is  known  as  the  "Scotch 
douche."  It  restores  the  tone  of  the  blood-vessels  and  plasma-channels  and 
promotes  the  absorption  of  inflammatory  exudate.  If  the  part  is  very  tender, 
the  water  should  be  squeezed  upon  it  from  sponges.  In  a  sprain  of  the  knee- 
joint,  after  a  time,  when  thickening  has  occurred,  pour  upon  the  part  dailv, 
from  a  height,  first  a  pitcherful  of  very  hot  water,  then  a  pitcherful  of  very  cold 
water;  then  use  friction  with  a  hand  greased  with  cosmolin.  Hot  vagina) 
douches  are  generally  employed  in  pelvic  inflammations. 

Massage. — Massage  is  a  procedure  not  employed  frequently  enough. 
It  is  very  useful  in  some  acute  inflammations,  though  in  these  it  must  be  gentle. 
It  is  of  great  service  in  the  treatment  of  sprains  of  joints  and  fractures  of  bones. 
It  is  influential  for  good  in  chronic  inflammations  at  the  period  when  rest  is 
abandoned.  It  acts  by  promoting  the  movements  of  tissue-fluids  (blood, 
lymph,  and  areolar  fluid),  stimulating  the  absorbents,  strengthening  local 
nervous  control,  and  thus  improving  nutrition.  Passive  motion  in  joints 
acts  as  massage. 

Heat. — Heat  may  be  used  continuously  or  intermittently,  and  may  be 
either  moist  or  dry.  A  considerable  degree  of  heat  will  act  like  cold  and 
contract  the  vessels.  The  degree  necessary  to  cause  vascular  contraction 
would  not  destroy  the  tissue,  but  would  produce  discomfort,  which  discomfort 
would  become  unbearable  during  the  continuance  of  the  application.  There- 
fore, heat  is  rarely  used  in  the  earhest  stage  of  an  acute  inflammation.  It  is 
hard  to  state  exactly  when  heat  should  be  substituted  for  cold.  Certainly 
when  retardation  and  stasis  are  manifest  it  is  to  be  preferred.     Moderate  heat 


Heat  in  Treatment  of  Inflammation  105 

should  be  used  when  inflammation  is  not  very  superficial.  In  a  cutaneous  in- 
flammation heat  usually  does  harm,  because  it  increases  the  congestion  of  an 
inflamed  superficial  part.  In  deep-seated  inflammations  heat  to  the  surface 
acts  as  a  revulsive  or  counterirritant.  Thus  a  poultice  to  the  chest  may  do 
good  in  the  first  stage  of  pneumonia,  and  cauterization  of  the  skin  near  a  joint 
may  benefit  an  acute  synovitis.  The  use  of  heat  for  purposes  of  counterirrita- 
tion  will  be  discussed  under  the  head  of  Counterirritants.  A  moderate 
degree  of  heat  applied  over  a  fully  developed  and  not  too  superficial  inflamed 
area  dilates  the  vessels,  especially  the  veins,  of  the  skin  and  superficial  tissues. 
Thus  circulation  is  re-established  in  an  area  filled  with  stagnant  blood  or 
blood  which  is  scarcely  moving  and  the  inflamed  region  is  drained,  fluid 
exudate  is  absorbed,  tension  is  lessened,  the  lymph-spaces  and  vessels  distend, 
and  lymphatic  absorption  becomes  active.  The  application  of  heat  increases 
the  ameboid  activity  of  the  leukocytes,  phagocytes  gather  in  great  numbers 
and  surround  an  area  of  infection,  and  those  which  have  taken  up  bacteria  or 
tissue  debris  hurry  away.*  Heat  also,  in  all  probability,  causes  antibodies  to 
escape  from  the  leukocytes  and  blood-serum.  Heat  notably  lessens  the  pain 
of  inflammation.     It  is  often  used  purely  to  relieve  pain. 

The  forms  of  heat  are — (i)  fomentations;  (2)  poultices;  (3)  w^ater-bath; 
and  (4)  dry  heat. 

Fomentation  is  the  application  to  the  skin  of  a  piece  of  flannel  containing 
a  hot  liquid.  A  basin  is  warmed  and  over  the  top  of  the  basin  a  towel  is  placed. 
A  piece  of  flannel  folded  in  two  or  three  thicknesses  is  laid  upon  the  towel  and 
boiling  water  is  poured  upon  it.  By  twisting  the  towel  the  water  is  squeezed 
out  of  the  flannel.  Great  care  must  be  taken  to  squeeze  the  water  out  of  the 
flannel,  otherwise  the  skin  may  be  scalded.  The  hot  flannel  is  laid  upon  the 
skin  over  the  disordered  part.  A  rubber  dam  larger  than  the  flannel  is  placed 
over  it,  a  mass  of  cotton  is  laid  upon  the  rubber  dam,  and  a  bandage  is  applied. 
The  fomentation  must  be  changed  within  an  hour  unless  a  hot-water  bag  has 
been  placed  outside  the  bandage,  in  which  case  it  need  not  be  changed  for 
two  hours  or  more.  The  flannel  which  is  dipped  into  the  hot  liquid  is  known  as 
a  "stupe."  The  turpentine  stupe  is  made  by  wringing  out  the  flannel  as  above 
and  then  putting  upon  it  from  10  to  20  drops  of  turpentine.  Instead  of  foment- 
ing the  part,  steam  may  be  thrown  upon  it.  Fomentations  are  used  chiefly 
for  their  reflex  influence  over  deep  congestions  or  inflammations.  The  liquid 
of  a  fomentation  may,  if  desired,  contain  corrosive  sublimate,  carbolic  acid, 
or  other  agents.  A  fomentation  containing  an  antiseptic  is  known  as  an 
antiseptic  fomentation.  An  antiseptic  fomentation,  or,  as  it  is  often  called, 
an  antiseptic  poultice,  is  made  and  applied  as  follows:  Gauze  is  used  instead 
of  flannel,  and  is  laid  upon  the  towel  over  the  basin  as  previously  described. 
A  very  w^arm  solution  of  corrosive  sublimate  (i  :  1000)  is  poured  upon  the 
gauze,  the  material  is  partly  wrung  out,  placed  upon  the  part,  covered  with  a 
rubber  dam,  and  upon  it  a  hot-water  bag  is  placed.  Fomentations  are  very 
useful  in  relieving  pain  in  any  stage  of  an  inflammation  and  act  also  as  counter- 
irritants.  Fomentations  are  used  in  preference  to  ordinary  poultices  if  there 
is  any  probability  of  a  surgical  operation  becoming  necessary,  because  skin  to 
which  a  poultice  has  been  applied  cannot  be  satisfactorily  sterilized.  The 
antiseptic  fomentation  is  of  great  service  in  remo\'ing  sloughs  from  foul  wounds 
*  Nancrede,  in  "Principles  of  Surgery." 


io6  Inflammation 

and  ulcers.  It  is  the  only  form  of  poultice  which  is  admissible  when  the  skin 
is  broken. 

Poultice  or  Cataplasm. — A  poultice  is  a  soft  mass  applied  to  a  part  to  bring 
heat  and  moisture  to  bear  upon  it.  Poultices  can  be  made  of  ground  flaxseed, 
of  slippery-elm  bark,  of  arrowroot,  starch,  bread  and  milk,  potatoes,  turnips, 
etc.  To  make  a  flaxseed  poultice,  scald  a  spoon  and  a  tin  basin,  put  the  flax- 
seed into  the  dry  hot  basin,  and  pour  upon  it  boiling  water  in  sufficient  quan- 
tity to  form  a  thick  paste.  The  proper  consistence  is  found  when  the  mass 
would  stick  if  it  were  thrown  against  a  wall.  It  is  now  spread  to  the  thickness 
of  a  quarter  of  an  inch  upon  a  piece  of  warm  muslin,  a  free  edge  being  left  all 
around,  the  edges  of  the  muslin  are  turned  in,  and  the  flaxseed  is  covered 
with  a  bit  of  gauze  to  prevent  adhesion  to  the  skin.  The  poultice  should  be 
placed  upon  the  part  and  be  covered  outside  with  oiled  silk,  a  rubber  dam,  or 
waxed  paper.  A  mass  of  cotton  is  applied  outside  of  the  rubber  and  the  poul- 
tice is  held  in  place  by  a  bandage  or  binder.  It  can  be  kept  very  warm  for  a 
considerable  period  by  placing  upon  it  a  bag  filled  with  hot  water.  If  a  hot- 
water  bag  is  not  employed,  a  poultice  should  be  changed  every  two  hours. 
Spongiopilin,  when  moistened  with  hot  water,  is  a  good  substitute  poultice. 
Lint  soaked  with  hot  water  and  covered  with  some  impermeable  material  does 
very  well.  The  fermented  poultice,  which  was  once  popular  for  gangrenous 
ulcers,  was  made  by  sprinkling  yeast  upon  an  ordinary  cataplasm.  The 
charcoal  poultice  is  made  by  stirring  charcoal  into  the  usual  poultice-mass. 
A  poultice  containing  opium  is  known  as  a  "  sedative"  poultice.  About  gr.  ij 
of  opium  to  the  ounce  of  poultice-mass  may  relieve  pain.  Flaxseed  is  a  vege- 
table material,  adheres  to  the  skin,  enters  the  mouths  of  glands  and  folHcles, 
undergoes  decay,  and  can  be  removed  only  with  great  difficulty.  The  prepa- 
ration of  an  antiseptic  poultice  or  fomentation  is  described  above.  Poultices 
must  not  be  kept  on  the  part  too  long,  as  they  will  cause  vesication,  especially 
in  adynamic  conditions.  If  a  poultice  is  causing  vesication,  remove  it  and 
do  not  replace  it.  or  replace  it  after  sprinkling  the  part  and  the  poultice  with 
powdered  oxid  of  zinc.  If  suppuration  exists  or  is  seriously  threatened,  do 
not  waste  time  by  using  poultices,  but  incise  at  once.  Incision  may  7)re- 
vent  suppuration  by  relieving  tension,  affording  drainage,  and  permitting  the 
local  use  of  antiseptics.  If  pus  exists,  it  cannot  be  evacuated  too  soon.  To 
use  poultices  and  delay  incision  is  often  productive  of  irreparable  harm. 
After  incision  of  a  purulent  focus  it  is  common  practice  to  apply  an  antiseptic 
fomentation  in  order  to  draw  quantities  of  leukocytes  to  the  part  and  thus 
limit  the  spread  of  infection  and  stimulate  granulation. 

Hot-water  Bath. — The  continuous  hot  bath  is  now  rarely  employed  except 
in  burns  and  cases  of  phagedena,  when  it  often  proves  curative.  In  these 
cases  an  antiseptic  agent  may  be  dissolved  in  the  water.  Continuous  immer- 
sion in  a  warm  bath  is  regarded  favorably  by  some  surgeons  for  the  treatment 
of  sloughing  wounds  and  large  purulent  areas.  The  immersion  of  a  part 
from  time  to  time  in  water  as  hot  as  can  be  tolerated  is  useful  in  fully  developed 
and  in  chronic  inflammation.  Such  immersion  benefits  an  inflamed  joint, 
lessening  the  pain,  swelling,  and  stiffness. 

Dry  heat  is  applied  by  a  metallic  object  dipped  in  hot  water  and  laid  upon 
the  part;  by  Leiter's  tubes,  through  which  hot  water  flows;  by  the  hot-water 
bag  or  by  the  hot-air  apparatus.     Some  surgeons  use  the  hot-water  bag  in 


Irritants  and  Counterirritants  107 

cases  of  mild  appendicitis,  in  order  to  favor  the  formation  of  adhesions.  The 
hot-water  bag  is  often  soothing  and  l^eneticial  when  laid  upon  an  inflamed 
joint,  or  on  the  perineum  or  the  hypogastric  region  in  cystiris.  A  bag  of  hot 
sand,  a  hot  brick,  or  a  bottle  or  can  of  hot  water  may  be  used  instead  of  the 
bag.  The  hot-air  apparatus  is  of  very  great  service  in  the  treatment  of  chronic 
inflammation  and  particularly  of  inflamed  joints  {vide  dry  hot-air  apparatus) . 

Treatment  when  Suppuration  is  Threatened. — When  suppuration  is  threat- 
ened, ordinary  hot  fomentations  or  antiseptic  fomentations  must  be  used, 
and  the  part  must  be  kept  at  rest.  As  previously  explained,  the  flaxseed 
poultice  is  inadmissible.  When  suppuration  is  threatened,  the  use  of  heat 
causes  the  collection  of  multitudes  of  leukocytes,  which  tend  to  limit  the  area 
of  infection  and  destroy  bacteria.  Even  when  suppuration  is  not  prevented, 
heat  aids  in  the  rapid  breaking  down  of  the  diseased  tissue  at  the  focus  of 
the  inflammation  and  causes  hordes  of  leukocytes  to  gather  and  encompass 
the  suppurating  tissue,  and  these  leukocytes  prevent  the  spread  of  the  in- 
fection. 

In  most  cases,  when  suppuration  is  obviously  inevitable  or  seriously 
threatened,  a  jree  incision  will  be  of  greatest  benefit. 

Irritants  and  Counterirritants  in  Inflammation. — Irritants  attract 
an  increased  supply  of  blood  to  the  part  whereon  they  are  applied,  and  are 
used  for  their  local  effects.  Counterirritants  are  used  to  affect  by  reflex 
influence  some  distant  part.  In  chronic  inflammation  irritants  may  do  good 
by  promoting  the  blood-supply,  thus  favoring  the  removal  of  exudates  (hni- 
ment  for  rheumatism  and  synovitis,  and  nitrate  of  silver  for  ulcers).  Counter- 
irritants  are  powerful  pain-relievers  when  used  over  an  inflamed  structure; 
they  bring  blood  to  the  surface  and  are  thought  by  many  writers  to  cause 
anemia  of  internal  parts,  the  site  and  area  of  anemia  depending  on  the  site, 
the  area,  and  the  duration  of  the  surface  irritation.  Some  recent  studies  seem 
to  indicate  that  counterirritation  produces  hyperemia  of  the  superficial  part, 
compensatory  anemia  of  surrounding  regions,  and  anemic  edema  of  the  sub- 
cutaneous tissue  and  muscles  (W.  Wecksberg,  "Zeit.  f.  klin.  Med.,"  Bd. 
xxxvii,  H.  3  u.  4).  Nancrede  dissents  from  the  statement  that  counterirritants 
cause  anemia  of  internal  parts;  and  he  maintains  that  they  irritate  deeper  parts 
and  cause  more  external  blood  to  be  taken  to  them.  He  claims  that  a  blister 
applied  to  the  chest  produces  a  hyperemic  area  in  the  pleura,  and  refers  to 
Fvirneaux  Jordan's  opinion  that  direct  irritation  to  the  surface  over  a  joint 
adds  to  synovial  hyperemia,  and  that  consequently  in  joint-inflammation 
counterirritants  should  be  applied  above  and  below  a  joint,  but  not  directly 
over  it.  As  a  matter  of  fact,  we  know  clinically  that  powerful  counterirritation 
directly  over  an  inflamed  superficial  joint  is  occasionally  followed  by  an  aggra- 
vation of  the  trouble,  and  that  in  pericarditis  blistering  directly  over  the  peri- 
cardium may,  as  pointed  out  by  Brunton,  make  the  condition  worse.  Coun- 
terirritants not  only  relieve  pain  in  the  earlier  stages  of  inflammation,  but  they 
also  promote  absorption  of  exudate  in  the  later  stages,  and  are  particularly 
valuable  in  chronic  inflammations.  Great  benefit  is  obtained  by  blistering 
old  thickened  ulcers,  and  by  painting  the  chest  with  iodin  to  relieve  pleuritic 
effusion.  Frictions,  besides  their  pressure  effects,  act  as  counterirritants. 
Frictions  may  reheve  skin  pain,  and  are  associated  with  the  apphcation  of 
stimulating  hniments  in  the  treatment  of  stiff  joints.     A  mustard  plaster  is  a 


io8  Inflammation 

valuable  counterirritant  in  an  acute  deeply  seated  inflammation.  Tincture 
of  iodin  is  extensively  used  in  chronic  inflammation. 

There  is  no  more  efficient  method  of  relieving  joleural  efl'usion  than  by 
the  application  of  a  succession  of  blisters.  Blisters  are  also  used  in  the  treat- 
ment of  inflamed  joints,  pericarditis,  pneumonic  consolidation  of  the  lung, 
acute  and  chronic  rheumatism,  etc. ;  and  are  applied  back  of  the  ears  or  at  the 
nape  of  the  neck  in  congestive  coma  or  meningitis.  A  blister  can  be  produced 
in  a  few  minutes  by  soaking  a  bit  of  lint  in  chloroform,  and  after  applying  it 
to  the  surface,  covering  it  with  oiled  silk  or  with  a  watch-glass.  Equal  parts 
of  lard  and  ammonia  will  blister  in  five  minutes.  It  is  easier  to  blister  with 
cantharidal  collodion  or  blistering  paper.  Before  applying  a  blister,  shave 
the  part  if  it  be  hairy;  then  grease  the  plaster  with  olive  oil  and  apply  it. 
Blistering  plaster  is  left  in  place  six  hours  in  the  case  of  an  adult,  but  only  two 
hours  in  the  case  of  an  old  person  or  a  child;  the  plaster  is  then  removed,  and 
if  a  bligter  has  not  formed,  the  part  must  be  poulticed  for  a  few  hours.  \\Tien 
a  blister  is  obtained,  open  it  with  a  needle  which  has  been  dipped  in  boiling 
water.  If  the  surgeon  wishes  the  blister  to  heal,  it  should  be  covered  with  a 
piece  of  lint  smeared  with  cosmolin  or  with  zinc  ointment.  If  it  is  to  be  kept 
open  for  a  time,  cut  away  the  stratum  corneum  and  dress  with  cosmolin,  each 
ounce  of  which  contains  six  drops  of  nitric  acid. 

Pustulation  can  be  effected  with  tartar-emetic  ointment  or  with  \^ienna 
paste.  Tartar-emetic  ointment  was  formerly  used  on  the  scalp  in  meningitis. 
Vienna  paste  consists  of  5  parts  of  caustic  potash  and  6  parts  of  lime  made  into 
a  paste  \vith  alcohol.  It  is  applied  for  five  minutes,  and  is  then  washed  off 
with  vinegar. 

The  hot  iron  is  the  most  powerful  of  counterirritants.  It  is  chiefly  used 
in  chronic  inflammation  of  joints,  bone,  and  the  spinal  cord.  The  application 
is,  of  course,  very  painful,  and  it  is  best  to  give  an  anesthetic  before  using  the 
cautery.  A  flat  cautery  iron  may  be  used,  or  the  round  iron.  The  latter  is 
known  as  the  button  or  Corrigan's  cautery.  The  iron  is  used  at  a  white  heat. 
One  area  or  several  may  be  seared.  The  cautery  is  drawn  lightly  two  or 
three  times  over  each  spot  we  wish  to  burn.  The  object  is  to  destroy  only  the 
superficial  layers  of  the  skin.  After  the  cauterization  is  completed,  lint  wet 
with  iced  water  is  applied  for  several  hours  to  allay  pain,  and  then  hot  anti- 
septic fomentations  are  used  until  the  slough  separates. 

If  we  wish  to  prevent  healing  after  separation  of  the  slough,  dress  the  sore 
with  cosmolin,  each  ounce  of  which  contains  6  drops  of  nitric  acid.  It  is  not 
wise  to  cauterize  deeply  directly  over  a  superficial  joint. 

Constitutional  Treatment  of  Inflammation. — Certain  remedies  are 
used  in  inflammation  for  their  general  or  constitutional  eft'ects;  these  remedies 
are — (i)  general  bleeding;  (2)  arterial  sedatives;  (3)  cathartics;  (4)  diaphor- 
etics; (5)  diuretics;  (6)  anodynes;  (7)  antipyretics;  (8)  emetics;  (9)  mercury 
and  iodids;  (10)  stimulants;  and  (11)  tonics. 

General  Bleeding,  Venesection,  or  Phlebotomy. — \'enesection  is  suited 
to  the  early  stages  of  an  acute  inflammation  in  a  young  and  robust  subject. 
The  indication  for  its  employment  is  increased  arterial  tension,  as  shown  by  a 
strong,  fuU,  rapid,  and  incompressible  pulse  in  a  vigorous  young  patient. 
General  blood-letting  diminishes  blood-pressure  and  increases  the  speed  of 
the  blood-current,  thus  amends  stasis,  absorbs  exudate,  and  washes  adherent 


Arterial  Sedatives  109 

corpuscles  from  the  vessel-wall;  furthermore,  it  reduces  the  whole  amount 
of  body  blood  and  thus  forces  a  greater  rapidity  of  circulation,  decreases  the 
amount  of  fibrin  and  albumin,  lowers  the  temperature,  arrests  cell-prolifera- 
tion, and  stops  effusion. 

This  procetlure  was  in  former  days  so  highly  esteemed  that  it  settled  into 
a  routine  formula  to  be  applied  to  every  condition  from  yellow  fever  to  dislo- 
cation. The  terrible  mortality  of  the  cholera  epidemics  from  1830  to  1835 
led  practitioners  to  question  the  belief  that  bleeding  was  a  general  panacea, 
and  from  this  doubt  there  was  born  in  the  next  generation  violent  opposition 
to  blood-letting  in  any  disease.  Like  most  reactions,  opposition  has  gone  too 
far,  the  pendulum  of  condemnation  has  swung  beyond  the  line  of  truth  and 
sense,  and  thus  is  universally  neglected  or  broadly  condemned  a  powerful  and 
valuable  resource.  Many  physicians  of  long  experience  have  never  seen  a 
person  bled;  its  performance  is  not  demonstrated  in  most  schools,  and  but 
few  patients  and  families  will  permit  it  to  be  done.  But  when  properly  used 
it  is  occasionally  beneficial.  It  is  applicable,  however,  only  to  the  young, 
strong,  and  robust,  and  not  to  the  old,  weak,  or  feeble.  It  is  used  for  violent 
acute  inflammations  of  important  organs  or  tissues,  and  not  for  low  inflam- 
mations or  for  slight  affections  of  unimportant  parts.  It  is  used  in  the  early, 
but  not  in  the  late,  stages  of  an  inflammation.  It  is  used  when  the  pulse  is 
frequent,  full,  hard,  and  incompressible,  but  not  when  it  is  slow,  small,  soft, 
compressible,  and  irregular.  It  is  used  when  the  face  is  flushed,  but  not  when 
it  is  pallid.  It  is  not  used  in  fat  persons,  drunkards,  very  nervous  people,  or 
the  sufferers  from  adynamic,  septic,  or  epidemic  diseases.  It  is  of  value  in 
some  few  cases  of  congestion  of  the  lungs,  pneumonitis,  pleuritis,  meningitis, 
prostatitis,  cystitis,  and  other  acute  inflammatory  conditions.  It  is  particularly 
valuable  when  uremia  exists  or  when  there  is  distention  of  the  right  side  of 
the  heart.     The  method  of  bleeding  is  described  on  page  463. 

After  bleeding,  the  patient  should  be  put  on  arterial  sedatives,  diuretics, 
diaphoretics,  anodynes,  and,  if  necessary,  purgatives.  A  favorite  mixture  of 
Prof.  S.  D.  Gross  was  the  antimonial  and  saline,  gr.  xl  of  Epsom  salt,  gr.  -^ 
of  tartar  emetic,  2  drops  of  tincture  of  aconite,  and  .^j  of  sweet  spirits  of  niter, 
in  enough  ginger  syrup  and  water  to  make  3ss;  given  every  four  hours. 

Arterial  Sedatives. — Drugs  of  this  character  are  of  great  use  before  stasis 
is  pronounced;  but  if  used  after  stasis  is  established  they  will  increase  it.  If 
stasis  exists  it  may  be  relieved  by  blood-letting,  local  or  general,  and  then 
arterial  sedatives  can  be  given.  Either  local  bleeding  or  venesection  abolishes 
stasis  and  lowers  tension,  and  arterial  sedatives  maintain  the  effect  and  hold 
the  ground  which  is  gained.  The  arterial  sedatives  employed  are  aconite, 
veratrum  viride,  gelsemium,  and  tartar  emetic.  These  sedatives  lessen  the 
force  and  the  frequency  of  the  heart-beats,  and  thus  slow  and  soften  the  pulse, 
and  are  suited  to  a  robust  person  with  an  acute  inflammation,  but  are  not 
suited  to  a  weak  individual  in  an  adynamic  state. 

Aconite  is  given  in  small  doses,  never  in  large  amounts.  One  drop  of 
the  tincture  in  a  little  water  is  given  every  half  hour  until  its  effect  is  manifest 
on  the  pulse,  when  it  may  be  given  every  two  or  three  hours.  Large  doses 
of  aconite  produce  pronounced  depression,  and  are  dangerous.  Aconite 
lowers  the  temperature,  slows  the  pulse,  and  produces  diaphoresis. 

Veratrum  viride  is  a  powerful  agent  to  slow  the  pulse  and  to  lower  blood- 


no  Inflammation 

pressure;  it  produces  moisture  of  the  skin,  and  often  nausea.  It  is  given  in 
I -drop  doses  of  the  tincture  every  half  hour  until  its  physiological  effects  are 
manifested,  when  the  period  between  doses  is  extended  to  two  or  three  hours. 
Ten  drops  of  laudanum  given  a  quarter  of  an  hour  before  each  dose  of  vera- 
trum  viride  will  prevent  nausea. 

Gelsemimn  is  an  arterial  sedative  highly  approved  by  Bartholow.  It  is 
given  in  doses  of  5  to  lo  drops  of  the  tincture  every  three  or  four  hours. 

Tartar  emetic  lowers  arterial  tension  and  lessens  the  pulse-rate.  This 
drug  is  not  generally  employed;  if  it  is  used  with  the  greatest  care  it  is  no 
better  than  some  other  agents,  and  if  it  is  not  so  used  it  will  cause  dangerous 
depression.  The  dose  is  from  gr.  2V  to  gr.  yg-  in  water  every  three  hours 
until  the  physiological  effects  are  manifest. 

Cathartics. — Purgation  is"  of  great  value  in  inflammation.  By  it  putrid 
material  is  removed  from  the  intestine,  fluid  containing  poisonous  elements 
is  drawn  from  the  blood,  and  the  liability  to  infection  of  the  tissues  is  lessened. 
The  administration  of  purgatives  is,  of  course,  not  to  be  a  routine  procedure 
in  inflammatory  states.  The  bowels  may  be  acting  so  freely  that  no  cathartic 
is  required.  Treatment  in  an  inflammation  should  be  inaugurated,  if 
constipation  exists,  by  giving  a  cathartic.  The  tongue  affords  important 
indications  as  to  the  necessity  for  purgation.  Castor  oil  can  be  given  in  cap- 
sules, or  in  the  froth  of  beer,  or  the  juice  of  half  a  lemon  is  squeezed  into  a  tum- 
bler, I  ounce  of  oil  poured  in,  and  the  rest  of  the  lemon  is  squeezed  on  top,  thus 
making  a  not  unjjalatable  mixture.  Alom,  podophyllum,  the  salines,  and  calo- 
mel in  5-  or  lo-grain  doses,  followed  by  a  saline,  have  their  advocates.  In  be- 
ginning peritonitis  the  salines  are  used  by  many  surgeons,  a  teaspoonful  of 
Epsom  salt  and  a  teaspoonful  of  Rochelle  salt  being  given  hourly  until  a  move- 
ment occurs.  In  the  course  of  inflammation,  from  time  to  time,  if  there  be 
constipation,  a  coated  tongue,  and  foulness  of  the  breath,  there  should  be 
ordered  gr.  j  of  calomel  with  gr.  xxiv  of  bicarbonate  of  sodiiim,  made  into 
twelve  powders,  one  being  given  every  hour;  if  the  bowels  are  not  moved  by  the 
time  the  powders  are  all  taken,  a  saline  should  be  given.  If  a  violent  purgative 
effect  is  desired,  as  in  meningitis,  croton  oil  or  elaterium  may  be  ordered.  If 
constipation  is  persistent,  give  fluidextract  of  cascara  sagrada  daily  (20  to  40 
drops),  or  a  pill  at  night  containing  gr.  \  of  extract  of  belladonna,  gr.  \  of 
extract  of  nux  vomica,  gr.  -jV  of  aloin,  gr.  \  of  extract  of  physostigma,  and  gtt. 
\  of  oil  of  cajuput.  Enemas  or  clysters  may  be  used  in  some  cases.  A  very- 
useful  enema  is  composed  of  f5j  of  oil  of  turpentine,  foiss  of  olive  oil,  f§ss 
of  mucilage  of  acacia,  in  fSx  of  water.  Soapsuds  and  vinegar  in  equal  parts 
make  a  serviceable  clyster.  A  combination  of  oil  of  turpentine,  castor  oil, 
the  yolk  of  an  egg,  and  water  can  be  used.  Asafetida,  gr.  xxx  to  the  yolk 
of  one  egg,  makes  a  good  enema  to  amend  flatulence. 

Diaphoretics. — These  agents  are  very  useful.  A  profuse  sweat  removes 
much  toxic  material  from  the  blood  and  in  the  beginning  of  an  acute  inflam- 
mation, such  as  tonsillitis,  may  abort  the  disease.  Dover's  powder  is  commonly 
used,  but  pilocarpin  is  preferred  by  some.  Camphor  in  doses  of  from  5  to 
10  grains  is  diaphoretic,  and  so  are  antimony  and  ipecac.  Acetate  and 
citrate  of  ammonium,  opium,  alcohol,  hot  drinks,  heat  to  the  surface  (baths, 
hot  bricks,  hot- water  bags),  serpentaria,  and  guaiac  are  diaphoretic  agents. 

Diuretics. — Diuretics  are  useful  in  fevers  when  the  urine  is  scanty  and 


Antipyretics  m 

high-colored,  and  are  valuable  aids  in  removing  serous  effusions  and  other 
exudates.  Among  the  diuretics  may  be  mentioned  calomel  in  repeated  large 
doses,  cocain,  alcohol,  digitahs,  the  nitrites,  squill,  turpentine,  copaiba,  and 
cantharides.  The  liquor  potassae  and  the  acetate  of  potassium  are  the  best 
agents  to  increase  the  solids  in  the  urine.  The  liquor  potassii  citratis  in 
doses  of  foj  to  f5iv  is  efficient.  Large  draughts  of  water  wash  out  the  kidneys. 
If  the  heart  is  weak,  citrate  of  caffein  is  a  good  stimulant  diuretic,  and  hot 
coffee  is  very  serviceable  in  promoting  the  secretion  of  urine.  The  injection 
of  hot  salt  solution  into  the  rectum  and  under  the  skin  favors  diuresis,  and  the 
intravenous  infusion  of  salt  solution  is  a  very  powerful  diuretic  (see  page  465). 
The  application  of  heat  to  the  loins  promotes  the  secretion  of  urine.  Sodio- 
theobromin  salicylate  (diuretin)  is  an  uncertain  but  often  valuable  diuretic, 
in  doses  of  gr.  x  every  two  or  three  hours. 

Anodynes  and  Hypnotics. — Drugs  may  be  required  to  allay  pain  or 
procure  sleep.  Dover's  powder,  besides  being  diaphoretic,  is  anodyne. 
Opium  acts  well  after  bleeding  or  purgation.  If  it  causes  nausea,  it  should  be 
preceded  one  hour  by  the  administration  of  gr.  xxx  of  bromid  of  potassium. 
Opium  is  used  by  the  mouth,  by  the  rectum,  or  hypodermatically.  It  is  used 
when  there  is  pain,  but  its  use  is  not  to  be  long  persisted  in  if  it  can  be  avoided. 
It  is  given  in  doses  measured  purely  by  the  necessities  of  the  case.  If  opium 
disagrees,  try  the  combination  of  morphin  with  atropin.  After  an  operation 
antipyrin  or  phenacetin  will  often  quiet  pain  and  secure  sleep.  When  a  person 
feels  "so  tired  he  can't  sleep,"  alcohol  in  the  form  of  whiskey  or  brandy  must 
be  given.  Sleeplessness  not  due  to  pain  is  met  by  chloral,  trional,  the  bromids, 
or  sulphonal.  Chloral  is  dangerous  in  conditions  of  weak  heart  or  exhaustion. 
Bromids  must  be  given  in  large  doses  to  be  efficient.  Sulphonal  must  be  given 
about  four  or  five  hours  before  sleep  is  expected,  in  doses  of  from  gr.  x  to  gr.  xx 
in  hot  milk  or  hot  mint-water.  Trional  is  safe  and  very  satisfactory.  It  is 
given  in  doses  of  gr.  xv  to  gr.  xxv  in  hot  water. 

Antipyretics. — Arterial  sedatives,  diaphoretics,  and  purgatives  lower 
temperature,  and  have  previously  been  alluded  to  (page  109).  There  are  two 
great  classes  of  febrifuges — those  which  lessen  heat-production  and  those 
which  increase  heat-elimination.  In  the  first  group  we  find  quinin,  sahcylic 
acid  and  the  salicylates,  kairin,  alcohol,  antimony,  aconite,  digitahs,  cupping, 
and  bleeding.  In  the  second  group  we  find  alcohol,  nitrous  ether,  antipyrin, 
acetanilid,  phenacetin,  opium,  ipecac,  cold  to  the  surface,  and  cold  drinks. 
In  surgical  inflammations  it  is  rarely  necessary  to  employ  heroic  means  to 
lower  temperature.  The  use  of  such  an  agent  as  antipyrin  is  contraindicated 
in  the  weak  and  adynamic,  and  it  is  never  to  be  thought  of  as  a  means  of  lower- 
ing temperature  unless  the  latter  goes  above  103°  F.  Quinin,  in  doses  of 
gr.  XX  to  gr.  xxx  given  at  4  p.  m.,  may  prevent  an  evening  rise;  salol  or  salicin 
can  be  given  during  the  day.  Inunctions  of  30  minims  of  guaiacol  lower  the 
temperature  in  tuberculous  conditions  and  in  septic  fevers.  These  inunctions 
are  made  upon  the  abdomen,  and  often  produce  surprising  results.  Dujardin- 
Beaumetz  maintained  that  fever  is  a  condition  in  which  the  animal  organism 
is  endeavoring  to  oxidize  and  render  inert  certain  poisonous  material,  and 
that  antipyretic  drugs  lessen  oxidation  and  actually  make  the  patient  worse. 
This  view  is  in  accordance  with  the  experience  of  a  number  of  surgeons.  It 
is  a  suggestive  fact  that  bacteria  are  said  to  multiply  more  rapidly  when  kept 


112  Inflammation 

at  about  the  normal  body  temperature  than  when  kept  at  fever  heat  (102°  F., 
or  more).  The  mere  discomfort  of  fever  may  be  much  mitigated  by  anti- 
pyretic drugs,  but  the  fever  process  is  not  benefited  by  them. 

Emetics. — Emetics  may  do  good  when  the  patient  suffers  from  a  parched, 
coated  tongue,  a  dry  and  liot  skin,  nausea,  and  gastric  oppression,  but  it  is 
very  rarely  in  these  days  that  we  employ  them.  There  can  be  used  oj  of  alum 
in  molasses,  gr.  xx  of  sulphate  of  zinc,  or  a  tablespoonful  of  mustard  and  a 
teaspoonful  of  salt  given  in  warm  water  and  followed  by  large  draughts  of 
warm  water.  Ipecac  in  a  dose  of  gr.  xx  can  be  employed.  The  emetic  dose 
of  tartar  emetic  is  gr.  ij,  but  it  is  too  depressant  a  drug  to  trifle  with.  The 
sulphuret  of  antimony  in  doses  of  from  i  to  5  grains  is  safe.  Apomorphin 
hypodermatically,  in  a  dose  of  from  gr.  y^^  to  gr.  |,  will  act  in  five  minutes. 
Emetics  are  valuable  in  inflammatory  conditions  of  the  air-passages,  but  their 
use  is  contraindicated  in  diseases  of  the  heart,  brain,  and  bowels,  in  hernia, 
in  dislocations,  in  fractures,  and  in  aneurysms. 

Mercury  and  the  lodids.— Mercury  is  an  alterative — that  is,  an  agent 
which  favorably  affects  body  nutrition  without  causing  any  recognizable 
change  in  the  fluids  or  the  solids  of  the  body.  Mercury  lessens  blood  plas- 
ticity, hinders  the  exudation  of  liquor  sanguinis — thus  furnishing  less  food  to 
the  cells  in  the  perivascular  tissues — and  retards  cell-proliferation.  Further, 
by  a  stimulant  action  on  the  absorbents  it  promotes  the  breaking  up  of  an 
existing  inflammatory  exudation,  and  hence  limits  damage  from  excess  of 
new  formation.  The  time  at  which  mercury  is  best  given  is  when  violent 
symptoms  have  abated,  the  guides  being  a  reduced  temperature  and  a  moist 
skin.  Mercury  is  often  given  in  conjunction  with  the  local  use  of  sorbefacients 
(ichthyol,  or  mercurial  ointment).  When  possible,  the  administration  of 
mercury  is  associated  with  compression  of  the  inflamed  part.  It  is  sometimes 
given  until  the  gums  are  slightly  touched,  but  it  is  not  given  to  the  point 
of  salivation.  When  the  breath  becomes  offensive  and  the  gums  tender  on 
snapping  the  teeth,  or  when  griping  and  diarrhea  begin,  the  dose  should  be 
reduced,  or  the  drug  should  be  stopped  (see  Ptyalism).  In  iritis  mercury  is 
used  to  get  rid  of  the  plastic  effusion  which  is  causing  pupillary  fixation  and 
opacity.  In  keratitis  the  gums  should  be  touched  slightly.  In  orchitis,  after 
the  subsidence  of  the  acute  symptoms,  mercury  should  be  employed.  In 
pericarditis,  meningitis,  and  in  many  chronic  and  lingering,  and  in  all 
syphilitic  inflammations,  this  drug  can  be  used. 

Some  persons  will  be  salivated  with  very  minute  doses  of  mercury,  either 
because  of  idiosyncrasy  or  previous  saturation.  Others  can  take  enormous 
doses  without  any  appreciable  constitutional  eft"ect.  The  action  of  mercurials 
can  be  favored  by  a  combination  with  ipecac  or  with  tartar  emetic. 

In  giving  mercury,  if  a  prompt  effect  is  desired,  give  gr.  iij  of  calomel  every 
three  hours  until  a  metallic  taste  is  noted  in  the  mouth.  If  the  case  is  not  so 
urgent,  gray  powder  is  a  good  combination.  Children  are  given  calomel  and 
sugar  or  mercury  and  chalk.  If  it  is  desired  to  give  the  drug  for  some  time, 
corrosive  sublimate  is  a  suitable  form,  and  small  doses  will  actually  increase 
the  number  of  red  blood-corpuscles.  Corrosive  sublimate  is  to  be  given  alone 
or  combined  only  with  iodid  of  potassium.  The  green  iodid  of  mercury  is  a 
drug  suitable  for  prolonged  administration.  In  the  prolonged  use  of  mercury 
it  will  often  be  necessary  to  give  at  the  same  time  a  little  opium  to  prevent 


Remedies  Directed  Against  Special  Morbid  States  113 

diarrhea  and  griping.  A  rapid  effect  can  be  obtained  by  rubbing  daily  with 
a  gloved  hand  5j  of  the  oleate  of  mercury  or  5ss  of  the  ointment  into  the 
groins,  the  axilla.%  or  the  inside  of  the  thighs.  Suppositories  of  mercurial 
ointment  induce  rapid  ptyalism.  Hypodermatic  injections  of  corrosive  sub- 
limate or  gray  oil  may  be  used,  and  must  be  thrown  deeply  into  the  muscles 
of  the  buttock  or  back.  Old  people,  those  who  are  exhausted,  anemic,  and 
broken  down,  and  the  tuberculous  bear  mercury  badly.  If  it  be  given  to  them 
at  all,  it  must  only  be  in  small  amounts  and  for  a  brief  time. 

Alkaline  iodids  are  useful  in  removing  the  products  of  inflammation;  they 
can  be  given  for  a  long  time,  and  admirably  supplement  mercurials.  lodid 
of  potassium  can  be  prescribed  in  combination  with  corrosive  sublimate  as 
follows : 

R  .       Hydrarg.  chlor.  corros., gr.  ij  ; 

Potass,  iodidi, Zvet  9j; 

Syr.  sarsaparillae  comp., q.  s.  ad  f^viij. — M. 

Sig. — f^ij,  in  water,  after  meals. 

lodid  of  potassium,  well  diluted,  is  given  on  a  full  stomach;  it  is  never 
given  concentrated  or  before  meals.  A  convenient  mode  of  administra4;ion 
is  to  procure  a  concentrated  solution  of  the  iodid  of  potassium,  remembering 
that  every  drop  equals  about  gr.  j  of  the  drug,  and  give  as  many  drops  as  may 
be  desired  in  half  a  glass  of  water  after  meals.  If  the  medicine  disagrees,  add 
to  each  dose,  after  it  is  put  in  water,  5j  of  the  aromatic  spirit  of  ammonia. 
Extract  of  licorice  is  a  good  vehicle  for  the  iodid.  If  the  mixture  in  water 
disagrees,  the  drug  should  be  given  in  milk.  Capsules  are  satisfactory,  but 
a  drink  of  water  should  be  taken  just  before  and  again  just  after  taking  a 
capsule,  to  protect  the  stomach  from  the  concentrated  drug.  Iodid  of  sodium 
may  agree  when  iodid  of  potassium  does  not.  When  the  iodids  disagree  they 
produce  iodism.  The  first  indications  of  iodism  are  a  bad  taste  in  the  mouth, 
running  of  the  eyes  and  nose,  and  sneezing,  followed  by  a  feeling  of  exhaustion, 
absolute  loss  of  appetite,  nausea,  tremor,  and  skin  eruptions  (acne,  hemor- 
rhages, blebs,  hydroa,  etc.).  If  iodism  occurs,  stop  the  drug  and  give  the 
patient  Fowler's  solution  in  increasing  doses,  laxatives,  diuretic  waters,  and 
also  nutritious  food,  and  stimulants  if  depression  is  great.  Sometimes  bella- 
donna does  good  in  obstinate  cutaneous  disorders  induced  by  the  iodids. 

Remedies  Directed  Against  Special  Morbid  States. — If  inflammation 
is  associated  with  rheumatism,  gout,  scurvy,  syphilis,  tuberculosis,  or  any 
other  constitutional  disease  or  predisposition,  appropriate  treatment  should  be 
instituted  to  control  the  disease  or  combat  the  predisposition,  and  at  the  same 
time  the  area  of  inflammation  should  be  locally  treated.  Syphilis  is  treated  by 
the  internal  use  of  mercury;  in  some  cases  the  iodids  are  also  given;  scurvy,  by 
vegetable  j  uices  and  potash  salts ;  rheumatism,  by  the  alkalies  or  salicylates ;  gout , 
by  colchicum  or  piperazin;  tuberculosis,  by  the  fats,  tonics,  and  open-air  life. 

Stimulants. — The  chief  stimulants  used  are  hot  black  coffee  by  the  stomach 
or  bowel;  hot  normal  salt  solution  by  the  bowel,  beneath  the  skin,  or  in  a  vein, 
alcohol  by  the  mouth  or  rectum;  and  strychnin  or  atropin  hypodermatically. 
The  use  of  alcoholic  stimulants  is  called  for  by  conditions  rather  than  by 
diseases,  being  indicated  by  the  state  of  the  patient  rather  than  by  the 
name  of  the  malady.  For  a  brief  acute  inflammation  in  a  robust  young 
person  alcohol  is  not  needed;  but  all  who  are  weak  or  exhausted,  be  they 


114  Inflammation 

young  or  old,  all  who  are  aged,  those  who  are  accustomed  to  alcoholic 
beverages,  those  who  have  high  temperatures  or  failure  of  circulation,  and 
those  who  labor  under  septic  inflammations  or  adynamic  processes  require 
alcohol,  and  it  should  be  given  with  a  free  hand.  In  an  acute  malady,  a  feeble, 
compressible,  rapid,  or  irregular  pulse,  and  great  weakness  of  the  first  sound 
of  the  heart  are  indications  that  alcohol  is  required.  Low,  muttering  delirium 
is  a  strong  indication  for  stimulation.  There  is  no  dose  of  alcohol  for  these 
states;  it  is  given  for  its  efi'ect.  Two  ounces  of  brandy  or  whiskey  may  be  needed 
in  a  day,  or  perhaps  20  ounces.  If  the  breath  of  the  patient  smells  strongly 
of  the  alcohol,  he  is  getting  too  much.  If  delirium  increases  after  each  dose, 
alcohol  is  doing  harm.  Alcohol  is  contraindicated  in  acute  meningitis.  In 
acute  illness  use  whiskey,  brandy,  champagne,  or  alcohol  and  water.  During 
convalescence  there  may  be  used  a  little  port,  claret,  or  shern,^  wine,  or  malt 
liquor.     These  agents  will  promote  appetite,  digestion,  and  sleep. 

Strychnin  is  a  very  valuable  stimulant.  It  can  be  given  in  doses  of  ^ 
to  To  gr.  three  times  a  day,  but  after  a  few  days  seems  to  lose  its  stimulant  effect. 

Atropin  is  one  of  the  best  remedies  for  exhaustion  of  the  vasomotor  sys- 
tem.    The  dose  is  gr.  y^  hypodermatically. 

Tonics. — The  use  of  tonics  is  indicated  during  convalescence  from  acute 
and  throughout  the  course  of  chronic  inflammations.  There  may  be  used 
iron,  quinin,  and  strychnin  in  the  form  of  elixir;  iron  alone,  as  in  the  tincture 
of  the  chlorid;  quinin  in  tonic  doses  (gr.  vj  to  gr.  viij  daily);  or  Fowler's  solu- 
tion of  arsenic.     An  excellent  pill  consists  of — 

I^.     Acid,  arsenos. , gr.  3 ; 

Stnxhnini, gr.  ss; 

Quinini, gr.  xl\-iij ; 

Ferri  redact., gr.  vj. — M. 

Ft.  in  pil.  No.  xxiv. 

Sig. — One  after  each  meal. 

Bitter  tonics  before  meals  improve  the  appetite.  One  of  the  best  of  tonics  is 
tincture  of  nux  vomica  in  gradually  increasing  doses. 

Antiphlogistic  Regimen. — This  term  comprises  the  necessary  directions 
relating  to  diet,  ventilation,  cleanhness,  etc. 

Diet. — When,  in  the  early  stages  of  an  acute  inflammation,  the  patient 
cannot  eat,  there  must  be  administered  a  cathartic  before  food  is  given. 
Nausea  is  combated  with  calomel  and  soda,  drop-doses  of  a  6  per  cent,  solu- 
tion of  cocain,  iced  champagne,  iced  brandy,  chloroform-water,  hot  water, 
cracked  ice,  and  counterirritation  of  the  epigastric  region.  WTien  the  process 
is  depressive  from  the  start,  and  in  any  case  after  the  earliest  stage,  feeding 
is  of  A-ital  moment.  The  great  tissue-waste  calls  for  large  quantities  of 
nutritive  material,  but  the  impaired  digestion  demands  that  the  food  shall 
be  easily  assimilable:  hence  it  is  taken  in  liquid  form,  small  quantities  being 
frequently  given.  Albumin-water  is  an  agreeable  beverage  of  some  nutri- 
tive value.  Milk  contains  all  the  elements  required  by  the  body,  and  is 
the  food  of  foods.  If  it  disagrees,  it  should  be  mixed  \\\\h  lime-water,  or  to 
each  dose  an  equal  amount  of  \'ichy  or  soda-water  may  be  added.  Pepton- 
ized milk  is  a  valuable  agent.  Some  people  can  take  boiled  milk  who  can- 
not take  cold  unboiled  milk.  Some  patients,  however,  digest  raw  better  than 
boiled  milk.       Peptonized  milk  has  been  to  a  great  extent  superseded  by 


Anti])hlogistic  Regimen  '  115 

pancreatized  milk.  It  is  given  cold,  either  alone  or  mixed  with  a  carbonated 
water-  Koumiss  is  retained  in  some  cases  when  the  stomach  rejects  all  other 
foods.  This  fermented  milk  is  nutritious,  stimulant,  and  very  useful.  One 
part  of  milk,  2  parts  of  cream,  and  2  parts  of  lime-water  make  a  nutritious 
and  digestible  mixture.  Milk  punch  is  largely  used.  Whey  may  be  used 
when  plain  milk  cannot  be  taken.  Eg^  are  highly  nutritious^  but  are  apt  to 
disturb  the  stomach;  they  may  be  given  as  egg-nog,  or  simply  soft-boiled,  or 
the  yolk  can  be  beaten  up  in  a  cup  of  tea,  or  raw  eggs  may  be  given  in  sherry 
or  brandy.  When  considerable  nausea  exists  the  yolk  of  an  egg  may  be  added 
to  Sj  of  lemon-juice  and  .5ij  of  sugar,  the  glass  being  filled  with  carbonated 
water.  Beef-tea  is  certainly  a  stimulant,  but  it  is  not  a  food.  It  contains 
the  excrementitious  elements  of  the  beef.  It  is  prepared  by  cutting  up  one 
pound  of  lean  beef,  adding  to  it  a  quart  of  water,  and  then  simmering,  but 
not  boiling,  down  to  a  pint,  finally  filtering  and  skimming  the  liquid.  The 
dose  is  a  wineglassful  seasoned  to  taste.  Beef  juice  is  nutritious.  It  Ls 
prepared  as  follows:  A  thick  and  tender  beefsteak  is  partly  broiled  over  a 
hot  fire,  the  outside  is  browned  and  the  juice  is  retained  within  the  meat. 
The  steak  is  cut  into  pieces  to  fit  a  lemon  squeezer  or  meat  press  (the  instru- 
ment having  been  warmed  by  previously  dipping  it  in  hot  water).  The  juice 
is  expressed  by  squeezing  and  may  be  given  warm,  seasoned  with  salt  and 
pepper,  or  may  be  taken  after  it  has  been  frozen.  Fresh  meat  juice  may  be 
used  plain  or  pancreatized.  The  meat  juices  obtained  in  the  shops  have 
little  nutritive  value.  Bouillon  and  beef  extracts  have  slight  nutritive  value. 
Meat  jellies  (calf's  foot  being  the  one  commonly  used)  have  a  certain  though 
small  nutritive  value  by  producing  a  certain  amount  of  energy'  which,  were 
they  not  given,  would  of  necessity  be  furnished  by  protein.  Hence,  meat  jelly 
saves  or  spares  protein  (Bauer).  Clam-juice  and  clam-broth  are  palatable 
and  slightly  nutritious.  They  are  retained  in  many  cases  when  any  other 
food  would  be  rejected.  The  broth  is  to  be  given  hot  and  the  juice  either 
hot  or  cold.  Coffee  is  a  valuable  stimulant  in  febrile  conditions.  When  the 
stomach  entirely  rejects  food  day  after  day,  nutritive  enemata  are  given.  There 
is  dispute  as  to  their  value  because  it  is  certain  that  the  large  intestine  does  not 
digest  by  juices  of  its  own  manufacture.  It  seems  equally  certain,  however, 
that  it  does  absorb  water  as  part  of  its  physiologic  duty  and  that  it  can 
absorb  alcohol,  saline  fluid,  grape-sugar,  certain  drugs,  and  digested  albumin 
and  fat.  Undigested  albumin  and  fat  should  never  be  given  by  enema. 
These  materials  should  be  pancreatized  before  injection  or  should  be  mixed 
with  pancreas  and  then  injected,  the  peptones  being  formed  in  the  bowel. 
Nutridve  enemata  are  given  at  a  temperature  of  9o°-95°  F.  They  should 
not  be  bulky  (not  over  7  or  8  ounces) ,  because  a  large  enema  is  usually  quickly 
expelled.  They  should  not  be  given  oftener  than  three  or  perhaps  four  times 
a  day  because  too  frequent  administration  irritates  the  rectum  and  enemas  will 
not  be  retained  by  an  irritated  rectum.  During  the  period  that  rectal  enemata 
constitute  the  method  of  feeding,  the  rectum  should  be  washed  out  once  a  day 
by  a  high  enema  of  warm  salt  solution;  this  cleansing  enema  is  given  one 
hour  before  a  nutritive  enema.  A  useful  enema  is  Leube's  meat  and  pan- 
creas— 3  ounces  of  pancreas  and  8  ounces  of  meat  are  rubbed  together  by  a 
pestle,  tepid  water  is  added,  and  the  mixture  is  injected.  It  undergoes  diges- 
tion in  the  large  bowel.    Bidwell's  formula  is  as  follows:    Two  ounces  of  milk, 


ii6  Inflammation 

2  ounces  of  strong  beef-tea,  yolk  of  i  egg,  i  dram  of  pancreatic  solution,  prepared 
one  hour  before  using  and  kept  during  the  interim  at  a  temperature  of  ioo°  F. 
Brandy  can  be  added  just  before  using.  Enemata  of  salt  solution  greatly 
relieves  thirst.  When  the  sufferer  feels  able  to  eat  a  little,  any  good  soup, 
strained  and  skimmed,  should  be  ordered.  As  the  patient  gets  better  he  may 
be  fed  on  scraped  meat,  broth  containing  crumbs,  tapioca  with  cream,  custard, 
milk-toast,  sweetbreads,  chops,  oysters,  chicken,  etc.,  until  he  gradually 
reaches  ordinary  diet. 

The  temperature  should  be  taken  at  regular  intervals,  and  the  condition  of 
the  gastro-intestinal  tract  should  be  observed.  The  urine  must  be  examined 
at  intervals,  and  the  daily  amount  passed  must  be  known.  If  insufficient 
urine  is  being  passed,  increase  the  amount  of  fluid,  particularly  of  water,  given 
by  the  mouth.  If  the  urine  is  scanty  and  the  patient  is  nauseated  by  drinking 
water,  give  enemata  of  hot  saline  fluid  or  employ  hypodermoclysis.  The 
pulse  and  heart  must  be  frequently  observed,  and  cardiac  weakness  must  be 
combated  by  suitable  stimulants. 

Ventilation  and  Cleanliness. — The  ventilation  of  the  apartment  is  of  the 
greatest  importance.  Every  day  the  windows  should  be  opened  widely  for  a 
time,  the  patient,  of  course,  being  protected  from  chilUng  and  kept  out  of  a 
draft.  When  the  windows  are  open  the  air  of  a  room  can  be  quickly  changed 
by  swinging  the  door  to  and  fro.  A  constant  access  of  fresh  air  must  be 
secured,  and  the  temperature  kept  as  near  as  possible  to  68°  F.  If  high  fever 
exists,  the  sick  man  must  be  cleaned  and  be  sponged  off  with  alcohol  and 
water  every  day.  It  is  important  that  the  bed-clothing  be  clean  and  that  the 
sheet  be  unwrinkled,  as  otherwise  bed-sores  may  form. 

Treatment  of  Chronic  Inflammation. — The  subject  of  chronic  inflam- 
mation has  been  referred  to  previously.  The  local  treatment  comprises  rest, 
relaxation,  elevation,  counterirritation,  massage,  passive  movements,  the 
douche,  the  application  of  sorbefacients,  the  use  of  compression,  incision,  and, 
perhaps,  certain  special  methods^  as  the  induction  of  passive  hyperemia  by 
Bier's  method  or  baking  the  part  in  a  hot-air  oven.  The  patient  must 
be  placed  under  proper  hygienic  and  climatic  conditions;  the  diet  must  be 
judiciously  regulated;  drugs  are  given  symptomatically  or  to  combat  some 
constitutional  tendency  or  disease  (see  articles  upon  Special  Regions  and 
Diseases) . 

Bier's  Hyperemic  Treatment  of  Inflammation.— (See  Bier's  Hyper- 
emic  Treatment,  by  Dr.  Willy  Meyer  and  Prof.  Dr.  Victor  Schmieden.)  Bier 
believes  that  hyperemia  in  inflammation  is  a  reaction  on  the  part  of  the  organ- 
ism; that  it  is  nature's  effort  to  remove  an  irritant  and  to  supply  increased 
nutritive  material,  hence  that  it  is  desirable  and  should  not  be  combated  by 
cold,  but  should  be  favored  by  every  means  in  our  power.  Bier  endeavors 
to  increase  the  hyperemia,  which  he  regards  as  beneficial,  and  to  combat  stasis, 
which  he  is  certain  is  harmful.  By  the  method  of  treatment  recommended 
by  Bier  the  surgeon  induces  venous  hyperemia  by  means  of  an  elastic  band  or 
a  cupping  glass,  or  arterial  hyperemia  by  means  of  hot  air. 

Obstructive  Hyperemia  by  Means  of  the  Elastic  Bandage. — The 
constrictor  should  be  the  soft  broad  bandage  of  an  Esmarch  apparatus. 
Fig.  55  shows  it  applied  around  the  arm.  The  bandage  must  not  be  so 
tight  as  to  cut  off  the  pulse  at  the  wrist  or  to  cause  unpleasant  sensations, 


Obstructive  Hyperemia  by  Means  of  the  Elastic  Bandage       117 

pain,  or  very  raj)id  distention  of  tlie  subcutaneous  veins  (Meyer  and  Schmieden) . 
The  part  below  the  band  should  become  bluish-red  and  warm,  but  never 
white  under  the  influence  of  the  constriction.  When  the  bandage  is  in  place 
an  area  of  intlammation  shows  an  increase  of  redness,  heat  and  swelling,  and 
a  diminution  of  pain.  In  chronic  conditions  the  bandage  is  usually  employed 
daily  and  for  two  or  three  or  four  hours  at  a  seance.  When  used  for  three 
hours  or  longer  temporary  edema  may  arise.     In  acute  cases  it  is  used  for 


Fig.  55. — Shows  elastic  bandage  in  phui  aruuiid  the  arm,  its  ends  tied  with  tapes  which 
are  attached  to  the  bandage.  This  is  the  style  of  bandage  usually  found  upon  the  market. 
If  the  bandage  is  to  remain  on  for  a  number  of  hours,  it  is  advisable  to  apply  a  strip  of  adhe- 
sive plaster,  to  guard  against  the  tapes  becoming  undone.  Note  the  engorgement  of  the  sub- 
cutaneous veins  of  the  forearm  showing  the  effect  it  is  desired  to  produce  by  the  bandage 
(Meyer  and  Schmieden). 


twelve,  fifteen,  or  twenty  hours  a  day.  Prolonged  apphcation  may  make  the 
skin  sore  unless  a  flannel  bandage  is  applied  before  the  band  is  used,  unless 
the  site  of  application  is  shifted  daily,  and  unless  the  skin  during  each  inter- 
mission is  well  rubbed  with  alcohol.  The  bandage  is  always  appHed  well 
above  the  inflamed  region  and  that  region  is  exposed  free  from  dressings  in 
order  that  its  condition  during  treatment  may  be  observed.  If  edema  occurs 
the  band  must  be  removed.  If  the  inflammation  is  accompanied  by  marked 
edema,  incisions  are  required.  If  an  abscess  forms  it  must,  of  course,  be 
opened. 


ii8 


Inflammation 


Obstructive  Hyperemia  by  Means  of  the  Cupping  Glass. — Endeavor 
to  make  the  skin  bluish-red  but  not  white.  Cupping  glasses  are  used  not 
only  to  treat  areas  of  intlammation.but  to  aid  inemj)tying  sinuses  and  abscesses 
which  have  ru])tured  or  have  been  incised.     Figs.  56-59  show  cupping  glasses. 


.^ 


Fig.  56. — The  simplest  form 
of  suction  glass.  The  rubber 
bulb  is  attached  directly  to 
the  glass.  This  glass  is  used 
in  the  treatment  of  furuncles 
of  smaller  size  and  sinuses 
(Meyer  and  Schmieden). 


Fi^.  57. — Illustrating  an  ordinary  suction  ap- 
paratus for  the  finger  (felon,  etc.)  with  a  con- 
vexity at  the  lower  surface,  designed  to  receive 
the  pus  (Meyer  and  Schmieden). 


taKtir: 


Fig.  58. — Show?  ,f;lass  of  simpler  configuration  ;  a  rubber  tube  eonneetj  glass  with  bulb  ; 
the  same  can  be  readily  detached,  thus  rendering  easy  the  sterilization  of  the  glass  by  boiling. 
In  the  tube  a  three-way  stop-cock  is  inserted.  This  cup  is  used  for  treating  furuncles  of 
larger  dimensions,  etc.  (Meyer  and  Schmieden). 


I  am  satisfied  from  personal  experience  that  Bier's  method  of  treatment 
is  of  great  value  in  acute  inflammation  as  well  as  in  chronic  inflammation 
and  that  it  is  not  used  as  often  as  it  should  be. 


Wright's  Views  Upon  Inflammation  and  Treatment  119 

Bier  claims  that  arterial  hyperemia  induced  by  hot  air  is  particularly 
useful  in  chronic  inflammation,  as  it  favors  the  absorption  of  exudates  and  of 
adhesions.  Venous  hyperemia  produced  by  the  elastic  band  or  the  cupping 
glass  is  claimed  to  be  of  great  value  in  infections.  Bier  asserts  that  it  may 
aboHsh  the  infection,  prevent  suppuration,  and  hasten  the  process  to  a  con- 
clusion. It  does  certainly  lessen  pain  and  favor  absorption.  The  elastic 
band  may  be  used  upon  an  extremity,  a  testicle,  the  scrotum,  and  the  head. 
In  other  regions  cupping  glasses  are  used,  a  partial  vacuum  being  estabUshed 
in  the  glass  by  means  of  a  pump  or  a  rubber  bulb. 


_  _.    _.  -  -      -  -        -  -J 

Fig.  5g. — Constructed  for  the  treatment  of  the  hand.     A  soft-rubber  band  wound  around  the 
cu£f  makes  it  ht  air-tight  around  the  arm  (Meyer  and  Schmieden). 

Sir  Aimroth  Wright's  Views  Upon  Inflammation  and  itsTreat= 
ment. — Wright  maintains  that  a  free  supply  of  blood  and  lymph  is  necessary 
for  repair,  that  both  the  blood  and  lymph  should  contain  a  sufficiency  of  pro- 
tective materials,  and  that  it  is  essendal  that  numerous  active  leucocytes  enter 
the  area  of  disease. 

When  there  is  a  large  serous  effusion  and  few  leucocytes,  a  condition 
met  with  often  in  tuberculous  pleurisy,  repair  does  not  take  place. 

In  abscess  the  leucocytes  are  dead  and  the  material  obtained  from  dead 
leucocytes  retards  healing.  If  the  fluid  exudate  does  not  contain  protective 
material  the  process  extends. 

Repair  is  retarded  by  induration,  or  by  the  formation  of  a  fistula  or  a 
sinus. 

If  there  is  a  small  amount  of  fluid  exudate  there  is  little  protective  sub- 
stance thrown  into  the  inflamed  part  and  repair  is  retarded. 

If  there  be  a  large  effusion  and  few  leucocytes,  cure  is  favored  by  remo\ang 
the  fluid.  This  is  done  in  abscess  and  in  serous  effusion.  If  there  is  too 
little  lymph  in  the  part  salt  solution  and  citric  acid  should  be  used  locally, 
and  citric  acid  should  be  administered  internally.  The  administration  of 
proper  bacterial  vaccines  will  increase  the  protective  quaUties  of  the  lymph. 
(See  Wright's  "The  Pathology  of  Inflammation"  and  the  resume  of  his 
views  in  "Progressive  Medicine,"  Sept.  i,  1908,  p.  31). 


I20  Repair 


IV.   REPAIR. 

When  a  tissue  is  damaged,  it  reacts  to  the  injury  and  Nature  attempts  to 
effect  repair.  It  is  held  by  many  that  inflammation  is  a  destructive  process 
and  repair  is  a  constructive  process;  that  repair  is  constantly  effected  in  an 
aseptic  wound  without  many  of  the  evidences  of  inflammation ;  that  repair 
does  not  proceed  from  inflammation,  but  is  retarded  or  prevented  if  inflam- 
mation occurs.  As  before  stated,  we  agree  with  Adami,  that  inflammation 
is  reaction  to  injury  and  the  effort  of  Nature  to  repair  the  injury.  As 
Adami  points  out,  the  attempt  to  repair  may  fail,  the  reaction  to  injury  being 
excessive  or  not  powerful  enough;  but  even  should  the  attempt  fail,  the 
conservative  intention  exists.  "What  is  the  development  of  cicatricial  tissue 
but  an  attempt  at  repair?  What  other  meaning  can  be  ascribed  to  the 
increased  bactericidal  power  of  the  inflammatory  exudate  as  compared  with 
that  of  ordinary  lymph  and  blood-serum  ?  Why  do  leukocytes  accumulate  in 
a  region  of  injury  ?  Why  do  some  of  them  incorporate  bacteria  and  irritant 
particles,  and  others  bring  about  the  destruction  of  these  without  necessarily 
ingesting  them  ?  All  these  are  means  whereby  irritants  are  antagonized  or 
removed,  and  reparation  and  return  to  the  normal  sought  after."  * 

Repair  is  favored  by  good  general  health,  asepsis  of  the  wound,  coaptation  of 
wound  edges,  and  rest.  It  is  retarded  or  prevented  by  infection,  gaping  of  the 
wound,  frequent  or  forcible  motion,  and  impairment  of  the  general  health. 

Albiiminnria  and  diabetes  particularly  obstruct  repair.  R.  T.  Morris 
points  out  that  sugar  in  the  blood  is  hygroscopic,  removes  water  from  the 
tissues,  and  thus  obstructs  repair;  and  also  that  the  wound  fluids  contain 
sugar  and  are  good  culture-media  ("Med.  News,"  June  29,  1901). 

Healing  by  First  Intention. — k  wound  may  heal  by  "first  inten- 
tion." This  mode  of  healing,  which  is  known  as  "primary  union,"  occurs 
without  suppuration,  and  is  observed  in  the  healing  of  an  aseptic  wound.  If 
infection  occurs,  primary  union  will  not  take  place.  The  phrase  "by  first 
intention"  comes  down  to  us  from  the  past.  It  was  properly  thought  that 
Nature  intends  to  repair  a  wound,  and  first  intention  signifies  the  first  or 
most  desirable  way  to  be  wished  for.  In  a  small  aseptic  incision,  in  which  no 
considerable  vessels  are  cut,  repair  will  take  place  very  rapidl\-  after  the  edges 
have  been  approximated  and  the  wound  dressed.  In  fact,  the  wound  edges 
may  be  firmly  held  together  in  twenty-four  hours.  In  such  a  wound  a  small 
amount  of  blood  flows  from  the  capillaries  between  the  edges  of  the  wound, 
and  this  blood  clots.  A  trivial  amount  of  exudation  and  some  few  migrated 
corpuscles  pass  into  the  clot  and  into  the  tissues.  The  fixed  connective-tissue 
cells  and  the  endothelial  cells  of  the  vessels  multiply,  and  form  epithelioid 
cells,  known  as  fibroblasts.  The  fibroblasts  eat  up  many  of  the  leukocytes 
and  multiply,  so  that  the  new  cells  from  one  side  of  the  wound  finally  interlace 
with  the  new  cells  from  the  other  side.  Nearby  capillaries  become  irregular 
in  outline;  at  certain  points  bulging  occurs,  and  at  these  points  new  capillaries 
develop,  extend  into  the  mass  of  fibroblasts,  and  join  new  capillaries  of  the 
opposite  side.  The  reparative  material  is  now  said  to  be  organized;  it  has 
*  Adami,  in  Allbutt's  "System  of  Medicine." 


Healing  by  First  Intention  121 

become  granulation  tissue.  The  fibroblasts  become  spindle-shaped  and 
develop  into  interlacing  fibers  (Fig.  60).  The  tissue  is  now  fibrous  tissue; 
it  contracts  strongly,  and  finally  most  of  the  capillaries  are  obliterated  by 
pressure.  In  such  a  slight  wound  the  reaction  to  injury  is  chiefly  noted  in  the 
cells  of  the  part,  and  the  vessels  and  leukocytes  play  but  a  small  part  in  repair. 
The  e.xudation  is  so  scanty  that  there  is  practically  no  swelling  unless  some 
arises  from  venous  obstruction.  The  vessels  are  so  slightly  affected  that  there 
is  no  redness.  The  final  step  in  healing  is  contraction  of  the  fibrous  tissue  and 
the  covering  of  the  surface  with  epithelium,  which  springs  from  the  epithelial 
cells  upon  the  edges.  This  final  process  is  called  "cicatrization,"  and  con- 
sists in  the  formation  from  fibroblasts  of  new 

fibrous  tissue  and  the  contraction  of  the  new  ^  _..::-;:!^:^^'^'^^"~f''^.:f 

tissue.     The     "immediate     union"     of     some         ^!^'%i:"'     '••     '■:'■    y'^ 
writers   never   occurs.     This   term    means   the  ^;::  ■-..•':      -      y 

union  of  microscopical  parts  to  their  counter-  y/i^i' 

parts    without    any    effort    at    repair.     A    first  '"-i.     ,        ,  i 

union  is  effected  alwavs  bv  clotted  blood  and  ,,^i^^:'^^-:-.0 :.:■:,  ^Z  ^"^^ 
coagulated  exudate,  next  by  proliferating  cells,  "'^^    j^  •^#/^'  / 

and  finally  by  fibrous  tissue.  A  wound  healing  ^.^  60. -Cells  developing  into 
by  first  intention  exhibits  no  evidence  of  inflam-  fibers  (Bennett). 

mation.     There  is  some  slight  tenderness,  but 

no  actual  pain.  A  certain  amount  of  swelHng  arises  because  of  exudation 
of  fluid  from  the  blood,  and  the  coagulation  of  this  fluid  makes  the  wound 
edges  hard.  Venous  obstruction  leads  in  some  cases  to  a  considerable  fluid 
swelling.  A  wound  may  heal  by  first  intention  even  if  some  bacteria  are 
present,  if  the  part  has  a  good  blood-supply  and  the  patient  is  in  good  health. 
Active  leukocytes  and  germicidal  blood-serum  may  prevent  infection.  In 
a  more  extensive  incised  wound  many  vessels  are  cut.  After  oozing  ceases 
the  vessels  are  closed  by  clots  continuous  with  the  clot  between  the  sides  of 
the  wound.  An  exudation  of  plasma  from  the  blood-vessels  and  of  lymph 
from  the  lymph-spaces  takes  place.  Leukocytes  in  great  numbers  invade 
the  wound  edges  and  the  exudate,  and  the  exudate  clots.  Thus,  an  infection 
may  be  surrounded  and  Hmited.  This  mass  of  blood-clot,  plasma-clot,  and 
leukocytes  used  to  be  known  as  "  coagulable  lymph."  The  leukocytes  actively 
eat  up  the  clot,  and  by  the  end  of  the  third  day  occupy  the  space  formerly 
occupied  by  the  clot.  The  fixed  connective-tissue  cells  and  endothelial  cells 
multiply  and  grow  into  the  mass  of  leukocytes,  eating  up  m"any  of  the  leuko- 
cytes, and  finally  join  the  fibroblasts  of  the  other  side  of  the  wound.  Some 
leukocytes  enter  into  the  lymph-spaces.  New  capillaries  form  from  the  capil- 
laries at  the  wound  margins.  By  the  end  of  the  first  week  the  fibroblasts 
begin  to  assume  various  outlines,  sending  out  poles  or  branches  or  becoming 
spindle-shaped.  These  spindle-shaped  cells  become  fibers,  and  the  fibers  of 
the  new  tissue  interlace  and  strongly  contract.  Thus  the  edges  are  pulled 
firmly  together.  Finally  new  epithelium  derived  from  epithelium  at  the  edges 
forms  and  grows  over  the  wound  (Figs.  61-63),  and  exhibits  the  stages  of 
repair  in  healing  by  first  intention.  In  order  to  obtain  primary  union  the 
surgeon  must  cleanse  the  wound  and  must  be  thoroughly  aseptic;  bleeding 
must  be  carefully  arrested;  the  parts  are  accurately  coaptated  by  sutures; 
aseptic  or  antiseptic  dressings  are  applied,  and  special  care  is  taken  to  secure 
rest.     In  a  large  wound  special  methods  to  secure  drainage  are  required.     In 


122 


Repair 


a  small  wound  drainage  is  obtained  between  the  stitches.  The  use  of  irritant 
germicides  in  a  wound  greatly  increases  the  amount  of  discharge  and  renders 
drainage  necessary  in  even  a  comparatively  small  wound  for  the  first  twenty- 


Fig.  62. 


Fig.  63. 
Figs.  61-63.— Healing  by  first  intention  (after  Pick) :  a.  Skin ;  b,  fibroblasts ;  r,  rf,  e,  capillaries. 
Fig. 61,  Clot  in  the  vessels  continuous  with  clot  between  the  edges  of  the  wound.     Fig.  62,  Migration 
of  leukocjtes  into  the  perivascular  tissues  and  into  the  clot  between  the  edges  of  the  wound.    Fig.  63. 
Formation  of  new  capillaries. 


four  hours.  During  the  first  twenty-four  hours  after  a  large  wound  begins  to 
heal  by  first  intention  the  discharge  of  bloody  serum  is  most  plentiful,  but  after 
this  period  it  becomes  very  scanty  and  soon  ceases  entirely,  and  can  be  much 


Healing  by  Second  Intention  123 

diminished  in  quantity  in  the  first  day  by  the  application  of  pressure.  Warren 
says  that  after  a  hip-joint  amputation  over  a  pint  of  bloody  serum  flows  out 
during  the  first  twenty-four  hours.  In  an  aseptic  wound,  as  a  rule,  one-half 
of  the  stitches  are  removed  on  the  sixth  or  seventh  day  and  the  remainder  on  the 
eighth  day,  but  for  two  weeks  more  the  wound  should  be  rested  and  supported, 
as  the  new  tissue  is  not  very  resistant  to  infection.  Aseptic  fever  always  arises 
when  much  exudation  is  poured  out  and  not  quickly  and  perfectly  drained. 
Aseptic  fever  is  due  to  the  absorption  of  aseptic  pyrogenous  material  (page 
134).  If  an  incised  wound  becomes  infected,  the  pyogenic  organisms  destroy 
the  bond  of  union  which  is  forming  between  the  wound  edges  by  liquefying 
the  intercellular  substance.  As  a  consequence,  the  wound  edges  are  widely 
separated  by  pus. 

What  used  to  be  known  as  '^healing  by  hlood-cloV^  is  heahng  by  first  in- 
tention. If  there  is  a  considerable  gap  between  the  edges  of  an  aseptic  wound, 
and  the  gap  is  filled  with  a  blood-clot,  healing  goes  on  in  the  same  manner  as 
when  the  gap  is  narrow,  although  more  corpuscles,  more  exudate,  and  more 
fibroblasts  are  required  to  effect  repair. 

Healing  by  Second  Intention.— Healing  of  a  wound  in  which  there  is  a 
large  cavity  in  the  tissue  or  in  which  the  edges  have  gaped  apart  is  known  as 
healing  by  granulation,  or  healing  by  "  second  intention."  It  is  called  heahng 
by  granulation  because  the  granulations  (areas  of  vascularizedembryonic  tissue) 
are  visible.  It  is  effected  in  the  same  manner  as  healing  by  "first  intention," 
the  processes  in  the  two  cases  being  practically  identical  if  pus  is  absent.  As 
a  matter  of  fact,  in  healing  by  granulation  there  is  usually  wound  infection. 
As  a  result  of  infection  intercellular  substance  is  peptonized,  many  reparative 
cells  are  cast  off,  and  repair  can  be  effected  only  after  the  formation  of  enormous 
numbers  of  fibroblasts  and  the  expenditure  of  considerable  time.  It  requires 
much  longer  for  an  infected  wound  to  heal  than  for  an  incised  wound  to  be  re- 
paired, and  an  infected  wound  can  heal  only  by  granulation.  A  short  time 
after  the  infliction  of  a  w-ound  the  oozing  ceases  because  thrombi  form  in  the 
vessels  and  some  clot  gathers  in  tissue-gaps  and  interstices.  Exudation  begins 
and  leukocytes  migrate  into  the  exudate  and  into  the  walls  of  the  wound.  In 
an  hour  or  two  the  surface  of  the  wound  becomes  distinctly  glazed  or  glistening, 
because  of  the  formation  and  coagulation  of  fibrin.  The  exudation  is  at  first 
thin  and  red,  and  it  becomes  so  profuse  as  to  wash  away  the  discolored  fibrin 
coat.  In  a  few  days  the  discharge  usually  becomes  purulent.  The  connec- 
tive-tissue cells,  especially  the  endothelial  cells  of  the  vessels,  proliferate  and 
form  fibroblasts,  and  the  fibroblasts  multiply  to  close  the  wound.  From  ad- 
jacent capillaries  new  capillaries  form.  This  formation  takes  place  as  follows: 
A  portion  of  a  capillary  thickens  and  a  whip-like  process  comes  off  from  the 
thickened  part.  This  process  fuses  with  a  second  filament  budded  from  an- 
other or  from  the  same  capillary,  or  runs  straight  out  as  a  terminal  vessel.  The 
filaments  after  a  time  are  hollowed  out  from  within,  protoplasmic  tubes  are 
formed,  and  endothelial  cells  develop  from  the  protoplasm.  In  some  cases  a 
tubular  prolongation  comes  off  from  a  capillary  directly.  Figs.  63  and  64  show 
the  formation  of  a  capillar}'.  In  a  wound  healing  by  granulation  these  newly- 
formed  capillaries  run  among  the  fibroblasts,  and  some  of  them  run  perpen- 
dicularly to  the  surface,  or  a  loop  forms  and  reaches  the  surface.  The  surface 
of  a  granulating  wound  is  covered  with  migrated  leukocytes,  and  directly  under 


124 


Repair 


these  are  fibroblasts  covering  the  new  vascular  strings  or  loops.  Vascular 
strings  or  loops  coated  with  fibroblasts  are  called  granulations  (Fig.  66  shows 
a  granulating  surface).  When  the  discharge  becomes  purulent,  many  leuko- 
cytes and  fibroblasts  are  destroyed,  inflammation  increases,  exudation  be- 
comes profuse,  and  cellular  multiplication  widespread  and  rapid  in  order  to 


Fig.  64. — Development  of  a  blood-vessel  in  mesentery  of  an  embryo  (Warren). 


make  up  for  the  cells  lost  by  microbic  action.  Gradually  the  gap  is  filled.  As 
it  is  being  filled  the  older  fibroblasts  in  the  deeper  layers  of  the  edges  and  base 
of  tfce  wound  are  converted  into  cicatricial,  fibrous,  or  scar  tissue.  (Fig.  65.) 
As  the  granulations  rise  to  a  higher  level  at  the  surface  the  area  of  fibrous  tissue 

becomes  broader  at  the  base 
and  margins,  and  this  young 
fibrous  tissue  contracts.  By 
contracting  it  draws  the  edges 
of  the  wound  nearer  together 
and  thus  lessens  the  area  of  the 
surface  which  must  be  covered 
with  epithelium.  When  the 
granulations  reach  the  level  of 
the  cutaneous  surface  the  epithe- 
lial cells  at  the  margin  of  the 
wound  proliferate,  and  young 
epithelial  cells,  constituting  a 
bluish  or  opalescent  film,  grow 
Epithelium  comes  only  from  epithelium.  Granula- 
The  epithelial  covering  comes  only 


Fig.  65.— Cicatricial  tissue  ;  X  670  (Fowler) 


over  the  granulations. 

tions  are  never  converted  into  epithelium 

from  the  epithelium  at  the  wound  margins,  unless  there  be  epithelial  remains 


Cicatrices  or  Scars  125 

in  the  wound;  for  instance,  an  undestroyed  papilla,  sweat-duct,  or  hair  follicle. 
The  process  of  covering  the  surface  with  epithelium  is  known  as  epidermizalion. 
The  epidermization  of  a  large  area  always  consumes  considerable  time  and 
sometimes  Nature  fails  to  accomplish  it.  In  such  cases  skin-grafting  is  em- 
ployed {q.  v.).  Before,  during,  and  for  a  time  after  epidermization  the  fibrous 
tissue  of  the  walls  and  base  of  the  wound  contracts.  Thus  the  wound  margins 
are  pulled  and  held  nearer  together,  the  gap  to  be  bridged  is  diminished  in  size, 
the  danger  of  tearing  apart  of  the  epithelial  coat  is  lessened,  many  capillaries 
are  destroyed  by  pressure,  and  the  scar  becomes  firm,  white,  and  puckered. 
Cicatrization  consists  in  the  conversion  of  immature  connective  tissue  into 
mature  fibrous  tissue  and  in  the  con- 
traction of  the  new  fibrous  tissue.  If 
infection  is  severe,  destruction  will  ex- 
ceed repair  and  healing  will  not  occur. 
In  such  a  case  there  is  coagulation  necrosis 
of  granulation  tissue,  and  the  wound  be- 
comes covered  with  tissue  remains  (aplas- 
tic lymph).     If  granulations  rise  above 

the  cutaneous  level,   healing  will  not  take  Fig.66.-Blood-vessels  in  granulation 

'  °  (Gross). 

place,  because  the  epithelium  cannot  then 

grow  over  the  raw  surface.  A  wound  in  this  condition  is  said  to  possess  ex- 
uberant granulations,  or  proud  flesh.  In  some  cases  the  granulations  are  pale 
from  insufficient  blood-supply,  and  in  others  edematous  horn  venous  congestion. 
Contraction  of  the  fibrous  tissue  may  be  insufficient  because  there  is  adhesion 
to  deep  unyielding  fascia  or  to  periosteum.  Excessive  contraction  is  frequent 
after  burns  and  often  produces  terrible  deformity.  The  scars  or  cicatrices  of 
burns  contain  much  elastic  tissue.  Infected  wounds  and  ulcers  heal  by  second 
intention. 

Healing  by  Third  Intention. — This  consists  in  the  union  of  two  granu- 
lating surfaces,  the  granulations  of  one  side  fusing  with  the  granulations  of 
the  other  side.  It  is  seen  in  the  union  of  collapsed  abscess-walls.  The  sur- 
geon occasionally  seeks  to  obtain  union  of  a  wound  several  days  old  by  third 
intention  by  approximating  two  granulating  surfaces.  If  the  surfaces  are 
aseptic,  he  will  often  succeed.  The  process  follows  what  is  known  as  secon- 
dary suturing.  It  is  not  unusual  to  pack  a  wound  with  iodoform  gauze  to 
control  oozing.  When  this  is  done  it  is  customary  to  pass  the  sutures,  but 
not  to  tie  them.  After  a  few  days  the  gauze  is  removed  and  the  sutures  are 
tied.  This  plan  renders  healing  much  more  rapid  than  would  be  possible 
by  the  process  of  healing  by  second  intention. 

Cicatrices  or  Scars. — The  newly-formed  connective  tissue  which  con- 
stitutes a  scar  will  be  present  in  large  amount  if  more  granulations  were  formed 
than  were  really  necessary  for  repair  or  if  a  considerable  defect  was  repaired. 

A  recent  scar  contains  fibrous  tissue,  many  fibroblasts,  and  numerous 
blood-vessels  but  no  nerves,  lymphatics  or  elastic  fibers.  The  skin  above 
recent  scars  is  usually  red  because  of  the  numerous  vessels  beneath  it  and  the 
layer  of  epidermis  is  well  developed.  In  old  scars  fibroblasts  have  disappeared 
and  fibrous  tissue  really  constitutes  the  cicatrix.  Some  blood-vessels  disappear 
and  the  diameters  of  those  remaining  are  much  reduced.  These  vascular  changes 
result  from  contraction  of  the  cicatrix.     Delicate  elastic  fibers  appear  in  old 


1 26  Repair 

scars.  They  appear  at  the  end  of  the  second  month  in  wounds  healed  by 
first  intention,  at  the  end  of  the  third  or  fourth  month  in  wounds  healed  by 
second  intention,  and  they  take  origin  directly  from  cell  protoplasm  and  not 
from  fibrous  tissue  (Minervini,  in  "Virchow's  Archiv,"  vol.  175,  No.  2).  No 
genuine  lymphatics  exist  in  old  scars  but  occasionally  nerve  filaments  are 
present.  Some  dermal  papillae  are  found  after  a  time,  but  skin  glands,  skin 
muscle,  and  hair  follicles  remain  absent. 

An  old  scar  is  smooth,  whiter  than  the  surrounding  skin,  somewhat  creased 
or  wrinkled  and  deficient  in  tactile  sense.  The  scar  of  a  healed  tuberculous 
ulcer  is  irregular,  livid,  and  often  actually  corrugated.  The  scar  of  a  healed 
syphilitic  ulcer  is  at  first  coppery-red  and  then  glistening  white  and  depressed. 
The  scar  of  an  old  ulcer  of  the  leg  and  of  the  skin  about  it  is  often  darkened 
by  pigmentation. 

A  cicatrix  may  be  discolored  by  retained  foreign  bodies,  for  instance, 
grains  of  gunpowder. 

During  scar  formation  shreds  of  epidermis  may  be  displaced  and  included 
in  granulation  tissue.  Subsequently  they  are  included  in  fibrous  tissue  and 
may  then  give  rise  to  transplantation  {implantation)  dermoids  or  to  epithelial 
tumors.  A  scar  may  be  deformed,  for  instance,  may  be  greatly  depressed  and 
adherent  to  underlying  bone,  and  in  certain  situations  such  a  scar  will  fix  the 
jaws  or  any  other  joint.  The  vicious  cicatrix  is  a  great  excess  of  a  scar  tissue 
and  results  from  delayed  healing  by  second  intention.  Such  cicatrices  are 
particularly  common  after  burns  and  tuberculous  ulcerations.  In  some  cases 
the  scar  is  irregular  and  lumpy,  in  other  cases  it  is  thickened  at  certain  parts 
and  discolored  and  resembles  keloid. 

A  cicatrix  may  block  a  natural  orifice,  as  the  mouth  or  nostril;  may  pro- 
duce great  deformities,  for  instance,  the  head  may  be  drawn  upon  the  chest 
or  shoulder  by  a  contracting  scar  in  the  neck,  fingers  may  be  grown  together 
after  a  burn,  or  a  hideous  depression  may  exist  on  the  forehead  after  an  injury, 
or  the  face  may  be  fearfully  contorted  by  contracting  cicatrices.  A  scar  may 
produce  great  disability  by  blocking  the  jaws,  obstructing  the  rectum  or  ure- 
thra, or  fixing  a  joint  or  certain  muscles  of  an  extremity. 

Most  scars  are  insensitive,  some  are  hypersensitive.  The  hypersensitive 
scars  are  usually  thin  and  pale.  The  itching,  burning  or  tingling  appreciated 
in  a  sensitive  scar  are  located,  as  a  rule,  at  the  junction  of  sound  skin  and 
newly-formed  epidermis.  Sometimes  acute  neuralgic  pain  exist  in  and  about 
a  scar  due  to  pressure  upon  nerve  filaments. 

A  scar  may  inflame  or  ulcerate,  warts  may  spring  from  its  cutaneous  sur- 
face, keloid  may  arise  from  the  fibrous  tissue,  carcinoma  may  come  from  the 
epithelial  elements  (Marjohn's  ulcer),  sarcoma  from  the  connective-tissue 
elements. 

Healing  of  Subcutaneous  Wounds. — Blood  fills  the  tissue  gap  and  the 
blood-clots.  Plasma  exudes  and  corpuscles  migrate  into  the  clot  and  the 
tissue  about  it.  The  clot  is  eaten  vip  by  the  leukocytes.  The  connective- 
tissue  cells  and  the  endothelial  cells  of  the  adjacent  tissue  proliferate  and  form 
fibroblasts,  and  fibroblasts  multiply  and  replace  the  clot.  The  area  of  fibro- 
blasts is  vascularized  by  the  formation  of  new  capillaries,  and  fibrous  tissue 
forms  and  strongly  contracts. 

Healing  of  Wounds  in  the  Non=vascular  Tissues. — In  a  trivial  injury 


Repair  of  Nerve  127 

of  the  cornea  a  few  leukocytes  gather  from  the  lymph-spaces  and  a  few  of  the 
fixed  cells  proliferate.  When  the  cornea  is  more  severely  wounded,  an  increased 
flow  of  lymph  occurs.  The  nerves  are  irritated,  vessels  adjacent  to  the  cornea 
distend,  and  many  leukocytes  invade  the  lymph  spaces.  The  corneal  cor- 
puscles multiply  and  alter  in  shape.  The  product  of  the  process  may  be 
transparent  if  fibrin  is  absorbed  and  leukocytes  pass  away,  because  proliferating 
corneal  corpuscles  form  transparent  tissue.  The  surface  epithelium  is  re- 
placed by  proliferation  of  the  deep  layer  of  corneal  epithelium.  If  the  wound 
has  penetrated  the  posterior  portion,  it  is  filled  by  proliferating  epithelium 
from  the  membrane  of  Descemet.  In  a  severe  injury  of  the  cornea  endothelial 
cells  and  corneal  corpuscles  proliferate,  vessels  grow  in  from  the  corneal  mar- 
gins toward  the  seat  of  inflammation,  fibrous  tissue  forms,  and  permanent 
opacity  results. 

Repair  in  cartilage,  if  it  occurs  at  all,  is  very  slow  and  is  accomplished  in 
the  same  way  as  repair  in  the  cornea.  Any  severe  injury  is  repaired  by  white 
fibrous  tissue,  furnished  by  the  cells  of  the  perichondrium,  and  the  scar  is 
permanent. 

Cell=division. — The  multiplication  of  connective-tissue  cells  in  repair 
may  be  by  direct,  but  is  usually  by  indirect,  cell-division.  Direct  cell-division 
consists  in  division  of  the  nucleus  followed  by  division  of  the  entire  cell. 

Indirect  cell-division,  or  karyokinesis,  takes  place  after  remarkable  changes 
in  the  nucleus.  The  membrane  of  the  nucleus  disappears;  the  nuclear  net- 
work becomes  first  close  and  then  more  open;  and  the  cell  becomes  round,  if 
not  so  before.  The  network  of  the  nucleus,  now  consisting  of  one  long  fiber, 
takes  the  shape  of  a  rosette;  next  it  takes  a  star  form— the  aster  stage;  two 
sets  of  V's  next  form — the  equatorial  stage;  an  equatorial  line  appears  and 
widens,  and  each  set  of  V's  retreats  toward  a  pole.  Thus  two  new  nuclei  are 
formed,  each  polar  V  passing  in  inverse  order  through  the  previous  changes  of 
shape,  and  the  protoplasm  of  the  original  cell  collecting  about  each  nucleus 
(Fig. 

Repair  of  Nerve. — A  nerve-fiber  consists  of  a  core  known  as  the  axis- 
cylinder,  which  is  the  essential  element  in  function.  About  the  axis-cylinder 
is  an  almost  Hquid  material,  known  as  the  medullary  sheath  or  white  substance 
of  Schwann,  or  myelin.  The  myelin  is  surrounded  by  a  firm  sheath  known 
as  the  neurilemma  (sheath  of  Schwann,  primitive  sheath,  neurolemma).  On 
its  inner  surface,  or  between  it  and  the  white  substance  of  Schwann,  are  nuclei 
which  are  supposed  by  some  to  be  peripheral  nerve-cells  (neuroblasts).  The 
neurilemma  is  absent  in  the  brain  and  cord.  The  continuity  of  the  white 
substance  of  Schwann  is  interrupted  at  frequent  intervals,  and  these  breaks  in 
the  myelin  are  called  nodes  of  Ranvier.  Numbers  of  fibers  of  the  kind  just 
described,  bound  into  bundles  by  connective  tissue  and  surrounded  by  a 
fibrous  sheath,  constitute  a  nerve.  It  is  known  that  a  nerve  may  be  regen- 
erated and  completely  regain  function  after  division;  that  regeneration  is 
strongly  favored  by  suturing  the  ends  together;  and  that  if  the  ends  of  a  di- 
vided nerve  are  more  than  one  inch  apart,  regeneration  will  rarely  take  place 
unless  they  are  sutured  together.  The  method  by  which  regeneration  is  affected 
has  been  much  disputed  and  is  still  involved  in  uncertainty.  If  a  nerve  is 
divided,  the  peripheral  segment  at  once  loses  its  function  and  then  undergoes 
degeneration    (Wallerian   degeneration).     The   degeneration    begins   within 


J  28  Repair 

twenty-four  to  forty-eight  hours  and  affects  the  entire  peripheral  segment 
The  axis-cvHnder  perishes,  the  myehn  runs  into  globules  and  is  absorbed, 
leaving  an  almost  empty  sheath;  the  nuclei  of  the  inner  surface  of  the  neuri- 
lemma proliferate  for  a  time,  but  cease  to  do  so  before  the  myelin  is  completely 
absorbed.  The  sheath  shrinks  and  looks  empty,  but  here  and  there  are  col- 
lected masses  of  proliferated  nuclei  and  protoplasm.  Degeneration  takes 
place  in  days,  but  regeneration  requires  months.  Regeneration  takes  place 
by  the  multiplication  of  pre-existing  nen'e-fibers  and  not  by  the  transforma- 
tion of  connective  tissue  into  nerve  structure.  The  ends  of  a  divided  nerve, 
it  is  true,  are  united  by  connective  tissue  formed  by  the  proliferation  of  fibro- 
blasts, but  this  connective  tissue  is  only  a  bridge  to  carry  nen-e  elements  across 
the  gap  between  the  proximal  and  peripheral  segments.  The  common  view 
is  that  regeneration  takes  place  as  follows:  The  new  axis-cylinder  of  the  per- 
ipheral segment  is  a  prolongation  of  the  old  axis-cylinder  of  the  proximal  seg- 
ment, projected  in  the  following  manner.  A  fiber,  which  is  at  first  devoid  of 
myelin,  is  prolonged  from  a  proximal  axis-cylinder;  it  divides  into  many  cyl- 
inders, which  pierce  the  granulation  tissue  between  the  ends  and  enter  into  the 
empty  sheaths  of  Schwann  of  the  distal  segment  or  insinuate  themselves  be- 
tween these  sheaths  (Ranvier,  Reclus,  Senn).  The  above  is  the  view  enter- 
tained by  those  who  teach  that  the  new  axis-cylinders  come  entirelv  and  only 
from  the  prolongation  of  old  axis-cylinders  of  the  proximal  segment,  and  that 
the  distal  segment  is  passive  in  the  process  until  "neurotised"  (Vanlair),  and 
that  regeneration  is  impossible  in  the  distal  segment  unless  it  is  in  approxima- 
tion with  the  proximal  segment  or  within  easy  reach  of  the  prolongations  of 
the  axis-cylinders  from  above.  Another  view  is  that  the  axis-cylinders,  myelin, 
and  neurilemma  are  formed  from  cells  which  exist  in  the  distal  segment,  and 
that  juvenile  axis-cylinders  and  medullary  sheaths  are  formed  in  the  peripheral 
portion  and  then  effect  a  junction  with  like  structures  of  the  central  segment. 
The  last-mentioned  view  is  advocated  by  Mayer  and  Eichhorst,  Tizzoni, 
Cattani,  and  others,  and  Ballance  and  Stewart  have  recently  published  a  most 
valuable  monograph  advocating  it  ("The  Healing  of  Ner\-es").  The  nuclei 
proliferate  and  form  a  mass  of  protoplasm  within  the  old  sheath,  which  pro- 
toplasm joins  the  proximal  segment.  Such  a  protoplasmic  fiber  has  "con- 
duction and  irritabihty"  (Raymond's  "Human  Physiology"),  but  there  is  as 
yet  neither  myelin  nor  axis-cylinder.  "  The  fiber  is  responsive  to  mechanical 
stimuli,  but  not  to  induction  shocks,  which  latter  property  returns  only  after 
the  axis-cylinder  is  developed.  The  medullary  substance  later  appears  and 
forms  a  tube;  and  still  later  the  axis-cylinder  is  formed,  having  its  origin  in 
the  central  end  of  the  nerv^e"  (Raymond's  "Human  Physiolog}^").  The 
views  of  Ballance  and  Stewart  may  be  set  forth  as  follows:  \\'hen  a  nerve- 
trunk  is  divided,  the  peripheral  segment  degenerates  whether  it  has  been 
sutured  to  the  proximal  segment  or  not,  and  the  portion  of  the  proximal  seg- 
ment near  the  wound  also  degenerates.  The  injury  produces  at  once  an  effu- 
sion of  blood,  migration  of  leukocytes  takes  place  into  and  about  the  wound 
at  the  proximal  segment,  but  leukocytic  invasion  of  the  entire  distal  segment 
is  noted.  After  three  days  connective-tissue  cells  begin  to  replace  the  leu- 
kocytes, and  after  two  weeks  the  excess  of  leukocytes  is  no  longer  observed, 
proliferated  connective-tissue  cells  having  taken  their  place  (page  94,  "  Heal- 
ing of  Ner\-es").     The  proximal  segment  in  the  neighborhood  of  the  wound 


Repair  of  the  Spinal  Cord  and  Brain  129 

and  the  entire  distal  segment  are  invaded  by  proHferating  connective-tissue 
cells.  The  connective-tissue  cells  completely  absorb  the  fatty  myelin  and  axis- 
cylinders.  The  cells  of  the  neurilemma  actively  multiply,  and  connective- 
tissue  cells  lying  among  chains  of  neurilemma  cells  become  spindle-shaped 
and  "the  degenerated  nerve-trunk  therefore  becomes  hard,  fibrous,  and  cir- 
rhosed"  (Ballance  and  Stewart  on  the  "  Healing  of  Nerves,"  page  94). 

In  the  proximal  end  oia  divided  nerve  an  "eud-biiib"  is  formed.  This 
was  long  supposed  to  be  due  to  the  prolongation  of  nerve-fibers  from  the 
central  fibers  and  a  turning  backward  because  they  cannot  cross  the  gap.  As 
a  matter  of  fact,  the  ends  of  the  divided  fibers  curl  up;  on  and  in  this  scafifold- 
like  arrangement  new  fibers  are  placed,  they  having  been  produced  by  the 
neurilemma  cells  which  have  taken  on  "  neuroblastic  function"  (Ballance  and 
Stewart).  When  a  nerve  has  been  sutured,  the  earliest  signs  of  regeneration 
"occur  at  the  end  of  three  weeks"  (Ballance  and  Stewart).  Short  lengths  of 
new  fibers  are  laid  down  within  old  neurilemma  sheaths.  The  new  axis- 
cylinder  "  is  seen  to  consist  in  the  deposition  along  one  side  of  a  spindle-shaped 
neurilemma  cell,  of  a  thin  thread  which  grows  in  length  until  it  projects  beyond 
the  limits  of  the  parent  cell  and  stretches  on  toward  its  next  neighbor  in  the 
same  longitudinal  row"  (Ballance  and  Stewart).  The  new  medullary  sheath 
is  "laid  down  by  a  process  of  secretion"  (Ballance  and  Stewart)  along  the 
sides  of  the  neurilemma  cells. 

Ballance  and  Stewart  go  on  to  point  out  that  if  the  central  theory  of  regen- 
eration is  true,  not  a  trace  of  regeneration  could  occur  in  the  distal  segment 
when  the  two  segments  have  not  been  united  by  sutures,  and  yet  such  regen- 
eration does  occur,  although  slowly,  the  new  axis-cylinders  and  medullary 
sheaths  not  attaining  full  size.  "Evidently  some  stimulus  afforded  by  the 
conduction  of  impulses  is  necessary  in  order  to  permit  of  their  full  develop- 
ment" (Ballance  and  Stewart).  In  the  notable  study  quoted  at  such  length 
are  some  experiments  on  the  "  conduct  and  fate  of  transplanted  nerve."  When 
the  gap  is  wide  between  the  two  ends,  a  portion  of  fresh  nerve-trunk  may  be 
inserted  to  bridge  it.  The  transplanted  piece  degenerates;  it  is  invaded  by 
leukocytes,  and  proliferating  connective-tissue  cells,  medullary  sheaths,  and 
axis-cyhnders  are  destroyed,  but  regeneration  may  subsequently  occur;  "but 
when  it  does  occur,  it  is  not  from  the  activity  of  the  cells  of  the  graft  itself" 
(Ballance  and  Stewart).  Blood-vessels  enter  the  degenerated  graft  at  each 
end  and  they  are  accompanied  by  chains  of  neurilemma  cells,  which  form 
axis- cylinders  and  medullary  sheaths.  The  graft  is  merely  a  scaffold  (Ballance 
and  Stewart). 

The  studies  of  Ballance  and  Stewart  persuade  us  that  regeneration  does 
occur  in  the  distal  part  independently  of  the  proximal  part,  although  full  de- 
velopment does  not  take  place  unless  there  is  a  junction  with  the  central  part. 
As  to  the  exact  method  of  regeneration  we  still  feel  somewhat  uncertain. 
When  we  remember  that  the  nerve-fibers  of  the  spinal  cord  are  devoid  of 
neurilemma  and  that  the  cord  can,  to  some  extent  at  least,  regenerate,  we 
must  conclude  that  regeneration  can  take  place  in  the  cord  without  the  aid 
of  neurilemma  cells,  and  must  infer  that  the  same  may  be  true  in  a  nerve. 

Repair  of  the  Spinal  Cord  and  Brain. — Can  the  spinal  cord  regenerate  ? 
Many  observers  have  doubted  it.  But  there  is  no  doubt  of  the  fact  that  some- 
times, after  the  subsidence  of  an  acute  myelitis  or  after  the  relief  of  a  pressure 
9 


I30 


Repair 


which  produced  complete  and  prolonged  paralysis,  there  is  a  return  of  func- 
tional power.  It  is  usually  assumed  that  restoration  is  possible  in  fibers  which 
have  not  been  hopelessly  damaged,  but  is  not  possible  in  those  which  have  been 
destroyed;  but,  as  Gowers  says,  there  are  cases  in  which  "we  can  scarcely 
believe  that  the  axis-cylinders  retain  their  continuity,  although  conducting 
capacity  is  ultimately  restored."  Clinical  evidence  indicates  strongly  that 
the  p}Tamidal  fibers  may  regenerate.  Mills  says  ("The  Nervous  System  and 
Its  Diseases"):  "Nerve-tracts  in  the  spinal  cord  and  brain  have  power  to 
regenerate,  but  this  is  not  so  great  as  in  the  peripheral  nerves,  and  yet  even  old 
cases  of  compression  of  the  spinal  cord  may  make  great  improvement  after  a 
long  time,  largely  through  the  regeneration  of  the  columns  of  the  cord." 
Mills  affirms  that  although  nerve-cells  sometimes  appear  to  regenerate,  the 
destruction  in  these  cases  was  not  complete. 

When  axis-cylinders  have  been  destroyed  in  the  cord  and  yet  some  power 
returns,  we  ask  ourselves  if  this  occurs  because  new  fibers  have  grown  doAATi 
from  above.     Gowers  says  that  such  a  growth  has  been  proved  to  occur  in  the 

lower  animals,  but  has 
not  as  yet  been  demon- 
strated in  man;  although 
specimens  have  been  de- 
scribed which  strongly 
suggest  such  an  occur- 
rence in  the  human  sub- 
ject. That  the  cord  can 
regenerate  to  some  ex- 
tent seems  highly  proba- 
ble from  the  report  of  a 
recent  case.  Dr.  Francis 
T.  Stewart,  of  Philadel- 
phia, sutured  a  com- 
pletely divided  spinal  cord  and  an  extraordinary  restoration  of  function  took 
place  (Francis  T.  Stewart  and  Richaud  H.  Harte,  in  "  Phila.  Med.  Journal," 
June  7,  1902).  This  case  is  commented  on  at  some  length  in  the  section  on 
Injuries  of  the  Spinal  Cord.  Another  somewhat  similar  case  was  reported 
by  George  Ryerson  Fowler  in  the  "Annals  of  Surgery,"  Oct.,  1905. 

Many  claim  that  a  brain  injury  cannot  be  followed  by  repair  with  restora- 
tion of  function;  some  think  that  complete  regeneration  can  take  place;  others, 
that  partial  regeneration  may  occur.  Vitzon  and  Tedcschi  even  believe  that 
nerve-cells  in  the  brain  can  regenerate.  It  seems  probable  that  extensive 
injuries  are  not  repaired,  but  slighter  ones  may  be,  new  ganghon-cells  and 
neuroglia  being  formed.  Tedeschi  describes  the  process  of  repair  after  a 
wound  of  the  brain  as  follows:  Degeneration  occurs  and  a  limited  focus  of 
necrosis  forms  and  then  the  adjacent  tissue  shows  evidences  of  repair.  Capil- 
laries form  from  the  endothelial  cells,  glia  tissue  from  the  neuroglia,  ganglion- 
cells  present  karyokinetic  changes,  and  some  nerve-fibers  appear  in  the  scar 
(Senn's  "Principles  of  Surgery"). 

Repair  of  Muscles. — It  has  long  been  taught  that  the  repair  of  muscle 
by  muscle  is  impossible,  and,  as  a  matter  of  fact,  it  does  not  take  place  if  the 
ends  of  a  divided  muscle  are  separated  to  the  extent  of  an  inch  or  more.  When 
a  muscle  is  divided  transversely  by  a  considerable  cut,  the  ends  retract  and  a 


Fig. 67. — Forms  assumed  by  a  nucleus  dividing  (Green,  from 
Flemming). 


Repair  of  Muscles 


131 


wide  space  is  left  between  them.  Blood  flows  into  the  space  between  the  ends 
and  also  between  individual  fibers  of  the  injured  muscle,  and  the  blood-clots. 
Exudation  of  plasma  occurs  and  migration  of  curpuscles  takes  place.  Fibro- 
blasts are  produced  by  proUferation  of  connective-tissue  cells  and  a  mass  of 
fibroblasts  soon  replaces  the  blood-clot.  Granulation  tissue  is  formed  by 
vascularization  of  the  mass  of  fibroblasts,  and  granulation  tissue  is  converted 
into  scar  tissue,  but  not  at  all  into  muscle.  After  slight  injuries  a  trivial 
amount  of  muscular  regeneration  does  occur  by  the  multiplication  of  living 
muscle-cells,  but  not  by  metamorphosis  of  fibroblasts.     Fibroblasts  are  in- 


Fig.  68.— Fracture  onu  week  :  blood-       Fig.  69.— Callus  of  fracture  Fig.  70.— Femur  of  a  child 

clot  containing  fragment  of  bone  (War-    (dog)  four  weeks  :  commenc-  fifth     week      after      fracture 

ren).                                                                 ing  ossification    of    external  (Warren). 

callus  (Warren). 

capable  of  a  transformation  into  muscular  tissue.  When  the  ends  of  a  divided 
muscle  are  separated  only  to  a  very  sHght  degree  or  when  they  have  been 
brought  together  and  sutured,  some  muscular  regeneration  occurs.  After  an 
injury  a  number  of  the  muscular  fibers  wither,  perish,  and  are  absorbed.  The 
process  of  regeneration  arises  from  the  remaining  fibers.  The  nuclei  of  the 
muscle-fiber  proliferate  and  so  do  the  nuclei  of  the  perimysium.  The  muscle- 
cells  are  called  myoblasts  and  the  nuclei  of  the  perimysium  are  called  sarco- 
blasts.  About  the  juvenile  muscle-cells  a  deposit  of  protoplasm  takes  place 
(Weber).  The  embryonal  cells  gradually  become  spindle-shaped  and  mus- 
cular fiber  is  formed  by  cellular  fusion  or  by  elongation  of  individual  cells. 

The  above  remarks  refer  to  striated  muscle.     Unstriated  muscle  fibers 
are  repaired  solely  by  ''indirect  multiplication  of  their  nuclei"  (Senn). 


132  Repair 

If  a  muscle  has  been  divided,  it  should  be  sutured.  This  process  insures 
more  rapid  repair  and  secures  a  better  functional  result,  and  is  followed  by 
a  much  greater  amount  of  muscular  regeneration. 

Repair  of  Tendon. — When  a  tendon  is  divided,  the  ends  retract,  and  the 
sheath,  as  a  rule,  becomes  filled  with  blood-clot.  The  blood-clot  is  rapidly 
removed,  fibroblasts  replacing  it.  This  new  tissue  arises  from  the  sheath, 
the  cut  ends  of  the  tendon  not  participating  in  its  formation.  Granula- 
tion tissue  is  formed;  this  is  converted  into  fibrous  tissue,  and  after  a  time  the 
fibrous  tissue  becomes  true  tendon.  If  no  blood-clot  forms  in  the  sheath,  the 
walls  of  this  structure  collapse  and  adhere,  and  the  separated  tendon-ends 
are  held  together  by  a  flat  fibrous  band  formed  from  the  collapsed  sheath 
(Warren's  "  Surgical  Pathology"). 

Repair  of  Bone. — When  a  bone  is  broken,  a  blood-clot  quickly  forms  in 
the  medullary  cavity,  between  the  broken  ends  and  under  and  outside  the  peri- 
osteum. Leukocytes  invade  and  destroy  the  clot.  The  cells  outside  the  peri- 
osteum, the  cells  of  the  periosteum  and  of  the  medullary  tissue,  particularly 
the  endothelial  cells,  proliferate  and  produce  cells  which  are  practically  fibro- 
blasts. The  osteoblasts  in  the  medullary  tissue,  and  perhaps  in  the  deeper 
layers  of  the  periosteum,  multiply  and  are  distributed  through  the  mass  of 
fibroblasts.  The  osteoblasts  may  form  bone  directly  or  may  form  cartilage 
first.  Some  teach  that  fibroblasts  can  be  converted  into  bone;  others  positively 
deny  such  a  conversion.  The  point  is  not  settled,  but  it  is  well  to  remember 
that  in  myositis  ossificans  a  muscle  is  converted  into  bone,  and  hence  that  it  is 
probable  that  fibroblasts,  formed  from  periosteum  and  medullary  tissue, 
should  be  much  more  prone  to  undergo  such  a  development.  During  regen- 
eration the  bone  ends  soften  and  are  partially  absorbed  by  osteoclasts.  These 
cells  are  large  osteoblasts  which  have  lost  the  power  of  bone  production  and 
furnish  a  secretion  which  dissolves  osseous  matter.  The  excess  of  callus  is 
finally  absorbed  by  osteoclasts.  (For  a  more  extended  description  see  Repair 
of  Fractures.)  Sir  Wm.  Macewan  has  recently  denied  that  the  periosteum 
plays  a  leading  rcMe  in  bone  production  ("Brit.  Med.  Jour.,"  June  22,  1907), 
He  believes  that  the  periosteum  is  a  membrane  to  limit  and  control  the  osteo- 
blasts and  that  new  bone  is  formed  from  bone  cells.  There  is  much  experi- 
mental evidence  to  confirm  Sir  William's  assertion.  If  he  is  correct  a  con- 
siderable osseous  defect  will  not  be  filled  up  by  new  bone  even  if  the  periosteum 
is  intact. 

Repair  of  Blood= vessels. — If  an  artery  is  cut  across  and  ligated,  a  clot 
forms  within  its  lumen  and  about  its  divided  end,  and  the  circulation  in  the 
vessel  at  this  point  is  permanently  arrested.  The  proximal  clot,  it  used  to  be 
thought,  always  reaches  the  first  collateral  branch.  This  statement  was  true 
before  the  days  of  asepsis;  it  is  not  always  true  now.  Often  a  clot  stops  far 
short  of  the  branch  above.  Exudation  of  plasma  and  migration  of  corpuscles 
take  place  from  the  vasa  vasorum.  The  clot  becomes  filled  with  leukocytes, 
which  gradually  destroy  it,  and  it  plays  no  active  part  in  repair.  Fibroblasts 
form  by  the  multiplication  of  the  cells  of  the  vessel  wall  and  the  clot  is  soon 
replaced  by  fibroblasts.  The  fibroblasts  are  converted  into  granulation  tissue, 
granulation  tissue  becomes  fibrous  tissue,  the  fibrous  tissue  contracts,  and  the 
artery  is  transformed  into  a  fibrous  cord  (Fig.  220).  Warren  insists  that  the 
muscle-cells  of  the  middle  coat  play  an  active  part  in  repair.  Usually,  when  a 
ligature  is  applied  to  an  artery  in  continuity,  a  deliberate  attempt  is  made  to 


Traumatic  Fevers  133 

rupture  the  internal  and  middle  coats,  in  order  to  permit  of  contraction  and 
retraction  above  and  below  the  seat  of  ligature,  and  a  turning  inward  of  the 
inner  coat.  Such  a  sequence  of  events  happens  when  an  artery  is  completely 
divided  across  and  not  tied,  and  favors  the  rapid  formation  of  a  clot. 

Ballance  and  Edmunds  ("Ligation  in  Continuity")  maintain  that  repair 
is  obtained  most  rapidly  when  the  artery  is  tied  with  two  ligatures,  the  vessel 
at  this  point  being  deprived  of  blood,  but  the  internal  and  middle  coats  being 
kept  intact.  Cell-proliferation  forms  a  spindle-shaped  mass  of  new  cells  and 
the  lumen  is  obliterated  at  the  seat  of  ligation  by  fibroblasts  obtained  from 
the  fixed  cells  of  the  wall  of  the  artery.  Senn  advocates  the  employment  of 
two  ligatures,  not  placed  side  by  side  as  in  the  method  of  Ballance  and  Ed- 
munds, but  so  applied  as  to  include  "  a  bloodless  space  about  half  an  inch  in 
length"  (Senn's  "Principles  of  Surgery"). 

When  a  lateral  ligature  is  applied  to  a  vein  or  when  a  small  wound  in  a 
vein  or  artery  is  sutured,  the  circulation  in  the  vessel  is  not  completely  cut  off, 
a  thrombus  of  small  size  is  formed  on  the  vessel-walls,  the  fixed  cells  of  the 
vessel-wall  proliferate,  and  a  scar  of  fibrous  tissue  effects  repair.  A  com- 
pletely divided  vein  heals  as  does  a  completely  divided  artery  (Fig.  221). 
The  clot  after  the  aseptic  application  of  a  ligature  to  a  vein  may  be  of  slight 
extent,  but  in  some  cases  the  proximal  clot  reaches  the  first  collateral  branch 
and  in  others  goes  far  above  it. 

Repair  of  Skin. — The  fibrous  structure  is  repaired  by  fibrous  tissue. 
Hair  follicles,  sweat-glands,  and  sebaceous  glands  are  not  reformed.  The 
epithelial  layer  is  regenerated  by  the  proliferation  of  adjacent  epithelial  cells. 

Repair  of  Lymphatic  Tissue. — Lymphatic  tissue  can  regenerate  either 
from  the  fatty  tissue,  the  divided  ends  of  the  lymph  ducts  or  both  structures. 

Repair  of  the  Kidney  and  Testicle. — These  organs  when  damaged  can 
undergo  some  regeneration. 

Repair  of  the  Liver  and  Spleen. — Each  of  these  organs,  after  injury,  is 
capable  of  considerable  regeneration. 


V.   SURGICAL  FEVERS. 

The  surgeon  encounters  fever  as  a  result  of  an  inflammation  or  an  aseptic 
wound,  in  consequence  of  infection,  as  a  result  of  poisoning  by  certain  drugs, 
and  in  several  maladies  of  the  nervous  system.  It  is  important  to  remem- 
ber that,  while  elevated  temperature  is  generally  taken  as  a  gauge  of  the  in- 
tensity of  fever,  it  is  not  a  certain  index.  There  may  be  fever  with  subnormal 
temperature  (as  in  the  collapse  of  typhoid  or  pneumonia),  and  there  may  be 
elevated  temperature  without  true  fever  (as  in  certain  diseases  of  the  nervous 
system).  It  is  true,  however,  that  elevation  of  temperature  is  almost  always 
noted,  and  is  usually  accepted  as  the  measure  of  the  severity  of  the  fever. 

The  essential  phenomena  of  fever,  according  to  Maclagan,  are — (i)  wasting 
of  nitrogenous  tissue;  (2)  increased  consumption  of  water;  (3)  increased 
elimination  of  urea;  (4)  increased  rapidity  of  circulation;  and  (5)  preternat- 
ural heat. 

Traumatic  fevers  follow  a  traumatism  and  attend  the  healing  or  in- 
fection of  a  wound.  The  forms  are  — (i)  benign  traumatic  fever;  (2)  malig- 
nant traumatic  fever. 


134  Surgical  Fevers 

Benign  traumatic  fever  is  divided  into  two  forms — the  aseptic  and  the 
septic.  There  is  but  one  form  of  aseptic  fever,  the  post-operation  rise.  The 
septic  benign  fevers  are  surgical  fever  and  suppurative  fever.  The  malignant 
traumatic  fevers  are  sapremia,  septic  infection,  and  pyemia.  In  this  section 
vi^e  discuss  only  the  benign  fevers. 

Aseptic  traumatic  fever,  or  the  post-operation  rise,  often,  but  not  always 
appears  after  a  thoroughly  aseptic  operation  and  after  a  simple  fracture  or  a 
contusion.  It  is  not  preceded  by  a  chill,  by  chilliness,  or  by  a  feeling  of  illness. 
It  may  appear  during  the  evening  of  the  day  of  operation  or  not  until  the  next 
day,  and  reaches  its  highest  point  by  the  evening  of  the  second  day  (ioo°  to  103° 
F.).  This  elevation  is  spoken  of  as  the  "  post-operation  rise"  because  it  is 
usually  encountered  after  an  operation.  Besides  the  elevated  temperature 
there  are  no  obvious  symptoms;  the  patient  feels  well,  sleeps  well,  and  often 
wants  to  sit  up;  there  are  no  rigors  and  there  is  no  delirium.  The  wound  is 
free  from  pain  and  appears  entirely  normal.  But  examination  may  show  mod- 
erate leukocytosis.  This  fever  is  due  to  absorption  of  pyrogenous  material 
from  the  wound  area,  the  material  being  obtained  from  clot  or  inflammatory 
exudate,  or  from  both.  Many  observers  believe  that  the  pyrogenous  element 
is  fibrin  ferment,  which  is  absorbed  from  disintegrating  blood-clot  and  coagu- 
lating exudate.  Warren  thinks  the  fever  is  due  to  fibrin  ferment,  and  "  also 
to  other  substances  slightly  altered  from  their  original  composition  during  life." 
Some  have  asserted  that  the  fever  is  due  to  nervous  shock. 

Schnitzler  and  Ewald  have  recently  studied  aseptic  fever.*  These  ob- 
servers maintain  that  aseptic  fever  can  exist  when  no  fibrin  ferment  is  free  in 
the  blood,  that  fibrin  ferment  can  be  free  in  the  blood  when  there  is  no  fever, 
and,  in  consequence,  that  fibrin  ferment  is  not  the  cause  of  the  elevation 
of  temperature.  They  rule  out  of  consideration  nervous  shock  as  a  cause,  and 
assert  that  a  combination  of  several  factors  is  responsible,  nucleins  and 
albumoses  which  are  set  free  by  traumatism  being  looked  upon  as  the  most 
active  causative  agents.  The  presence  of  nuclein  in  the  blood  in  aseptic 
fever  is  indicated  by  leukocytosis  and  by  the  increase  of  the  alloxur  bodies 
(including  uric  acid)  in  the  urine.  The  capacity  of  nucleins  and  albumoses 
to  cause  fever  is  greater  in  the  tuberculous  than  in  the  non-tuberculous,  and 
we  know  clinically  that  a  tuberculous  patient  is  apt  to  exhibit  a  more  violent 
post-operation  rise  than  is  a  non-tuberculous  subject.  The  diagnosis  of  asep- 
tic traumatic  fever  is  only  to  be  made  after  a  careful  examination  has  assured 
the  surgeon  that  there  is  no  obscure  or  hidden  area  of  infection. 

In  some  cases  aseptic  fever  may  appear  after  an  operation,  and  later  be 
replaced  by  a  septic  fever.  If  the  temperature  remains  high  after  a  few  days, 
if  other  symptoms  appear,  or  if  after  the  temperature  has  become  normal  it 
again  rises,  the  wound  should  be  examined  at  once,  as  trouble  almost  certainly 
exists. 

True  traumatic  or  genuine  surgical  fever  is  seen  as  a  result  of  in- 
fected wounds  in  which  there  is  decided  inflammation,  but  no  pus.  The 
real  cause  is  the  presence  of  fermentative  bacteria  in  the  wound  and 
the  absorption  of  a  moderate  amount  of  their  toxic  products.  The 
most  active  and  commonly  present  organisms  are  those  of  putrefaction. 
Surgical  fever    ceases    as    soon    as    free    discharge    occurs,    and   the   ap- 

*See  Archiv  fiir  klinische  Medicin,  Bd.  liii,  H.  3,  i8g6;  also  statement  of  their  views 
in  Medical  Record,  Dec.  19,  1896. 


Fever  of  Morphinism  135 

pearance  of  such  a  fever  is  an  indication  for  instant  drainage.  The 
condition  is  ushered  in  two  or  three  days  after  the  operation  by  chilly  sen- 
sations and  general  discomfort.  The  temperature  rises  pretty  sharply, 
ascends  with  evening  exacerbations  and  morning  remissions,  and  reaches  its 
height  about  the  third  or  fourth  day,  when  suppuration  sets  in;  the  tempera- 
ture begins  to  drop  when  pus  forms,  if  the  pus  has  free  exit,  and  reaches 
normal  at  the  end  of  a  week  (see  Suppurative  Fever).  The  temperature  may 
reach  104°  F.  or  more,  but  rarely  rises  above  103°  F.  The  patient  has  the 
general  phenomena  of  fever,  that  is  to  say,  thirst,  anorexia,  nausea,  dry  and 
coated  tongue,  constipation,  pain  in  the  back  and  legs,  and  headache.  The 
urine  is  scanty  and  high-colored.  Blood  examination  usually  shows  decided 
leukocytosis.  The  wound  is  painful,  tender,  swollen,  discolored,  and  often 
foul,  and  stitch-abscesses  may  form.  Some  or  all  of  the  stitches  must  be  cut, 
and  the  area  should  be  asepticized,  and  packed  with  iodoform  gauze  or 
drained  by  a  tube.  The  fact  that  this  fever  is  apt  to  cease  when  discharge 
of  pus  begins  led  the  older  surgeons  to  hope  for  pus  and  to  endeavor  to  cause 
it  to  form.  A  severe  grade  of  surgical  fever,  such  as  arises  when  there  is 
putrefaction  in  a  large  and  ill-drained  wound,  is  due  to  the  absorption  of  a 
large  quantity  of  the  toxic  products  of  putrefactive  bacteria  and  is  known  as 
sapremia  (page  209) . 

Suppurative  Fever. — This  fever,  which  is  due  to  the  absorption  of  the 
toxins  of  pyogenic  organisms,  occurs  after  suppuration  has  begun,  is  found 
when  the  pus  has  not  free  exit,  and  is  an  intoxication  rather  than  an  infection. 
It  can  follow  or  be  associated  with  surgical  fever,  or  may  arise  in  cases  in  which 
surgical  fever  has  not  existed.  Suppuration  in  a  wound  is  indicated  by  a  rapid 
rise  of  temperature — possibly  by  a  chill.  The  temperature  rises  to  a  con- 
siderable height,  shows  morning  remissions  and  evening  exacerbations,  and 
as  it  begins  to  fall  toward  morning  sweating  occurs.  The  patient  is  much 
exhausted  and  presents  the  phenomena  of  fever  previously  described.  The 
skin  about  the  wound  becomes  swollen,  dusky  in  color,  and  edematous, 
pain  becomes  pulsatile,  and  much  tenderness  develops.  Blood  examination 
shows  very  marked  leukocytosis.  The  wound  must  at  once  be  drained  and 
asepticized.  In  a  chronic  suppuration,  such  as  occurs  when  there  is 
pyogenic  infection  of  a  tuberculous  area,  there  exists  a  fever  with  marked 
morning  remissions  and  vesperal  exacerbations,  attended  with  drenching 
night-sweats,  emaciation,  diarrhea,  and  exhaustion.  This  is  known  as  hectic 
fever;  it  is  really  a  chronic  suppurative  fever.  The  treatment  of  hectic  fever 
consists  in  the  drainage  and  disinfection,  if  possible,  the  excision  of  the  infected 
area,  the  employment  of  a  nutritious  diet,  stimulants,  tonics,  remedies  for  the 
exhausting  sweats,  and  free  access  of  fresh  air. 

Some  Other  Forms  of  Fever  Seen  by  the  Surgeon.— Fever  of 
Tension. — When  there  is  great  tension  upon  the  stitches  the  spots  where  the 
stitches  perforate  ulcerate  and  some  fevers  arise.  To  relieve  the  fever  of 
tension  cut  one  or  several  stitches.  This  fever  is  in  some  cases  surgical,  and 
in  some  suppurative,  according  as  to  whether  the  infective  organisms  cause 
fermentation  or  suppuration. 

Fever  of  Iodoform  Absorption  (see  page  31). 

Fever  of  Ptyalism,  or  Mercurial  Fever  (see  page  334) . 

Fever  of  Morphinism. — Sometimes  a  morphia  habitue  suffers  from  se- 
vere chills  and  intermittent  fever  of  the  quotidian  or  tertian  type.     The  con- 


136  Surgical  Fevers 

dition  is  usually  thought  to  be  malarial,  a  view  which  is  strengthened  by  the 
common  association  with  neuralgia;  but  quinin  proves  futile  as  a  remedy 
and  blood-examination  gives  a  negative  result.  If  we  have  reason  to  suspect 
that  the  patient  is  using  morphia,  examine  the  urine  for  the  drug  and  wash 
out  the  stomach  and  examine  the  washing.  The  latter  test  is  of  value  even 
when  morphin  is  used  hyperdermatically,  because  that  drug  is  excreted  into  the 
stomach. 

Fever  of  Cocain-poisoning  (see  Local  Anesthesia). 

Hepatic  Fever  (see  section  on  Liver  and  Gall-bladder). 

Hysterical  Fever. — This  remarlcable  condition  is  occasionally,  though 
seldom,  encountered.  Most  of  the  reported  cases  of  great  hyperpyrexia  are 
instances  of  simulation  and  fraud.  It  may  happen  that  elevated  temperature 
is  the  sole  evidence  of  illness,  there  being  no  wasting  or  other  febrile  symp- 
toms. Such  elevated  temperature  may  be  attained  daily  for  months.  As  a 
rule,  hysterical  stigmata  can  be  detected.  Osier  points  out  that  cases  of 
hysterical  fever  "with  spurious  local  manifestations"  are  very  deceptive. 
The  case  may  resemble  meningitis,  peritonitis,  or  some  other  acute  inflam- 
matory condition;  but  the  course  of  the  supposed  malady  is  found  to  be 
atypical  and  the  symptoms  are  observed  to  be  variable  and  often  anomalous. 
There  is  no  leukocytosis ;  frequently  there  is  an  apparent  increase  in  red  cells 
because  of  vasomotor  disturbance,  a  fall  in  hemoglobin,  and  an  increased 
proportion  of  lymphocytes  and  eosinophiles  ("CHnical  Hematology,"  by  J.  C. 
DaCosta,  Jr.). 

An  emotional  fever  sometimes  occurs  after  accidents  or  operations. 
The  patient  may  have  a  chill,  and  then  develop  violent  headache,  photo- 
phobia, and  hysterical  excitement,  with  elevated  temperature. 

Malaria. — It  is  wise  to  examine  the  blood  in  supposed  septic  fevers,  for 
only  by  this  means  can  malaria  be  excluded.  It  is  more  common  to  mistake 
sepsis  for  malaria  than  malaria  for  sepsis.  In  malaria  the  spleen  is  enlarged, 
the  febrile  attacks  exhibit  periodicity,  neuralgias  are  common  associates,  and 
quinin  cures  the  condition. 

Surgical  Scarlet  Fever. — It  is  maintained  by  some  writers  (notably  Sir 
Victor  Horsley  and  Sir  James  Paget)  that  a  child  is  rendered  especially  sus- 
ceptible to  scarlet  fever  by  the  shock  of  a  surgical  operation.  Scarlet  fever 
which  develops  after  a  wound,  a  burn,  or  an  operation  is  spoken  of  as  surgical 
scarlet  fever.  Warren  quotes  Thomas  Smith  as  having  had  ten  cases  of 
scarlet  fever  in  forty-three  operations  of  Hthotomy  in  children.  The  puer- 
peral state  is  supposed  also  to  predispose  to  scarlet  fever.  It  is  not  certain 
whether  the  poison  enters  by  the  wound,  or  whether  shock  and  exhaustion 
predispose  to  ordinary  scarlatina,  or  whether  ordinary  scarlatina  was  incu- 
bating before  the  accident  or  operation.  Some  surgeons  hold  that  an  attack 
of  scarlet  fever  after  an  operation  is  a  mere  coincidence.  Others  maintain, 
and  with  great  show  of  reason,  that  a  red  scarlatiniform  eruption  appearing 
after  an  operation,  rarely  indicates  genuine  scarlet  fever,  but  usually  points 
to  infection,  as  such  eruptions  are  known  occasionally  to  arise  in  septicemia. 
It  rarely  indicates  scarlet  fever,  and  yet  it  sometimes  does.  There  is  such  a 
condition  as  surgical  scarlet  fever,  as  is  proved  by  the  facts  that  victims  of 
the  disease  have  been  known  to  communicate  it,  and  that  it  is  often  followed 
by  "nephritis  and  usually  by  desquamation"  (Holt's  " Diseases  of  Infancy 
and  Childhood"). 


Suppuration  137 

Hoffa  has  discussed  this  subject  elaborately.  He  concludes  that  four  types 
of  eruption  can  follow  operation:  (i)  a  vasomotor  disturbance  due  to  irrita- 
tion of  sensory  nerves,  and  manifested  by  a  transient  urticaria  or  erythema; 
(2)  a  toxic  erythema  due  to  absorption  of  aseptic  pyrogenous  material  from 
the  injured  area — the  absorption  of  carbolic  acid,  iodoform,  of  corrosive 
subhmate,  or  the  effect  of  ether;  (3)  an  infectious  rash  which  is  sometimes 
found  in  septicemia  or  pyemia,  and  is  due  to  minute  emboli  composed  of  bac- 
teria, which  emboli  lodge  in  the  capillaries;  (4)  true  scarlet  fever,  with  the 
usual  symptoms  and  complications,  the  micro-organisms  having  entered  by  way 
of  the  wound  and  the  eruption  often  beginning  at  the  wound  edges  (quoted 
in  Warren's  "Surgical  Pathology").  Surgical  scarlatina  is  aberrant.  It  de- 
velops rapidly,  the  period  of  incubation  is  extremely  brief,  and  the  throat  may 
or  may  not  be  involved.  Holt  tells  us  that  the  rash  is  usually  atypical  and  that 
"the  general  symptoms,  particularly  those  relating  to  the  nervous  system," 
are  "especially  severe"  ("Diseases  of  Infancy  and  Childhood").  The  in- 
fection is  believed  to  be  due  to  a  specific  germ,  but  it  has  not  been  certainly 
identified.  Streptococci  have  been  found  in  the  throat,  skin,  and  the  pus  from 
secondary  otitis  media. 

If  surgical  scarlet  fever  develops  the  wound  should  be  drained  and  asepti- 
cized, and  if  the  situation  admits  of  it,  dressed  with  hot  antiseptic  fomentations. 
The  general  treatment  is  the  same  as  for  ordinary  scarlatina. 

Urinary  Fever  and  Urethral  Fever  (see  section  on  Disease  of  Genito- 
urinary Organs). 

Syphilitic  Fever  (see  page  318). 

Thyroid  Fever  (see  section  on  Thyroid  Gland). 


VI.    SUPPURATION  AND  ABSCESS. 

Suppuration  is  a  process  in  which  damaged  living  tissues  and  inflamma- 
tory exudates  are  Hquefied  by  the  action  of  pyogenic  organisms,  and  it  is  a  com- 
mon result  of  microbic  inflammation.  The  organisms  which  are  responsible 
are  referred  to  on  page  47.  Staphylococci  tend  to  produce  local  suppuration; 
streptococci  tend  to  cause  spreading  suppuration.  It  is  generally  taught  that 
pyogenic  bacteria  Hquefy  damaged  tissue  and  exudate  by  peptonizing  them, 
the  active  agent  in  effecting  the  chemical  change  being  poison  furnished  by 
the  bacteria.  There  is  some  evidence  that  white  corpuscles  by  disintegration 
set  free  enzymes  which  dissolve  or  aid  in  dissolving  albumin.  Streptococci 
and  staphylococci  vary  greatly  in  virulence  and  the  intensity  and  diffusion  of 
a  pyogenic  infection  depends  upon  the  virulence  and  number  of  the  bacteria 
and  the  level  of  vital  resistance.  Streptococci  and  staphylococci  may  both  be 
present  in  one  focus,  and  there  may  be  secondary  infection  with  bacteria  of  put- 
refaction or  other  bacteria.  The  pyogenic  infection  may  be  primary  or  it  may 
be  secondarily  implanted  in  a  diseased  area  containing  other  micro-organisms. 
The  pyogenic  organisms  are  very  irritant,  and  when  deposited  cause  in- 
flammation; inflammation  leads  to  exudation,  but  the  exudate  cannot  co- 
agulate or  coagulates  but  imperfectly,  because  it  is  peptonized  by  the  fer- 
ment of  the  micro-organisms  and  also  perhaps  because  albumin  is  dissolved 
by  leukolysin  from  the  white  corpuscles.     If  an  area  of  embryonic  tissue  is 


138  Suppuration  and  Abscess 

invaded  by  the  pyogenic  micro-organisms,  it  is  promptly  peptonized.  The 
peptonizing  action  is  upon  the  fibrinous  elements  of  an  exudate  and  upon  the 
intercellular  substance  of  embryonic  or  granulation  tissue.  Cells  are  separated 
from  intercellular  substance,  and  in  consequence  degenerate  and  die.  Pep- 
tonized exudate  or  peptonized  embryonic  tissue  is  called  pus.  In  suppurations 
induced  by  staphylococci  a  barrier  of  leukocytes  is  first  formed  around  the  region 
of  irritation;  this  barrier  is  reinforced  by  fibroblasts,  the  pus  is  imprisoned,  and 
rapid  spreading  and  wide  diffusion  are  prevented.  In  inflammations  induced 
by  streptococci  the  peptonizing  action  of  the  organisms  is  so  great  that  no 
barrier  of  white  blood-cells  or  of  proliferating  connective-tissue  cells  forms  in 
time  to  imprison  the  micro-organisms;  hence  the  suppuration  spreads  rapidly 
and  widely.  Suppiu-ation  can  be  induced  by,  the  injection  of  pyogenic  bacteria, 
by  their  entry  through  a  wound,  and  by  rubbing  them  into  the  skin.  In 
some  rare  instances,  especially  when  the  diet  has  been  putrid,  they  may  enter 
through  the  blood  and  lodge  at  a  point  of  least  resistance.  When  a  medullary 
canal  suppurates  after  a  chill  to  the  surface  or  after  a  blow  that  does  not  cause 
a  wound,  we  know  that  the  bacteria  must  have  arrived  by  means  of  the 
blood.  Bacteria  which  reach  a  point  of  least  resistance  through  the  blood 
come  from  some  atrium  of  infection  which  may  be  discoverable  or  which  may 
not  be  found.  The  entry  of  pyogenic  bacteria  does  not  necessarily  cause 
suppuration,  as  the  healthy  human  body  can  destroy  a  considerable  number, 
even  if  given  in  one  "dose";  but  a  large  number  in  a  healthy,  or  even  a  small 
number  in  an  unhealthy  body,  almost  certainly  leads  to  pus-formation. 
The  pus  of  all  acute  abscesses  contains  bacteria  of  suppuration,  but  the  pus 
of  tuberculous  abscesses  does  not,  unless  there  be  a  mixed  infection;  in  other 
words,  pvire  tuberculous  pus  is  not  pus  at  all. 

Can  suppuration  be  induced  without  the  actual  presence  of  bacteria  ?  It  is 
true  that  the  injection  of  irritants  can  cause  the  formation  of  a  thin  fluid  which 
contains  no  bacteria;  but  this  non-bacterial  fluid  is  not  pus.  A  purulent  fluid 
is  formed  by  injecting  cultures  of  pus  cocci  which  have  been  rendered  sterile  by 
heat,  the  bacteria  having  been  killed,  and  a  ferment  contained  in  the  bacterial 
cells  being  the  active  agent.  Purulent  material  also  results  from  the  injection 
simply  of  the  sterile  products  of  the  growth  of  pyogenic  cocci.  This  purulent 
or  sterile  fluid  is  known  as  spurious  or  aseptic  pus.  An  area  of  such  aseptic 
suppuration  does  not  tend  to  spread  and  the  process  concerns  us  but  little  as 
surgeons,  except  in  cases  of  pyemia  in  which  thrombi  containing  toxins  alone 
may  occasionally  induce  hmited  secondary  abscesses. 

Impaired  health  or  an  area  of  lowered  vitahty  predisposes  to  suppura- 
tion. Diabetes  and  albuminuria  are  common  and  influential  predisposing 
causes,  because  in  these  diseases  tissue  resistance  is  always  at  a  low  ebb. 
The  lymphatic  glands,  medulla  of  bones,  serous  membranes,  and  connective 
tissue  are  especially  prone  to  suppurate. 

Pus  may  form  within  twenty-four  hours  after  bacteria  have  been  deposited, 
or  it  may  not  be  formed  for  days.  The  older  surgeons  claimed  that  pus  could 
do  good  by  protecting  granulations  and  separating  disorganized  tissue.  It 
is  now  held  that  it  is  absolutely  harmful  by  melting  down  sound  tissue  and 
poisoning  the  entire  organism.  Modern  surgery  has  to  a  great  degree  abolished 
pus. 

If  pus  stands  for  a  time,  it  separates  into  two  portions — (i)  a  watery  por- 


Forms  of  Pus 


139 


tion,  the  liquor  puris  or  pus-serum,  containing  peptone,  fat,  microbic  products, 
osmazone,  and  salts,  and  not  tending  to  coagulate;  (2)  a  solid  portion,  or 
sediment  composed  of  dead  and  living  micro-organisms  of  suppuration,  connec- 
tive-tissue cells,  often  epithelial  cells,  perhaps  red  blood-cells,  lymphocytes, 
pus-corpuscles  (Fig.  71),  debris  of  tissue,  and  shreds  of  dead  tissue.  The 
pus-corpuscles  are  either  polynuclear  white  blood-cells  or  altered  connective- 
tissue  cells  containing  many  nuclei.  Some  of  them  are  dead,  some  have  ame- 
boid movements,  some  are  fatty,  others  are  granular  and  contain  more  than  one 
nucleus,  and  all  are  degenerating.  A  pus-cell  is  v^aste  matter,  and  it  cannot 
aid  in  repair.  Very  exceptionally  pus  disappears  by  absorption,  by  caseation, 
or  by  calcification. 

Pus  in  General. — The  color  of  pus  is  variable  and  depends  upon  the  na- 
ture of  the  bacteria;  the  presence  or  absence  of  blood,  fibrin,  body  secretions 


Fig.  71.— Fragmentation  of  nucleus   in  leukocytes    undergoing   transformation  into   pus-corpuscles 

(Senn). 


or  body  excretions  (bile,  urine,  mucus,  feces,  etc.) ;  and  the  existence  or  non- 
existence of  putrefaction. 

Its  consistence  varies.  In  some  cases  it  is  scarcely  thicker  than  v^ater,  in 
others  it  is  like  cream  and  in  still  others  it  is  cheesy.  Thick  pus  is  usually 
of  a  greenish-yellow  color  and  thin  pus  has  usually  a  reddish  or  yellowish 
tinge  (Leonard  Freeman).  When  freshly  evacuated  many  varieties  are  almost 
or  quite  odorless,  and  are  alkaline  or  slightly  acid  in  reaction. 

Some  varieties  possess  a  very  offensive  odor.  Pus  contaminated  by  the 
bacteria  of  putrefaction  is  certain  to  have  a  foul  odor.  Pus  which  forms  in  the 
tonsil,  in  the  brain,  about  the  vermiform  appendix,  or  around  the  rectum  usu- 
ally possesses  an  offensive  odor. 

Forms  of  Pus. — Laudable,  or  healthy  pus,  a  name  long  in  vogue,  is  a  con- 
tradiction, no  pus  being  healthy.  In  former  days  free  suppuration  after  an 
operation  was  regarded  as  a  favorable  indication,  and  when  it  occurred  the 


140  -  Suppuration  and  Abscess 

surgeon  congratulated  himself  that  surgical  fever  was  at  an  end.  At  the 
present  day  suppuration  after  an  operation  is  an  evidence  of  previous  infection, 
of  lack  of  care,  failure  in  our  precautions,  or  of  infection  by  the  blood.  The 
so-called  laudable  pus  is  seen  coming  from  a  healing  ulcer,  and  is  an  opaque, 
yellowish-white,  or  a  greenish  fluid  of  the  consistence  of  cream,  without 
odor  or  with  a  very  sHght  odor  if  it  is  not  putrid,  and  having  a  specific  gravity 
of  about  1030. 

Malignant,  watery,  or  ichorous  pus  is  a  thin,  watery,  putrid  fluid.  It  is 
pus  filled  with  the  organisms  of  putrefaction. 

Stinking  pus  may  be  ichorous.  Its  odor  may  be  due  to  the  bacterium  coli 
commune.  If  this  bacterium  is  the  cause  the  pus  is  very  foul,  but  not  thin. 
Pus  of  this  nature  is  met  with  in  ischiorectal  abscess  and  appendiceal  abscess. 
Its  odor  may  be  due  to  ordinary  bacteria  of  putrefaction,  in  which  case  the 
pus  is  thin. 

Sanious  pus  is  a  form  of  ichorous  pus  containing  blood  coloring-matter 
or  blood.  It  is  thin,  of  a  reddish  color,  and  very  acrid,  corroding  the  parts 
that  it  comes  in  contact  with.     It  is  found  notably  in  caries  and  carcinoma. 

Concrete  or  fibrinous  pus,  which  contains  flakes  of  fibrin  or  coagulated 
fibro-purulent  masses,  is  met  with  in  serous  cavities  (joints,  pleura,  etc.). 
These  masses  also  form  in  infective  endocarditis. 

Red  pus  signifies  the  presence  of  the  bacillus  prodigiosus. 

Blue  Pus. — The  color  of  blue  pus  is  due  to  the  bacillus  pyocyaneus. 

Orange  Pus. — The  color  of  orange  pus  is  due  either  to  the  action  of  sarcina 
aurantiaca,  or  to  the  formation  of  crystals  of  hematoidin  from  the  coloring- 
matter  of  red  blood-cells  which  have  been  mingled  with  the  pus.  Pus  of  this 
color  appears  only  in  violent  inflammations. 

Serous  pus  is  a  thin  serous  fluid  containing  a  few  flakes. 

So-called  tuberculous,  scrofulous,  or  curdy  pus  is  not  pus  at  all,  unless  the 
tuberculous  area  has  undergone  pyogenic  infection. 

So-called  gummy  pus  arises  from  the  breaking  down  of  a  gumma  which 
has  outgrown  its  own  blood-supply.     It  is  not  pus. 

Muco-pus  is  found  in  purulent  catarrh — that  is,  in  suppurative  inflammation 
of  an  epithehal  structure.     It  contains  pus  elements  and  epithelial  cells. 

Caseous  pus  comes  from  the  fatty  degeneration  of  pus-corpuscles  or  in- 
flammatory exudations.  It  occurs  especially  in  tuberculous  processes.  A 
caseous  mass  may  calcify. 

Signs  and  Symptoms  of  Suppuration. — Suppuration  is  announced  by 
the  intensification  of  all  local  inflammatory  signs.  The  heat  becomes  more 
marked,  the  discoloration  dusky,  the  swelling  augments,  the  pain  becomes  throb- 
bing or  pulsatile,  and  the  sense  of  tension  is  greatly  increased.  The  skin  at  the 
focus  of  the  inflammation  after  a  time  becomes  adherent  to  the  parts  beneath, 
and  fluctuation  soon  appears.  This  adhesion  of  the  skin  is  a  preparation  for  a 
natural  opening,  and  is  known  as  pointing.  An  important  sign  of  pus  beneath 
is  edema  of  the  skin.  This  is  always  observed  in  a  superficial  abscess,  and  is 
sometimes  noticeable  in  empyema  or  pyothorax,  in  appendiceal  abscess,  and 
in  perirenal  suppuration.  The  above  symptoms  can  be  reinforced  and  their 
significance  proved  by  the  introduction  of  an  aseptic  tubular  exploring  needle 
and  the  discovery  of  pus.  Irregular  chills,  high  fever,  drenching  sweats,  weak- 
ness, and  a  feeling  of  serious  sickness  are  very  significant  of  suppuration  in  an 
important  structure  or  of  a  large  area.     It  must  always  be  remembered  that  in 


Wooden  or  Li'gneus  Phlegmon  141 

some  virulent  pyogenic  infections  the  human  organism  is  overwhelmed  with 
toxins  and  although  the  patient  is  des])eratcly  ill  the  temperature  is  normal 
or  even  subnormal.  In  abscess  of  the  brain  the  temperature  may  be  normal 
or  subnormal. 

Diffused  Cellulitis  or  Phlegmonous  Suppuration;  Purulent  Infil- 
tration.— This  process  may  involve  a  small  area  or  an  entire  limb,  and  is  due 
to  infection  by  the  streptococcus  pyogenes  (or  streptococcus  of  erysipelas) 
usually  associated  with  mi.xed  infection  with  other  bacteria  particularly  the 
bacteria  of  putrefaction.  The  streptococci  are  intensely  virulent.  Barriers 
of  white  corpuscles  will  not  restrain  them,  and  tissues  break  down  before  cellu- 
lar multiplication  is  able  to  encompass  the  bacteria.  The  bacteria  disseminate 
through  the  lymph-spaces  and  lymph- vessels.  The  disease  in  severe  cases 
produces  enormous  swelling,  areas  which  feel  boggy,  a  dusky  red  discoloration, 
and  great  burning  pain.  Gangrene  of  superficial  areas  is  not  unusual,  due  to 
thrombosis  of  vessels  or  coagulation  necrosis  from  toxins.  The  discharges 
of  the  wound,  if  a  wound  exists,  are  apt  to  dry  up,  and  the  wound  becomes  foul, 
dry,  and  brown.  The  adjacent  lymphatic  glands  are  much  enlarged.  The 
disease  is  ushered  in  by  a  chill,  which  is  followed  by  high  oscillating  tempera- 
ture, due  to  suppurative  fever,  sapremia,  or  even  septic  infection  or  pyemia. 
Sweats  are  noted  during  falling  temperature.  Diffuse  suppuration  tends  to 
arise  in  infected  compound  fractures,  in  extravasation  of  urine,  and  after  the 
infliction  of  a  wound  upon  a  person  broken  down  in  health.  It  is  not  unusual 
after  typhoid  or  scarlet  fever,  and  is  typical  of  phlegmonous  erysipelas.  The 
pus  is  sanious  and  offensive,  and  burrows  widely  in  the  subcutaneous  tissue  and 
intermuscular  planes.  This  diffused  suppuration  may  widely  separate  muscles 
and  even  lay  bare  the  bones.  It  is  a  very  grave  condition,  and  may  cause  death 
by  exhaustion,  septic  intoxication,  septic  infection,  pyemia,  or  hemorrhage 
from  a  large  vessel  which  has  been  corroded.  Cellulitis  of  a  mild  degree  is  due 
to  attenuated  streptococci  or  to  staphylococci.  An  area  of  cellulitis  may  sur- 
round an  infected  wound  or  a  stitch-abscess.  Its  spread  is  manifested  by  red 
lines  of  lymphangitis  running  up  to  the  adjacent  lymphatic  glands.  Light 
cases  may  not  suppurate,  the  lymphatics  carrying  off  the  poison.  Any  case  of 
cellulitis  is,  however,  a  menace,  and  any  severe  case  is  highly  dangerous  (see 
Erysipelas) . 

Wooden  or  Ligneus  Phlegmon. — This  condition  was  fully  described  by 
Reclus  in  1894.  It  is  chronic  inflammation  of  the  cellular  tissue  and  fascia  of 
the  neck.  It  is  a  very  chronic  condition  beginning  with  hard  swelling  of  one 
side  or  of  the  front  of  the  neck  and  for  weeks  is  unaccompanied  by  any  other  sign. 
The  swelling  may  be  at  first  localized,  but  it  spreads  slowly  and  widely  and 
finally  comes  to  involve  an  extensive  area,  even  perhaps  the  front  of  the  neck  and 
both  sides  from  the  jaw  to  the  collar-bone.  It  may  involve  the  cervical  muscles 
and  thus  create  rigidity  and  it  may  compress  the  larynx  and  trachea  and  thus 
interfere  with  breathing.  After  weeks  or  perhaps  a  month  or  two  the  skin 
becomes  edematous  and  red  or  rather  of  a  violet  hue.  There  is  rarely  pain  and 
the  significant  facts  are  the  gradually  advancing  hard  swelling  long  unac- 
companied by  pain,  discoloration,  or  cutaneous  edema.  The  condition  is  due 
to  the  deposition  and  multiplication  of  pyogenic  bacteria  which  reach  the  tissues 
from  the  lymph-glands  and  reach  the  glands  from  the  mouth.  Pus  does  not 
form  at  all  or  only  minute  encapsuled  foci  form  because  the  bacteria  are  of 


142  Suppuration  and  Abscess 

greatly  attenuated  virulence  or  because  the  local  vital  resistance  is  at  a  high 
level  to  these  bacteria.  Inflammation  occurs,  there  is  copious  exudate  and 
enormous  amounts  of  fibrous  tissue  form. 

Wooden  phlegmon  is  occasionally  found  in  syphilitics  and  is  most  apt  to 
arise  in  those  'in  poor  health.  It  is  frequently  mistaken  for  sarcoma  or  car- 
cinoma, in  fact  Lange  believes  it  to  be  cancer.  Wooden  phlegmon  is  always 
dangerous  and  is  frequently  fatal. 

Treatment. — Extirpation  is  not  feasible  and  the  surgeon  instead  makes  nu- 
merous incisions  and  usually  dresses  with  an  antiseptic  poultice.  In  these  cases 
free  suppuration  occasionally  occurs  after  a  long  delay  and  when  it  does  occur 
a  cure  may  promptly  follow  evacuation.  If  free  suppuration  were  induced 
to  occur  by  inoculations  the  effect  might  be  favorable.  In  view  of  the  diffi- 
culties, dangers,  and  great  prolongation  of  these  cases  it  is  desirable  that 
staphylococcic  suppuration  ensue  upon  the  multiple  incisions  and  it  is  justi- 
fiable to  secure  this  by  direct  inoculation,  or,  better,  by  making  multiple  in- 
cisions and  applying  old-fashioned  flaxseed  poultices. 

Acute  Abscesses. — An  acute  abscess  is  a  circumscribed  cavity  of  new  for- 
mation containing  pus.  \\'e  emphasize  the  fact  that  it  is  a  circumscribed  cavity 
— circumscribed  by  a  mass  of  leukocytes  and  proliferating  connective-tissue 
cells.  A  purulent  infiltration  is  not  circumscribed,  hence  it  does  not  consti- 
tute an  abscess.  An  essential  part  of  the  definition  is  the  assertion  that 
the  pus  is  in  a  cavity  of  new  formation,  in  an  abnormal  cavity;  hence  pus  in 
a  natural  cavity  (pleural,  pericardial,  synovial,  or  peritoneal)  constitutes  a 
purulent  ejjusion,  and  not  an  abscess,  unless  it  is  encysted  in  these  localities 
by  walls  formed  of  inflammatory  tissue. 

An  acute  abscess  is  due  to  the  deposition  and  multiplication  of  pyogenic 
bacteria  in  the  tissues  or  in  inflammatory  exudates.  These  bacteria  attack 
exudates  or  tissues,  form  irritants  which  cause  inflammation  or  intensify, 
existing  inflammation,  and  by  exerting  a  peptonizing  action  on  intercellular 
substance  and  the  fibrin  of  the  exudate  liquefy  tissue  and  the  products  of 
inflammation,  and  form  pus.  As  a  rule,  within  twenty-four  hours  after 
lodgment  of  the  bacteria  the  exudation  increases  in  amount,  the  migrated 
leukocytes  gather  in  enormous  numbers,  the  fibers  of  tissues  swell,  and  the 
connective-tissue  spaces  distend  with  cells  and  fluid.  The  connective-tissue 
cells,  acted  on  by  pus  cocci,  multiply  by  karyokinesis,  develop  many  nuclei, 
lose  their  stellate  projections,  degenerate,  and  constitute  one  form  of  pus- 
corpuscle,  leukocytes  forming  the  other.  All  the  small  vessels  are  choked 
with  leukocytes,  this  blocking  serving  to  cut  off  nourishment  and  tending  to 
produce  anemic  necrosis.  Liquefaction  occurs  at  many  foci  of  the  inflam- 
mation, drops  of  pus  being  formed,  the  amount  of  each  being  progressively 
added  to  and  many  foci  coalescing  (Fig.  72).  The  pus-cavity  is  circumscribed, 
not  by  a  secreting  pyogenic  membrane,  but  by  a  mass  of  fibroblasts,  whose 
cells  and  intercellular  material  have  not  as  yet  broken  down;  such  a  mass  of 
fibroblasts  is  often  called  embryonic  tissue,  and  it  is  circumscribed  by  a  zone 
of  inflammation  in  which  there  are  hordes  of  migrated  leukocytes  (Fig.  73). 
As  an  abscess  increases  in  size,  the  embr\^onic  tissue  from  within  outward 
liquefies  into  pus,  and  the  zone  of  inflammation  beyond  continually  enlarges 
and  forms  more  embryonic  tissue.  After  a  time  the  inflammation  reaches 
the  surface,  the  embryonic  tissue  glues  the  superficial  to  the  deeper  parts,  the 


Acute  Abscesses 


143 


superficial  part  inflames  and  becomes  embryonic  tissue,  and  the  intercellular 
substance  is  liquefied.  When  pus  has  all  but  reached  the  surface,  a  thin  layer 
of  tissue  only  being  undestroyed,  an  elevation'or  tit  of  thin  tissue  is  formed,  due 
to  the  fluid  pressure.     This  process  is  known  as  pointing.     The  elevation  or 


Fig.  72. — Infiltration  of  connective  tissue  of  cutis  (X  500)  with  beginning  suppuration  in  the  center 

iSenn). 


point  thins  from  tension  and  liquefaction,  and  finally  gives  way  and  spon- 
taneous evacuation  occurs.  When  an  abscess  forms  in  an  internal  organ  or  in 
some  structure  which  is  not  loose,  like  connective  tissue, — for  instance,  in  a 
lymphatic  gland, — a  mass  of  pyogenic  bacteria,  floating  in  the  blood  or 
lymph,  lodges,  and  these  bacteria  by  means  of  irritant  products  cause  coagu- 
lation necrosis  of  the  adjacent  tissue  and 
inflammatory  exudation  around  it.  The 
area  of  coagulation  necrosis  becomes  filled 
with  white  blood-cells,  and  the  dn,-  ne- 
crosed part  is  liquefied  by  the  cocci. 
Suppuration  in  dense  structures  causes 
considerable  masses  of  tissue  to  die  and  to 
be  cast  off,  and  these  masses  float  in  the 
pus.  Death  of  a  mass  with  dissolution  of 
its  elements  is  necrosis,  or  inflammatory 
gangrene.  Pus  travels  in  the  line  of  least 
resistance.  It  may  reach  a  free  surface, 
or  may  break  into  a  cavity  or  joint,  may 
invade  bone  or  destroy  a  vessel.  When 
an  abscess  ceases  to  spread  or  is  evacu- 
ated, the  fibroblastic  layer  forming  the 
walls  becomes  vascularized  and  is  con- 
verted into  granulation  tissue.  An  abscess  heals  by  the  collapse  of  its  walls  and 
fusion  of  the  granulations  (union  by  third  intention),  or  by  granulation  (union 
by  second  intention).  In  either  case  granulation  tissue  is  ultimately  con- 
verted into  fibrous  or  scar  tissue. 


P'S-  73« — Diagram  of  an  abscess  :  A, 
pus:  B,  layer  of  fibroblasts  ;  C,  tissue  in- 
filtrated with  leukocytes ;  D,  zone  of  sta- 
sis ;  E,  zone  of  active  hyperemia ;  F, 
healthy  tissue. 


144  Suppuration  and  Abscess 

Forms  of  Abscesses.— The  following  are  the  various  forms  of  ab^ 
scesses:  Acute,  which  follows  an  acute  inflammation.  Strumous,  cold,  lym- 
phatic, tuberculous,  or  chronic  abscess  is  due  to  the  bacilli  of  tuberculosis  and 
does  not  contain  true  pus  unless  there  is  secondary  pyogenic  infection.  It  pre- 
sents no  signs  of  inflammation.  A  lymphatic  abscess  may  form  in  a  week  or 
two,  and  hence  is  not  necessarily  chronic,  which  term  is  properly  applied  to  a 
pyogenic  infection  of  an  infective  granuloma.  Caseous  or  cheesy  abscess,  a 
cavity  containing  thick  cheesy  masses,  is  due,  perhaps  to  the  fatty  degenera- 
tion of  inflammatory  exudate  and  pus-corpuscles,  but  most  commonly  results 
from  the  caseation  of  a  tuberculous  focus.  Circumscribed  abscess  is  one  limited 
by  a  layer  of  fibroblasts.  Diffused  abscess  is  an  unlimited  collection  of  pus,  in 
reality  not  an  abscess,  but  either  a  purulent  effusion  or  a  purulent  infiltration. 
Congestive,  gravitative,  wandering,  or  hypostatic  abscess  is  a  collection  of  pus 
or  tuberculous  matter  which  travels  from  its  formation-point  and  appears  at 
some  distant  spot  (as  a  psoas  abscess).  Critical  or  consecutive  abscess  is  one 
which  arises  during  an  acute  disease.  Diathetic  abscess  finds  its  predisposing 
cause  in  a  diathesis.  Embolic  abscess  is  due  to  an  infected  embolus.  Tym- 
panitic or  emphysematous  abscess  is  one  which  contains  air  or  the  gases  of 
putrefaction.  Encysted  abscess,  in  which  pus  is  circumscribed  in  a  serous 
cavity.  Fecal  or  stercoraceous  abscess  is  one  containing  feces  in  consequence 
of  a  communication  with  the  bowel.  Follicular  abscess  is  one  arising  in  a  fob 
licle;  hematic  abscess,  one  arising  around  a  blood-clot,  as  a  suppurating  hema- 
toma; marginal  abscess,  which  appears  upon  the  margin  of  the  anus.  Pyemic 
or  metastatic  abscess  is  the  embolic  abscess  of  pyemia.  Milk  abscess  is  an 
abscess  of  the  breast  in  a  nursing  woman.  Ossifluent  abscess  arises  from 
diseased  bone.  Psoas  abscess  is  a  tuberculous  abscess  arising  from  vertebral 
caries,  the  matter  following  the  psoas  muscle,  and  usually  pointing  in  the  groin. 
A  sympathetic  abscess,  arising  some  distance  from  the  exciting  cause,  such  as  a 
suppurating  bubo  from  chancroid,  is  not  in  reality  sympathetic,  because  in- 
fective material  has  been  carried  from  the  primary  focus.  Thecal  abscess  is  a 
purulent  effusion  in  a  tendon-sheath.  Tropical  abscess  is  an  abscess  of  the 
liver,  so  named  because  it  occurs  chiefly  in  those  dwelling  in  tropical  countries: 
it  usually  follows  dysentery;  urinary  abscess,  caused  by  extra vasated  urine. 
A  verminous  abscess  is  one  which  contains  intestinal  worms  and  communicates 
with  the  bowel.  A  syphilitic  abscess  occurs  in  the  bones  during  tertiary 
syphilis,  and  is  gummatous  and  not  pyogenic.  Brodie's  abscess  is  a  chronic 
abscess  of  the  bone,  most  common  in  the  head  of  the  tibia.  A  superficial  ab- 
scess occurs  above  the  deep  fascia;  a  deep  abscess  occurs  below  the  deep 
fascia.  A  residual  or  Paget's  abscess  is  a  recurrence  of  active  changes,  it  may 
be  after  years,  around  the  residue  of  a  former  tuberculous  abscess. 

Symptoms  of  Acute  Abscess.— In  an  acute  abscess,  as  before  stated,  a 
part  becomes  inflamed  and  a  quantity  of  fibroblasts  are  formed;  fibroblastic 
tissue  is  liquefied  (as  above  noted)  and  pus  is  produced.  An  acute  abscess  can 
occur  in  a  person  of  any  constitution. 

Local  Symptoms. — Locally  there  is  intensification  of  inflammatory 
signs  and  enormous  increase  of  the  swelling.  At  first  the  area  is  hard,  but 
afterwards  becomes  soft,  and  it  finally  fluctuates.  The  discoloration  becomes 
dusky.  The  pain  becomes  throbbing  and  the  sense  of  tension  increases. 
The  pain  is  greater  the  more  dense  the  implicated  tissue  and  the  greater 


Acute  Abscesses  in  Various  Regions  145 

the  number  of  nerves  it  contains.  At  every  pulse-beat  the  tension  in  tlie 
abscess  increases  temporarily,  and  hence  the  pain  momentarily  increases. 
Pain  is  increased  by  a  dependent  position  of  the  part.  There  is  great  tender- 
ness. The  pain  may  be  felt  at  the  seat  of  suppuration  or  may  be  referred  to 
some  distant  point.  Tenderness  is  located  at  the  focus  of  disease.  The  cuta- 
neous surface,  if  the  abscess  is  adjacent,  is  seen  to  be  polished  and  edematous, 
and  after  a  time  pointing  is  observed  and  fluctuation  can  be  detected.  If  pus 
is  deeply  situated  the  skin  may  not  be  reddened  and  perhaps  the  area  of  in- 
duration cannot  be  palpated.  In  such  a  case  there  is  often  rigidity  of  the 
muscles  overlying  the  abscess  (as  in  abdominal  suppurations),  the  skin  may 
be  edematous  (as  in  some  cases  of  empyema),  and  besides  local  pain  there 
may  be  pain  due  to  pressure  upon  a  nerve  trunk,  the  pain  perhaps  being  re- 
ferred to  a  distant  point. 

Constitutional  Symptoms. — If  there  is  a  small  collection  of  pus  in  an 
unimportant  structure  there  may  be  no  obvious  constitutional  disturbance. 
If  the  abscess  contains  much  pus  or  affects  an  important  part,  disturbances 
generally  appear,  from  slight  rigors  or  moderate  fever  to  chills,  high  tempera- 
ture, and  drenching  sweats.  The  constitutional  condition  typical  of  an  ab- 
scess is  due  to  the  absorption  of  retained  toxins,  and  is  known  as  "  suppurative 
fever."  When  an  abscess  is  open  but  ill-drained,  or  when  it  is  unopened 
and  deep-seated,  long-continued  suppuration  causes  a  fever  which  is  markedly 
periodic:  the  temperature  rises  in  the  evening,  attaining  its  highest  point 
usually  between  4  and  8  p.  M.,  and  sinks  to  normal  or  nearly  normal  in  the 
early  morning  (from  4  to  8  A.  M.).  When  the  temperature  begins  to  fall,  pro- 
fuse perspiration  takes  place.  This  fever  is  known  as  hectic.  Prolonged 
suppuration  causes  albuminoid  changes  in  various  organs,  notably  in  the  liver, 
spleen,  and  kidneys.  Albuminoid  changes  are  especially  common  when  there 
has  been  mixed  infection  of  a  tuberculous  area  and  long-continued  suppura- 
tion.    It  also  occurs  as  a  result  of  syphilis. 

Dr.  J.  C.  DaCosta,  Jr.,  tells  us  ("CHnical  Hematology")  that  "in  both 
trivial  and  extensive  pus  foci  the  number  of  leukocytes  may  be  normal  or  even 
subnormal;  in  the  former  instance  because  systemic  reaction  is  not  provoked, 
and  in  the  latter  because  it  is  overpowered.  Leukocytosis  may  also  be  absent 
in  case  toxic  absorption  is  impossible,  owing  to  the  complete  walling  off  of 
the  abscess.  In  all  other  instances  save  these,  a  definite  and  usually  well- 
marked  leukocytosis  occurs,  amounting  on  the  average  to  a  count  of  about 
twice  the  mean  normal  standard,  but  frequently  greatly  exceeding  this  figure 
in  the  individual  case." 

The  signs  and  symptoms  of  an  abscess  are  somewhat  modified  by  location, 
and  it  is  wise  to  discuss  acute  abscesses  in  different  situations. 

Acute  Abscesses  in  Various  Regions.— ^ft^ce^^  oj  the  brain  may 
follow  cerebral  concussion  or  fracture  of  the  skull  may  arise  during  a  general 
infection  but  in  about  50  per  cent,  of  cases  results  from  chronic  suppurative 
disease  of  the  middle  ear.  In  abscess  of  a  silent  region  of  the  brain  symptoms 
may  long  be  entirely  absent.  The  usual  symptoms  are  a  temporary  initial  rise 
of  temperature  which  soon  gives  place  to  a  normal  and  in  one-half  of  the  cases 
to  a  subnormal  temperature,  headache,  vomiting,  delirium,  drowsiness,  and 
choked  disk.  Localizing  symptoms,  spasmodic  or  paralytic,  may  be  present. 
There  is  usually  leukocytosis.     In  but  few  cases  are  there  elevated  tempera- 


146  Suppuration  and  Abscess 

tare  and  sweats.  Toward  the  end  of  the  case  there  may  be  elevated  tempera- 
ture and  delirium.  In  extradural  abscess  there  is  fever  from  beginning  to  end 
(page  823). 

Appendiceal  or  appendicular  abscess  results  from  inflammation,  usually 
but  not  always  with  perforation  of  the  vermiform  appendix,  plastic  peritonitis 
leading  to  agglutination  of  the  mesentery  and  omentum,  adhesion  of  the  bowels 
and  mesentery,  and  the  formation  of  a  barrier  of  leukocytes  and  a  mass  of  fibro- 
blasts. This  process  circumscribes  the  pus.  If  the  pus  in  suppurative  ap- 
pendicitis has  been  formed  by  colon  bacilli  or  staphylococci,  it  will  probably 
be  circumscribed  and  limited.  If  the  pus  has  been  formed  by  streptococci, 
it  will  probably  not  be  limited,  and  the  peritoneum  will  be  attacked  by  diffuse 
septic  peritonitis.  The  signs  of  appendicular  abscess  are  pain,  tenderness, 
muscular  rigidity,  the  existence  of  a  mass,  which  may  be  palpated  through  the 
abdominal  wall  or  rectum  and  which  is  dull  on  percussion,  vomiting,  sometimes 
constipation,  and  sometimes  diarrhea.  Very  seldom  is  there  skin  edema  and 
fluctuation.  The  patient  lies  upon  his  back,  usually  with  one  or  both  thighs 
flexed.  In  appendicular  abscess  there  is  fever,  usually  higher  at  night  than 
in  the  morning,  profuse  sweating  occurring  during  the  fall.  In  some  cases 
the  temperature  is  peristently  high.  In  some  the  elevation  is  trivial.  In 
some  chills  occur.  A  sudden  fall  of  temperature  with  shock  is  produced  by  rup- 
ture of  the  abscess-wall.  If  this  accident  happens,  general  peritonitis  quickly 
arises.  In  appendicular  abscess  there  is  marked  leukocytosis  unless  the  walls 
are  very  thick  or  unless  the  process  has  diffused  and  general  peritonitis  has 
taken  place,  in  which  conditions  it  may  be  absent.  Appendiceal  abscess  may 
be  assumed  to  exist  when  the  symptoms  of  appendicitis  persist  after  the  fifth 
or  sixth  day,  or  when,  after  the  symptoms  have  subsided,  they  reappear  a  day 
or  two  later  (page  988) . 

Abscess  of  the  liver  may  not  be  announced  by  symptoms  until  rupture. 
It  may  follow  dysentery,  may  be  a  result  of  the  lodgment  of  infected 
clots  from  the  hemorrhoidal  veins,  may  follow  upon  the  infective  phlebitis  of 
appendicitis,  may  result  from  septic  cholangitis  or  suppuration  of  a  hydatid 
cyst.  We  usually  find  fever  of  an  intermittent  type,  profuse  sweats,  pain  in 
the  back,  the  right  shoulder,  or  the  right  h}^)ochondriac  region,  enlargement 
of  the  area  of  liver-dulness,  also  hepatic  tenderness,  and  finally  constitutional 
symptoms  of  the  existence  of  pus.  Sometimes  there  are  fluctuation  and  skin 
edema  over  the  liver,  and  the  general  cutaneous  surface  may  be  a  little  jaun- 
diced. The  symptoms  vary  as  the  pus  invades  adjacent  organs.  When  there 
are  pain  on  respiration  and  evidences  of  diaphragmatic  pleuritis  the  pus  is  prob- 
ably breaking  into  the  pleural  sac.  There  may  or  may  not  be  leukocytosis 
(seepage  1017). 

Deep  Abscess  0}  the  Neck.— T\it  majority  of  these  abscesses  are  due  to 
suppuration  of  lymph  glands,  bacteria  having  reached  the  glands  from  an  ad- 
jacent area  of  infection,  cutaneous,  mucous,  or  osseous.  Suppuration  beneath 
the  deep  fascia  induces  great  pain  and  extensive  swelling  and  often  interfer- 
ence with  respiration.  The  constitutional  evidences  of  suppuration  are  noted. 
Acute  suppuration  under  the  deep  fascia  of  the  submaxillary  region 
causes  extensive  inflammatory  edema,  interference  with  respiration  and 
deglutition,  violent  constitutional  symptoms,  and  often  sloughing  of  tissues 
(see  Ludwig's  "Angina").     A  deep  abscess  over  the  carotid  artery  is  lifted 


Acute  Abscesses  in  Various  Regions  147 

by  each  arterial  beat  and  may  be  mistaken  for  aneurysm,  but  the  pulsation  is 
not  expansible.  The  pus  of  a  deep  cervical  abscess  may  track  its  way  into  the 
mediastinum  or  axilla  or  the  abscess  may  break  into  a  large  blood-vessel,  the 
pharynx,  the  wind-pipe  or  the  gullet. 

Axillary  Abscess. — Superficial  abscesses  are  usually  multiple,  are  in  reality 
furuncles,  and  result  from  infection  of  the  sweat  glands  and  hair  follicles. 

Deep  abscesses  are  in  most  instances  due  to  suppuration  of  the  axillary 
lymph-glands.  The  most  common  cause  is  an  infected  wound  or  a  focus  of 
suppuration  about  the  hand,  forearm,  arm  or  chest.  An  axillary  abscess  may 
result  from  caries  of  a  rib  or  may  follow  a  deep  cervical  abscess.  An  axillary 
abscess  ma}'  be  lifted  at  each  beat  of  the  artery  and  to  this  extent  it  resembles 
an  aneurysm,  but  the  pulsation  is  not  expansile. 

Acute  retropharyngeal  abscess  is  due  to  pyogenic  infection  of  the  retro- 
pharyngeal tissues.  The  abscess  usually  forms  upon  one  of  the  lateral  halves 
of  the  pharynx.  It  may  be  due  to  traumatism,  to  acute  infectious  diseases, 
to  infective  processes  of  the  mucous  membrane  of  the  mouth,  ear,  and  naso- 
pharynx, or  to  pyogenic  infection  of  a  tuberculous  abscess.  In  the  great  ma- 
jority of  cases  the  disease  is  due  to  suppuration  of  the  deep  cervical  glands. 
There  is  pain,  difficulty  in  swallowing,  dyspnea,  nasal  voice,  bulging  into  the 
pharynx,  which  is  detected  by  inspection  and  palpation,  enlargement  of  the 
deep  cervical  glands,  fever,  sweats,  and  great  weakness.  Tuberculous  retro- 
pharyngeal abscess  is  considered  on  page  161. 

Subphrenic  or  subdiaphragmatic  abscess  is  apt  to  begin  beneath  the  diaph- 
ragm, though  in  some  few  instances  the  pus  forms  above  this  muscle,  and 
subsequently  gains  access  to  the  region  beneath.  Such  an  abscess  may  con- 
tain not  only  pus,  but  gas,  and  in  some  cases  also  fluid  from  the  stomach  or 
intestine.  The  gas  of  a  subphrenic  abscess  may  have  entered  from  a  perfora- 
tion of  a  hollow  viscus  or  may  have  been  made  by  gas-forming  bacteria.  Sub- 
phrenic abscess  may  arise  after  perforation  of  the  bowel  or  stomach,  or  it  may 
result  from  Pott's  disease,  perinephric  abscess,  traumatism,  abscess  of  liver, 
kidney,  spleen,  or  pancreas,  empyema  or  pneumonia  (Greig  Smith) .  The  symp- 
toms are  pain,  fever,  sweats,  dyspnea,  cough,  and  the  physical  signs  of  a  collec- 
tion of  fluid  beneath  the  diaphragm  and  often  of  gas  in  the  cavity  of  the  abscess. 
As  in  any  other  abscess  there  may  or  may  not  be  leukocytosis  (page  145)- 

Abscess  of  the  lung  gives  the  physical  signs  of  a  cavity;  the  expectoration  is 
offensive  and  contains  fragments  of  lung-tissue.  An  abscess  may  occasionally 
be  located  by  the  use  of  the  jc-rays.  Pyemic  abscesses  may  exist  and  yet  escape 
discovery.     (See  Surgery  of  Respiratory  Organs.) 

Abscess  of  the  mediastinum  may  arise  secondary  to  deep  abscess  of  the  neck 
or  vertebral  suppuration;  suppuration  of  the  mediastinal  glands,  lung  or  pleura; 
caries  of  a  rib  or  of  the  sternum,  ulceration  of  the  esophagus  or  pericarditis.  It 
causes  throbbing  retrosternal  pain,  pain  in  the  back,  chills,  fever,  sweats, 
irregular  pulse,  and  often  dyspnea.  A  lump  may  appear  which  pulsates  and 
fluctuates,  but  the  pulsation  is  not  expansile. 

Perinephric  abscess  usually  causes  tenderness  and  pain  in  the  lumbar 
region  or  about  the  hip-joint,  which  pain  runs  down  the  thigh  and  is  accom- 
panied by  retraction  of  the  testicle.  Induration,  fluctuation,  or  edema  of  the 
skin  may  be  observed  in  the  limibar  region.  The  constitutional  symptoms  of 
suppuration  usually  e.xist  (page  145). 


148  Suppuration  and  Abscess 

Abscess  or  empyema  oj  the  antrum  of  Highmore  is  a  collection  of  pus  within 
the  maxillary  antrum.  It  results  from  inflammation  of  the  jaws,  the  teeth  or 
the  mucous  membrane  of  the  nose.  It  causes  pain,  edematous  swelling  of  the 
overlying  soft  parts,  and  crepitation  on  pressure  upon  the  superior  maxillary 
bone.  Pus  may  escape  from  the  nostril  of  the  diseased  side  when  the  head 
is  bent  in  the  direction  of  the  healthy  side.  A  rhinoscopic  examination  dis- 
closes the  liuid  passing  into  the  nares.  The  antrum  on  the  side  of  the  abscess 
cannot  be  transilluminated  by  an  electric  light  in  the  mouth  (Garel's  sign). 
The  constitutional  symptoms  of  suppuration  usually  arise. 

Alveolar  abscess  is  suppurative  dental  periostitis  due  to  diseased  teeth. 
The  simplest  form  is  a  gum-boil,  a  collection  of  pus  between  the  gum  and  the 
bone  "external  to  the  root  of  the  tooth  which  is  the  seat  of  inflammation" 
("Dental  Surgery,"  by  Sewill).  In  more  severe  cases  the  suppuration  begins 
within  the  tooth  socket  and  the  pus  escapes  around  the  neck  of  the  tooth,  a  dis- 
tinct and  local  abscess  may  be  situated  at  the  end  of  the  root,  absorption  of 
bone  having  occurred,  or  a  considerable  cavity  may  form  in  the  bone,  the  ex- 
ternal maxillary  plate  being  perforated.  In  the  very  severe  cases  the  cheek  is 
involved.  An  alveolar  abscess  may  break  through  the  gum  into  the  mouth  or 
it  may  break  externally  through  the  cheek.  Alveolar  abscess  causes  intense 
pulsatile  pain,  marked  swelling  of  the  gum  and  cheek,  and  sometimes  very 
great  edematous  and  dusky  sweUing  of  the  face.  A  sinus  may  follow  its 
evacuation.     Dead  bone  may  form. 

Abscess  of  the  larynx  invariably  causes  laryngeal  edema  which  obstructs 
respiration  and  puts  life  in  jeopardy.  Such  an  abscess  is  most  apt  to  appear 
upon  the  oral  surface  of  the  epiglottis  but  may  arise  within  the  larynx.  It  in- 
duces violent  cough,  pain,  interference  with  the  voice,  swallowing,  and 
breathing,  and  the  swelling  can  often  be  felt  with  a  finger  and  can  always  be 
seen  by  the  aid  of  a  laryngoscope. 

An  ischiorectal  abscess  is  situated  in  the  areolar  tissue  of  the  ischiorectal 
fossa.  The  pyogenic  organisms  usually  gain  entrance  to  the  lymphatics  by 
way  of  an  abrasion,  fissure,  or  ulceration  of  the  rectum  or  anus.  A  perfora- 
tion made  by  a  foreign  body  may  inaugurate  the  condition.  In  rare  cases 
bacteria  reach  the  fossa  in  the  blood-stream.  The  pain  is  severe  and  throbbing ; 
there  are  great  tenderness,  redness  and  edema  of  skin,  induration,  and  usually 
the  constitutional  symptoms  of  pus-formation.  Fluctuation  is  a  very  late 
sign  because  of  the  density  of  the  fascia. 

Prostatic  abscess  may  result  from  catheter  infection,  from  infection  of  the 
bladder  or  urethra,  or  from  traumatism,  but  the  commonest  cause  is  gonorrhea. 
There  may  be  one  abscess,  several  abscesses,  or  multiple  abscesses.  Pus  may 
break  into  the  rectum,  the  bladder,  or  the  urethra  or  may  break  externally. 
A  prostatic  abscess  is  manifested  by  chills,  fever,  sweats,  frequency  of  mic- 
turition, tenderness  of  the  perineum  and  rectum,  and  agonizing  pain,  develop- 
ing during  an  attack  of  acute  prostitis.  A  finger  in  the  rectum  can  palpate 
the  swollen  gland. 

Abscess  of  the  breast  follows  absorption  of  pyogenic  bacteria  from  a 
fissure  or  abrasion  of  the  nipple.  Some  surgeons  maintain  that  the  bacteria 
enter  along  the  milk-ducts,  while  others  assert  that  they  gain  entrance  by  the 
lymphatics.  It  is  most  common  in  nursing  women.  Its  symptoms  are 
swelling,  tenderness,  pulsatile  pain,  dusky  discoloration,  skin  edema,  fluctua- 
tion, and  usually  constitutional  disorder.     (See  Mastitis.) 


Diagnosis  of  Abscess  149 

Orbital  abscess  is  a  diffuse  suppuration  due  to  cellulitis  or  a  collection  of 
pus  due  to  caries  or  necrosis  of  the  orbital  wall,  suppuration  of  the  accessory 
nasal  sinus,  facial  erysipelas,  or  dental  caries.  In  severe  orbital  cellulitis 
the  movements  of  the  eye  are  limited,  the  lids  are  very  red  and  edematous, 
the  conjunctiva  is  red  and  swollen  (chemosis),  and,  if  the  case  is  not  promptly 
relieved,  optic  neuritis  may  arise  and  sloughing  of  the  cornea  occur. 

Von  Bezold's  Abscess. — In  this  condition  the  pus  of  a  suppurating  mastoid 
process  breaks  through  the  mastoid  near  the  tip  and  enters  into  the  sheath  of 
the  digastric  muscle  or  the  sheath  of  the  sternocleidomastoid.  There  exist  ex- 
tensive inflammatory  sweUing  of  the  neck,  a  history  of  mastoid  trouble,  usually 
a  lessened  amount  of  pus  from  the  ear,  pain  in  the  neck  and  constitutional 
symptoms.  The  condition  suggests  thrombosis  of  the  lateral  sinus,  but  the 
symptoms  are  not  so  violent  and  are  not  pyemic  as  they  are  in  that  disease. 

Abscess  of  the  Groin  or  Pyogenic  Bubo. — Such  an  abscess  may  have  mounted 
up  from  the  pelvis,  tracked  forward  from  the  sacro-iHac  joint,  or  descended  in 
the  psoas  sheath  from  the  vertebra?,  but  in  a  very  great  majority  of  cases  it  is 
due  to  suppuration  of  the  lymphatic  glands.  A  bubo  may  be  tuberculous, 
venereal  or  pyogenic.  A  pyogenic  bubo  results  from  an  area  of  infection  in 
the  trajectory  drained  by  the  lymph-vessels  of  the  inguinal  or  femoral  glands. 
The  glands  involved  may  be  superficial  or  deep.  The  symptoms  are  those 
ordinarily  linked  with  suppuration.  Occasionally  the  pulsations  of  the  great 
vessels  may  lift  the  mass. 

Abscess  of  the  Popliteal  Space.— This  results  from  traumatism,  mixed  in- 
fection of  a  tuberculous  or  syphilitic  area,  suppuration  of  the  contained  lymph- 
glands  of  one  of  the  adjacent  bursas  or  of  the  neighboring  bone.  In  rare 
cases  it  arises  as  a  result  of  suppuration  of  the  sac  of  an  aneurysm.  The 
symptoms  are  severe  pain,  swelling,  flexion  of  the  knee,  arid  edema  of  the  leg. 
The  pulsations  of  the  popliteal  artery  may  be  transmitted  to  the  abscess. 
These  pulsations  are  not  expansile,  as  in  aneurysm.  Pus  may  pass  under 
the  deep  fascia  up  or  down  the  extremity,  or  may  break  into  the  knee-joint. 

Suppurative  thecitis  or  felon  is  a  form  of  diffuse  suppuration.     (See  Felon.) 

Palmar  abscess  is  a  purulent  effusion  (page  735). 

Furuncle  and  carbuncle  are  discussed  on  pages  1222  and  1223. 

Empyema  is  a  purulent  effusion  into  the  pleural  sac  (page  890).  It  is 
technically  an  abscess  if  it  becomes  encapsuled. 

Diagnosis. — The  diagnosis  of  an  abscess  rests  upon — (i)  its  history;  (2) 
fluctuation;  (3)  pointing;  (4)  surface  edema;  (5)  the  use  of  the  tubular  ex- 
ploring needle;  and  (6)  leukocytosis. 

Fluctuation  is  the  sensation  imparted  to  a  finger  held  against  a  sac  con- 
taining fluid  when  a  wave  is  started  in  the  fluid  by  striking  the  mass  with  a 
finger  of  the  other  hand.  Fluctuation  cannot  be  obtained  if  the  amount  of 
fluid  is  small.  It  should  never  be  sought  for  across  a  limb,  but  rather  along  it, 
because  a  false  sense  of  fluctuation  can  always  be  obtained  across  the  muscles 
of  the  limb.     Pointing  and  surface  edema  have  been  discussed. 

A  suspected  abscess  in  a  part  containing  large  blood-vessels  under  no  cir- 
cumstance should  be  opened  by  a  bistoury  without  knowing  that  the  diagnosis 
is  certainly  correct.  This  knowledge  is  obtained  in  some  cases  by  inserting 
a  small  aspirating  needle  and  observing  the  nature  of  the  fluid  which  exudes. 
This  operation  must  be  performed  with  aseptic  care;   otherwise,  if  there  is  no 


i^o 


Suppuration  and  Abscess 


abscess,  infection  may  be  inaugurated;  if  there  is  an  abscess,  mixed  infection 
may  occur.  The  older  operators  used  a  grooved  exploring  needle,  l)Ut  many 
able  surgeons  object  to  its  use  on  the  ground  that  when  plunged  into  an  in- 
fected area,  pus  bathes  the  track  of  penetration  and  may  cause  infection  of 
other  tissues  and  diffusion  of  the  pyogenic  process.  The  tubular  exploring 
needle  is  the  proper  instrument. 

An  abscess  which  moves  with  the  pulse  because  it  rests  upon  an  artery 
may  be  confounded  with  an  aneurysm.  The  pulse  movements  of  such  an 
abscess  are  in  one  direction  only;  the  abscess  is  lifted  with  each  pulse-beat; 
but  does  not  enlarge,  and  if  a  finger  is  laid  upon  either  side  of  it  the  fingers 
will  be  lifted,  but  not  separated.  The  pulse  movements  of  an  aneurysm  are 
in  all  directions;  they  are  expansile,  the  tumor  grows  larger,  and  the  fingers 
will  not  only  be  lifted,  but  will  also  be  separated.  The  small  tubular  exploring 
needle  may  be  used  in  doubtful  cases;  if  aseptic,  it  will  do  no  harm  even  to  an 
aneurysm.  A  rapidly  growing,  small-cell  sarcoma  feels  not  unlike  an  abscess, 
but  the  exploring  needle  discovers  blood,  and  not  pus.     A  cystic  tumor  is 


Fig.   74.— Vischer's  case  for  carrying  culture-tubes  for  inoculation. 


separated  from  an  abscess  by  the  absence  of  inflammation,  or,  if  it  inflames, 
by  the  nature  of  the  contained  fluid.  Ordinary  caution  will  prevent  one  con- 
founding an  abscess  with  strangulated  hernia.  A  tuberculous  abscess  is  sepa- 
rated from  an  acute  abscess  by  the  absence  of  inflammatory  signs  in  the 
former.  The  contents  of  the  acute  abscess  differ  from  those  of  the  tuberculous 
abscess.  "When  an  abscess  exists  in  an  important  region  (brain,  appendix, 
liver,  etc.),  cultures  of  the  pus  should  be  taken  after  incision.  Such  studies 
often  give  valuable  information  as  to  the  probable  course  of  the  condition, 
and  an  accumulation  of  many  accurate  observations  will  add  greatly  to 
scientific  information.  Fig.  74  shows  a  convenient  case  for  carrying  cul- 
ture-tubes. 

Prognosis. — The  prognosis  varies  according  to  the  number  of  abscesses, 
their  location  and  size,  the  strength  of  the  patient,  and  the  virulence  of  the 
causative  bacteria. 

Treatment. — In  the  treatment  of  an  abscess  there  is  one  absolute  rule 
which  knows  no  exception,  namely,  that  whenever  and  wherever  pus  is  found 


Treatment  of  Abscess  151 

the  abscess  should  be  evacuated  at  once,  and,  after  evacuating;  it,  thorough 
drainage  must  be  provided  for.  It  sliould  Ije  opened  early,  if  possible  even 
before  fluctuation  and  positively  before  pointing,  to  prevent  tissue  destruc- 
tion, sub-fascial  burrowing,  and  general  contamination.  Drainage  is  continued 
until  the  discharge  becomes  scanty,  thin,  and  scropurulent. 

Alveolar  abscess  recjuires  prompt  incision  through  the  gum,  extraction  of 
the  diseased  tooth  in  most  cases,  and  the  rinsing  of  the  mouth  at  frequent 
intervals  with  hot  fluid.  Heat  should  not  be  applied  externally,  as  it  would 
favor  external  ruptvire.  If  spontaneous  rupture  externally  is  inevitable,  then 
an  incision  must  he  made  at  the  point  where  the  abscess  is  nearest  the  sur- 
face. The  cut  will  leave  less  scar  than  will  spontaneous  evacuation.  It  is 
sometimes  necessary  to  gouge  a  line  through  the  external  table  of  the  bone, 
pus  being  lodged  within  the  two  osseous  plates. 

Abscess  0}  the  liver,  if  the  liver  is  adherent  to  the  parietal  peritoneum,  is 
opened  at  one  operation;  if  the  liver  is  not  adherent,  the  abscess  is  often 
operated  upon  in  two  stages.  In  the  two-stage  operation  an  incision  is 
made  along  the  edge  of  the  ribs  down  to  the  liver,  which  organ  is  then  stitched 
to  the  edges  of  the  wound.  In  a  day  or  two  after  the  first  operation  the  two 
layers  of  peritoneum  are  firmly  adherent  and  the  abscess  can  be  opened  with- 
out danger  of  the  passage  of  pus  into  the  peritoneal  cavity.  The  abscess, 
located  by  an  aspirating  needle,  is  opened  by  the  Paquelin  cautery,  is  washed 
out  with  salt  solution,  and  a  tube  is  inserted.  If  care  is  taken  the  operation 
can  be  safely  completed  in  one  seance  even  if  the  liver  is  not  adherent  to 
the  parietal  peritoneum.  If  this  course  is  determined  on,  after  the 
liver  is  exposed  by  incision,  the  exposed  surface  of  the  organ  is  surrounded 
with  iodoform  gauze,  the>abscess  is  located  by  an  aspirating  needle,  is  opened 
by  the  cautery,  is  irrigated  and  drained  as  directed  above.  Some  physicians 
try  to  locate  an  abscess  by  plunging  an  aspirating  needle  into  the  liver  before 
making  an  incision.     This  procedure  seems  to  me  uncertain  and  dangerous. 

Abscess  of  the  dome  of  the  liver  may  be  reached  by  resecting  a  rib,  in- 
cising the  pleura,  and  opening  through  the  diaphragm  (transthoracic  hep- 
atotomy) . 

Abscess  of  the  mediastinum,  like  all  other  abscesses,  requires  incision  and 
drainage.  This  is  effected,  if  the  abscess  can  be  reached  from  in  front,  by 
cutting  between  the  rib  cartilages  or  by  trephining  the  sternum.  Abscess  of  the 
posterior  mediastinum  can  be  reached  only  by  resecting  portions  of  several  ribs 
near  their  vertebral  ends. 

In  abscess  of  the  lung  an  incision  is  made  and  the  pleura  is  exposed.  The 
incision  is  usually  through  an  intercostal  space;  but  if  the  spaces  are  narrow, 
it  will  be  necessary  to  resect  a  rib.  If  the  two  layers  of  pleura  are  found 
adherent,  the  operation  is  proceeded  with.  If  they  are  not  adherent,  they  are 
stitched  together  with  catgut  sutures,  and  the  surgeon  waits  forty-eight  hours 
before  continuing.  This  precaution  is  taken  in  order  to  prevent  collapse 
of  the  lung  from  acute  traumatic  pneumothorax,  during  operation.  The 
operation  is  completed  by  locating  the  pus  by  means  of  an  aspirating  needle, 
evacuating  it  by  the  cautery  at  a  dull-red  heat,  and  inserting  a  drainage-tube 
into  the  abscess-cavity. 

A  subphrenic  abscess  requires  operation  at  once.  Immediately  before  oper- 
ating, if  in  doubt,  it  may  be  justifiable  to  endeavor  to  locate  pus  with  an  aspi- 


152  Suppuration  and  Abscess 

rating  needle.  Incise  the  abscess  and  open  any  secondary  abscesses.  Many 
cases  point  below  the  diaphragm  and  are  easily  reached  by  an  incision  in  the 
loin  or  in  the  epigastric  region.  Lannelonge  resects  the  eleventh  and 
twelfth  ribs  and  raises  the  pleura  out  of  the  way.  Some  surgeons  prefer  to 
practice  rib  resection  and  incise  the  adherent  pleural  layers  and  the  diaph- 
ragm. After  drainage  has  been  continued  for  a  time  it  may  be  neces- 
sary to  do  a  secondary  operation  in  order  to  cure  the  lesion  causative  of  the 
abscess,  for  instance,  it  may  be  necessary  to  close  a  gastric  perforation. 

In  abscess  0}  the  antrum  0}  Highmore  bore  a  gimlet-hole  through  the  supe- 
rior maxillary  bone,  above  the  canine  tooth,  or  perforate  the  bone  by  means  of 
a  trocar.  Irrigate  daily  with  boiled  water  or  normal  salt  solution.  Keep 
the  opening  from  contracting  by  inserting  a  small  tent  of  iodoform  gauze.  In 
persistent  cases  it  may  be  necessary  to  draw  a  tooth,  break  through  the  socket 
of  the  first  or  second  bicuspid  into  the  antrum,  and  insert  a  silver  or  hard- 
rubber  tube,  and  also  to  perforate  the  antrum  from  the  inferior  meatus  and 
keep  the  opening  patent.  In  very  persistent  cases  osteoplastic  resection  of  a 
portion  of  the  upper  jaw  will  be  demanded. 

In  appendicular  abscess  incise,  support  the  abscess-walls  with  gauze, 
remove  the  appendix  in  most  cases,  but  not  in  all,  and  insert  a  drainage-tube 
and  strands  of  gauze  (page  1000). 

An  ischiorectal  abscess  must  be  opened  early.  The  surgeon  never  waits 
for  fluctuation.  Fluctuation  is  a  very  late  symptom.  To  wait  for  it  entails 
great  destruction  of  tissue  and  serves  no  useful  purpose.  Place  the  patient 
on  his  side,  with  the  legs  drawn  up.  Insert  a  linger  in  the  rectum,  lift  the 
abscess  toward  the  surface,  and  incise  it  from  the  surface.  The  incision  runs 
from  the  anal  margin  hke  a  spoke  from  the  hub  of  a  wheel.  Irrigate  with 
salt  solutivin,  inject  iodoform  emulsion,  insert  a  drainage-tube,  dress,  and  let 
the  patient  know  he  is  in  danger  of  developing  a  fistula. 

A  retropharyngeal  abscess  must  be  opened  early  because  delay  may 
lead  to  fatal  obstruction  and  because  if  spontaneous  evacuation  occurs  the 
patient  may  be  suffocated.  Some  surgeons  open  it  from  within  the  mouth, 
but  this  exposes  the  patient  to  the  danger  of  septic  bronchopneumonia  from 
inhalation  of  purulent  elements  and  to  serious  gastro-intestinal  disorder  from 
swallowing  quantities  of  pus.  Again,  if  opened  through  the  mouth,  the 
abscess  is  liable  to  become  putrid.  It  is  better  to  open  it  from  the  neck 
by  Hilton's  method,  the  incision  being  carried  through  the  sternocleidomas- 
toid muscle  or  posterior  to  it.  Drainage  is  inserted  and  the  abscess  treated 
in  the  usual  way. 

In  abscess  of  the  breast  make  an  incision  radiating  from  the  nipple,  or,  what 
is  better,  incise  under  the  breast  by  means  of  a  cut  at  the  inferior  thoracic 
mammary  junction,  and  enter  the  abscess  from  beneath. 

In  abscess  of  the  brain  the  skull  should  be  trephined,  the  membranes  incised, 
and  the  abscess  sought  for,  opened,  and  drained  (page  821). 

In  suppuration  within  the  orbit  due  to  celluhtis,  incise  from  the  conjunctiva 
and  drain.  In  suppuration  due  to  caries  or  necrosis  of  the  upper  orbital  wall 
make  a  transverse  incision  through  the  upper  lid,  reach  the  pus  by  Hilton's 
method  (page  154),  remove  carious  or  loose  necrotic  bone,  and  drain. 

A  perinephric  abscess  requires  an  incision  in  the  lumbar  region  and  free 
drainage. 


Treatment  of  Abscess  153 

An  abscess  of  the  larynx  requires  immediate  scarification  and  inhalation 
of  steam  to  abate  swelling.  In  a  severe  case  the  surgeon  should  at  once  per- 
form tracheotomy. 

Bezold^s  abscess  requires  one  or  more  incisions  in  the  neck  for  drainage. 
Then  the  mastoid  is  exposed,  its  tip,  including  the  osseous  fistula,  is  removed, 
and  its  interior  is  cleared  out  by  a  complete  operation. 

A  prostatic  abscess  should  be  opened  promptly  by  a  perineal  incision. 

In  an  ordinary  superficial  abscess,  after  cleansing  the  parts,  make  the  skin 
tense,  locate  the  superficial  vessels  and  nerves,  and  plan  the  incision  to  avoid 
them.  Incise  with  a  sharp-pointed  curved  bistoury  at  the  most  dependent 
part  of  the  abscess  or  through  the  region  of  pointing.  If  the  abscess  is  upon 
the  face  or  neck,  make  the  incision  in  the  line  of  the  skin  creases  so  as  to  limit 
the  scar.  The  incision  must  not  be  made  suddenly  and  fiercely,  neither  should 
it  be  made  with  hesitation  and  uncertainty.  As  Bryant  says:  "It  should  be 
done,  as  ought  every  other  act  of  surgery,  with  confidence  and  decision,  bold- 
ness and  rapidity  of  action  being  governed  by  caution  and  made  subservient 
to  safety"  (Bryant's  "Practice  of  Surgery").  Permit  the  pus  to  run  out  spon- 
taneously; pressure,  as  a  rule,  is  undesirable  because  it  may  damage  the  ab- 
scess-wall and  cause  diffusion  of  the  infection.  If  tissue  shreds  block 
the  opening,  they  must  be  picked  out  with  forceps.  If  the  atmospheric 
pressure  will  not  cause  the  pus  to  flow  out,  make  light  pressure  with  warm, 
moist,  aseptic  gauze  pads.  After  the  pus  has  come  away  gently  wash  the  cav- 
ity with  normal  salt  solution  or  boiled  water,  and  drain  with  a  tube  for  two  or 
three  days,  when  the  discharge  becomes  serous.  It  is  not  desirable  to  overdis- 
tend  the  abscess-cavity  with  fluid,  because  the  hydrostatic  pressure  might  break 
down  the  wall  of  young  cells  and  infection  be  diffused.  Do  not  irrigate  with 
powerful  disinfectants.  They  cannot  be  used  strong  enough  to  really  disin- 
fect, but  may  easily  be  used  strong  enough  to  cause  necrosis  of  an  abscess- 
wall.  Peroxid  of  hydrogen  is  not  to  be  used  unless  the  incision  is  large, 
because  the  gas  it  generates  may  tear  the  abscess-wall  and  diffuse  the  infection. 
Peroxid  of  hydrogen  is  a  dangerous  agent  to  inject  into  the  cavity  of  a  deep 
abscess  of  the  neck,  as  the  liberated  gas  may  not  escape  from  the  opening,  but 
may  pass  widely  into  the  tissues  and  cause  great  distention.  The  author  saw 
a  child  who  narrowly  escaped  death  after  such  an  injection.  In  this  patient 
the  gas  passed  beneath  the  pharyngeal  mucous  membrane  and  the  swelling 
almost  occluded  the  air-passages.  If  an  abscess  contains  putrid  pus  the  in- 
cision should  be  free  and  after  evacuation  it  should  be  irrigated  with  hot  salt 
solution  or  peroxid  of  hydrogen  and  injected  with  iodoform  emulsion.  Pursue 
rigid  antisepsis  in  dealing  with  purulent  areas.  It  is  true  we  already  have  infec- 
tion with  pyogenic  bacteria,  but  infection  can  also  take  place  with  organ- 
isms of  putrefaction,  causing  pus  to  become  putrid,  or  with  other  bacteria, 
for  instance  those  of  tetanus.  If  a  tube  is  not  used  and  the  cavity  is  packed 
with  iodoform  gauze,  remember  that  gauze  will  not  drain  pus  and  requires 
to  be  changed  once  a  day  or  oftener.  An  abscess  should  be  dressed  with 
hot,  moist  antiseptic  dressings  (antiseptic  fomentation)  and  the  part  must 
be  put  at  rest.  When  the  discharge  becomes  thin  and  scanty,  dry  aseptic  or 
antiseptic  dressings  are  used. 

In  a  deep  abscess  or  an  abscess  situated  near  important  vessels,  do  not 
boldly  plunge  in  a  knife.     Hilton  says  to  "plunge  in  a  knife  is  not  courageous, 


154 


Suppuration  and  Abscess 


as  it  is  without  danger  to  the  surgeon,  but  may  be  fatal  to  the  patient."  Re- 
member also  that  a  large  amount  of  pus  displaces  normal  anatomical  relations. 
Hilton's  method  of  opening  a  deep  abscess  (as  in  the  axilla  or  neck)  is  to  cut 
to  the  deep  fascia,  nick  the  fascia  with  a  knife,  and  then  push  into  the  abscess 
a  grooved  director  until  pus  shows  in  the  groove;  along  the  groove  push  a  pair 
of  closed  dressing  forceps;  after  they  reach  the  depths  take  out  the  director, 
open  the  forceps,  and  withdraw  them  while  open,  and  so  dilate  the  opening; 
then  insert  a  tube  and  gently  irrigate  with  warm  salt  solution. 

Always  endeavor  to  open  an  abscess  at  its  most  dependent  part,  remem- 
bering that  the  situation  of  this  part  may  depend  upon  whether  the  patient  is  to 
be  erect  or  recumbent.  If  we  do  not  make  the  opening  at  the  lowest  point,  all 
the  pus  will  not  run  out  and  the  walls  will  not  completely  collapse.  A  deep 
abscess  must  be  drained  thoroughly  until  the  discharge  becomes  seropurulent. 
When  the  tube  is  removed  it  is  wise  to  insert  a  tent  of  iodoform  gauze  just 
through  the  outlet  of  the  abscess.  This  tent  prevents  the  skin  from  closing 
over  the  channel.  It  is  removed  and  a  new  one  inserted  every  day  until  it  is 
clear  that  there  is  no  longer  danger  of  fluid  becoming  blocked  and  retained. 
When  an  abscess  contains  diverticula  or  pouches  they  should  be  slit  up  or  a 
counter-opening  ought  to  be  made.     A  counter-opening  is  made  by  entering 

the  dressing  forceps  at  the  first  in- 
cision, pushing  them  through  the 
abscess  to  the  point  where  we  wish 
to  make  our  counter-opening, 
opening  the  blades,  and  cutting 
between  them  from  without  in- 
ward. The  blades  are  then  closed 
and  projected  through  the  incision; 
they  are  opened  in  order  to  dilate 
the  new  door,  and  are  closed  again 
upon  a  drainage-tube,  which  is  pulled  through  from  opening  to  opening 
as  the  instrument  is  withdrawn.  When  pus  burrows,  insert  a  grooved 
director  in  each  channel  and  slit  the  sinus  with  a  knife.  An  abscess  may 
make  an  opening  through  dense  fascia,  the  opening  being  small  like  the 
neck  of  an  hour-glass  (shirtrstud  abscess).  Always  examine  to  see  if  such 
a  condition  exists,  and  if  it  is  found,  incise  the  fascia. 

In  a  deep  abscess  containing  putrid  pus,  frequent  irrigation  is  desirable. 
In  such  a  case  two  tubes  may  be  employed  (Fig.  75).  The  tubes  are  pre- 
vented from  slipping  in  by  the  use  of  a  safety-pin  (a).  The  irrigating  fluid  is 
passed  into  the  cavity  (d)  through  the  tube  b,  which  is  without  fenestra,  and  it 
runs  out  through  the  tube  c,  which  possesses  fenestra. 

Rest  is  of  the  first  importance  in  the  healing  of  an  abscess,  and  we  try  to 
obtain  it  by  bandages,  splints,  and  pressure,  which  will  immobilize  adjacent 
muscles  and  approximate  the  abscess-walls.  If  an  abscess  is  slow  to  heal,  use 
as  a  daily  injection  a  solution  of  corrosive  sublimate  of  the  strength  of  i  :  1000, 
or  three  drops  of  nitric  acid  to  §  j  of  water,  or  3  grains  of  zinc  sulphate  to  §  j 
of  water,  or  a  5  per  cent,  solution  of  carboHc  acid,  or  a  2  per  cent,  aqueous 
solution  of  pyoktanin,  or  20  drops  of  tincture  of  iodin  to  §  j  of  water,  or  a  very 
dilute  solution  of  bichlorid  of  palladium.  The  constitutional  treatment  of  an 
abscess  depends  upon  the  severity  of  the  morbid  process  and  the  importance 


Fig. 


"5- — Drainage-tubes  for  abscess  requiring   irri- 
gation. 


Tuberculous  Abscess  155 

of  the  structures  involved.  In  a  serious  case  the  patient  should  be  put  to 
bed,  opiates  should  be  given  with  a  free  hand,  the  bowels  be  kept  active  by 
calomel  and  salines,  skin  activity  be  maintained,  the  taking  of  nutritious  food 
insisted  on,  and  stimulants  liberally  employed. 

Purulent  Effusions. — (See  Suppurative  Thecitis,  Palmar  Abscess,  Sup- 
purative Synovitis,  Purulent  Peritonitis,  Empyema,  etc.) 

Tuberculous  Abscess.— The  tuberculous  abscess  is  called,  also,  the 
cold,  the  lymphatic,  the  congestive,  the  scrofulous,  the  strumous,  the  wan- 
dering, or  the  migrating  abscess;  and  it  is  very  commonly  called  the  chronic 
abscess.  The  Germans  call  it  Senkungsabscess.  Tuberculous  abscess  is  the 
best  designation,  as  this  indicates  the  cause  of  the  trouble. 

The  term  cold  abscess  is  often  used,  because  the  cutaneous  surface  over  the 
disease  is  not  warmer  to  the  touch  than  is  the  skin  of  the  corresponding  part  of  the 
opposite  side  of  the  body.  The  term  lymphatic  abscess  was  employed  because 
it  was  once  thought  that  such  abscesses  arose  only  from  lymphatic  structures. 
Scrofulous  abscess  was  the  name  given  it  when  scrofula  was  supposed  to  be  a 
definite  disease,  the  common  phase  of  which  was  this  form  of  abscess.  The 
term  chronic  abscess  is  employed  because  the  condition  usually  develops 
slowly,  and  does  not  present  the  evidences  of  acute  inflammation;  an  acute 
pyogenic  abscess  developing,  as  a  rule,  rapidly,  and  presenting  positive  signs 
of  inflammation.  I  agree  with  the  late  Professor  Ashhurst  that  the  term 
chronic,  in  this  connection,  is  improper;  as  it  tends  to  give  a  wrong  idea.  It 
refers  merely  to  time;  and  we  know  that  an  acute  pyogenic  abscess  that  is 
deep-seated  may  be  rather  slow  in  developing,  and  that  a  tuberculous  abscess 
that  is  superficial  may  develop  with  considerable  rapidity.  When  used  prop- 
erly, the  term  chronic  abscess  means  that  genuine  pus  exists,  this  pus  having 
arisen  from  the  pyogenic  infection  of  the  granulation-tissue  of  a  lesion  of  syph- 
ilis, tuberculosis,  or  actinomycosis.  In  other  words,  a  genuine  chronic  abscess 
is  secondary  pyogenic  infection  of  an  infective  granuloma.  The  terms  wan- 
dering, migrating,  gravitating,  and  congestive  have  been  used  because  the 
fluid  products  of  a  tuberculous  inflammation  are  liable  to  wander  a  consider- 
able distance  awaj^  from  the  primary  focus  of  disease.  For  instance,  a  tuber- 
culous abscess  that  is  discovered  in  the  groin  may  have  arisen  from  tuberculous 
caries  of  the  vertebrae.  This  tendency  to  wander  is  not  due  to  gravity,  as  one 
of  the  names  of  the  condition  would  suggest;  but  the  wandering  always  takes 
place  in  the  line  of  least  resistance. 

It  will  be  seen  from  the  foregoing  that  a  true  tuberculous  abscess  is  not  an 
abscess  at  all,  because  it  does  not  contain  genuine  pus.  It  is  a  collection  of  the 
degenerated  products  of  tuberculous  inflammation;  and  a  tuberculous  abscess 
may  be  defined  as  a  circumscribed  cavity  of  new  formation,  containing  the  de- 
generated products  of  a  tuberculous  inflammation.  These  products  may  have 
been  formed  in  that  region  or  may  have  passed  to  that  point  from  some  adja- 
cent or  distant  focus  of  tuberculous  disease.  If  a  supposed  tuberculous  abscess 
is  found  to  contain  genuine  pus,  there  must  have  been  mixed  infection  with 
pyogenic  bacteria;  and  such  mixed  infection  either  causes  violent  and  danger- 
ous inflammation  or  leads  to  the  formation  of  a  true  chronic  abscess,  in  which 
there  is  no  sign  of  acute  inflammation.  The  tubercle  bacillus  is  not  pyogenic. 
It  can  produce  inflammation,  but  not  pus,  and  pus  can  be  formed  in  a 
tuberculous  focus  only  by  secondary  infection  with  pus  bacteria. 


156  Suppuration  and  Abscess 

Situations  of  Tuberculous  Abscesses. — These  abscesses  are  particularly 
apt  to  form  as  the  result  of  tuberculous  disease  of  bones,  joints,  lymph-glands, 
and  subcutaneous  connective  tissue;  but  the  brain,  any  viscus,  or  any  tissue  in 
the  body  may  present  the  condition. 

Age. — No  age  is  exempt,  but  children  are  most  prone  to  the  trouble;  and 
the  period  of  greatest  liability  is  before  the  age  of  twenty  years. 

Contents. — The  usual  term  for  the  contents  is  scrofulous,  curdy,  or  caseous 
pus.  As  I  said,  it  is  not  trus  pus;  but  it  resembles  pus  when  viewed 
with  the  naked  eye.  Examination  of  this  fluid  by  staining  methods,  by  cul- 
tures, and  by  inoculations  shows  that  it  contains  no  pyogenic  bacteria.  It 
consists  of  liquefied  and  caseated  tubercle;  masses  of  coagulated  fibrin;  and 
bits  of  necrotic  tissue.  The  tuberculous  material  is  whitish,  yellowish,  or 
yellowish-green;  thick;  and  without  odor.  Floating  in  this  pus  are  portions 
of  caseous  matter,  which,  as  the  elder  Gross  said,  resemble  bits  of  soft  boiled 
rice.  Occasionally  the  tuberculous  material,  especially  if  it  comes  from  disease 
of  a  lymph-gland  or  of  a  bone,  is  almost  watery  and  nearly  colorless,  and  con- 
tains curd-like  masses,  consisting  of  tuberculous  granulations,  coagulated  fibrin, 
and  necrotic  tissue.  It  was  previously  stated  that  tuberculous  pus  is  free 
from  odor.  This  is  not  true  of  tuberculous  pus  of  the  ischiorectal  fossa,  which 
is  highly  putrid;  but  in  an  ischiorectal  abscess,  as  a  matter  of  fact,  there  is 
usually  mixed  infection  with  pyogenic  organisms,  as  well  as  with  the  organisms 
of  putrefaction.  If  tuberculous  pus  is  permitted  to  stand,  the  curdy  mass 
settles  to  the  bottom,  and  a  thin  serous  fluid  remains  above. 

Formation  of  Tuberculous  Abscess. — During  their  growth,  the  tubercle 
bacilli  in  the  tissues  cause  a  chronic  inflammation.  The  cells  of  the  tissues, 
especially  the  fixed  cells,  proliferate  and  form  granulation  tissue.  This 
granulation  tissue  consists  of  multitudes  of  cell  clusters,  and  each  cluster  is 
called  a  primitive  tubercle  (page  229).  Each  individual  tubercle  enlarges; 
myriads  of  new  ones  form;  and  many  of  the  old  ones  fuse.  These  new  cells, 
however,  do  not  become  vascularized.  In  the  earliest  stage  of  their  formation, 
there  are  blood-channels;  but  these  become  closed  through  endothelial  prolifer- 
ation and  through  the  pressure  of  cells  external  to  them.  The  tuberculous  area 
then  becomes  absolutely  avascular.  This  avascular  mass  of  cells  is  composed  of 
what  are  known  as  epithelioid  cells,  and  the  cells  obtain  nourishment  by  imbibi- 
tion. The  nourishment  is  very  incomplete.  As  the  nodule  enlarges,  the  nour- 
ishment grows  more  and  more  insufficient.  Finally,  the  adjacent  blood-vessels 
that  furnished  the  fluid  for  imbibition  become  occluded,  and  nourishment  is 
no  longer  possible.  The  toxins  of  the  tubercle  bacilli,  acting  upon  this  area 
of  greatly  lowered  nutritional  activity,  produce  coagulation  necrosis;  and 
caseation  follows  this.  The  caseation  begins  at  many  points  near  the  middle 
of  the  tuberculous  nodule.  Each  area  of  caseation  enlarges.  Several  of  them 
fuse,  and  eventually  many  caseated  areas  coalesce.  The  tuberculous  lesion  may 
be  spreading  at  the  periphery  at  the  same  time  that  it  is  undergoing  caseation 
at  the  center.  The  bacilli  in  the  caseated  material  soon  die  for  want  of  nourish- 
ment. When  an  area  of  caseated  tubercle  is  liquefied  by  the  addition  of  serum, 
what  we  call  caseous  or  curdy  pus  is  produced;  and  the  lesion  is  then  known  as 
a  tuberculous  abscess. 

The  Wall  of  the  Abscess. — The  wall  of  the  abscess  is  formed  by  com- 
pressed or  solidified  tissues.     In  a  very  recent  case  the  wall  is  soft  and  will  readily 


Tuberculous  Abscess  157 

collapse.  In  an  old  case  it  is  dense  or  actually  fibrous  and  will  not  collapse. 
This  wall  of  compressed  tissue  is  not,  as  used  to  be  thought,  a  pyogenic  mem- 
brane, which  secretes  the  tuberculous  material;  but  it  actually  surrounds  the 
tuberculous  material  and  hinders  its  diffusion.  As  Roswell  Park  says,  it  is  not 
a  pyogenic  membrane,  but  it  is  a  prophylactic  membrane.  The  inner  surface  of 
the  wall  of  the  compressed  tissue  is  lined  with  tuberculous  granulations,  which 
at  different  points  show  different  stages  of  the  tuberculous  lesion.  This  layer 
of  tuberculous  granulations  is  known  as  Volkmann's  membrane.  The  fluid 
in  the  abscess  may  contain  a  few  living  bacteria,  but  often  none  can  be  found; 
and  certainly  the  bacteria  are  not  multiplying  in  this  fluid,  but  they  do  multiply 
in  Volkmann's  membrane.  When  tuberculous  matter  has  been  long  retained 
and  thoroughly  encapsulated  the  bacilli  soon  die  for  want  of  nourishment, 
and,  because  a  culture  from  a  supposed  tuberculous  area  fails  to  show  the 
bacilli  of  tuberculosis,  we  have  not  obtained  conclusive  evidence  that  the 
area  is  not  tuberculous.  We  know  this  same  fact  to  be  true  of  the  fluid  of 
tuberculous  empyema. 

From  the  abscess-wall  there  may  be  one,  two,  several,  or  many  sinuses 
tracking  out.  These  sinuses  are  lines  with  granulation  tissue  exactly  like 
the  Volkmann's  membrane  in  the  main  abscess;  and  they  may  spread  by  a 
sort  of  crawling  progression  for  long  distances,  perhaps  passing  through  dense 
fascia,  and  at  their  terminations  form  secondary  tuberculous  abscesses.  The 
wall  of  an  abscess  may  contain  expansions  or  loculi.  If  an  abscess  spreads 
to  some  distant  place,  the  tuberculous  infection,  of  course,  goes  with  it;  and  it 
is  the  tuberculous  infection  that  causes  the  spread.  The  wandering  of  a 
tuberculous  abscess  is  in  the  line  of  least  resistance  and  is  not  the  result  of 
gravity.  Injury,  breaking,  or  contusion  of  this  granulation  tissue,  if  unac- 
companied with  the  removal  of  all  the  tissue  or  the  killing  of  all  the  germs 
it  contains,  may  diffuse  the  pus  and  actually  cause  disseminated  tuberculosis. 
We  sometimes  see  such  dissemination  after  spontaneous  opening,  non-aseptic 
operation,  or  forcible  squeezing;  and  particularly  after  an  imperfect  opera- 
tion that  removes  only  a  part  of  the  tuberculous  area. 

Terminations  of  Tuberculous  Abscess. — The  abscess  may  slowly  and 
gradually  enlarge,  and  finally  open  of  itself,  either  on  the  skin  or  on  the  mu- 
cous surface,  or  into  some  viscus  or  joint.  It  may  become  encapsulated  by 
fibrous  tissue,  there  being  absorption  of  the  fluid  and  shrinking  of  the  entire  focus, 
the  caseous  part  perhaps  remaining  or  becoming  calcified.  The  tuberculous 
abscess  may  actually  be  replaced  by  fibrous  tissue,  and  this  constitutes  a  per- 
manent cure.  WTien  the  tuberculous  area  is  merely  encapsuled  by  fibrous 
tissue,  some  living  bacilli  may  remain  latent  in  the  wall;  and  long  afterwards, 
as  the  result  of  injury  or  of  some  other  damage,  an  abscess  may  reform  at  the 
old  site  of  disease.  Sir  James  Paget  calls  this  condition  residual  abscess, 
As  a  rule,  the  abscess,  as  it  shrinks,  tends  toward  cure.  The  bacilli  usually 
die  for  want  of  material  to  nourish  them;  but  occasionally  they  remain  latent 
for  a  long  period  of  time.  WTien  they  do  die,  the  tuberculous  granulation 
tissue  may  become  healthy  tissue,  be  vascularized  through  the  entrance  of 
blood-vessels,  and  be  converted  into  scar-tissue.  Tuberculous  abscess  may 
also  be  cured  by  a  surgical  operation. 

Secondary  Infection  of  a  Tuberculous  Area  with  the  Bacilli  of 
Suppuration.— This  is  Hable  to  occur  when  the  abscess  undergoes  sponta- 


158  Suppuration  and  Abscess 

neous  evacuation,  and  may  occur  when  it  has  been  opened  by  the  surgeon.  It 
occasionally  occurs  when  the  abscess  has  neither  undergone  spontaneous  evacu- 
ation nor  has  been  opened  by  the  surgeon,  having  been  infected  apparently 
as  a  point  of  least  resistance.  When  such  infection  does  occur,  there  is,  in  all 
probability,  some  area  of  ordinary  suppuration  elsewhere  in  the  person's  body; 
and  the  bacteria  of  suppuration  have  entered  the  body  fluids.  Pyogenic  in- 
fection is  apt  to  produce  violent  inflammation  and  profuse  suppuration — a 
condition  that  is  extremely  dangerous,  because  septicemia  is  very  liable  to 
develop.  In  some  very  rare  cases  suppuration  destroys  the  tuberculous  area 
and  cures  the  tuberculous  disease.  More  commonly,  however,  it  produces 
illness;  and  in  large  abscesses  it  may  cause  death.  Because  of  this  liability 
to  secondary  infection  surgeons  were  long  opposed  to  operating  on  tuber- 
culous abscess  unless  it  was  evidently  going  to  evacuate  itself.  In  some 
cases,  secondary  infection  produces  a  true  chronic  abscess  (page  155). 
Infection  with  streptococci  is  much  more  dangerous  than  is  infection  with 
staphylococci.  Acute  inflammation  with  dangerous  constitutional  symptoms 
is  particularly  apt  to  arise:  if  the  walls  of  the  abscess  contain  very  little 
tuberculous  tissue,  if  they  have  been  bruised  or  damaged  with  powerful  chemi- 
cals ;  if  there  is  poor  drainage  (and  there  is  certain  to  be  poor  drainage  if  loculi 
exist,  or  when  the  incision  is  small  and  blocked  with  plugs  of  fibrin  or  necrotic 
tissue),  if  a  partial  or  imperfect  operation  has  been  performed,  if  a  number  of 
virulent  bacteria  have  been  introduced,  or  if  the  vital  resistance  is  at  a  low  ebb. 

Secondary  Infection  with  the  Bacteria  of  Putrefaction. — This  com- 
plication is  extremely  grave  and  may  produce  death.  It  is  commonly  as- 
sociated with  pyogenic  infection.  The  wound-fluid  becomes  intensely  putrid, 
violent  acute  inflammation  arises,  and  the  absorption  of  materials  from  the 
wound  induces  the  systemic  condition  known  as  sapremia  or  putrid  intoxi- 
cation. 

Signs  and  Symptoms  of  Tuberculous  Abscess. — A  purely  tuberculous 
abscess  presents  no  evidence  of  inflammation,  except  swelling;  and,  owing 
to  the  absence  of  heat,  it  has  received  its  name  of  cold  abscess.  The  cutane- 
ous surface  looks  and  feels  normal  or  is  paler  than  normal  until  the  struc- 
tures just  beneath  the  skin  or  the  skin  itself  become  involved.  When  this 
happens,  livid  discoloration  appears;  but  the  lividity  presents  a  very  different 
appearance  from  the  dusky  discoloration  of  an  acute  abscess.  Neither  is  the 
skin  edematous  or  glossy  as  it  is  in  acute  abscess. 

There  is  rarely  tenderness  in  the  region  of  the  abscess,  and  still  more  rarely 
spontaneous  pain.  Pain  and  tenderness,  although  frequently  absent  in  the 
area  of  a  tuberculous  abscess,  may  be  complained  of  at  the  primary  focus  of 
disease.  Tenderness  is  especially  likely  to  be  noted  at  the  primary  focus; 
and  in  cases  of  joint-tuberculosis  and  of  bone-tuberculosis,  it  is  nearly  always 
present.  There  may  or  may  not  be  pain  at  the  primary  focus,  but  there 
is  frequently  referred  pain.  For  instance,  in  tuberculous  disease  of  the  hip- 
joint  the  pain  may  be  referred  to  the  inner  side  of  the  knee;  and  severe  belly- 
ache is  frequently  observed  in  Pott's  disease  of  the  spine.  At  the  point  to 
which  pain  is  referred,  however,  there  is  no  tenderness.  For  instance,  in  the 
belly-ache,  particularly  of  Pott's  disease  of  the  spine,  the  belly  is  not  tender 
although  the  spine  is.  In  sacroiliac  tuberculosis  the  disease  is  often  referred  to 
the  distribution  of  the  sciatic  nerve;  but  the  nerve  is  seldom  tender  on  pressure. 


Tuberculous  Abscess  159 

In  a  psoas  abscess  we  find  that  pain  in  the  spine  can  be  induced  by  pressing 
on  the  spinous  process  of  the  diseased  vertebra,  by  concussion  to  the  heels  or 
the  head  when  the  spine  is  held  stiff,  and  especially  by  flexion  of  the  spine;  but 
the  spinal  pain  is  lessened  or  completely  abolished  by  extension,  fixation,  and 
rest.  The  primary  focus  of  disease,  if  spinal  or  articular,  produces  rigidity 
in  the  adjacent  muscles;  and  rigidity  obtains  rest  by  inhibiting  movement, 
but  it  also  impairs  the  function  of  the  part.  In  an  intra-abdominal  tubercu- 
lous abscess,  there  is  rigidity  of  the  abdominal  muscles. 

In  a  tuberculous  abscess  fluctuation  is  usually  obtained  readily  because 
the  fluid  is  not  surrounded  by  a  thick  mass  of  granulation  tissue  and  also  be- 
cause a  considerable  amount  of  fluid  is  usually  present.  A  notable  character- 
istic of  a  tuberculous  abscess  is  the  tendency  to  wander,  and  it  may  appear 
with  suddenness  at  some  distant  point.  Abscesses  of  the  spine  wander  long 
distances,  but  the  wandering  is  not  the  effect  of  gravity  and  is  due  to  the 
disposition  of  the  tuberculous  matter  to  travel  in  the  line  of  least  resistance. 
The  temperature  of  the  body  may  be  entirely  normal  if  the  infection  is  purely 
tuberculous.  As  a  rule,  however,  there  is  a  slight  evening  elevation;  and  the 
patient  is  weak  and  pale,  grows  tired  readily,  sleeps  poorly,  and  has  a  wretched 
appetite  and  impaired  digestion.  The  blood  examination  sometimes,  but  not 
often,  shows  a  notable  diminution  in  the  number  of  red  blood-cells;  but  the 
hemoglobin  is  usually  lowered  to  60  or  70  per  cent.  There  is  no  leukocytosis. 
In  multiple  tuberculous  foci,  and  particularly  in  tuberculosis  in  children,  there 
is  a  marked  decrease  in  the  red  blood-cells.  If  secondary  infection  occurs, 
there  is  a  rapid  and  progressive  diminution  in  the  number  of  these  cells  and 
usually  leukocytosis. 

A  tuberculous  abscess  underneath  the  deeper  fascia  may  break  through 
the  fascia  by  way  of  a  small  opening,  and  a  large  secondary  abscess  may  arise 
in  the  subcutaneous  tissue.  The  entire  abscess  is  thus  shaped  like  an  hour- 
glass, the  opening  through  the  fascia  being  the  narrowest  point.  Such  an 
abscess  is  called  a  shirt-stud  abscess.  A  tuberculous  abscess  is  liable  to  form 
one,  several,  or  many  sinuses;  and  the  end  of  each  sinus  may  expand  into  a 
secondary  abscess.  The  surgeon  must  always  make  a  careful  examination 
to  try  to  determine  whether  the  abscess  is  the  primary  disease-focus  or  whether 
the  tuberculous  matter  has  wandered  from  a  distant  point.  He  must  also  make 
a  thorough  examination  to  see  whether  anywhere  in  the  body  there  are  other 
regions  of  disease.  He  will  often  find  such  areas;  for  instance,  in  the  lungs. 
In  many  cases,  however,  there  is  no  clinical  evidence  that  other  areas  exist. 

The  tuberculous  abscess  usually  requires  weeks  or  months  to  reach  the 
overlying  skin  or  mucous  membrane  and  undergo  spontaneous  evacuation. 
That  spontaneous  evacuation  is  imminent  is  shown  by  livid  discoloration  and 
thinning  of  the  skin.  Finally,  at  the  area  in  which  the  skin  is  thinnest  a  little 
tit  is  elevated.  This  condition  is  known  as  pointing  and  a  rupture  occurs  at 
this  point,  tuberculous  pus  running  out.  Spontaneous  evacuation  is  a  peril, 
because  it  is  liable  to  be  followed  by  secondary  pyogenic  or  putrefactive  infec- 
tion. After  spontaneous  evacuation  has  occurred,  a  true  chronic  abscess  may 
form;  but  there  may  instead  be  violent  acute  inflammation,  manifested  by 
pain,  heat,  and  dusky  discoloration.  If  acute  inflammation  does  arise,  there 
develops  a  fever,  which  presents  evening  exacerbations  and  morning  remissions, 
and  is  accompanied  by  an  exhausting  sweat  during  the  night  or  early  morning. 
Fatal  septicemia  or  sapremia  may  follow  spontaneous  evacuation. 


it)0  Suppuration  and  Abscess 

Results  of  a  Tuberculous  Abscess. — It  may  undergo  spontaneous 
cure,  and  the  cure  may  be  lasting;  but  long  after  an  apparent  cure,  a  new 
abscess  may  form  (the  residual  abscess  of  Sir  James  Paget).  A  tuberculous 
abscess  may  remain  stationary  for  a  very  long  time,  and  then  perhaps  diminish 
in  size  and  be  cured,  or  extend  in  size  and  rupture.  After  spontaneous  rupture, 
suppuration  may  cure  the  tuberculous  area  by  annihilating  the  tuberculous 
tissue;  but,  as  a  rule,  after  spontaneous  rupture  there  is  either  an  acute  septic 
process  or  a  chronic  suppuration,  constituting  a  genuine  chronic  abscess. 

The  pyogenic  infection  of  a  tuberculous  area,  if  it  induces  long-lasting 
suppuration,  may  lead  to  the  development  of  albuminoid,  amyloid,  waxy  or 
lardaceous  disease  in  the  middle  and  inner  coats  of  blood-vessels,  in  connec- 
tive tissue,  lymphatic  glands,  the  membrana  propria  of  mucous  membranes, 
the  heart,  the  liver,  the  spleen,  and  the  kidneys.  The  victim  of  albuminoid  dis- 
ease is  pale,  greatly  exhausted  and  emaciated,  and  very  anemic;  suffers  with 
diarrhea  and  usually  has  capillary  hemorrhages  beneath  the  skin  and 
mucous  membranes.  The  albuminoid  material  can  be  detected  chemically  in 
the  urine,  if  the  kidneys  are  involved.  Albuminoid  degeneration  is  incura- 
ble, and  is  usually  fatal;  but  if  the  patient  is  subjected  to  proper  treatment 
soon  after  it  begins  it  may  be  arrested  and  not  progress.  The  amyloid  material 
is  deposited  between  the  cells  and  not  in  them.  The  disease  is  apt  to  arise 
in  chronic  tuberculosis  with  secondar}'  pyogenic  infection,  especially  in  bone 
tuberculosis,  but  it  may  arise  in  syphilis,  chronic  suppuration  in  non-tubercu- 
lous subjects,  and  chronic  dysentery.  The  albuminoid  substance  resembles 
fibrin  and  there  are  many  theories  as  to  its  source.  One  theory  is  that  the 
condition  is  due  to  the  flow  of  pus  removing  potash  salts  from  the  blood,  and 
thus  leaving  a  dealkalinized  blood-serum. 

Diagnosis. — The  fluctuation,  the  absence  of  evidences  of  acute  inflamma- 
tion, the  tendency  to  wander,  and,  in  some  cases,  the  sudden  appearance,  mark 
the  diagnosis.  The  surgeon  always  examines  with  care  to  see  whether  there  is 
some  distant  tuberculous  focus  from  which  the  abscess  may  have  wandered,  or 
whether  the  abscess  itself  is  at  the  primary  seat  of  disease.  The  advancing 
impairment  of  the  general  health,  the  lessened  amount  of  hemoglobin,  the 
normal  or  almost  normal  temperature,  and  the  absence  of  leukocytosis  are 
points  in  the  diagnosis  of  the  condition.  In  a  doubtful  case  the  aseptic  use  of 
the  tubular  exploring  needle  is  important,  the  fluid  that  emerges  being  studied 
with  the  microscope  after  staining,  by  cultures,  and  perhaps  by  inoculating 
it  into  guinea-pigs.  The  fluid  that  is  withdrawn  may  contain  no  bacteria 
that  can  be  demonstrated;  but  if  it  is  sterile  and  there  are  no  pyogenic  organ- 
isms, one  should  strongly  suspect  tuberculosis.  Various  diagnostic  tests 
for  tuberculosis  will  be  found  on  pages  241-243. 

Prognosis. — Advanced  albuminoid  degeneration  gives  a  hopeless  prog- 
nosis and  any  extent  of  albuminoid  degeneration  is  unfavorable.  Secondary 
pyogenic  infection,  as  already  stated,  may  produce  death  or  a  hngering 
suppuration.  The  prognosis  is  worse  in  very  young  children  than  in  adults; 
and  in  any  case  it  is  unfavorable  if  the  exhaustion  deepens,  if  the  anemia  is 
marked,  if  there  are  tuberculous  lesions  in  distant  parts  or  in  important  organs 
or  structures,  if  the  patient  is  unable  to  take  and  digest  food,  and  if  the  regions 
of  tuberculosis  cannot  be  extirpated  or  sterilized.  Under  other  circumstances, 
the  prognosis  is  favorable. 


Tuberculous  Abscess 


i6i 


Tuberculous  Abscesses  in  Various  Regions. — Tuberculous  abscess 

of  the  head  of  a  bone  (see  Brodie's  abscess,  page  504)  arises  in  the  can- 
cellous structure  of  a  long  bone,  most  often  in  the  head  of  the  tibia,  and  is 
frequcnth'  noted  as  having  been  preceded  by  a  trivial  traumatism.  The  focus 
of  tuberculosis  seldom  induces  severe  symptoms  unless  secondary  pyogenic  in- 
fection occurs  (page  230).  A  tuberculous  nodule  forms  as  a  result  of  tubercu- 
lous osteomyelitis.  The  bone  about  the  nodule  is  hyperemic,  the  bony  tra- 
becular are  thickened,  and  the  cancellous  spaces  "are  devoid  of  fat  cells,  and 
they  contain  a  swollen  semi-fibrous  material"  (Warren's  "  Surg.  Pathol. ").  The 
center  of  the  nodule  becomes  cheesy,  the  bone  trabeculae  are  absorbed  and  the 
bone  becomes  cheesy  and  broken  up,  the  cheesy  mass  containing  bone  frag- 
ments.   Finally  the  area  becomes  filled  with  tuberculous  pus,  the  cavity  which 


Fig.  76. — Case  of  cold  abscess  which  had  been  treated  as  a  hernia. 


contains  it  being  lined  with  tuberculous  granulations.  Distinct  sequestra  may 
form  and  the  bone  about  the  diseased  focus  undergoes  sclerosis.  In  Brodie's 
abscess  pain  is  continued  but  is  not  usually  very  severe,  is  of  a  boring  character, 
and  is  worse  when  the  patient  is  in  bed.  Attacks  of  synovitis  arise  from  time  to 
time  in  the  adjacent  joint.  The  bacteria  of  tuberculosis  obtain  access  to  the 
bone  by  means  of  the  blood,  and  find  in  the  bone  a  point  of  least  resistance. 
There  is  no  such  thing  as  an  acute  abscess  of  bone.  A  pyogenic  inflammation, 
of  such  severity  that  it  would  cause  an  acute  abscess  in  soft  parts,  in  bone 
causes  acute  necrosis. 

Retropharyngeal  or  postpharyngeal  abscess  is  often  tuberculous.  Such 
an  abscess  is  usually  due  to  caries  of  the  cervical  vertebras,  but  can  arise  in  the 
connective  tissue  of  the  parts  or  as  a  tuberculous  adenitis.  An  abrasion  of 
the  mucous  membrane  may  admit  the  bacilli  to  the  connective  tissue  or  the 
glands.  A  swelling  projects  from  the  posterior  pharyngeal  wall,  and  there  is 
great  interference  with  respiration  and  deglutition.     Caseous  matter  from 


l62 


Suppuration  and  Abscess 


caries  of  the  cervical  vertebra;  may  reach  the  posterior  mediastinum  by  following 
the  esophagus,  or  may  appear  in  front  of  or  behind  the  sternomastoid  muscle  in 
the  neck  (Edmund  Owen).  A  tuberculous  abscess  in  this  region  is  apt  to  un- 
dergo pyogenic  infection,  in  which  case  the  patient  develops  fever,  sweats,  pain, 
and  prostration. 

Dorsal  Abscess. — The  tuberculous  matter  in  dorsal  abscess  arises  from 
dorsal  caries,  flows  into  the  posterior  mediastinum,  and  reaches  the  surface 
by  passing  between  the  transverse  processes.  The  tuberculous  matter  from 
dorsal  caries  may  run  forward  between  the  intercostal  muscles  or  between 
these  muscles  and  the  pleura,  pointing  in  an  intercostal  space,  at  the  side  of  the 
sternum,  or  bv  the  rectus  muscle.     It  may  burst  into  the  gullet,  windpipe, 

bronchus,  pleural  sac,  or  pericardium.  It 
may  descend  to  the  diaphragm  and  travel 
under  the  inner  arcuate  hgament  to  form 
a  psoas  abscess,  or  under  the  outer  arcuate 
Hgament  to  form  a  lumbar  abscess.  A 
psoas  abscess  points  external  to  the  femoral 
vessels,  a  characteristic  which  distinguishes 
it  at  once  from  a  femoral  hernia. 

Iliac  abscess  arises  from  lumbar  caries, 
the  swelling  lying  in  the  iliac  fossa  and 
pointing  above  Poupart's  ligament. 

Psoas  abscess  is  usually  due  to  lumbar 
caries,  but  may  arise  from  dorsal  caries. 
The  fluid  usually  points  in  Scarpa's  tri- 
angle external  to  the  femoral  vessels,  but 
may  descend  much  lower  (Fig.  77).  A 
psoas  or  iliac  abscess,  by  following  the 
lumbosacral  cord  and  great  sciatic  nerve, 
forms  a  gluteal  abscess.  These  abscesses 
may  open  into  the  bowel,  bladder,  ureter, 
or  peritoneal  cavity. 
Lumbar  Abscess. — In  a  lumbar  abscess  the  fluid  produced  by  dorsal 
caries  descends  beneath  the  outer  arcuate  ligament,  or  the  fluid  from  lum- 
bar caries  which  collected  anterior  to  or  in  the  quadratus  lumborum  muscle 
passes  between  the  last  rib  and  iliac  crest  in  the  triangle  of  Petit,  the  small 
space  bounded  by  the  crest  of  the  ilium,  the  posterior  edge  of  the  external 
oblique  muscle,  and  the  anterior  edge  of  the  latissimus  dorsi  muscle.* 

Tuberculous  abscess  of  the  neck  results  from  tuberculosis  of  the  cervical 
glands.  It  is  not  often  that  such  an  abscess  attains  any  considerable 
size.  It  tends  strongly  to  spontaneous  rupture,  and,  if  this  is  permitted  to 
occur,  a  livid,  corrugated  scar  results. 

Tuberculous  abscesses  of  joints  (see  Chapter  XIX). 
Tuberculous  Abscess  of  Rib. — It  is  not  uncommon  to  find  a  tubercu- 
lous abscess  of  moderate  size  about  a  tuberculous  rib.     The  pleura  may 
become  involved  secondarily. 

Tuberculous    mediastinal   abscess   may   result   from   the  downward 

*For  a  lucid  description  of  these  abscesses  see  Owen's  "Manual  of  Anatomy,"  from 
which  much  of  the  above  is  condensed. 

I 


Fig.  77. — Psoas  abscess  (Albert). 


Tuberculous  Abscess  163 

passage  of  a  cervical  abscess;  from  tuberculosis  of  the  sternum,  ribs,  vertebra; 
or  pleura,  or  from  tuberculous  mediastinal  glands. 

Tuberculous  abscess  of  the  breast  is  a  caseated  and  liquefied  area  of 
tuberculosis  of  the  breast.  A  lump  is  detected,  which  slowly  enlarges  and  finally 
ruptures,  sinuses  being  formed.  The  axillary  glands  are  apt  to  be  implicated. 
The  patient  may  belong  to  a  tuberculous  stock,  as  a  rule  gives  a  history  of 
previous  tuberculous  troubles  of  various  sorts,  and  has  usually  borne  children. 
Chronic  abscess  of  the  breast  causes  little  or  no  pain. 

Treatment  of  Tuberculous  Abscess. — For  many  years  the  majority  of 
surgeons  would  not  operate  upon  a  tuberculous  abscess  unless  it  was  on  the 
point  of  rupturing.  With  the  advent  of  antiseptic  surgery,  it  was  assumed  that 
aseptic  incision  and  drainage  would  be  the  proper  treatment  for  these  cases; 
but  the  results,  except  in  small  superficial  tuberculous  abscesses,  have  been  ex- 
tremely disappointing.  If  a  large  abscess  is  so  treated,  pyogenic  infection  wiU, 
in  all  probability,  sooner  or  later  occur,  with  all  its  possibilities  of  disaster. 
Incision  and  drainage  is,  therefore,  restricted  to  small  and  superficial  abscesses. 

Treatment  of  Small  Superficial  Tuberculous  Abscesses. — The  surgeon 
must  remember  that  after  one  has  opened  an  apparently  superficial  abscess 
it  is  his  duty  to  make  an  examination  to  see  that  there  is  no  channel  connecting 
the  abscess  with  a  deep  or  a  distant  focus.  If  he  finds  such  a  channel,  he  maybe 
disposed  to  follow  one  of  the  plans  of  treatment  outlined  on  pages  163  and  164. 
It  is  also  his  duty  to  see  whether  there  are  sinuses  tracking  off  from  the  abscess ; 
and  if  these  exist,  he  must  slit  them  up.  If  there  are  loculi  in  the  wall  of  the 
abscess,  he  must  stretch  their  mouths.  He  must  be  particularly  careful  to  see 
that  he  is  not  dealing  with  a  shirt-stud  abscess,  in  which  there  is  a  little  opening 
through  the  deep  fascia  connecting  the  abscess  above  with  the  abscess  below. 
In  a  shirt-stud  abscess  the  deep  fascia  must  be  freely  incised.  After  the  abscess 
has  emptied  itself,  its  walls  must  be  thoroughly  scraped  with  a  curet,  and  the 
cavity  must  be  drained  with  a  tube  or,  preferably,  packed  with  iodoform 
gauze.  If  the  skin  above  a  superficial  abscess  is  diseased  and  discolored,  and 
the  abscess  is  on  the  eve  of  spontaneous  ruptvu-e  or  has  ruptured,  the  dis- 
colored skin  must  be  cut  away  with  scissors.  If  the  discolored  skin  is  allowed 
to  remain,  a  livid  and  jagged  scar  will  inevitably  result.  If  it  is  cut  away, 
a  healthy  scar,  not  very  deforming,  will  result. 

Treatment  of  Tuberculous  Abscesses  of  Considerable  Size. — Method 
I.  Aspiration,  Irrigation,  and  the  Introduction  0/  lodojorm. — The  operation 
is  carried  out  \nth  the  most  scrupulous  aseptic  care.  The  trocar  is  passed 
through  the  sound  skin;  is  carried  beneath  the  skin  for  an  inch,  as  Senn  sug- 
gests; and  is  then  made  to  enter  into  the  cavity  of  the  abscess.  The  stylet  is 
pulled  out,  and  the  tiow  of  fluid  is  aided  with  very  delicate  pressure.  Occa- 
sionally the  tube  will  become  blocked  by  necrosed  tissue  or  plugs  of  fibrin. 
It  is  opened  up  again  by  pushing  in  a  wire  or  forcing  in  a  stream  of  sterile  fluid. 
When  tuberculous  matter  ceases  to  run  out  of  the  trocar,  a  very  warm  solution 
of  boracic  acid  is  thrown  in  in  order  to  wash  the  abscess- walls.  This  can  be 
inserted  with  a  fountain  syringe  or  with  the  special  apparatus  of  Senn  (Fig.  78). 
Enough  of  it  is  allowed  to  enter  to  overdistend  the  abscess-cavity,  as  ^Mr.  Cal- 
lender  long  ago  advised.  The  fluid  is  then  allowed  to  pass  out;  fresh  fluid  is 
passed  in;  and  this  procedure  is  repeated,  perhaps  again  and  again,  until  entirely 
clear  fluid  flows  out.    W^hen  this  takes  place,  an  emulsion  of  iodoform  is  thrown 


i64 


Sup}juration  and  Abscess 


in  by  Senn's  syringe.  A  lo  per  cent,  emulsion  in  glycerin  is  as  satisfactory 
as  the  more  elaborate  formulas.  Verneuil  used  to  employ  iodoform  and  ether; 
but  this  is  painful,  is  more  liable  to  cause  iodoform-poisoning,  and  sometimes 
induces  gaseous  distention  and  ruptures  the  wall  of  the  abscess.  In  order  to 
prevent  the  danger  of  iodoform-poisoning  the  surgeon  should  not  introduce  at 
one  time  more  than  eight  drams  of  the  emulsion,  if  dealing  with  an  adult; 

or  more  than  four  drams,  if  dealing 
with  a  child.  After  the  emulsion  has 
been  inserted  into  the  abscess-cavity, 
the  wound  in  the  skin  is  sealed  with 
a  bit  of  gauze  and  iodoform  collodion. 
Gauze  is  fluffed  up  and  laid  on  the 
skin  above  the  abscess,  and  the  walls 
of  the  cavity  are  then  forced  toward 
each  other  by  applying  a  roller  band- 
age. The  part  is  put  at  complete 
rest,  and  it  is  usually  necessary  to 
put  the  patient  in  bed.  Sometimes, 
although  very  seldom,  one  injection 
will  produce  a  cure;  but  usually,  after 
one  or  two  weeks,  it  will  be  observed 
that  the  cavity  has  to  some  extent 
filled  again.  A  second  operation  is 
then  performed;  and,  if  improvement 
is  really  taking  place,  it  will  be  found 
that  the  fluid  is  not  nearly  so  thin  as 
it  was  at  the  first  operation.  It  is  needless  to  persist  in  this  method  after 
six  or  seven  attempts  have  failed  to  cure.  If  the  abscess  has  thick  and  un- 
collapsed  walls,  it  is  not  fitted  for  treatment  by  aspiration  and  injection. 

Method  2.  Incision,  Cleansing,  and  Suture. — If,  owing  to  the  considerable 
size  or  the  rather  rigid  walls  of  the  abscess,  one  believes  that  the  aspiration 
method  would  be  useless;  or  if  the  aspiration  method  has  been  tried  and  has 
failed,  one  may  adopt  the  following  plan.  It  should  not,  however,  be  em- 
ployed, if  the  walls  are  very  thick  and  rigid.  An  incision  is  made  at  the  most 
dependent  part  of  the  abscess.  The  walls  are  scraped  carefully  with  Barker's 
sharp-edged  irrigating  curet  (Fig.  79),  and  are  rubbed  smooth  with  bits  of 


Fig.  78. — Senn's  injection  syrini^e. 


Fig-  79- — Barker's  sharp-edged  irrigating:  curet  (Keen's  Surgery). 


gauze.  The  part  is  freely  irrigated  with  hot  boracic  acid  solution,  and  pressure 
is  applied  to  arrest  bleeding.  Iodoform  emulsion  is  introduced;  the  skin  is 
sutured;  dressings,  compresses,  and  bandages  are  applied;  and  complete  rest 


Tuberculous  Abscess  165 

is  secured.  This  operation  may  cure  an  abscess;  or  it  may  be  necessary  to 
repeat  the  procedure  two  or  three  weeks,  or  many  weeks,  afterward. 

Method  3.  Incision  and  Removal  0}  the  Primary  Focus  of  Tuberculosis. — If 
one  has  not  used  the  iodoform  treatment,  or  if  it  has  failed  and  if  one  finds  that 
the  primary  seat  of  disease  may  be  attacked  and  removed,  an  operation  should 
be  undertaken  to  get  rid  of  Volkmann's  membrane  in  the  last-formed  abscess 
and  also  to  remove  the  primary  tuberculous  focus.  An  incision  is  made,  when 
possible,  that  will  lay  open  not  only  the  last-formed  abscess,  but  the  primary 
lesion.  Tuberculous  tissue  is  thoroughly  removed  with  Barker's  spoon  and 
by  rubbing  with  gauze,  or,  perhaps,  by  scissors  and  forceps.  Any  focus  of 
bone  disease  is  curetted  and  touched  with  pure  carbolic  acid,  and  loose  frag- 
ments of  bone  are  removed.  The  part  is  irrigated  with  a  hot  solution  of 
boracic  acid;  bleeding  is  arrested  by  pressure;  and  the  wound  is  nearly,  but 
not  quite,  closed,  drainage  being  inserted  at  the  most  appropriate  spot.  Dress- 
ings, compresses,  and  bandages  are  then  applied.  In  this  operation,  the  en- 
tire tuberculous  area  has  been  removed,  and  the  raw  surfaces  have  been  forced 
into  contact;  and  there  is  no  more  danger  of  secondary  pyogenic  infection 
than  there  is  in  any  ordinary  wound. 

General  Treatment. — It  is  never  to  be  lost  sight  of  that  in  every  case  of 
tuberculous  abscess  the  general  treatment  of  tuberculosis  must  be  rigorously 
pursued  (see  page  245).  In  the  treatment  of  a  cold  abscess  give  nutritious 
food,  cod-liver  oil,  quinin,  iron,  and  the  mineral  acids.  Removal  to  the  sea- 
side is  often  indicated,  life  in  the  open  air  is  imperative,  and  mechanical  appli- 
ances may  be  needed  for  diseases  of  the  bones  and  joints. 

Chronic  Abscess  of  Bone. — Make  an  incision  to  bare  the  bone.  Open 
the  abscess  with  the  trephine,  the  gouge,  or  the  chisel;  curet  interior  of  the 
wall  of  the  cavity  with  a  sharp  spoon  and  rub  it  with  bits  of  gauze;  cut  away 
the  edges  of  the  bone  with  rongeur  forceps;  irrigate  the  cavity  with  hot  normal 
salt  solution,  dry  its  walls  with  gauze,  and  paint  the  cavity  with  pure  car- 
bolic acid;  pack  with  iodoform  gauze  and  apply  antiseptic  dressings.  It  is 
better  not  to  employ  an  Esmarch  apparatus.  Bleeding  will  not  be  severe, 
and  when  no  apparatus  is  used  to  prevent  bleeding  one  can  be  sure  that  all 
the  diseased  bone  has  been  removed,  because  sound  bone  bleeds  and  dead 
bone  does  not. 

Cold  Abscess  of  Lymphatic  Glands. — In  non-exposed  portions  of  the 
body  the  capsule  of  the  gland  should  be  incised  and  dissected  or  scraped  away 
and  the  cavity  swabbed  out  with  pure  carbolic  acid  or  iodin  and  packed  with 
iodoform  gauze,  but  drainage  should  not  be  prolonged.  If  the  abscess  is 
allowed  to  burst,  it  will  cause  an  ugly  scar;  therefore,  in  exposed  portions  of 
the  body,  as  the  neck,  special  effort  should  be  made  to  prevent  a  scar  by  incising 
early  before  the  skin  is  involved.  When  only  a  little  caseated  matter  exists 
and  the  skin  is  not  discolored,  prepare  the  parts  antiseptically,  incise,  rub  the 
interior  with  gauze,  inject  iodoform  emulsion,  and  suture  the  wound.  It  used 
to  be  a  custom  in  such  cases  to  carry  a  silk  thread  by  means  of  a  needle  through 
the  skin,  through  the  gland,  and  out  at  its  lowest  point,  the  part  being  then 
dressed  with  gauze.  In  three  days  the  thread  was  removed  and  a  firm  com- 
press was  applied.  The  plan  is  not  satisfactory  and  incision  is  to  be  preferred. 
When  the  gland  is  almost  entirely  broken  down  and  the  skin  above  it  is  becom- 
ing purple  and  thin,  insert  a  hypodermatic  needle  through  sound  skin  into  the 


1 66  Suppuration  and  Abscess 

abscess,  draw  off  the  fluid  tul)erculous  matter,  and  inject  iodoform  emulsion. 
This  procedure  is  to  be  repeated  when  the  fluid  again  accumulates.  By  this 
means  we  can  sometimes  effect  a  cure  in  a  week  or  so.  When  an  abscess 
breaks  or  is  on  the  point  of  breaking,  cut  away  all  purple  skin,  curet  the 
abscess- walls  (the  abscess  having  become  a  tuberculous  ulcer),  remove  the 
remains  of  gland  and  capsule,  swab  the  cavity  with  pure  carbolic  acid,  and 
dress  with  iodoform  and  antiseptic  gauze. 

Tuberculous  glands  ought  to  be  extirpated  before  they  caseate  and  form 
an  abscess.  If  an  abscess  does  form  it  is  treated  as  is  directed  above  and  after 
healing  takes  place  the  diseased  glands  are  extirpated.  If  sinuses  exist  they 
are  curetted  and  touched  with  iodin  or  carbolic  acid.  After  healing,  the 
glands  are  extirpated.     When  sinuses  exist  there  is  always  mixed  infection. 

Tuberculous  Abscess  of  a  Rib. — This  lesion  requires  incision  of  the 
soft  parts  and  resection  of  the  diseased  bone.  The  tuberculous  area  is 
thoroughly  curetted,  rubbed  with  pure  carbolic  acid,  and  packed  with  iodo- 
form gauze. 

Tuberculous  Mediastinal  Abscess. — In  tuberculous  abscess  of  the  me- 
diastinum aspiration  and  injection  of  iodoform  may  prove  efficient.  In  some 
cases  it  will  be  necessary  to  open  and  drain. 

Cold  Abscess  of  the  Mammary  Gland. — Many  operators  simply  incise, 
curet,  pack  with  iodoform  gauze,  and  dress  antiseptically.  It  is  wiser  to 
remove  the  entire  gland,  and  to  clear  out  the  axilla,  as  in  an  operation  for 
cancer,  in  order  to  prevent  both  recurrence  and  dissemination. 

Large  Cold  Abscesses. — In  view  of  the  facts  that  these  abscesses  may 
cause  no  trouble  for  years  and  that  an  operation  may  be  fatal,  some  eminent 
surgeons  are  opposed  to  an  operation  unless  the  abscess  is  moving  toward 
inevitable  rupture  or  is  disturbing  the  functions  of  organs  by  pressure.  Most 
practitioners  believe,  however,  and  I  agree  with  them,  that  this  mass  of 
tuberculous  matter  is  a  source  of  danger  through  being  a  depot  of  infective 
organisms  which  may  overwhelm  the  system,  and  that  death  will  seldom 
result  from  an  operation  performed  by  one  who  employs  with  intelligence 
strict  antisepsis.  In  no  other  cases  is  attention  to  every  detail  more  impor- 
tant, as  a  mixed  infection  may  easily  take  place,  and  will  probably  mean 
death.  As  W.  Watson  Cheyne  points  out,  over  seventy  per  cent,  of  cases 
of  spinal  abscess  treated  by  aseptic  methods  recover  completely  and  without 
any  real  illness  after  such  an  operation.  The  recoveries  from  the  old  let- 
alone  method  will  be  infinitely  less  than  this,  and  cases  cured  by  operation 
usually  remain  well.  The  surgeon  must  always  remember  that  the  wall  of 
the  abscess  and  not  the  fluid  in  the  cavity  is  the  real  seat  of  disease,  and 
this  wall  must  be  actually  removed  or  completely  sterilized  if  operation  is 
to  be  safe.  To  simply  open,  drain,  and  leave  the  wall  to  Nature  to  get  rid 
of  if  she  can  is  fraught  with  the  gravest  peril. 

Psoas  Abscess. — Some  of  these  cases  can  be  treated  by  aspiration  and 
injection  (page  163),  others  by  incision  and  subsequent  suture  (page  164), 
others  by  the  radical  operation  set  forth  on  page  165. 

Treves's  operation  for  psoas  abscess  is  described  on  j)age  707. 

An  operation  occasionally  performed  for  psoas  abscess  consists  in  an 
incision  in  the  groin,  an  incision  in  the  back,  removal  of  carious  vertebras, 
thorough   cleansing  of    the  abscess-wall,  and  through-and-through   tubular 


Necrosis  167 

drainage.  It  has  been  found,  iiowever,  that  this  operation  is  uncertain  and 
dangerous.  It  is  not  advisable  to  remove  carious  vertebrae,  and  through-and- 
through  tubular  drainage  is  rarely  used  unless  mixed  infection  already  exists. 
\Vhen  a  large  abscess  breaks  spontaneously,  it  should  be  widely  opened  at 
once,  scraped  and  irrigated,  rubbed  with  gauze,  swabbed  with  pure  carbolic 
acid,  washed  out  with  alcohol,  and  packed  with  iodoform  gauze.  If  secondary 
pyogenic  infection  of  a  large  tuberculous  abscess  does  occur,  the  patient  will 
develop  septic  fever  and  will  probably  die  {q.  v.). 

Dorsal  abscess  and  lumbar  abscess  are  treated  after  the  same  plan  as 
psoas  abscess.  One  incision  only  is  usually  necessary'  unless  the  fluid  has 
traveled  to  a  distant  point. 

A  postphar)mgeal  abscess  must  not  be  opened  through  the  mouth.  To 
open  it  in  this  manner  puts  the  patient  in  danger  of  suffocation  by  fluid  running 
into  the  larynx  during  or  after  the  operation.  Further,  mixed  infection  of  the 
abscess-area  will  be  certain  to  ensue.  Septic  pneumonia  will  be  apt  to  arise 
from  inhaled  infected  particles,  and  profound  gastro-intestinal  disturbance 
will  be  liable  to  develop  because  of  the  inevitable  swallowing  of  purulent, 
putrid,  and  tuberculous  masses.  Incise  the  neck  and  open  into  the  abscess 
by  Hilton's  method,  going  through  the  sternocleidomastoid  muscle  or  behind 
it.  Rub  the  wall  of  the  abscess  with  bits  of  gauze,  remove  any  loose  bone, 
irrigate  with  hot  normal  salt  solution,  inject  iodoform  emulsion,  insert  a  tube 
or  pack  with  iodoform  gauze. 


VII.    ULCERATION    AND    FISTULA. 

An  ulcer  is  a  loss  of  substance  due  to  molecular  death  of  a  superficial 
.structure.  The  molecular  death  is  brought  about  by  bacteria.  Ordinary 
ulcers  are  caused  by  pus  organisms.  The  action  of  the  pus  organisms  is  the 
same  as  in  an  abscess.  A  broken  abscess  becomes  an  ulcer,  and  an  ulcer  is 
in  structure  a  half-section  of  an  abscess.  The  floor  of  an  ulcer  consists  of 
granulation  tissue  and  corresponds  with  the  abscess-wall.  An  abscess  arises 
from  molecular  death  within  the  tissues;  an  ulcer,  from  molecular  death  of 
a  free  surface.  An  ulcer  may  increase  in  size  by  molecular  death  of  adja- 
cent structures  or  by  sloughing,  that  is  to  say,  by  death  of  visible  masses  of 
tissue.  A  wound  heahng  by  granulation  is  often  wrongly  called  an  ulcer. 
An  ulcer  must  not  be  confounded  with  an  excoriation.  In  an  ulcer  the  corium 
is  always,  and  the  subcutaneous  tissue  is  generally,  destroyed,  and  a  scar  is 
left  after  healing.  In  an  excoriation  the  mucous  layer  of  epithelium  is  ex- 
posed, or  this  is  destroyed  and  the  corium  is  exposed.  In  an  excoriation  the 
corium  is  never  destroyed,  and  no  scar  remains  after  heahng.  An  ulcer  heals 
by  granulation  (page  123).  Embryonic  tissue  by  vascularization  becomes 
granulation  tissue,  granulation  tissue  is  converted  into  fibrous  tissue,  the  fibrous 
tissue  contracts,  and  by  puUing  the  edges  of  the  ulcer  toward  each  other  lessens 
the  size  of  the  cavity.  When  the  granulations  reach  the  level  of  the  skin  the 
epithelium  at  the  edges  of  the  ulcer  prohferates  and  the  sore  is  soon  covered 
over  with  new  epithelium. 

Necrosis  of  a  superficial  part  may  arise  from — (i)  Inflammation.  The 
pressure  of  the  exudate  can  cut  off  the  circulation,  or  bacteria  may  directly 


i68  Ulceration  and  Fistula 

destroy  tissue.  Suppuration  occurs.  (2)  The  acdon  of  pus  bacteria,  causing 
primary  cell-necrosis.  (3)  Bacteria  of  putrefaction  and  organisms  of  suppura- 
tion acting  upon  a  wound.  (4)  Traumatism  or  irritants,  producing  at  once 
stasis,  which  is  added  to  by  secondary  ini3ammation,  the  exudate  undergoing 
purulent  liquefaction.  (5)  Prolonged  pressure.  (6)  Deficient  blood-supply. 
(7)  Faulty  venous  return.  (8)  Degeneration  of  a  neoplastic  infiltration 
(gummatous,  malignant,  or  tuberculous).  (9)  Trophic  disturbance.  (10) 
Nutritional  disturbances  (as  scurvy).  Most  ulcers  are  due  to  pus  organisms, 
and  even  areas  of  necrosis  that  arise  from  something  else  (as  gummatous 
degeneration)  are  likely  to  suppurate. 

Classification. — Ulcers  are  classified  into  groups  according  to  the  con- 
dition of  the  ulcer  and  the  associated  constitutional  state.  In  the  first  group 
we  find  the  varicose,  hemorrhagic,  acute,  chronic,  irritable,  neuralgic,  etc. 
In  the  second  group  are  placed  the  tuberculous,  syphilitic,  senile,  scorbutic, 
etc.  All  ulcers,  whatever  their  origin,  are  either  acute  or  chronic,  and  such 
conditions  as  great  pain,  hemorrhage,  edema,  exuberant  granulations,  phage- 
dena, sloughing,  eczema,  gout,  s}'philis,  scurvy,  etc.,  are  to  be  looked  upon 
as  complications.  The  leg  is  so  common  a  site  of  ulcers  as  to  warrant  a  special 
description  of  ulcers  of  this  part.  In  describing  an  ulcer  state  the  patient's 
previous  histor}';  the  supposed  cause;  the  situation;  the  outhne;  the  dura- 
tion; and  the  mode  of  onset  of  the  ulcer.  State  if  the  ulcer  is  single  or  if 
multiple  sores  exist,  and  if  there  is  or  is  not  pain;  whether  or  not  any  healing 
has  ever  occurred,  and  the  patient's  constitutional  condition.  Set  forth  the 
complications;  the  state  of  anatomically  related  glands;  the  condition  of  the 
edge,  the  floor,  and  the  parts  about  the  ulcer,  and  the  nature  and  quantity  of 
the  discharge. 

Acute  or  inflamed  ulcer  of  the  leg  may  follow  an  acute  inflammation 
and  may  be  acute  from  the  start,  or  may  be  first  chronic  and  then  become  acute. 
It  is  especially  common  in  drunkards,  and  among  those  of  dilapidated  con- 
stitutions. It  is  characterized  by  rapid  progress  and  intense  inflammation. 
There  is  rarely  more  than  one  ulcer.  In  outline  these  ulcers  are  usually  oval, 
but  may  be  irregular.  The  floor  of  an  acute  ulcer  contains  no  granulations, 
but  is  composed  of  the  raw  and  inflamed  tissues,  or  is  covered  with  a  mass  of 
gray  aplastic  lymph,  or  it  may  have  upon  it  large  greenish  sloughs.  The 
edges  are  thin  and  undermined.  The  discharge  is  very  profuse  and  ichorous, 
excoriating  the  surrounding  parts.  The  adjacent  cutaneous  surface  is  in- 
flamed and  edematous,  and  there  is  much  burning  pain.  In  some  cases  the 
glands  in  the  groin  enlarge.  Constitutionally,  there  is  gastro-intestinal  de- 
rangement, but  rarely  fever.  When  the  ulcer  spreads  with  great  rapidity 
and  becomes  deeper  as  well  as  larger  in  surface  area,  it  is  called  "  phagedenic." 
The  formation  of  sloughs  indicates  that  tissue  death  is  going  on  so  rapidly 
that  the  dead  portions  have  not  time  to  break  down  and  be  cast  off.  Limited 
stasis  produces  molecular  death;  more  extensive  stasis,  a  slough.  If  a  chronic 
ulcer  becomes  acute,  the  granulations  are  destroyed. 

Treatment. — In  treating  an  acute  ulcer  of  the  leg,  give  a  dose  of  blue 
mass  or  calomel,  followed  in  eight  or  ten  hours  by  a  saline  (3ij  each  of  Rochelle 
and  Epsom  salts),  and  order  light  diet.  Deny  stimulants  except  in  a  case  of 
diphtheritic  ulcer.  Administer  opium  if  pain  is  severe.  Spray  the  ulcer 
with  hydrogen  peroxid,  use  the  scissors  and  forceps  to  get  rid  of  sloughs,  and 


Chronic  Ulcer  of  the  Leg  169 

after  sloughs  are  removed  wash  the  ulcer  with  corrosive  sublimate  solution 
(i  :  1000),  or  paint  it  with  pure  carbolic  acid.  Paint  the  skin  adjacent  to  the 
ulcer  with  equal  parts  of  tincture  of  iodin  and  alcohol.  Dress  with  hot  anti- 
septic fomentations.  Apply  a  bandage  from  the  toes  to  well  above  the  ulcer. 
Insist  on  the  patient  remaining  in  bed  with  the  leg  slightly  elevated.  Change 
the  dressings  before  they  become  cool  and  always  as  soon  as  they  are  satu- 
rated with  discharge.  Every  day  paint  the  parts  about  the  ulcer  with  equal 
parts  of  iodin  and  alcohol. 

Many  cases  do  very  well  after  antiseptization,  and  dusting  the  ulcer  with 
iodoform,  lead-water  and  laudanum  being  apphed  to  the  inflamed  parts  around 
the  ulcer;  but  in  a  bad  case  hot  antiseptic  fomentations,  compression,  and 
elevation  are  more  useful  until  sloughs  separate.  If  the  discharge  is  offen- 
sive, apply  acetanilid,  aristol,  or  iodoform,  or  use  gr.  iij  of  chloral  to  5j  of 
water,  before  a|)plying  hot  fomentations  or  ordinary  antiseptic  dressings.  A 
25  per  cent,  ointment  of  ichthyol  is  very  useful  when  applied  to  parts  around 
the  ulcer.  If  sloughs  continue  to  form,  touch  the  sloughing  area  with  a  i  :  8 
solution  of  acid  nitrate  of  mercury  or  with  a  solution  of  pure  carbolic  acid, 
and  reapply  antiseptic  fomentations.  If  an  ulcer  continues  to  spread,  clean 
with  peroxid  of  hydrogen,  dry  with  absorbent  cotton,  touch  with  nitrate  of 
mercury  solution  (i:  8),  and  apply  an  antiseptic  fomentation.  Repeat  appli- 
cation of  nitrate  of  mercury  every  day  until  the  ulcer  ceases  to  extend  and  granu- 
lations  begin  to  form.  When  granulations  begin  to  form  moist  hot  dressings 
are  no  longer  necessary,  and  dry  aseptic  or  antiseptic  dressings  can  be  used. 

If  an  ulcer  is  covered  with  a  great  mass  of  aplastic  lymph,  touch  daily  with  a 
solution  of  silver  nitrate  (gr.  xl  to  §  j)  or  with  acid  nitrate  of  mercury  (i  :  15), 
and  dress  with  iodoform  and  antiseptic  fomentations.  Give  internally  tonics, 
stimulants,  and  nutritious  liquid  food.  In  any  case,  when  granulations  form, 
dress  antiseptically  with  dry  dressings,  or  employ  a  non-irritant  ointment,  such 
as  cosmolin.  If  granulations  form  slowly  touch  them  every  day  with  a  solution 
of  silver  nitrate  (gr.  x  to  oj)  and  dress  antiseptically,  or  apply  a  stimulating 
ointment  (resin  cerate  or  5j  of  ung.  hydrarg.  nitratis  to  5vij  of  ung.  petrolii, 
or  an  ointment  of  copper  sulphate,  gr.  iij  to  oj))  or  dress  with  gauze  soaked 
in  a  solution  of  3  drops  of  nitric  acid  to  §j  of  gum  Arabic. 

Chronic  ulcer  of  the  leg  is  characterized  by  low  action  and  slow  prog- 
ress. It  may  be  chronic  from  the  start,  or  it  may  result  from  acute  ulcer. 
Usually  it  is  found  as  a  solitary  ulcer  two  inches  above  the  internal  mal- 
leolus. Syphilitic  ulcers  often  occur  in  a  group,  are  usually  crescentic,  and 
are  frequent  upon  the  front  of  knee.  A  tuberculous  ulcer  may  have  no  granu- 
lations, but  is  usually  covered  with  pale  edematous  granulations,  which  signify 
the  existence  of  a  tendency  to  venous  stasis.  The  edges  of  the  tuberculous 
ulcer  are  undermined  and  irregular,  the  parts  about  it  are  livid  and  tender, 
and  the  discharge  is  thin  and  scanty  (page  250).  An  ordinary  chronic  ulcer 
is  circular  or  oval,  and  is  surrounded  by  congested,  discolored,  and  indurated 
skin,  this  induration  being  due  to  fibrous  tissue,  and  there  is  often  eczema  or  a 
brown  pigmentation  of  the  neighboring  skin.  The  floor  of  the  ulcer  is  uneven, 
and  usually  is  covered  with  granulations,  each  of  which  is  red  and  the  size  of 
a  pin-point,  but  which  may  be  exuberant  or  edematous.  If  granulations  are 
absent,  the  ulcer  has  the  appearance  of  a  piece  of  liver,  or  is  smooth  and 
glazed.     The  edges  are  thick,  turned  out,  and  not  sensitive  to  the  touch. 


1 7©  Ulceration  and  Fistula 

Occasionally,  but  rarely,  they  are  thin  and  undermined.  Some  ulcers  are 
indurated  and  adherent;  this  adhesion  to  the  deeper  structures  prevents 
healing  by  antagonizing  contraction.  An  ulcer  may  fail  to  heal  because  of 
severe  infection;  because  of  want  of  rest;  because  of  absence  of  granulations 
resulting  from  deficient  blood-supply;  because  of  edematous  granulations;  be- 
cause of  exuberant  granulations;  because  of  adhesion  to  deep  structures,  or 
because  of  some  constitutional  disease. 

Treatment. — In  treating  a  chronic  ulcer,  give  a  saline  cathartic  every 
day  or  so.  Treat  any  existing  diathesis.  Insist  on  rest  and,  if  possible, 
elevation.     Asepticize  the  ulcer.     Draw  blood  by  shallow  scarifications  of  the 

bottom  and  edges  of  the  ulcer  and  the 
skin  about  it.  If  the  ulcer  is  adherent  to 
deeper  structures,  make  incisions  like 
those  shown  in  Fig.  80,  each  cut  going 
through  the  deep  fascia.  These  incisions, 
besides  permitting  contraction,  allow  gran- 
ulations to  sprout  in  the  cuts  and  absorb 
Fig.  8o.-incisions  foi  adherent  ulcer.  exudate.  Nussbaum  advocated  encir- 
cling the  ulcer  with  an  incision  about 
one-half  or  two-thirds  of  an  inch  away  from  the  edge  of  the  ulcer,  the  in- 
cision passing  through  the  skin.  After  incision  keep  the  part  elevated 
and  dressed  antiseptically  for  two  days.  In  two  days  after  scarification 
or  incision  scrape  the  ulcer  with  a  curet  until  sound  tissue  is  reached. 
Use  hot  antiseptic  fomentations  for  two  days  more,  then  paint  the  parts 
adjacent  to  the  ulcer  with  tincture  of  iodin  and  alcohol  (1:3),  dress  the 
parts  about  the  ulcer  with  ichthyol  ointment,  and  dress  the  ulcer  antiseptically 
or  with  sterile  gauze.  In  a  day  or  so  the  use  of  ichthyol  should  be  discon- 
tinued and  the  ulcer  be  dressed  with  sterile  gauze,  normal  salt  solution,  boric 
acid,  bichlorid  of  palladium,  chlorin-water,  a  solution  of  permanganate  of 
potassium,  sulphur,  glutei,  protonuclein,  or  bovinin.  Glutol  (formahn- 
gelatin)  is  very  useful  in  some  cases  and  so  is  protonuclein.  When  heahng 
begins,  treat  as  outlined  for  healing  acute  ulcer  (page  168).  Many  cases  can 
be  cured  by  baking  in  the  hot-air  aj^paratus  for  half  an  hour  to  an  hour  daily. 
A  moderate  heat  is  indicated  and  in  the  intervals  of  treatment  an  elastic  ban- 
dage should  be  used  and  if  possible  the  patient  should  be  kept  in  bed. 

Unna's  dressing  is  satisfactory  in  many  cases.  It  is  applied  as  a  fluid, 
painted  on  when  hot.  It  solidifies  on  cooling  and  resembles  rubber.  The 
paint  is  made  as  follows:  Dissolve  4  parts  of  the  best  gelatin  in  10  parts  of 
water  by  means  of  a  hot-water  bath.  While  the  fluid  is  hot  add  10  parts  of 
glycerin,  and  then  4  parts  of  powdered  white  oxid  of  zinc  and  stir  energetically 
until  the  mixture  is  cold.  Melt  the  paint  before  using  by  placing  the  receptacle 
in  a  hot-water  bath.  The  extremity  must  be  clean  and  thoroughly  dry. 
Apply  the  paint  from  just  above  the  roots  of  the  toes  to  just  below  the  knee. 
Cover  the  layer  of  paint  with  a  gauze  bandage;  put  over  this  another  layer  of 
paint,  then  another  bandage,  and  so  on  until  three,  four,  or  five  bandages  have 
been  applied.  To  prevent  wrinkling,  put  the  bandages  on  in  pieces.  The 
outer  layer  of  the  dressing  is  a  coat  of  the  paint.  This  dressing  is  worn  from 
four  to  eight  weeks  unless  it  loosens  sooner.  When  it  loosens,  it  is  changed. 
If  the  ulcer  discharges  freely  and  stains  the  dressing,  cut  a  trap-door  in  the 


Varicose  Veins  171 

dressing  and  through  this  cleanse  the  ulcer  and  apply  dressings  and  a  bandage 
as  often  as  necessary  (Michel,  in  "Chicago  Clinic,"  No.  8,  1900). 

An  excellent  treatment  if  the  patient  must  walk  about  is  camphor,  first 
recommended  by  Schulze  ("Miinchener  medicinische  Wochenschrift, "  March 
19,  1901).  It  is  most  conveniently  used,  as  Walbaum  shows,  in  the  form  of 
spirits  of  camphor  ("  Miinchener  medicinische  Wochenschrift, "  June  25, 1901). 
He  applies  the  dressing  in  the  following  manner:  Clean  the  ulcer  with  green 
soap  and  dress  it  daily  with  dressings  wet  with  a  2  per  cent,  solution  of  the 
acetate  of  aluminium.  In  about  three  days  the  discharge  will  become  scanty 
and  free  from  odor.  It  is  at  this  period  that  camphor  should  be  used.  A 
small  piece  of  gauze  wet  with  spirits  of  camphor  is  applied  directly  and  only  to 
the  ulcer.  Over  this  is  applied  a  large  piece  of  dry  sterile  gauze,  a  rubber 
dam,  a  large  piece  of  absorbent  cotton,  and  a  bandage  from  the  toes  up. 
Every  other  day  the  dressings  are  removed,  the  ulcer  is  washed  with  a  2  per 
cent,  solution  of  carbolic  acid,  and  the  dressings  are  reapplied.  Usually  the 
ulcer  is  healed  in  three  weeks. 

Complications. — Remove  by  scissors  and  forceps  any  badly  damaged 
tissue.  Take  out  dead  bone;  sHt  sinuses;  trim  overhanging  edges.  Treat 
eczema  locally  by  washing  with  ethereal  soap  and  applying  powdered  oxid 
of  zinc  or  borated  talcum,  the  leg  then  being  wrapped  in  cotton.  Unna's 
paint  is  very  useful  in  chronic  eczema.  If  the  part  is  crusted,  the  crusts 
should  be  removed  by  applying  some  oily  materials  and  washing  with  ethereal 
soap  and  water.  Ordinary  soap  should  not  be  used.  In  an  acute  case  soap 
and  water  always  do  harm  and  the  part  is  to  be  cleaned  by  "gently  wiping 
with  cold  cream  or  petrolatum"  (Stelwagon,  on  "Diseases  of  the  Skin").  If 
crusting  is  very  marked  it  may  be  necessary  to  remove  it  by  means  of  an  ordi- 
nary poultice,  or,  better,  a  starch  poultice  made  with  a  2  per  cent,  solution  of 
boracic  acid.  When  scales  or  crusts  are  slight  or  absent  or  when  they  have 
been  removed,  the  remedial  agent  should  be  applied.  The  remedies  for 
eczema  are  legion.  Among  them  are  a  solution  of  lead  acetate;  lead- water 
and  laudanum;  a  powder  composed  of  30  grains  of  powdered  boracic  acid 
and  I  ounce  each  of  talc  and  zinc  oxid;  ung.  picis  liquidse,  5j)  with  sufficient 
ung.  zinci  oxidi  to  make  5j;  h  ounce  of  liquor  carbonis  detergens  to  i  pint 
of  water.  In  every  case  of  eczema  place  the  patient  upon  a  plain  and  nutri- 
tious diet;  order  him  to  avoid  wines  and  liquors;  give  an  occasional  saline 
laxative;  keep  the  skin  and  kidneys  active,  and  if  the  patient  is  gouty  or  rheu- 
matic, give  appropriate  remedies.  The  value  of  arsenic  in  eczema  has  been 
much  overrated. 

Varicose  veins  demand  either  ligation  at  several  points,  excision,  Tren- 
delenburg's operation  (page  461),  circumcision  by  Schede's  method  (page 
461),  or  the  continued  use  of  a  flannel  roller  or  a  Martin  rubber  bandage. 
Never  operate  on  varicose  veins  if  phlebitis  exists  unless  a  clot  has  formed, 
in  which  case  apply  a  ligature  above  the  clot.  Inflammation  is  met  by  rest, 
elevation,  painting  the  neighboring  parts  with  dilute  tincture  of  iodin,  and 
applying  about  the  ulcer  ichthyol  ointment.  For  calloused  edges,  blister, 
employ  radiating  incisions,  or  cut  the  edges  away.  Ordinary  tJiick  edges 
should  be  strapped.  In  strapping  use  zinc  oxid  adhesive  plaster  and  do  not 
completely  encircle  the  Umb  (Fig.  81).  When  the  parts  are  adherent  the 
ulcer  is  immovable,  being  firmly  anchored  to  structures  beneath  it.     In  such 


172 


Ulceration  and  Fistula 


a  condition  completely  or  partly  surround  the  sore  with  a  cut  through  the 
deep  fascia  (Fig.  80).  This  cut  sets  the  ulcer  free  from  its  anchorage  and 
permits  it  to  contract.  Edematous  granulations  require  dry  dressings  and 
pressure  by  a  flannel  bandage,  a  rubber  bandage,  or  adhesive  plaster.  If  the 
bottom  of  the  ulcer  is  joul,  dry  it  and  touch  with  a  solution  of  acid  nitrate 
of  mercury  (i  :  8)  or  with  crystals  of  pure  carbolic  acid.  Repeat  this  every 
third  day  and  dress  with  hot  antiseptic  fomentations  until  granulations  appear. 
Superfluous   granulations  (proud   flesh)   should  be   cut  away  with   scissors, 

scraped  away,  or  burned 
\  _  ^        down  with  a  strong  solu- 

tion of  silver  nitrate,  with 
the  solid  stick  of  lunar 
caustic,  or,  better,  with 
pure  carbolic  acid,  which 
causes  much  less  pain  than 
does  silver.  Absertce  oj 
granulations  or  scantiness 
of  granulations  means  de- 
ficiency of  blood-supply. 
The  surgeon  endeavors  to 
bring  more  blood  to  the 
part,  and  to  do  this  in- 
duces inflammation.  The 
usual  method  of  procedure 
is  to  apply  daily  to  the 
sore  a  solution  of  nitrate 
of  silver  (10  or  15  grains 
to  the  ounce).  Argyrol 
of  a  strength  of  25  per 
cent,  is  not  painful  and  is 
as  eflficient.  In  obstinate 
cases  blister  the  ulcer  or  scrape  it,  or  paint  it  with  tincture  of  iodin,  or  apply 
pure  carbolic  acid,  or  touch  it  with  the  actual  cautery. 

Irritable  ulcer  is  due  to  exposure  of  a  nerve  and  destruction  of  its  sheath 
(page  173).  Find  with  a  probe  the  painful  point  and  incise  it  with  a  teno- 
tome, or  curet  the  ulcer  or  burn  it  with  the  solid  stick  of  silver  nitrate. 

If  healing  entirely  fails,  skin-grajt.  Among  the  methods  of  skin-grafting 
are — (i)  Reverdin's,  (2)  Thiersch's,  and  (3)  Wolfe's.    (See  Plastic  Surgery.) 

When  a  man  having  an  ulcer  must  go  out  and  about,  the  camphor  treatment 
can  be  employed  (page  171),  Unna's  dressing  may  be  applied  (page  170),  or 
the  patient  can  use  a  firmly  applied  roller,  or,  better  still,  a  Martin  bandage. 
Martin's  bandage,  which  is  made  of  red  rubber,  limits  the  amount  of  arterial 
blood  going  to  the  ulcer  and  favors  venous  flow  from  the  sore  and  its  neigh- 
borhood. The  bandage  should  be  used  as  follows:  Before  getting  out  of  bed 
spray  the  sore  with  hydrogen  peroxid  by  means  of  an  atomizer,  remove  the 
froth  with  absorbent  cotton,  wash  the  leg  with  soap  and  water,  dry  it  with  a 
towel,  dust  the  skin  with  borated  talcum  powder,  and  apply  the  bandage. 
All  of  these  things  should  be  done  before  putting  the  foot  to  the  floor.  At 
night,  after  getting  on  the  bed,  remove  the  bandage,  wash  it  with  soap  and 


Fig.  81. — Strapping  an  ulcer  of  leg  (Keen's  Surgery). 


Erethistic,  Irritable,  or  Painful  Ulcers  173 

water,  dry  it  with  a  towel,  hang  it  unrolled  over  the  back  of  a  chair  to  air,  and 
again  cleanse  the  leg  and  ulcer.  If  these  rules  are  not  strictly  observed,  the 
Martin  bandage  will  produce  pain,  suppuration,  and  eczema  of  the  leg. 

Tuberculous  Ulcers  (see  pages  249,  250). 

Syphilitic  Ulcers  (see  page  324). 

A  healthy  ulcer  is  covered  with  small,  bright-red  granulations  which  do 
not  bleed  on  touching,  are  painless,  and  grow  rapidly.  The  edges  of  the  sore 
are  soft  and  show  the  opalescent  blue  line  of  proliferating  epithelium.  The 
sore  is  movable,  the  discharge  is  purulent  and  yellow,  and  the  parts  about 
are  not  inflamed. 

Various  Ulcers. — The  fungous  or  exuberant  ulcer  is  produced  by 
interference  with  the  return  of  venous  blood  from  the  part,  and  it  is  specially 
common  after  burns  and  other  injuries  when  cicatricial  contraction  causes 
venous  obstruction.  The  granulations  are  large,  deep  red  in  color,  bleed 
when  touched,  form  rapidly,  and  mount  above  the  level  of  the  skin.  The 
discharge  from  a  fungous  ulcer  is  profuse,  thin  and  bloody.  In  the  treatment 
of  such  an  ulcer  venous  return  must  be  favored  by  bandaging  and  by  elevation 
of  the  part.  If  the  edges  are  very  thick,  divide  them  in  a  number  of  places. 
The  superfluous  granulations  should  be  burnt  down  with  lunar  caustic  or 
pure  carbolic  acid  or  should  be  cut  off.  Strapping  with  adhesive  plaster  or 
the  use  of  a  rubber  bandage  does  good.  The  sore  can  be  dressed  with 
europhen,  aristol,  or  dry  aseptic  gauze. 

A  varicose  ulcer  is  an  ulcer  complicated  by  varicose  veins.  It  is  usually 
single,  is  oval,  round,  or  irregular  in  outline,  and  is  most  often  seen  above  the 
inner  malleolus.  Its  edges  are  thick,  everted,  and  swollen.  The  swelling  is 
largely  due  to  edema,  and  is  found  to  pit  on  pressure.  The  edges  are  not 
undermined,  but  slope  gently  to  the  floor  of  the  ulcer.  The  floor  is  usually 
covered  with  rather  large  granulations  which  bleed  freely  on  touching.  In  a 
varicose  ulcer  the  destruction  of  tissue  often  begins  at  the  margin  of  a  con- 
gested area  and  advances  toward  the  center.  Such  an  ulcer  is  usually  sur- 
rounded by  eczema.  To  aid  the  heaHng  of  a  varicose  ulcer  it  is  first  of  all 
necessary  to  favor  the  return  of  venous  blood  from  the  part  by  position  and 
bandaging.  Martin's  bandage  is  very  useful  and  the  daily  use  of  the  hot-air 
apparatus  is  of  value.     It  may  be  necessary  to  operate  on  the  veins. 

Erethistic,  irritable,  or  painful  ulcers  are  very  sensitive,  a  condition 
due  to  the  exposure  of  nerve-filaments  and  destruction  of  nerve-sheaths. 
Irritable  ulcers  are  especially  found  near  the  ankle,  over  the  tibia,  in  the  anus 
(fissure),  or  in  the  matrix  of  the  nail  (ingrowing  nail).  Fissure  of  the  anus 
is  considered  on  page  1172.  An  ingrowing  nail  is  sometimes  encountered  on 
the  finger  but  far  more  commonly  affects  the  toe.  The  great  toe  is  especially 
apt  to  suffer.  We  call  it  ingrowing  nail  but  the  condition  is  really  overgrowing 
skin.  As  a  result  of  wearing  ill-fitting  boots  or  stockings,  especially  shoes 
which  are  too  short  or  are  pointed,  the  toes  are  forced  together  and  the  skin 
at  the  edge  of  the  nail  is  pushed  open.     After  a  time  an  ulcer  forms. 

When  a  nail  begins  to  ingrow  the  condition  can  usually  be  arrested  by 
wearing  well-fitting  shoes  and  stockings,  allowing  the  nail  to  grow  somewhat 
long  and  cutting  it  square  across  instead  of  cutting  away  the  troublesome 
corner.  Daily  a  little  absorbent  cotton  should  be  packed  under  the  ingrowing 
corner.  In  more  severe  cases  under  local  anesthesia,  cut  away  the  overlap- 
ping skin  and  a  portion  of  the  flesh  on  the  side  of  the  toe,  split  the  nail  Ion- 


174  Ulceration  and  Fistula 

gitudinally,  remove  the  ingrown  portion  of  nail  and  a  corresponding  part  of 
the  matrix. 

An  erethistic  ulcer  of  the  cutaneous  surface  is  treated  as  follows:  Curet 
and  touch  with  pure  carbolic  acid  or  with  the  solid  stick  of  silver  nitrate. 
Chloral,  gr.  xx  to  the  ounce,  allays  the  pain;  so  do  cocain  and  eucain  for  a 
time.  In  some  cases  the  painful  area  can  be  located  with  a  probe  and  the 
nerve-filament  divided  with  a  tenotome. 

The  indolent  ulcer  shows  no  tendency  to  heal.  In  such  an  ulcer  there 
is  usually  venous  congestion  from  varicose  veins  or  from  cardiac  weakness. 
A  great  mass  of  scar-tissue  forms  at  the  base  and  edges,  which  fastens  the 
ulcer  to  bone  or  fascia,  so  that  the  edges  cannot  contract.  Healthy  granula- 
tions cease  to  form.  The  edges  of  such  an  ulcer  are  thick,  smooth,  immovable, 
and  free  from  tenderness.  Granulations  are  entirely  absent  or  there  are  seen 
here  and  there  a  few  unhealthy  granulations.  The  discharge  is  thin,  sero- 
purulent,  and  offensive.  The  parts  about  the  ulcer  are  congested  and  pig- 
mented. The  pigmentation  is  due  to  the  fact  that  in  the  area  of  chronic 
congestion  numbers  of  red  blood-cells  have  been  disintegrated.  Such  an 
ulcer  is  treated  by  making  incisions  to  loosen  the  base  and  edges,  so  that  con- 
traction can  take  place.  Venous  congestion  is  corrected  by  means  of  posi- 
tion, the  use  of  compression,  and  in  some  cases  the  administration  of  cardiac 
stimulants.  In  all  cases  the  surgeon  employs  stimulating  applications  to  the 
ulcer  in  order  to  increase  the  supply  of  arterial  blood. 

The  callous  ulcer  is  the  most  chronic  form  of  indolent  ulcer  and  is  sunken 
deeply  below  the  level  of  the  skin.  Its  border  is  hard  and  knobby.  Its  floor 
shows  no  granulations,  and  is  either  smooth  and  glistening  or  foul  and  liver- 
colored.  The  discharge  is  thin  and  scanty,  and  the  ulcer  varies  little  in 
appearance  from  week  to  week  or  even  from  month  to  month.  The  treat- 
ment consists  in  scraping  and  cauterizing  the  ulcer;  making  radiating  incisions 
through  the  margins  and  floor  or  eUiptical  incisions  about  the  ulcer;  applying 
antiseptic  dressings  and  a  firm  liandage.  In  some  cases  the  ulcer  should  be 
strapped.  The  daily  baking  in  the  hot-air  oven  is  often  of  great  benefit. 
In  severe  cases  it  is  necessary  to  extirpate  the  ulcer  and  apply  skin-grafts. 

Hemorrhagic  ulcers  bleed  easily  and  profusely.  Pressure  must  be 
applied;  it  is  sometimes  necessary  to  cut  or  burn  away  the  granulations. 

Phagedenic  Ulcers. — The  phagedenic  ulcer  results  from  the  profound 
microbic  infection  of  tissues  debilitated  by  local  or  constitutional  disease,  and 
is  commonly  venereal.  This  ulcer  has  no  granulations  and  is  covered  with 
sloughs;  its  edges  are  thin  and  undermined,  and  it  spreads  rapidly  in  all 
directions.  Such  an  ulcer  should  be  touched  with  strong  caustics  or  Paque- 
Hn's  cautery,  and  dressed  with  iodoform  gauze  and  antiseptic  fomentations. 
Tonics  and  stimulants  should  always  be  administered. 

The  edematous  ulcer  may  result  from  impediment  to  the  venous  return 
or,  as  Nancrede  points  out,  may  be  produced  by  the  persistent  use  of  poultices 
or  wet  dressings  upon  any  ulcer.*  It  is  most  often  met  with  in  tuberculous 
processes  and  is  occasionally  seen  when  varicose  veins  exist.  The  granula- 
tions are  large  and  pale,  and  are  apt  to  bend  over  like  unsupported  vines. 
The  discharge  is  profuse  and  seropurulent.  The  edges  are  softened  and 
desquamating.  An  edematous  ulcer  requires  dry  dressings,  stimulation,  and 
compression. 

*  "  Principles  of  Surgen'." 


Miirjolin's  Ulcer 


175 


A  rodent  or  Jacob's  ulcer,  noli  me  tangere,  or  cancroid  ulcer,  is  a 

superficial  epilhelionia  developing  u>ually  from  sebaieous  glands,  sweat- 
glands,  or  hair  follicles.  It  recjuires  scraping  and  cauterization,  or,  what  is 
better,  excision  (page  390). 


Fig.  82. — Marjolin's  ulcer  in  a  man  twenty  years  of  age,  arising  in  the  cicatrix  of  a  burn. 


Fig.  83. — Same  case  as  Fig.  82,  after  excision  and  skin-grafting  by  the  Thiersch  methofl. 

Marjolin's  ulcer  (Figs.  82-84)  is.  an  epitheUoma  arising  from  a  chronic 
ulcer  or  an  old  cicatrix.  The  malignant  change  begins  at  some  point  of  the 
edge  of  the  ulcer,  and  its  first  evidence  is  induration.     The  induration  spreads 


176 


Ulceralion  and  Fistula 


slowly  and  comes  to  involve  a  considerable  part  of  or  even  the  entire  ulcer. 
Marjolin's  ulcer  is  the  seat  of  scalding,  dardng  pain;  the  discharge  is  profuse, 
ichorous,  and  foul,  and  the  floor  of  the  ulcer  is  uneven,  warty,  or  cauliflower- 
like. The  anatomically  related  lymph-glands  eventually  become  involved. 
This  involvement  is  seldom  early  because  induration  has  blocked  lymph- 
channels.  In  order  to  confirm  the  diagnosis  a  bit  of  tissue  should  be  removed, 
and  the  removed  piece  must  include  a  portion  of  the  edge  of  the  ulcer  and  of 
some  apparently  sound  tissue  beyond  it.  If  a  microscopical  examination 
shows  epithelial  infiltration  of  the  apparently  sound  tissue,  a  diagnosis  of 
malignant  disease  must  be  made.  In  an  early  stage  of  such  an  ulcer  free 
extirpation  and  removal  of  the  anatomically  related  glands  may  cure  the 
patient.  In  a  more  advanced  case,  if  an  extremity  is  involved,  amputate  and 
clear  out  the  related  lymphatic  area.     In  a  very  advanced  case  use  the  .v-rays. 


P'ig.  84. — Marjolin's  ulcer,  arising  from  a  chronic  ulcer  of  the  leg. 


Fig.  82  shows  a  Marjolin's  ulcer  in  a  man  twenty  years  of  age.  It  arose 
in  the  cicatrix  of  a  burn.  I  removed  it  and  applied  Thiersch  grafts  to  the 
raw  surface. 

Decubitus,  or  bed-sore,  is  due  to  pressure  upon  an  area  of  feeble  circu- 
lation (page  195).     It  is  in  most  instances  a  condition  of  gangrene. 

Neuroparalytic  or  trophic  ulcer  is  due  to  impairment  of  the  trophic 
nerve-fibers  or  of  the  trophic  centers  in  the  cord. 

The  perforating  ulcer,  as  it  was  named  by  Vesigne,  is  believed  to  result 
from  peripheral  neuritis.  It  is  certain,  however,  that  in  some  of  these  cases 
there  is  arterio-sclerosis  and  it  has  been  held  that  the  vascular  sclerosis  is  the 
real  cause  and  that  the  nerve  changes  are  secondary  to  the  vascular  changes. 
My  own  belief  is  that  perforating  ulcer  is  a  condition  dependent  upon  both  ar- 
teriosclerosis and  peripheral  neuritis,  traumatism  usually  being  the  exciting 
cause  of  the  ulcer.  It  is  met  with  most  frequently  in  diabetics,  but  may  be  en- 
countered in  the  victims  of  chronic  alcoholism,  injuries  and  diseases  of  the  spinal 
cord,  injuries  and  diseases  of  nerves,  Bright's  disease,  and  syphilis.     I  have 


Curling's  Ulcer  177 

seen  this  ulcer  in  an  individual  with  a  fractured  spine,  in  two  tabetics, 
and  in  several  diabetics.  The  perforating  ulcer  commonly  affects  the 
plantar  surface  of  the  metatarsophalangeal  joint  or  the  pulp  of  the  great 
toe  or  little  toe  about  a  callosity  or  corn.  It  may  arise  on  the  heel  or 
the  sole  or  the  side  of  the  foot.  It  is  usually  unilateral  but  sometimes 
both  feet  are  affected.  Very  rarely  it  affects  the  palm  of  the  hand.  The 
parts  about  the  corn  inflame,  and  pus  forms  and  reaches  into  the  bone. 
A  sinus  evacuates  the  pus  by  the  side  of  the  corn  or  callosity  or  the 
center  of  the  callosity  exhibits  a  blister  containing  sero-pus.  A  portion 
of  the  callous  mass  is  cast  off  and  a  shallow  ulcer  is  often  exposed.  This 
ulcer  is  small,  has  a  punched-out  appearance,  and  is  surrounded  by  cal- 
loused margins.  The  ulcer  penetrates  deeply  and  after  a  time  the  bone  is  laid 
bare  or  the  joint  opened.  The  margins  of  the  ulcer  or  sinus  exhibit  sprout- 
ing granulations  and  these  are  encircled  by  an  area  of  markedly  thickened 
epidermis.  In  very  rare  cases  more  than  one  ulcer  is  present  on  the  foot.  The 
discharge  from  a  perforating  ulcer  is  thin  and  scanty  and  the  ulcer,  which 
slowly  advances,  is  very  chronic.  It  is  not  painful  and  is  slightly,  if  at  all, 
tender.  The  foot  is  cold  and  often  edematous  and  the  parts  about  the  ulcer 
may  be  anesthetic.  The  ulcer  may  heal  when  the  patient  is  kept  in  bed  and 
open  again  when  he  gets  about.  The  disease  is  far  more  common  among 
males  than  among  females  and  is  most  often  met  with  in  the  fourth  or  fifth 
decades  of  life.  As  this  ulcer  may  be  present  in  anesthetic  leprosy,  in  diabetes, 
peripheral  neuritis,  syphilis,  in  a  paralyzed  limb,  and  tabes  dorsalis,  and  as 
the  part  on  which  it  occurs  is  apt  to  be  sweaty,  cold,  and  more  or  less  anesthetic, 
and  as  the  sore  may  be  hereditary,  it  is  usually  set  down  as  trophic  in  origin. 
In  treatment  of  a  perforating  ulcer  I  follow  the  plan  suggested  by  Treves. 
This  consists  in  putting  the  patient  to  bed  and  applying  poultices  to 
the  sore.  Every  time  a  poultice  is  removed  the  raised  epithelium  around 
the  ulcer  is  cut  away  and  then  the  poultice  is  reapplied.  In  about  two 
weeks  an  ulcer  remains  surrounded  by  healthy  tissue.  Treves  treats  this 
sore  with  glycerin  made  to  a  creamy  consistency  with  saUcylic  acid,  to  each 
ounce  of  which  mixture  n\x  of  carbohc  acid  have  been  added.  He  directs  the 
patient  to  wear  during  the  rest  of  his  life  some  form  of  bunion-plaster  to 
keep  off  pressure.  If  in  a  perforating  ulcer  the  bone  is  diseased,  it  must  be 
removed.  If  the  patient  is  diabetic  he  must  be  placed  on  antidiabetic  diet  and 
drugs.  Nerve-stretching  has  been  recommended  as  the  proper  treatment  for 
perforating  ulcer,  but  I  have  never  tried  it.  No  matter  what  treatment  is 
employed,  the  sore  is  apt  to  reappear  in  the  old  situation  or  an  adjacent 
region,  when  the  part  is  subjected  to  pressure.  In  order  to  prevent  pressure 
upon  the  region  of  ulceration  some  advise  the  use  of  an  artificial  leg,  the  knee 
being  kept  bent.     It  may  be  necessary  to  amputate  the  toe  or  the  foot. 

The  scorbutic  ulcer  is  covered  with  a  dark-brown  crust,  beneath  which 
are  pale  and  bleeding  granulations.     The  parts  adjacent  are  of  a  violet  color. 

EpitheHomatous,  sarcomatous,  tuberculous,  and  syphilitic  ulcers  and  ulcers 
of  the  stomach  and  duodenum  are  considered  under  these  respective  diseases. 

Curling's  Ulcer. — This  is  an  ulcer  of  the  first  portion  of  the  duodenum 
which  in  rare  cases  follows  an  extensive  burn  of  the  cutaneous  surface.  It  is 
snj^ll,  clean  cut,  and  deep  and  is  due  to  embolism,  the  emboli  being  hyaUne 
material  precipitated  from  the  blood.     The  treatment  is  gastro-enterostomy^ 


lyS  Ulceration  and  Fistula 

If  perforation  occurs  the  treatment  is  as  for  any  other  perforating  duodenal 
ulcer. 

Fistula. — A  fistula  is  an  abnormal  communication  between  the  surface 
and  an  internal  part  of  the  body,  or  between  two  natural  cavities  or  canals. 
The  first  form  is  seen  in  a  rectal  fistula,  a  urethral  fistula,  or  a  biliary  fistula; 
and  the  second  form  is  seen  in  a  vesicovaginal  fistula.  Fistulas  may  result 
from  congenital  defect,  as  when  there  is  failure  in  the  closure  of  the  branchial 
clefts,  and  can  arise  from  sloughing,  traumatism,  and  suppuration.  Fistulas 
are  named  from  their  situation  and  communications.  For  instance,  a  pleural 
fistula,  an  intestinal  or  fecal  fistula,  a  rectal  fistula,  an  anal  fistula,  a  gastric 
fistula,  a  bronchial  fistula,  a  vesical  fistula,  a  biliary  fistula,  etc.  Many  fis- 
tula' are  tuberculous  and  lead  to  some  deeply  placed  tuberculous  focus.  A 
fistula  in  communication  with  a  viscus  (for  instance,  the  gall-bladder)  may  be 
maintained  by  an  obstruction  of  the  duct  of  that  viscus  the  removal  of  which 
cures  the  fistula. 

A  sinus  is  a  tortuous  track  opening  usually  upon  a  free  surface  and  leading 
down  into  the  cavity  of  an  imperfectly  healed  abscess.  A  sinus  may  be  an 
unhealed  portion  of  a  wound.  Many  sinuses  are  due  to  pus  burrowing  sub- 
cutaneously.  A  sinus  fails  to  heal  because  of  the  presence  of  some  irritant 
fluid,  as  saliva,  urine,  or  bile;  because  of  the  existence  of  a  foreign  body,  as 
dead  bone,  a  bit  of  wood,  a  bullet,  a  septic  ligature,  etc.;  or  because  of  rigidity 
of  the  sinus-walls,  which  rigidity  will  not  permit  collapse.  Sinuses  may  be 
maintained  by  want  of  rest  (muscular  movements)  and  general  ill  health. 
The  walls  of  a  tuberculous  sinus  are  lined  with  a  material  identical  with  the 
Volkmann's  membrane  of  a  cold  abscess. 

Treatment. — In  treating  a  fistula  or  a  sinus,  remove  any  causative 
obstruction  and  any  foreign  body,  lay  the  channel  open,  curet,  brush  with 
pure  carbolic  acid,  and  pack  with  iodoform  gauze.  Sometimes  cure  of  a 
tuberculous  sinus  may  be  secured  by  repeated  injections  of  iodoform  emul- 
sion or  by  injecting  a  paste  of  subnitrate  of  bismuth  and  vaselin  (page  892). 
The  mixture  remains  in  the  sinus  and  serves  as  a  framework  for  granulations. 
In  obstinate  cases  of  fistula  or  sinus  entirely  extirpate  the  fibrous  walls,  sew 
the  deeper  parts  of  the  wound  with  buried  catgut  sutures,  and  approximate 
the  skin  surfaces  with  interrupted  sutures  of  silkworm-gut.  To  stimulate 
a  sinus  to  granulation  it  is  sometimes  necessary  to  touch  it  throughout  with 
the  actual  cautery,  nitric  acid,  pure  carbolic  acid,  nitrate  of  silver  fused  on  a 
metallic  probe,  or  in  a  solution  of  a  strength  of  gr.  xl  to  the  ounce,  or  argyrol 
of  a  strength  of  50  per  cent.  Fresh  air  is  a  necessity  to  the  j)atient,  and  nutri- 
tious food  and  tonics  must  be  ordered.  There  is  some  testimony,  although 
scarcely  as  yet  evidence,  that  the  use  of  bacterial  vaccines  may  at  times  be  of 
value  in  the  treatment  of  certain  sinuses  (see  page  46). 


AJicrobic  (jangrcne  179 


Vm.  MORTIFICATION,  GANGRENE,  OR  SPHACELUS. 

Mortification,  or  gangrene,  is  death  in  mass  of  a  portion  of  the  Hving  body 
— the  dead  portions  being  large  enough  to  be  visible — in  contrast  to  ulceration, 
or  molecular  death,  in  which  the  dead  particles  have  been  liquefied,  cannot 
be  seen,  and  are  cast  away.  When  all  the  tissues  of  a  part  are  dead,  the  pro- 
cess is  spoken  of  as  sphacelus.  Gangrene  is  in  reality  a  form  of  necrosis, 
but  clinically  the  term  necrosis  is  restricted  to  molar  death  of  bone  or  to  death 
of  parts  below  the  surface  en  masse.  In  gangrene  a  portion  of  tissue  dies 
because  of  anemia,  and  the  dead  portions  may  either  desiccate  or  putrefy. 
Gangrene  may  be  due  to  tissue  injury,  either  chemical  or  mechanical,  to  heat 
or  cold,  to  failure  of  the  general  health,  to  circulatory  obstruction,  to  nerve 
disorder,  the  nerves  involved  being  the  vasomotor  or  possibly  the  trophic,  or 
to  microbic  infection.  A  microbic  poison  can  directly  destroy  tissues.  It 
can  indirectly  destroy  them  by  causing  such  intlammation  that  the  products 
obstruct  the  circulation,  but  gangrene  can  occur  when  no  bacteria  are  present. 
The  essential  cause  of  gangrene  is  that  the  tissues  are  cut  off  from  a  due  supply 
of  nourishment,  and  cell-nutrition  is  no  longer  possible.  In  other  words, 
the  essential  cause  of  gangrene  is  the  cutting  off  of  arterial  blood.  Nancrede 
says:  "Indeed,  except  when  the  traumatism  physically  disintegrates  tissues, 
as  a  stone  is  reduced  to  powder,  heat  or  strong  acids  physically  destroy  struc- 
ture, or  cold  suspends  cellular  nutrition  so  long  that  when  this  nutrition  be- 
comes a  physical  possibility  vital  metabolism  cannot  be  resumed,  gangrene 
always  results  from  total  deprivation  of  pabulum."  * 

Classification. — Gangrene  is  divided  into  the  following  three  great 
groups: 

(i)  Dry  gangrene,  which  is  due  to  circulatory  interference,  the  arterial 
supply  being  decreased  or  cut  off.     The  tissues  dry  and  mummify. 

(2)  Moist  gangrene,  which  is  due  to  interference  not  only  with  arterial 
ingress,  but  also  with  venous  return  or  capillary  circulation,  the  dead  parts 
remaining  moist. 

(3)  Microbic  -gangrene,  arising  from  virulent  bacteria.  In  this  form 
the  bacterial  process  causes  the  gangrene,  and  is  not  merely  associated  with  it. 

The  above  classification,  if  unqualified,  suggests  erroneous  ideas.  It  in- 
dicates that  there  is  an  essential  difference  between  dry  gangrene  and  moist 
gangrene,  which  is  not  the  case.  If,  when  gangrene  begins,  the  tissues  are 
free  from  fluid,  the  patient  develops  dry  gangrene;  if  they  are  full  of  fluid,  he 
develops  moist  gangrene.  If  the  arterial  supply  is  gradually  cut  off,  the  tissues 
are  sure  to  be  free  from  fluid,  and  the  gangrene  will  certainly  be  of  the  dry 
form.  If  arterial  blood  is  suddenly  cut  off,  the  gangrene  may  be  dry  or  moist, 
according  as  to  whether  the  tissues  are  or  are  not  drained  of  fluid.  When 
gangrene  results  from  inflammation,  strangulation,  and  infection,  it  is  certain 
to  be  of  the  moist  variety,  because  the  tissues  are  sure  to  be  filled  with  fluid. 

Nancrede  says,  in  his  very  valuable  work  on  the  "Principles  of  Surgery": 
"Yet,  let  accidental  inflammation  have  preceded  the  final  blocking  of  an 
artery,  or  let  ligation  of  the  main  artery  cause  gangrene  because  the  collateral 

*  "  Principles  of  Surgery." 


i8o  Mortification,  Gangrene,  or  Sphacelus 

circulation  cannot  become  developed,  and  if  an  aneurysmal  sac  is  so  situated 
as  to  interfere  with  a  free  return  of  venous  blood  and  lymph,  this  anemic 
gangrene  will  in  both  instances  prove  moist  and  not  dry." 

There  are  many  gangrenous  processes  which  belong  under  one  or  other 
of  the  above  heads,  namely:  congenital  gangrene,  a  rare  form  existing  at  birth; 
constitutional  gangrene,  arising  from  a  constitutional  cause,  as  diabetes; 
cutaneous  gangrene,  which  is  limited  to  skin  and  subcutaneous  tissue,  as  in 
phlegmonous  erysipelas;  gaseous  or  emphysematous  gangrene,  in  which  the 
subcutaneous  tissues  are  filled  with  putrefactive  gases  and  crackle  on  pressure; 
hospital  gangrene,  which  is  defined  by  Foster  as  specific  serpiginous  necrosis, 
the  tissues  being  pulpefied:  some  consider  it  a  traumatic  diphtheria;  cold 
gangrene,  a  form  in  which  the  parts  are  entirely  dead  (sphacelus) ;  hot  gan- 
grene, which  is  associated  with  inflammation,  as  shown  by  heat;  dermatitis 
gangrcBnosa  infantum,  or  the  multiple  cachectic  gangrene  of  Simon;  idiopathic 
gangrene,  which  has  no  ascertainable  cause;  mixed,  which  is  partly  dry  and 
partly  moist;  primary,  in  which  the  death  of  the  part  is  direct,  as  from  a  bum; 
secondary,  which  follows  an  acute  inflammation;  multiple,  as  gangrenous 
herpes  zoster;  diabetic  or  glycemic  gangrene,  which  arises  during  the  existence 
of  diabetes;  gangrenous  ecthy?na,  a  gangrenous  condition  of  ecthyma  ulcers; 
pressure,  which  is  due  to  long  compression;  purpuric  or  scorbutic,  which  is 
due  to  scurvy ;  Raynaud^ s  or  idiopathic  symmetrical,  which  is  due  to  vascular 
spasm  from  nerve  disorder;  senile,  the  dry  gangrene  of  the  aged;  venous  or 
static,  which  is  due  to  obstruction  of  circulation,  as  in  a  strangulated  hernia; 
trophic,  which  is  due  to  nutritive  failure  by  reason  of  disorder  of  the  trophic 
nerves  or  centers;  thrombotic,  which  is  due  to  thrombus;  embolic,  which  is  due 
to  embolus;  and  decubitus,  decubital  gangrene,  or  bed-sores  due  to  pressure. 

Dry  gangrene  arises  from  deficiency  of  arterial  blood.  For  this  reason 
Nancrede  calls  it  anemic  gangrene. 

This  form  of  gangrene  is  far  more  apt  to  result  from  the  gradual  than  from 
the  sudden  cutting  off  of  the  supply  of  arterial  blood,  and  is  more  common  if 
the  blood-vessels  are  atheromatous  than  if  they  are  healthy;  but  even  in  a 
person  with  healthy  arteries  gangrene  will  ensue  upon  blocking  of  the  main 
artery,  if  the  collaterals  fail  to  supply  the  part  with  blood.  This  form  of 
gangrene  can  occur  after  laceration,  ligation,  or  the  lodgment  of  an  embolus 
in  the  main  arter}"^  of  a  limb ;  but  in  such  accidents  considerable  fluid  usually 
remains  in  the  tissues  and  the  gangrene  is  apt  to  be  moist  rather  than  dry. 

Non-senile  Dry  Gangrene. — An  embolus  may  cause  dry  gangrene  in 
rare  instances.  If  it  does  so,  it  is  probable  that  the  blocking  was  not  at  once 
complete.  When  an  embolus  lodges  in  an  artery  and  causes  dry  gangrene, 
the  case  runs  the  following  course:  sudden  severe  pain  at  the  seat  of  impaction, 
and  also  tenderness;  pulsation  above,  but  not  below,  this  point,  after  obstruc- 
tion has  become  complete;  the  limb  below  the  obstruction  is  blanched,  cold, 
and  anesthetic;  within  forty-eight  hours,  as  a  rule,  the  area  of  gangrene  is 
widespread  and  clearly  evident;  the  limb  becomes  reddish,  greenish,  blue, 
and  then  black;  the  skin  becomes  shriveled  and  its  outer  layer  stony  or  like 
horn  because  of  evaporation.  The  entire  part  may  become  dry;  but  usually 
there  are  spots  where  some  fluid  remains,  and  these  spots  are  soft  and  moist, 
and  the  dead  tissue,  where  it  joins  the  living,  is  sure  to  be  moist.  The  moist 
areas  become  foul  and  putrid,  but  the  dry  spots  do  not.     In  dry  gangrene,  at 


Senile  Gangrene 


i8i 


the  point  of  contact  of  the  dead  and  living  tissues,  inflammation  arises  in  the 
latter  structures,  a  bright-red  line  forms,  and  exudation  and  ulceration  take 
place.  This  line  of  ulceration  in  the  sound  tissues  is  called  the  "  line  of  de- 
marcation." It  is  Nature's  effort  at  amputation,  and  in  time  may  get  rid  of  a 
large  portion  of  a  limb,  and  then  heal  as  any  other  ulcer.  A  line  of  demarca- 
tion rarely  causes  hemorrhage,  because  it  ulcerates  through  a  vessel  only  after 
inflammation  has  caused  occlusion  by  thrombosis.  In  dry  gangrene  from 
arterial  obstruction  there  is  gastro-intestinal  derangement  and  also  some  fever. 
The  gangrene  does  not  extend  up  to  the  point  of  obstruction,  but  only  to  a 
region  in  which  the  anastomotic  circulation  is  sufificiently  active  to  permit  of 
the  formation  of  a  hne  of  demarcation.  Below  this  point  inflammatory  stasis 
arises,  but  before  this  can  go  on  to  ulceration  the  parts  die.  In  cases  where  the 
arterial  obstruction  is  sudden  and  complete  the  limb  swells  decidedly.  This  is 
due  to  the  sudden  loss  of  z'is  a  tergo  in  the  arterial  system,  venous  reflux  occur- 
ring and  fluids  transuding.  In  such  a  case  the  tissues  contain  fluid  and  putrefy, 
and  the  process,  though  due  to  the  cutting  oiT  of  the  arterial  circulation,  is 
moist  gangrene.  Dry  gangrene  attacks  the  leg  more  often  than  the  arm. 
A  thrombus  in  an  artery  rarely  causes  gangrene  except  in  the  aged,  as  the 
collateral  circulation  has  time  to  adjust  itself;  but  gangrene  may  follow 
thrombus  formation,  and  when  it  does  it  comes  on  more  slowly  than  does  gan- 
grene from  embolus,  and  is  certain  to  be  of  the  dry  form. 

Treatment  oj  Non-senile  Dry  Gangrene. — When  injury  or  blocking  of  a 
healthy  artery  causes  us  to  fear  the  onset  of  dry  gangrene,  the  patient  should 
be  placed  in  bed  and  the  part  elevated  a  little,  kept  wrapped  in  cotton-wool 
and  surrounded  with  bottles  filled  with  warm  water.  If  gangrene  begins,  wait 
for  a  line  of  demarcation,  and  while  waiting  dress  the  dying  and  dead  parts 
antiseptically,  wrap  the  extremity  in  cotton  and  keep  it  warm,  and  see  to  it 
that  the  patient  gets  plenty  of  sleep  and  nourishment.  It  is  also  advisable  to 
give  tonics  and  stimulants.  When  a  line  of  demarcation  forms,  amputate  well 
above  it. 

Senile  gangrene,  chronic  gangrene,  Pott's  gangrene  (Fig.  85),  is  a 
form  of  gangrene  due  to  feeble  action  of  the  heart  plus  obliterating  endarteritis 
or  atheroma  of  periph- 
eral vessels.  The  ves- 
sels do  not  carry  a  nor- 
mal amount  of  blood, 
and  may  at  any  time  be 
occluded  by  thrombosis. 
In  a  drunkard,  or  in  a 
victim  of  syphilis  or  tu- 
bercle, the  changes  sup- 
posed to  characterize  old 
age  may  appear  while  a 
man  is  young  in  years. 
It  was  long  ago  said, 
with  truth,  "a  man  is  as 
occurs  in  a  toe  or  the  foot. 

Symptoms. — A  man  whose  vessels  are  in  the  state  above  indicated  is  gener- 
ally in  feeble  health  and  has  a  fatty  heart  and  an  arcus  senilis  (a  red  or  white 


Fig.  85.— Senile  gangrene  of  the  feet  (Gross). 


old  as  his  arteries."     Senile  gangrene  most  often 


l82 


Mortification,  Gangrene,  or  Sphacelus 


line  of  fatty  degeneration  around  the  cornea).  His  toes  and  feet  are  cold  and 
feel  numb,  and  they  "go  to  sleep"  very  easily,  and  he  suflfers  from  cramp  of  the 
legs  and  feet.  He  is  dyspeptic  and  short  of  breath,  and  his  urine  is  frequently 
albuminous.  The  arteries  are  felt  as  rigid  tubes,  hke  pipe-stems.  He  is  in 
danger  of  edema  of  the  lungs  and  of  dry  gangrene  of  the  toes.  A  shght  injury 
of  a  toe — for  instance,  cutting  a  corn  too  close — will  produce  extensive  in- 
tiammatory  stasis  followed  by  thrombosis,  which  completely  cuts  off  the  blood- 
supply  and  causes  gangrene  of  the  part.  Gangrene  is  usually  announced  by 
the  appearance  of  a  purple  and  anesthetic  spot  followed  by  a  vesicle  which 
ruptures  and  liberates  a  small  amount  of  bloody  serum  and  e.xposes  a  dry 
floor.  In  the  parts  about  the  gangrenous  area  there  is  often  burning  pain. 
The  circulation  in  the  tissues  immediately  adjacent  to  the  dead  spot  is  retarded 
or  stagnated,  the  parts  being  purple  and  the  color  not  disappearing  or  dis- 
appearing  slowly   under  pressure.      If   the  color  fades   under   pressure  it 

returns  slowly  when  pressure 
is  removed.     The  parts  a  httle 
further  removed  are  h}'pere- 
.  ^H^^K^^^^^HPHi^B^^^^^H     ^^'    ^^^  color   disappearing 

m  ^A^^^H^^^^E^^^^I^^^^^H    rapidly  on  pressure,  and  re- 

turning rapidly  when  pres- 
sure is  removed.  The  dead 
parts  do  not  putrefy  at  all  or 
do  so  but  sHghtly,  hence  the 
odor  is  never  ver}'  ofl'ensive 
and  is  usually  trivial.  They 
are  anesthetic,  hard,  leather}-, 
and  WTinkled,  and  resemble  a 
varnished  anatomical  speci- 
men or  the  extremity  of  a 
mummy  (hence  the  term  minn- 
mificatiou).  Before  the  line 
of  demarcation  forms  there 
is  burning  pain;  after  it  forms 
pain  is  rarely  present.  If  em- 
bolism or  thrombus  in  a  dis- 
eased vessel  caused  the  gangrene,  the  pain  is  severe  at  the  point  of  im- 
paction. In  senile  gangrene  the  distal  portion  of  the  dead  area  is  always 
dry,  the  part  nearer  the  body  being  generally  somewhat  moist.  The  process 
may  be  very  limited  or  it  may  spread  up  to  the  knee.  As  it  spreads  the  area 
of  h}-peremia  advances  at  the  margin,  the  area  of  stasis  follows,  and  the 
zone  of  gangrene  becomes  more  extensive.  When  tissues  are  reached,  the 
blood-supply  of  which  is  sufficiently  good  to  permit  of  inflammation  going  be- 
yond the  stage  of  stasis  and  to  allow  of  stasis  without  extensive  thrombosis, 
Nature  tries  to  Hmit  the  gangrene  by  the  formation  of  a  line  of  de- 
marcation. A  Hne  of  demarcation  may  begin,  but  prove  abortive,  the 
tissue  mortifying  above  it.  This  proves  that  tissue  near  the  hne  is  in 
a  state  of  low  \'itaht\'.  The  line  of  demarcation  may  prove  durable 
and  in  some  few  cases  spontaneous  amputation  takes  place  (Fig.  86). 
When  a  limited  area  is  gangrenous,  constitutional  s}Tnptoms  are  trivial  or 


Fig.  86.— Dr.  Keller's  case  of  spontaneous  amputation  of  a 
toot  and  part  of  a  leg  in  a  condition  of  senile  gangrene. 


Senile  Gangrene  183 

absent;  but  when  a  large  area  is  involved,  the  fever  of  septic  absorption  exists. 
Death  may  ensue  from  exhaustion  caused  by  sleeplessness  and  pain,  from 
septic  absorption,  or  from  embolism  of  internal  organs.  In  many  cases  of 
senile  gangrene  clots  are  formed  in  the  superficial  femoral  artery  or  its  branches 
(Heidenhain),  an  observation  it  is  important  to  bear  in  mind  when  am- 
putating. 

Prez'ention  of  Senile  Gangrene  in  the  Predisposed. — Such  a  patient  must 
avoid  injuring  his  toes  and  feet.  Cutting  his  corns  carelessly  is  highly  dan- 
gerous, and  any  wound,  however  sUght,  requires  rest  and  antiseptic  dressing. 
The  victim  of  general  atheroma  must  wear  woolen  stockings,  put  a  rubber 
bag  containing  warm  water  to  his  feet  on  cold  nights,  and  attend  to  his  gen- 
eral health.  A  httle  whiskey  after  each  meal  is  indicated,  and  occasional 
courses  of  nitroglycerin  are  desirable. 

Treatment  oj  Senile  Gangrene. — When  gangrene  occurs,  if  it  is  Hmited  to 
one  toe  or  a  portion  of  several  toes,  if  it  is  a  first  attack,  if  there  is  no  fever  or 
exhausting  diarrhea,  if  there  is  no  tendency  to  pulmonary  congestion,  if  the 
appetite  is  fair  and  sleep  refreshing,  it  is  best  to  avoid  radical  interference 
and  to  await  the  formation  of  a  line  of  demarcation.  While  awaiting  the  line 
of  demarcation  dress  the  part  antiseptically,  raise  the  foot  several  inches 
from  the  bed  and  surround  the  part  with  bottles  of  moderately  warm  water. 
Very  warm  water  may  do  harm.  Give  the  patient  nourishing  diet,  stimulants, 
and  tonics;  see  to  it  that  he  sleeps,  and  during  the  spread  of  the  gangrene 
watch  for  fever,  diarrhea,  pulmonary  congestion,  and  kidney  failure.  AVhen 
a  line  of  demarcation  forms,  dress  with  warm  antiseptic  fomentations  and 
iodoform,  and  every  day  pick  away  dead  bits  with  the  scissors  and  forceps. 
A  tendon  or  ligament  should  be  cut  through  and  a  protruding  phalanx  should 
be  divided  with  a  Gigli  saw.  If  an  ulcer  forms  skin-grafts  may  be  applied. 
In  many  cases  lieaUng  wall  occur;  but  even  when  the  parts  heal,  the  patient 
will  always  be  in  deadly  peril  of  another  attack.  If  the  gangrene  shows  a 
tendency  to  spread,  if  it  involves  more  than  a  portion  of  several  toes,  if  it  is 
not  a  firet  attack,  if  there  is  sleeplessness,  fever,  exhausting  diarrhea,  anorexia, 
or  a  strong  tendency  to  pulmonary  congestion,  do  not  delay,  but  at  once  am- 
putate high  up.  If  the  gangrene  shows  no  tendency  to  limit  itself,  or  if  the 
patient  develops  sepsis  or  exhaustion,  at  once  amputate  high  up.  The  best 
point  at  which  to  amputate  is  above  the  knee,  so  that  the  deep  femoral  artery, 
which  rarely  becomes  atheromatous,  will  nourish  the  flap  and  gangrene  will 
not  occur.  It  has  been  pointed  out  that  the  superficial  femoral  artery  and  its 
branches  often  contain  a  clot.  Never  amputate  below  the  tubercle  of  the  tibia. 
Some  operators  disarticulate  at  the  knee-joint.  Heidenhain  affirms  that  so 
long  as  the  gangrene  is  Hmited  to  one  or  two  toes  we  should  merely  treat  it 
antiseptically,  elevate  the  limb,  and  wait  for  the  dead  part  to  be  cast  off  spon- 
taneously, if,  however,  it  extends  to  the  dorsum  or  sole  of  the  foot,  we  should 
amputate  at  once  above  the  knee.  He  further  states  that  gangrene  of  the 
flaps  almost  always  occurs  in  amputations  below  the  knee,  and  high  amputa- 
tion is  indicated  in  advancing  gangrene  with  or  without  fever.*  \\Tien  am- 
putation has  been  performed  and  the  Esmarch  band  has  been  removed  and 
no  arterial  bleeding  takes  place  from  the  superficial  femoral  artery,  a  clot  is 
lodged  in  that  vessel.  If  such  a  condition  exist,  insert  into  the  artery  a  fine 
*  Deutsche  mediciniscLe  Wochenschrift,   1891,  p.  1087. 


184  Mortification,  Gangrene,  or  Sphacelus 

rubber  catheter  or  a  filiform  bougie  and  breal<  up  the  clot.    When  blood  flows 

we  are  sure  that  the  clot  has  been  washed  out.* 

Some   surgeons   have  practised  arteriovenous   anastomosis  between   the 

femoral  vein  and  common  femoral  artery  in  hopes  of  establishing  sufficient 

circulation  to  prevent  impending  or  to  cure  existing  gangrene.     The  results 

are  as  yet  inconclusive,  but  not  very  promising. 

Moist  or  Acute  Gangrene.— In  moist  or  acute  gangrene  (Fig.  87)  the 

dead  part  remains  moist 
and  putrefies.  As  Nan- 
crede  points  out,  there 
are  two  forms  of  moist 
gangrene:  "that  limited 
to  the  areas  actually 
killed  by  a  traumatism, 

rent;   (Gross)  With    SOmC    SUrrOUUdlUg 

tissue  which  dies,"  and 
"that  which  tends  to  spread  widely,  this  latter  being  usually  caused  by  specific 
micro-organisms,  an  intense,  widespread,  pyogenic  inflammation  resuUing,  in- 
volving the  subcutaneous  and  intermuscular  cellular  planes,  by  strangulation  of 
the  vessels  by  which  all  blood-supply  to  the  remaining  soft  parts  is  destroyed."  f 
In  a  case  of  moist  gangrene  the  parts  remain  moist,  either  because  the  main  artery 
has  become  suddenly  blocked,  and  the  tissue  fluids  are  not  urged  by  sufficient 
vis  a  tergo  to  cause  them  to  flow  out  of  the  limb,  or  because  the  main  vein  is 
blocked.  It  may  arise  in  a  limb  after  ligation,  obstruction,  or  destruction 
of  its  main  artery,  main  vein,  or  both;  after  long  constriction,  as  by  a  tight 
bandage;  after  crushes  and  lacerated  wounds;  and  after  thrombosis  of  the 
vein.  Moist  gangrene  may  follow  severe  pyogenic  infection,  or  may  be  due  to 
local  constriction  (strangulated  hernia),  crushing,  chemical  irritants,  heat,  and 
cold. 

Moist  gangrene  of  a  limb  may  be  seen  typically  in  certain  cases  in 
which  the  main  vein  or  artery  or  both  vein  and  artery  are  constricted,  dam- 
aged, or  destroyed.  The  leg  swells  greatly  and  is  pulseless  below  the  obstruc- 
tion ;  the  skin,  at  first  pale,  cold,  and  anesthetic,  becomes  livid,  mottled,  purple 
or  greenish.  A  greenish  color  signifies  putrefaction.  Blebs  are  formed  which 
contain  a  reddish  or  brown  fluid.  "  These  blebs,  being  caused  by  the  accumu- 
lation of  serum  beneath  epithehum  which  has  lost  its  vital  connection  with  the 
derm,  can  be  slipped  around  upon  the  surrounding  true  skin,  the  epithelium 
readily  separating  for  long  distances  around,  as  in  a  cadaver  "  (Nancrede).  The 
extremity  swells  enormously,  there  may  be  pain  at  the  seat  of  obstruction,  but 
there  is  no  pain  in  the  gangrenous  area,  and  sapremic  symptoms  quickly  develop. 
The  bulte  break  and  disclose  the  brown  derm  and  sometimes  the  deeper 
structures,  which  are  swollen  and  edematous.  The  fetor  is  horrible.  Slight 
or  moderate  fever  usually  exist.  In  mild  cases  a  fine  of  demarcation  soon 
forms.  In  severe  cases  in  which  virulent  saprophytes  are  present  the  process 
spreads  with  great  rapidity,  neighboring  glands  enlarge,  the  temperature  is 
much  elevated,  no  line  of  demarcation  forms,  there  is  profound  exhaustion, 

*  Severeanu.     See  Mancozet's  report  before  the  Second  Pan-American  Medical  Con- 
gress. 

t  Nancrede's  "  Principles  of  Surgery."  , 


Acute  Microbic  Gangrene  185 

and  gases  of  decomposition  accumulate  in  and  distend  the  tissues  and  cause 
crackling  when  the  parts  are  pressed  upon.  Such  severe  cases  are  in  reality 
examples  of  foudroyant  or  emphysematous  gangrene. 

Moist  gangrene  from  inflammation  is  due  to  pressure  of  the  exudate 
cutting  of  the  blood-supply,  or  to  loss  of  blood-circulation  because  of  microbic 
involvement  of  vessels  and  clotting  of  blood.  It  occurs  typically  in  phleg- 
monous erysipelas.  When  an  inflammation  is  about  to  terminate  in  gangrene 
all  the  signs  of  inflammation,  local  and  constitutional,  increase;  swelling 
becomes  very  great  and  may  be  due  partly  to  fluid  and  partly  to  gas.  If  gas 
is  present  pressure  will  cause  crackling.  The  color  becomes  livid  or  purple. 
The  anatomically  related  glands  are  enlarged  and  the  symptoms  of  sapremia 
or  suppurative  fever  exist.  When  gangrene  is  actually  present,  the  signs  of 
inflammation  have  passed  away,  buUcT  and  emphysema  are  noted,  with  great 
swelling  and  all  the  other  symptoms  of  molar  death.  The  sudden  cessation 
of  pain  is  very  suggestive  of  gangrene.  The  constitutional  symptoms  are 
those  of  suppurative  fever  and  sapremia,  or  possibly  of  septic  infection. 

When  a  wound  becomes  gangrenous  the  surface  looks  like  yellow  or  gray 
tow,  the  discharge  becomes  profuse  and  very  fetid,  and  the  parts  about  swell 
enormously  and  gradually  become  gangrenous. 

Treatment  0}  Moist  Gangrene. — In  extensive  moist  gangrene  of  a  limb,  if 
the  condition  is  of  the  form  described  as  mild,  in  which  there  are  not  severe 
symptoms  of  sepsis  and  in  which  the  gangrene  is  not  rapidly  progressive, 
wait  for  a  line  of  dernarcation,  and  amputate  clear  of  and  above  it.  While 
waiting  for  the  line  to  form,  dress  the  dead  parts  antiseptically,  wrap  the  ex- 
tremity in  cotton,  apply  warmth,  and  slightly  elevate  the  limb.  Give  opium, 
tonics,  nourishing  food,  and  stimulants.  In  the  severe  form  of  moist  gangrene 
(really  foudroyant  gangrene),  amputate  at  once  high  above  the  gangrenous 
process.  In  inflammatory  gangrene,  such  as  is  sometimes  associated  with 
phlegmonous  erysipelas,  relieve  tension  by  incisions,  cut  aw'ay  the  dead  parts, 
brush  the  raw^  surface  with  pure  carbolic  acid,  dust  with  iodoform,  and  dress 
with  hot  antiseptic  fomentations.  Stimulate  freely,  administer  nourishment 
at  frequent  intervals,  and  treat  the  patient  in  general  as  we  would  a  case  of 
sapremia,  or  suppurative  fever.  A  gangrenous  wound  is  treated  as  pointed 
out  in  the  section  on  Sloughing. 

Acute  microbic  gangrene,  fulminating  gangrene,  emphysematous 
gangrene,  gaseous  phlegmon,  gangrenous  emphysema,  gangrene 
foudroyante,  or  traumatic  spreading  gangrene,  results  from  a  virulent 
infection  of  a  wound.  It  was  first  described  in  1853  by  Maisonneuve  under  the 
name  of  gaseous  phlegmon.  The  condition  may  be  due  to  a  mixed  infection 
with  virulent  streptococci  and  organisms  of  putrefaction;  or  to  infection  wnth 
the  bacilli  of  malignant  edema,  and  putrefactive  organisms.  Some  case  are  due 
to  the  bacillus  of  malignant  edema  alone;  some  are  due  to  the  bacillus  aerogenes 
capsulatus  of  Welch  and  Flexner.  These  gas  bacilli  are  found  in  soil  in 
animal  and  human  feces,  in  street  dirt,  and  the  dust  of  floors.  The  injury  is 
usually  severe — often  a  crush  which  destroys  the  main  artery  and  renders  an 
anastomotic  circulation  impossible,  sometimes  a  compound  fracture  or  a  gun- 
shot w^ound.  In  such  severe  accidents  the  limb  is  much  sw^ollen  and  the  pulse 
below  the  seat  of  injury  is  imperceptible,  and  the  surgeon  is  often  at  this  time 
uncertain  whether  to  amputate  at  once  or  wait.     Emphysematous  gangrene  is 


1 86  Mortification,  Gangrene,  or  Sphacelus 

commonest  after  compound  fractures,  and  Ijcgins  within  forty-eight  hours  of 
the  accident.  The  extremity  becomes  enormously  swollen  from  edema  and 
gas.  The  gangrene  does  not  begin  at  the  periphery,  as  does  ordinary  moist 
gangrene,  but  at  the  wound  edges,  which  turn  red,  green,  and  fmally  black; 
the  extremity  soon  undergoes  a  like  change  and  becomes  mortified.  The  skin 
peels  off,  emphysematous  crackling,  due  to  gas  formed  and  retained  in  the 
tissues,  can  be  detected  over  large  areas,  and  the  extremity  becomes  anesthetic 
and  pulpy.  The  gases  formed  in  the  tissues  are  sulphid  of  hydrogen,  sulphid 
of  ammonium,  volatile  fatty  acids,  and  ammonia.  Great  fetor  is  soon  noted. 
The  gangrene  spreads  up  and  down  from  the  wound,  and  red  lines,  due  to 
lymphangitis,  run  from  above  the  wound.  The  adjacent  lymph-glands  swell, 
and  in  thirty-six  hours  the  gangrene  may  involve  an  entire  limb.  No  line  of 
demarcation  forms.  The  system  is  soon  overwhelmed  with  ptomains,  and 
the  patient  suffers  from  putrid  intoxication,  with  delirium,  and  often  passes 
into  profound  collapse  with  coma  and  subnormal  temperature.  Traumatic 
spreading  gangrene  must  not  be  confused  with  er>'sipelas.  In  er\'sipelas  the 
color  is  red,  pressure  instantly  drives  it  out,  and  on  the  release-  of  pressure  it 
at  once  returns.  In  early  gangrene  the  color  is  purple,  pressure  fails  to  drive 
it  out  at  all  or  only  does  so  very  slowly,  and  if  the  surface  is  blanched  by  pres- 
sure, on  the  release  of  pressure  the  color  crawls  slowly  back.  Sometimes 
emphysematous  gangrene,  in  the  form  of  gangrenous  cellulitis,  follows  a 
trivial  injury  such  as. a  puncture,  the  entrance  of  a  splinter,  an  abrasion,  or 
a  slight  cut.  The  region  about  the  injury  becomes  red,. then  livid,  and  finally 
green  or  black.  Enormous  swelling  takes  place,  partly  due  to  edema,  partly 
to  gas,  and  the  swelling  and  discoloration  spread  rapidly.  Red  lines  subse- 
quently becoming  greenish  run  toward  enlarged  lymphatic  glands  above  the 
gangrenous  part.  The  tissues  are  rapidly  separated  and  destroyed  and  the 
bone  is  often  quickly  exposed  and  infected.  The  symptoms  point  to  over- 
whelming sepsis.  There  is  high  fever  and  delirium,  and  coma  and  death 
are  apt  to  ensue.  The  patient  may  die  in  from  twenty-four  to  forty-eight 
hours.  Welch  estimates  the  mortality  from  gaseous  phlegmon  at  almost  60  per 
cent. 

Treatment. — In  acute  spreading  gangrene  of  an  extremity  following  a 
severe  injury  no  delay  is  admissible.  To  wait  for  a  line  of  demarcation  is  to 
expect  the  impossible,  and  a  delay  dooms  the  patient  inevitably  to  death. 
Amputation  must  be  performed  at  once  high  up,  the  flaps  should  be  brushed 
with  pure  carbolic  acid,  and  then  every  efi'ort  is  to  be  made  to  sustain  the 
patient's  strength  by  the  administration  of  food  and  stimulants.  Antistrep- 
tococcic serum  may  possibly  be  useful.  In  cases  of  acute  spreading  gangrene 
following  trivial  injuries  it  may  be  possible  to  arrest  the  process  by  free  in- 
cisions, thorough  drainage,  hot  antiseptic  fomentations,  the  continuous  hot 
bath,  or  continuous  antiseptic  irrigations,  stimulants,  etc.,  but  in  some  cases 
amputation  is  necessary.  Some  surgeons,  notably  Doerfler  ("Miinchener 
medicinische  Wochenschrift,"  April  23  and  30,  1901),  oppose  amputation  in 
cases  of  spreading  gangrene  following  trivial  or  moderately  severe  injurv. 
Doerfler  maintains  that  cases  which  recover  after  amputation  would  have 
recovered  if  amputation  had  not  been  performed.  From  this  positive  state- 
ment I  am  obliged  to  dissent. 

Hospital  gangrene  or  sloughing  phagedena  is  a  disease  that  has  prac- 


Special  Forms  of  Gangrene  187 

ticiilly  disai)])cart'd  from  civilized  communilies.  It  formerly  occurred  in 
crowded,  ill  ventilated  hospitals.  Some  consider  it  traumatic  dif)htheria. 
Koch  thinks  it  is  due  to  streptococci.  Jonathan  Hutchinson  says:  "Hospital 
gangrene  is  set  up  by  admitting  to  the  wards  a  case  of  sy[jhilitic  phagedena." 
It  may  show  itself  as  a  diphtheritic  condition  of  a  wound,  as  a  process  in  which 
sloughs  which  look  like  masses  of  tow  form,  or  as  a  phagedenic  ulceration. 
The  surrounding  parts  are  inflamed  and  painful,  and  buboes  form  in  adjacent 
lymphatic  glands.     The  system  passes  into  a  low  septic  state. 

Treatment. — In  treating  hospital  gangrene  ether  should  be  given,  the  large 
sloughs  removed  with  scissors  and  forceps,  the  parts  dried  with  gauze  and 
cauterized  with  bromin.  The  surgeon  should  take  a  tumblerful  of  water 
and  into  it  pour  the  bromin,  which  M^ill  fall  to  the  bottom  of  the  glass.  The 
drug  can  be  drawn  up  with  a  syringe  and  injected  into  the  depths  of  the  wound. 
The  wound  should  be  plentifully  sprinkled  with  iodoform  and  dressed  with 
hot  antiseptic  fomentations.  When  the  sloughs  separate,  the  sore  can  be  treated 
as  an  ordinary  ulcer.     The  constitutional  treatment  is  that  employed  for  sepsis. 

Special  Forms  of  Gangrene.— Symmetrical  or  Raynaud's  gangrene 
arises  in  severe  cases  of  Raynaud's  disease.  It  is  a  dry  gangrene.  Ray- 
naud's disease  is  a  vaso-motor  neurosis,  seen  particularly  in  children  and  young 


Fig.  88.— Raynaud's  disease  (Philadelphia  Hospital)  (Horwitz). 

female  adults  but  sometimes  met  with  in  men.  Chlorotic  and  hysterical 
women  seem  more  apt  than  others  to  suffer  from  it.  The  condition  is  much 
commoner  in  winter  than  in  summer,  and  cold  seems  to  be  an  exciting  cause. 
The  essential  cause  of  Raynaud's  disease  is  uncertain.  In  some  acute  cases 
associated  with  fever,  albuminuria,  and  splenic  enlargement,  it  seems  to  be  a. 
part  of  an  acute  infectious  disease.  It  can  occur  in  a  variety  of  toxic  con- 
ditions and  in  a  number  of  infectious  diseases  (typhoid  fever,  for  instance). 
It  may  develop  in  the  course  of  gout  and  also  of  diabetes.  In  many  cases 
neuritis  exists;  in  some  there  is  obHterative  endarteritis  of  the  peripheral  ves- 
sels. Some  cases  seem  to  be  purely  hysterical.  The  fact  that  attacks  of 
Raynaud's  disease  are  sometimes  accompanied  by  hemoglobinuria  has  sug- 


i88  Mortification,  Gangrene,  or  Sphacelus 

gested  malaria  as  a  possible  cause.  Raynaud's  disease  is  characterized  by 
attacks  of  cold,  dead  bloodlessness  in  the  fingers  or  toes  as  a  result  of  exposure 
to  cold  or  of  emotional  excitement  {local  syncope).  In  the  more  severe  cases 
there  are  capillary  congestion  and  mottled,  livid  swelling  ilocal  asphyxia). 
The  patient  complains  of  pain,  tingling,  numbness,  coldness,  and  stiffness  in 
the  affected  parts.  In  some  few  cases  the  skin  of  the  face  or  trunk  is  attacked. 
Local  syncope  is  thought  to  be  due  to  vascular  spasm,  and  local  asphyxia  to 
some  contraction  of  the  arterioles,  with  dilatation  of  the  capillaries  and 
venules.  It  is  after  local  asphyxia  that  gangrene  may  appear.  A  chilblain  is 
an  area  of  local  asphyxia.  Attacks  of  Ra}'naud's  disease  occur  again  and 
again,  and  may  never  eventuate  in  gangrene. 

Raynaud's  disease  is  seldom  fatal  and  is  often  recovered  from. 

Raynaud's  gangrene  is  most  commonly  met  with  upon  the  ends  of  the 
fingers  or  the  toes,  but  it  may  attack  the  lobes  of  the  ears,  the  tip  of  the  nose,  or 
the  skin  of  the  arms  or  the  legs.  Sometimes  the  disease  is  seen  upon  the  trunk. 
When  gangrene  is  about  to  occur  the  local  asphyxia  at  that  point  deepens, 
anesthesia  becomes  complete,  and  the  part  blackens  and  feels  cold  to  the 
touch.  The  epidermis  may  raise  into  blebs  at  the  margin  of  the  gangrene, 
which  blebs  rupture  and  expose  dry  surfaces.  A  hne  of  demarcation  forms,  and 
the  necrosed  area  is  removed  as  a  slough.  Widespread  gangrene  from  Ray- 
naud's disease  is  rare;  there  is  not  often  an  extensive  area  involved — rather 
a  small  superficial  spot.     Recovery  is  the  rule. 

Treatment  oj  Raynuitd's  Disease  and  oj  Raynaitd's  Gangrene. — If  an  indi- 
vidual suffers  from  attacks  of  Ra}Tiaud's  disease,  every  effort  should  be  made 
to  improve  the  general  health  and  to  avoid  chiUing  the  surface  of  the  body. 
During  the  attack  employ  gentle  massage,  place  the  extremity  in  warm 
water,  and,  if  pain  is  severe,  give  morphia  hj-podermatically.  Amyl  nitrite 
is  without  value  in  this  condition.  When  attacks  of  Raynaud's  disease  are 
so  severe  as  to  threaten  gangrene,  put  the  patient  to  bed,  if  the  feet  are 
attacked,  elevate  the  legs  slightly,  wrap  the  affected  extremities  in  cotton- wool, 
and  apply  warmth.  If  the  hands  are  affected,  wrap  them  in  cotton-wool,  ele- 
vate them  slightly,  and  apply  warmth.  Massage  is  useful.  \\'Tien  gangrene 
occurs,  dress  the  part  antiseptically  until  a  line  of  demarcation  forms,  and 
then  remove  the  dead  parts  by  scissors,  forceps,  and  antiseptic  fomentations. 
If  amputation  becomes  necessary,  which  will  rarely  be  the  case,  wait  for  a 
line  of  demarcation. 

Diabetic  gangrene  often  resembles  in  many  points  senile  gangrene,  but  the 
dead  portions  remain  somewhat  moist  and  putrefy.  Some  attribute  it  directly 
to  the  presence  of  sugar  in  the  blood.  Some  think  diabetes  causes  gangrene 
indirectly  by  rendering  the  tissues  less  resistant  to  infection  and  less  capable 
than  normally  of  repair.  Many  hold  that  it  is  of  neurotic  origin,  being  the 
result  of  nerve  degeneration.  Heidenhain  believes  that  it  is  due  to  arterial 
sclerosis.  That  most  of  the  victims  of  diabetic  gangrene  suffer  from  arterio- 
sclerosis is  certain.  It  seems  probable  that  the  gangrene  is  due  to  infection  of 
tissue  predisposed  to  infection  by  the  presence  of  sugar  and  weakened  by 
changes  in  the  nerves  and  blood-vessels.  Diabetic  gangrene  is  most  usually 
met  with  upon  the  feet  and  legs  of  elderly  people,  but  it  may  arise  at  any  age 
and  may  attack  the  genital  organs,  thigh, 'lung,  buttock,  eye,  back,  finger,  or 
neck.     It  may  affect  only  a  single  area,  may  attack  several  areas,  or  may  be 


Diabetic  Gangrene  189 

symmetric.  It  may  arise  in  any  stage  of  diabetes,  from  the  earliest  to  the 
latest.  It  may  begin  as  a  perforating  ulcer.  It  is  much  more  common  in  men 
than  in  women.  There  are  clearly  two  forms  of  this  condition.  In  one  there 
is  a  slowly  progressive  fairly  dry  gangrene,  probably  due  to  arterial  sclerosis. 
As  in  senile  gangrene,  a  trivial  injury  is  apt  to  be  the  exciting  cause.  In  such  a 
case  the  urine  contains  sugar  and  perhaps  albumin, but  seldom  either  acetone  or 
diacetic  acid.  In  the  other  form  an  injury,  perhaps  a  trivial  one,  is  followed 
by  a  rapidly  spreading  cellulitis,  which  seldom  forms  pus  and  which  eventuates 
in  moist  gangrene.  In  such  a  case  the  urine  is  apt  to  contain  acetone  and 
diacetic  acid  and  there  is  grave  danger  of  coma.  When  the  gangrene  follows 
a  traumatism  there  are  no  prodromic  symptoms.  When  it  arises  spontan- 
eously in  the  skin,  it  is  often  preceded  by  pain  of  a  neuralgic  nature  and  attacks 
of  "li\id  or  violaceous  discoloration  of  the  skin,  with  lowered  surface  tempera- 
ture and  sometimes  loss  of  sensation"  (Elliot).  Diabetic  gangrene  is  often 
superficial,  but  may  become  deep  if  it  follows  an  injur}-  or  ulceration.  A 
sufferer  from  diabetic  gangrene  is  liable  to  cardiac  failure,  collapse,  and 
coma. 

Diabetic  coma  is  an  acid  intoxication  due  to  the  presence  in  the  blood  of 
acids  which  do  not  belong  there,  the  chief  of  which  is  ,5-oxybut\Tic  acid. 
It  commonly  comes  on  rapidly,  ^\'ith  vomiting,  abdominal  pain,  weakness,  and 
drowsiness,  which  soon  passes  into  coma.  Sometimes  it  is  ushered  in  by  col- 
lapse, at  other  times  by  confusion  of  thought  and  speech.  In  coma  the  res- 
piration is  usually  slow  and  deep,  but  may  be  sighing.  The  pulse  is  small 
and  usually  rather  frequent.  The  temperature  becomes  subnormal,  although 
during  the  onset  it  may  be  elevated.  Cyanosis  arises,  the  breath  smells  of 
acetone,  the  patient  lies  quietly  in  bed,  and  the  pupils  are  dilated.  In  from 
t«'ent}^-four  to  fort\'-eight  hours,  as  a  rule,  the  patient  dies. 

Never  fail  to  carefully  examine  the  urine  in  every  surgical  case  and 
especially  in  even,-  case  of  gangrene,  because  diabetes  may  exist  when  least 
suspected. 

Treatment. — Most  surgeons  had  grown  xtrx  shy  of  amputating  for  diabetic 
gangrene  until  Kiister,  of  Berlin,  warmly  advocated  amputating  above  the  knee 
without  waiting  for  a  line  of  demarcation.  He  showed  that  if  amputation 
is  performed  below,  the  flaps  will  become  gangrenous,  and  that  after  high 
amputation  sugar  may  disappear  from  the  urine.  Of  11  amputations  by 
Kiister,  6  recovered  and  5  died;  and  of  these  5,  3  had  albumin  in  the  urine  as 
well  as  sugar. 

Heidenhain  warmly  advocated  early  high  amputation,  \\\lh  the  making  of 
short  flaps,  and  in  the  United  States,  Powers,  of  Denver,  defended  the  views  of 
Kiister  ("Amer.  Jour,  of  Med.  Sciences,"  Nov.  11.  1892).  Most  writers  now 
advocate  high  operation  \\-ithout  waiting  for  Une  of  demarcation  if  the  gangrene 
is  moist  and  due  to  bacteria  attacking  tissue  weakened  by  diabetes.  The 
same  practitioners,  if  dr}'  gangrene  due  to  arterial  changes  exists  advocate 
waiting  the  formation  of  a  line  of  demarcation  before  amputating.  I  agree 
with  Klemperer  ("'Therapie  der  Gegenwart."  Jan..  1907)  that  we  should  reach 
a  conclusion  as  to  the  proper  course  to  pursue  more  from  the  character  of  the 
diabetes  than  from  the  nature  of  the  gangrene.  If  neither  diacetic  acid  nor 
acetone  is  in  the  urine,  the  glycosuria  can  be  much  improved  and  the  general 
health  vastly  benefited  by  restricting  the  carbohydrates  and  administering 


iQO  Mortification,  Gangrene,  or  Sphacelus 

codein  or  opium.  In  such  a  case  during  the  improvement  of  the  glycosuria 
we  await  the  formation  of  a  line  of  demarcation^  and  while  waiting,  the  gan- 
grenous area  and  the  parts  immediately  above  are  dressed  with  warm  antiseptic 
fomentations.  When  a  line  of  demarcation  forms,  spontaneous  healing  wiil 
probably  occur.     If  it  does  not  occur,  amputate  high  up. 

If  the  urine,  though  free  from  acetone  and  diacetic  acid,  contains  not  only 
sugar  but  also  quantities  of  albumin,  we  cannot  dare  to  wait  for  a  line  of 
demarcation  because  of  the  certainty  that  during  the  wait  the  patient  will 
perish  of  septicemia  (Klemperer,  ibid.).  In  such  a  case  perform  an  immediate 
high  operation. 

If  the  urine  contains  acetone  and  diacetic  acid  a  line  of  demarcation  will 
not  form,  and  high  amputation  must  be  performed  at  once. 

To  put  such  a  patient  on  a  pure  meat  diet  increases  the  risk  of  diabetic  coma. 
In  order  to  lessen  the  risk  of  coma  give  bicarbonate  of  sodium  before  and  after 
operation.  Twenty  grains  of  this  drug  dissolved  in  \'ichy  water  are  given 
every  two  or  three  hours.  If  coma  arises  give  intravenously  40  grains  of  car- 
bonate of  sodium  in  a  quart  of  water. 

The  worst  cases  are  those  in  which  the  urine  contains  sugar,  albumin, 
acetone,  and  diacetic  acid.  In  any  case  if  over  one  grain  of  ammonia  is  e.x- 
creted  in  twenty-four  hours,  postpone  operation  until  ammonia  is  reduced  by 
diet. 

In  operating,  ether  and  chloroform  (especially  chloroform)  are  to  be  avoided, 
because  either  is  liable  to  induce  acid  intoxication.  The  operation  should 
I)e  performed  under  spinal  anesthesia. 

My  experience  in  diabetic  gangrene  comprises  4  cases.  In  each  case  the 
urine  contained  sugar,  acetone,  and  diacetic  acid,  and  in  2  cases  albumin  was 
also  present.  In  each  case  a  high  ampuatation  was  performed — i  case  (the 
one  with  albumin)  died  of  shock;  2  cases  died  in  coma;  i  case  recovered. 

Operations  on  Diabetics. — Surgical  operations  upon  diabetics  are  regarded 
as  very  dangerous  and  are  employed  by  most  surgeons  only  in  emergencies. 
In  operations  upon  such  subjects  gangrene  may  rise  in  the  wound  or  diabetic 
coma  may  develop.  It  is  important  to  remember  that  glycosuria  may  result 
from  a  surgical  condition  (head  injury,  sepsis,  etc.),  and  this  temporary  dia- 
betes will  be  relieved  by  operation.  I  have  seen  it  in  appendicitis,  and  in  such 
cases  operation  is  not  contraindicated,  but  is  imperative.  Llewellyn  Phillips 
in  a  recent  article  ("Lancet,"  May  10  and  17,  1902)  refers  to  the  temporary 
glycosuria  produced  by  injury  and  sepsis.  He  thinks  that  diabetes  may 
directly  cause  cataract  and  balanoposthitis,  but  produces  gangrene  indirectly 
by  causing  nerve  degeneration  and  arteriosclerosis.  Phillips  points  out  that 
a  surgical  condition  and  glycosuria  may  exist  independent  of  and  uninfluenced 
by  each  other,  and  many  such  cases  can  be  operated  upon,  although  operation 
should  be  avoided  if  there  is  serious  disease  of  some  important  organ  (the  liver, 
for  instance).  PhilUps,  in  the  valuable  article  referred  to,  insists  that  the 
percentage  of  sugar  is  not  a  measure  of  the  degree  of  danger;  that  albuminuria 
adds  greatly  to  the  danger;  that  the  presence  of  acetone  in  the  urine,  and  also 
the  presence  of  ammonia,  gives  a  bad  prognosis.  PhilUps's  conclusions  as 
to  when  to  operate  and  when  to  refuse  operation  are  as  follows  ("Lancet," 
May  10  and  17,  1902) :  An  operation  for  malignant  disease  in  a  diabetic  can  be 
performed  if  the  operation  would  be  proper  on  a  non-diabetic  individual. 


•  Gangrene  from  Frost-bite  191 

Large  abdominal  tumors  can  be  removed.  Cosmetic  operations  are  justifiable 
if  the  general  health  is  good  and  there  is  not  marked  arterial  disease  or  nerve 
degeneration.  Operation  is  justifiable  in  all  emergencies  without  regard  to 
the  condition  of  the  urine.  In  a  diabetic  with  a  surgical  malady  it  is  often 
possible  to  lessen  danger  by  preliminary  treatment.  Only  an  operation  of  the 
greatest  urgency  should  be  performed  if  over  i  gram  of  ammonia  is  excreted 
during  twenty-four  hours;  and  if  aceto-acetic  acid  or  much  albumin  is  present, 
every  case  but  the  most  urgent  should  be  postponed  and  subjected  to  medical 
treatment. 

I  would  add  to  the  conclusions  of  Phillips  that  the  anesthetic  is  a  danger 
to  the  kidneys  irritated  by  the  secretion  of  sugar,  and  it  is  desirable,  when 
possible,  to  use  local  anesthesia,  or,  a.s  Robt.  T.  ^Morris  advises,  nitrous  oxid 
and  oxygen  ("  Medical  News,"  June  29,  1901),  or  spinal  anesthesia.  In  two 
cases  I  used  spinal  anesthesia,  but  in  one  of  them  the  patient  died  in  coma. 
If  sugar  diminishes  in  the  urine  but  increases  in  the  blood,  the  condition  is 
one  of  danger. 

Gangrene  from  Ergotism. — Ergotism  is  a  diseased  condition  resulting 
from  eating  bread  made  with  rye  which  has  been  attacked  by  a  fungus  {Clavi- 
ceps  purpurea).  In  former  days  it  was  not  unusual  to  have  epidemics  of  er- 
gotism from  time  to  time,  but  at  present  the  disease  is  found  in  individual> 
or,  at  most,  in  a  few  of  a  community.  Ergotism  is  very  rare  in  the  United 
States,  but  it  is  not  uncommon  in  southern  Russia.  It  has  occurred  during  the 
administration  of  ergot  as  a  drug.  Billroth  reported  such  a  case.  It  is  never 
seen  in  unweaned  children.  The  eating  of  Lread  made  of  diseased  rye  provokes 
gastro-enteritis,  the  evidences  of  which  are  abdominal  pain  of  a  crampy  char- 
acter, vomiting,  diarrhea,  and  exhaustion.  The  patient  complains  of  formi- 
cation and  itching  of  the  skin  of  the  extremities;  severe,  cramp-like,  and  tingling 
pains  in  the  limbs,  and  disorders  of  vision.  The  pulse  becomes  small  and  slow. 
In  some  cases  very  painful  spasms  attack  the  muscles  of  the  extremities  and, 
finally,  tonic  spasm  is  noted,  and  the  patient  probably  perishes  from  exhaustion 
after  developing  general  convulsions  and  passing  into  coma.  In  other  cases 
certain  areas  exhibit  "gradual  blood-stasis"  (Osier),  anesthesia,  and,  finally, 
gangrene.  The  gangrene  is  dry  and  peripheral.  It  usually  affects  the  fingers 
or  toes,  but  may  involve  an  entire  Umb,  and  may  be  symmetric.  Chronic 
ergotism  is  usually  recovered  from,  but  acute  cases  die  in  from  seven  to  ten 
days.*  The  ingestion  of  ergot  in  quantity  sufficient  to  produce  chronic  poison- 
ing causes  tonic  contraction  of  the  peripheral  blood-vessels,  degeneration  of  the 
inner  coat,  and  thrombosis  of  some  arterioles.  It  is  also  maintained  that 
degeneration  of  the  posterior  columns  of  the  spinal  cord  takes  place. 

Treatment.— Ergotism  is  treated  by  forbidding  the  eating  of  the  poison- 
ous bread,  allaying  gastro-enteric  inflammation,  favoring  elimination,  and 
administering  nourishment  and  stimulants.  If  gangrene  is  threatened,  en- 
deavor to  prevent  it  by  gentle  massage  and  the  application  of  warmth.  If 
superficial  gangrene  occurs,  dress  with  warm  antiseptic  fomentations  and 
elevate  the  pp.rt,  and  even^  day  take  scissors  and  forceps  and  remove  the  loose 
crusts.  If  deeper  and  more  extensive  gangrene  arises  in  an  extremity  wait 
for  a  line  of  demarcation  and  amputate  above  it. 

Gangrene  from  Frost-bite. — Frost-bite  is  most  common  in  the  fingers, 

*Pick,  in  Heath's  "Surgical  Dictionary." 


192  Mortification,  Gangrene,  or  Sphacelus  . 

toes,  nose,  and  ears,  but  the  genital  organs,  the  cheei^s,  the  chin,  the  feet  and 
legs,  and  the  hands  and  arms  may  be  attacked.  Cold  causes  a  primary  con- 
traction of  the  vessels  and  pallor  and  numbness  of  the  part.  After  reaction 
the  vessels  dilate,  the  part  reddens  and  swells,  and  a  burning  sensation  or 
actual  pain  is  experienced.  In  a  trivial  frost-bite  the  swelling  and  redness 
usually  disappear  after  a  few  days,  but  in  some  cases  the  redness  is  permanent, 
and  in  many  cases  the  redness,  in  the  form  of  local  asphyxia,  returns  under 
the  influence  of  slight  cold  (see  Chilblains). 

In  a  more  severe  frost-bite  the  aflfected  part  becomes  purple  and  covered 
with  vesicles,  and  gangrene  may  or  may  not  follow.  When  a  part  has  been 
badly  frozen  the  peripheral  portion  dries.  The  part  is  deprived  of  all  blood 
because  of  contraction  of  the  vessels  and  because  plasma  coagulates  at  a  few 
degrees  above  freezing.  Cold  disorganizes  the  blood,  breaking  up  white 
corpuscles  with  the  liberation  of  fibrin  ferment.  Coagulation  of  plasma 
and  destruction  of  red  corpuscles  with  the  liberation  of  hemoglobin  subse- 
quently takes  place.  The  thrombosis  which  is  established  prevents  circula- 
tion, and  the  tissue-cells  are  damaged  beyond  repair.  The  part  is  bloodless 
and  anesthetic,  and  a  line  of  demarcation  forms.  Hence  we  note  that  severe 
frost-bite  causes  dry  gangrene.  If  a  part  which  is  not  so  badly  frozen  is 
brought  suddenly  into  a  warm  atmosphere,  hyperemia  takes  place  when  the 
blood  runs  into  the  frosted  tissues,  blebs  form,  and  moist  gangrene  may  result. 
Areas  of  superficial  gangrene  are  not  uncommon. 

Treatment  0}  Frost-bite  and  0}  Gangrene  from  Frost-bite. — A  frost-bite  in 
which  the  skin  is  livid  and  not  as  yet  gangrenous  should  be  treated  by  frictions 
with  snow  or  rubbing  with  towels  soaked  in  iced  water.  As  the  skin  becomes 
warmer  and  congestion  disappears  the  part  should  be  wrapped  in  cotton- 
wool. A  sufferer  from  frost-bite  should  not  suddenly  be  brought  into  a  warm 
room.  When  gangrene  follows  frost-bite,  if  only  small  areas  are  involved,  allow 
the  dead  parts  to  come  away  spontaneously,  applying  in  the  meanwhile  hot 
antiseptic  fomentations.  If  separation  be  delayed  by  cartilage,  ligament,  or 
bone,  cut  through  the  retaining  structure.  If  amputation  becomes  necessary, 
await  a  line  of  demarcation,  as  it  is  not  possible  otherwise  to  be  certain  how 
high  tissue  damage  extends,  and  to  amputate  through  devitalized  parts  would 
mean  renewed  gangrene. 

Noma. — Noma  is  a  rapidly  spreading  gangrenous  process  which  is  most 
apt  to  begin  upon  the  mucous  membrane  of  the  gums  or  cheeks.  Noma  of 
this  region  is  known  as  cancriim  oris.  Occasionally  it  begins  in  the  ears,  the 
genitals,  or  the  rectum.  When  it  attacks  the  vulva  it  is  called  noma  pudendi. 
It  may  originate  in  the  mouth  and  subsequently  attack  other  regions.  Noma 
is  a  very  rare  disease,  is  chiefly  met  with  in  children  between  the  ages  of  three 
and  ten,  but  it  can  attack  older  persons.  (O.  Zusch,  in  "  Miinchener  medicin- 
ische  Wochenschrift,"  for  May  14,  1901,  reports  a  case  in  a  man  sixty-six 
years  of  age.)  It  occurs  in  girls  oftener  than  in  boys.  The  disease  is  most 
frequently  encountered  in  children  recovering  from  an  acute  disease.  It  is 
seen  after  scarlatina,  typhoid,  pneumonia,  dysentery,  and  especially  after 
measles;  in  fact,  Osier  says  that  over  one-half  the  cases  follow  measles. 
Children  of  tuberculous  tendencies  seem  more  liable  than  others.  Young  chil- 
dren who  live  amid  filth  and  squalor  in  damp  and  ill-lighted  apartments  are 
most  prone  to  suffer,  but  that  such  conditions  are  not  essential  to  the  genesis 


Noma 


193 


of  the  disease  is  shown  by  the  report  of  an  epidemic  of  noma  in  the  Albany 
Orphan  Asylum.  In  this  excellently  situated,  well-lighted,  and  well-ventilated 
building  the  children  are  carefully  fed  and  cared  for,  and  yet  16  cases  of 
noma  occurred  after  an  epidemic  of  measles.  (See  "An  Epidemic  of  Noma," 
by  Geo.  Blumer  and  Andrew  MacFarlane,  in  "Amer.  Journal  of  Med. 
Sciences,"  Nov.,  1901.)  The  disease  is  thought  by  many  to  be  due  to  pus 
organisms.  Lingard  describes  a  bacillus  which  he  considers  causative. 
Blumer  and  MacFarlane  conclude  that  the  disease  begins  as  a  simple  infec- 
tion and  a  mixed  infection  takes  place  later.  The  mixed  infection  is  not  al- 
ways due  to  the  same  organism,  but  is  usually  due  to  a  long  organism  of  a  lep- 


Fig.  89. — Noma.  Seven  days  after  first  appearance  of  measles  child  showed  gangrenous 
condition  of  mouth.  Now,  three  days  later,  involves  both  cheeks  and  under  surface  of  upper 
and  lower  lips.  Left  cheek  perforated.  Two  days  before  death  a  septic  diarrhea  developed 
which  was  uncontrollable  (Crandon,  Place,  and  Brown). 

tothrix  type  ("Amer.  Journal  of  Med.  Sciences,"  Nov.,  igoi).  Some  think 
that  cases  of  noma  are  due  to  some  spirochaeta  and  it  is  an  interesting  observa- 
tion that  in  noma  the  Wassermann  serum  reaction  can  be  obtained. 

In  1908  Crandon,  Place,  and  Brown  studied  an  outbreak  of  noma. 
Measles  had  been  through  the  ward,  46  children  had  had  gangrenous  stoma- 
titis, and  6  of  them  developed  gangrene  of  the  lip  and  cheek.  A  seventh 
case  of  gnngrene  appeared  from  another  source  ("  Boston  Med.  and  Surg. 
Jour.,"  April  15,  1909).  They  decide  that  the  lesion  is  necrosis  due  to  fusi- 
form baciUi,  which  invades  Hving  tissue  but  rapidly  dies  in  necrotic  tissue. 
Of  these  7  cases,  2  recovered.  The  writers  state  the  duration  of  the  dis- 
ease as  from  four  to  ten  days.  They  do  not  regard  it  as  proved  that  noma 
is  contagious  and  do  not  advise  isolation. 

Symptoms. — The  disease  begins  as  a  sloughing  ulcer,  and  thrombosis  and 
gangrene  soon  begin.  The  edges  of  the  ulcer  are  dark  red  and  indurated.  The 
13 


194 


Mortification,  Gangrene,  or  Sphacelus 


gangrene  usually  spreads  with  very  great  rapidity,  but  in  some  cases  it  remains 
apparently  stationary  for  days  at  a  time.  There  is  little  or  no  pain.  The 
odor  is  horrible.  The  disease  is  frightfully  destructive,  and  if  the  mouth  is 
involved  is  apt  to  destroy  the  cheeks,  lips,  eyelids,  and  large  portions  of  the 
jaws.  There  is  usually  fever,  but  the  temperature  may  be  normal  or  even 
subnormal.  The  pulse  is  rapid  and  exhaustion  appears  early  and  deepens 
rapidly.  The  mortality  is  large;  Bruns  says  70  per  cent.;  Rilliet  and  Barthez 
say  95  per  cent.  ("Amer.  Journal  of  Med.  Sciences,"  Nov.,  1901).  The 
cause  of  death  is  exhaustion,  pyemia,  or  septic  bronchopneumonia. 

Treatment. — Administer  an  anesthetic  and  destroy  the  gangrenous  area 
with  the  Paquelin  cautery.  In  noma  of  the  mouth  chloroform  is  used  instead 
of  ether  because  the  hot  iron  is  to  be  applied  in  a  region  surrounded  with 
anesthetic  vapor  and  ether  vapor  is  inflammable.  In  noma 
in  some  other  regions  ether  can  be  given.  After  cauterization 
directions  are  given  to  wash  the  part  every  few  hours  with 
peroxid  of  hydrogen,  irrigate  it  with  hot  salt  solution  or 
boracic  acid  solution,  and  dress  it  with  compresses  soaked  in 
Labarraque's  solution  (Blumer  and  MacFarlane,  in  "Amer. 
Journal  of  Med.  Sciences,"  Nov.  1901).  Nourishing  food 
is  given  at  frequent  intervals,  alcohol  is  administered,  and 
strychnin  is  used  to  combat  weakness.  If  the  surgeon  suc- 
ceeds in  arresting  the  gangrene  it  will  probably  be  necessary 
later  to  perform  a  plastic  operation  in  order  to  replace  loss 
of  substance. 

Sloughing  is  a  process  by  which  visible  portions  of  dead 
tissue  are  separated.  These  visible  portions  are  called 
"sloughs";  if  they  were  large,  they  would  be  called  "gan- 
grenous masses."  A  large  septic  slough  is  a  gangrenous  mass; 
a  small  gangrenous  mass  is  a  slough;  there  is  no  difference  in 
the  process,  which  corresponds  to  the  formation  of  a  line  of 
demarcation. 

Treatment. — Sloughing  requires  thorough  and  frequent 
irrigation  with  an  antiseptic  fluid,  removal  of  the  sloughs,  and 
antiseptic  treatment.  An  irrigator  can  be  improvised  from 
an  ordinary  bottle  (Fig.  90).  Warm  antiseptic  fomentations 
are  applied  until  granulation  is  well  advanced.  In  some  cases 
continuous  irrigation  with  a  hot  antiseptic  fluid  is  useful;  in 
other  cases  continued  immersion  in  a  hot  antiseptic  solution 
is  employed. 
Phagedena  is  a  process  of  ulceration  (most  common  in  venereal  sores)  in 
which  the  surrounding  tissues  are  rapidly  eaten  up,  the  sore  becoming  jagged 
and  irregular,  with  a  sloughy  floor  and  thin  edges.  The  discharge  is  thin 
and  reddish,  and  the  encircling  tissues  are  deeply  congested.  This  ulcer 
has  no  tendency  to  heal.  Phagedena  may  attack  wounds,  but  in  this  age  is 
almost  never  seen  except  in  venereal  sores.  When  it  does  so  the  wound  dis- 
charge is  arrested,  the  parts  about  the  wound  become  dark  red  and  swollen, 
a  black  slough  forms  upon  the  wound  and  the  process  spreads  rapidly  in  all 
directions.  The  process  when  it  attacks  a  wound  is  similar  to  or  identical 
with  a  mild  case  of  hospital  gangrene,  differing  from  the  gangrenein  the  fact 


Fig.  90. —  Im- 
provised appara- 
tus for  the  irriga- 
tion of  a  wound. 


Treatment  of  Bed-sores  195 

that  in  most  cases  a  line  of  demarcation  forms  and  the  depression  is  not  so 
great.     Phagedena  is  probably  due  to  mixed  infection  with  pus  organisms. 

The  treatment  of  phagedena  consists  in  repeated  touching  with  dncture 
of  chlorid  of  iron  and  the  local  use  of  iodoform,  the  employment  of  continued 
irrigation  or  immersion  in  hot  antiseptic  fluids,  or  the  application  of  the 
cautery,  chemical  or  actual.  After  using  the  cautery  the  part  is  dressed  with 
hot  antiseptic  fomentations.  Whatever  else  is  done,  tonics,  sdmulants,  and 
nutritious  diet  must  be  given  and  opium  is  often  required. 

Decubitus,  Decubital  Gangrene,  or  Bed=sore.— A  bed  sore  is  the 
result  of  local  failure  of  nutrition  in  a  person  whose  tissues  are  in  a  state  of 
low  vitality  from  age,  disease,  or  injury.  The  arterial  condition  of  the  aged 
favors  the  development  of  bed-sores.  Such  sores  are  due  to  pressure,  aided 
it  may  be  by  some  slight  injury  or  by  the  irritation  produced  by  urine,  feces, 
sweat,  crumbs  or  other  foreign  bodies  in  the  bed,  or  by  wrinkling  of  the 
sheets.  The  pressure  destroys  vascular  tone,  stasis  results,  thrombosis  occurs, 
and  gangrene  follows.  They  occur  over  the  heels,  elbows,  scapulae,  trochan- 
ters, sacrum,  and  nucha.  In  some  cases  after  pressure  is  removed  there 
are  stasis,  vesication,  suppuration,  and  the  formation  of  an  ugly  ulcer,  sur- 
rounded by  a  zone  of  swelling  and  hyperemia.  These  ordinary  pressure-sores 
arise  like  splint-sores  due  to  the  pressure  of  a  splint  upon  the  tissues  over  a 
bony  prominence.  The  pressure  interferes  with  the  blood-supply,  the  weak- 
ened tissues  inflame,  vesication  occurs,  sloughs  form,  and  an  ugly  ulcer 
is  exposed.  When  a  bed-sore  is  about  to  form,  the  skin  becomes  red  and 
edematous.  Pressure  with  the  finger  drives  the  color  out  rather  slowlv.  The 
color  becomes  purple  or  black,  a  slough  forms  and  separates,  and  a  large, 
irregular,  foul  cavity  is  exposed.  The  discharge  is  profuse  and  offensive. 
The  parts  about  are  swollen  and  red.  If  the  sore  is  not  upon  an  anesthetic 
part,  much  suffering  is  produced  by  it.  Bed-sores  are  most  common  in  par- 
alyzed parts;  such  parts  are  anesthetic,  and  injurious  pressure  is  not  painful 
and  does  not  attract  attention,  and  in  such  parts  there  is  vaso-motor  paresis. 

The  acute  bed-sores  of  Charcot  are  seen  during  certain  diseases  and 
after  some  injuries  of  the  nervous  system.  These  sores  are  usual  over  the 
sacrum  in  acute  myelitis,  and  may  appear  in  four  or  five  days  after  the  begin- 
ning of  that  disease  or  the  infliction  of  an  injury  upon  the  spinal  cord.  The 
svugeon  sees  acute  bed-sores  upon  the  buttock  of  the  paralyzed  side  after 
brain-injuries,  and  over  the  sacrum  in  spinal  injuries.  Some  believe  these 
sores  are  due  to  vasomotor  disorder;  but  others,  notably  Charcot,  attribute 
them  to  disturbance  of  the  trophic  nerves  or  centers. 

Treatment  of  Bed-sores. — The  "ounce  of  prevention"  is  here  invalu- 
able. From  time  to  time,  if  possible,  alter  the  position  of  the  patient,  keep 
him  clean,  maintain  the  blood-distribution  to  the  skin  by  frequent  rubbing 
with  alcohol  and  a  towel,  keep  the  sheet  clean  and  smooth,  and  in  some  situa- 
tions use  a  ring-shaped  air-cushion  to  keep  pressiue  from  the  part.  When 
congestion  appears  (paratrimma,  or  beginning  sore),  at  once  use  an  air-cushion 
or  a  water-bed  and  redouble  the  care  to  frequently  change  the  position  of  the 
patient.  Not  only  protect,  but  also  harden,  the  skin.  Wash  the  part  twice 
daily  and  apply  spirits  of  camphor  or  glycerol  of  tannin;  or  rub  with  salt  and 
whiskey  ( 5  ij  to  O j) ;  or  apply  a  mixture  of  5  ss  of  powdered  alum,  f  5  ij  of  tinc- 
ture of  camphor,  and  the  whites  of  four  eggs;  or  paint  with  corrosive  subli- 


196  Mortification,  Gangrene,  or  Sphacelus 

mate  and  alcohol  (gr.  ij  to  5j);  or  apply  tannate  of  lead  or  equal  parts  of  oil 
of  copaiba  and  castor  oil;  or  paint  upon  the  part  a  protective  coat  of  flexible 
collodion. 

When  the  skin  seems  on  the  verge  of  breaking,  paint  it  with  a  solution  of 
nitrate  of  silver  (gr.  xxto  5j)-  ^NTien  the  skin  breaks,  a  good  plan  of  treat- 
ment is  to  touch  once  a  day  with  a  solution  of  silver  nitrate  (gr.  x  to  §  j)  and 
cover  with  zinc-ichthyol  gelatin.  We  can  wash  the  sores  daily  with  i  :  2000 
corrosive  sublimate  solution,  dust  with  iodoform,  and  cover  with  soap  plaster, 
with  hnt  spread  with  zinc  ointment,  or  with  dry  aseptic  gauze.  When  sloughs 
form,  cut  most  of  them  off  with  scissors  after  cleaning  the  parts,  sht  up  sinuses, 
and  use  antiseptic  fomentations.  In  sloughing  Dupuytren  employed  pieces  of 
Hnt  wet  with  lime-juice  and  dusted  the  sore  with  cinchona  and  charcoal.  In 
obstinatfe  cases  use  the  continuous  hot  bath.  When  the  sloughs  separate, 
dress  antiseptically  or  with  equal  parts  of  resin  cerate  and  balsam  of  Peru. 
If  healing  is  slow,  touch  occasionally  with  a  solution  of  silver  nitrate  (gr.  x  to 
§j).  Bed-sores,  being  expressive  of  lowered  vitality,  demand  that  the  patient 
shall  be  stimulated,  shall  be  well  nourished,  and  shall  obtain  sound  sleep. 

Ludwig's  Angina  (Angina  Ludovki). — This  disease,  which  was  first  de- 
scribed by  Ludwig,  of  Stuttgart,  in  1836,  is  an  acute  septic  infection  about  the 
submaxillary  saUvary  gland  and  in  the  cellular  tissue  beneath  the  mucous 
membrane  of  the  flloor  of  the  mouth  and  of  the  upper  portion  of  the  neck. 
Ludwig  called  it  "gangrenous  induration  of  the  neck"  (D.  Ludwig,  "  Med. 
Correspondez  Blatt,"  p.  21,  Feb.,  1836,  Stuttgart).  The  disease  may  arise 
in  an  apparently  healthy  man  or  during  or  after  an  infectious  fever.  It  can 
arise  at  any  age.  The  bacteria  enter  from  the  mouth  by  way  of  abrasions, 
wounds,  ulcerations,  or  dental  caries.  It  may  be  caused  by  delayed  develop- 
ment of  the  third  molar,  necrosis  of  the  tooth  and  alveolar  process  taking  place 
and  an  abscess  forming  (G.  G.  Ross,  "Annals  of  Surger)-,"  June,  1901). 
In  most  cases  the  condition  is  a  pure  streptococcic  infection  or  a  streptococcic 
infection  associated  with  infection  by  some  other  organism,  for  instance,  sta- 
phylococci, pneumococci,  or  bacilU.  In  one  of  Da\is's  cases  it  was  due  to 
pneumococcus  alone;  in  another,  to  staphylococcus  alone  (Gwillym  W.  Davis, 
"Annals  of  Surger>%"  .\ugust,  1906).  In  a  case  reported  by  Lockwood  the 
bacillus  of  mahgnant  edema  was  found.  The  condition  is  essentially  an  acute 
spreading  cellulitis  about  the  submaxillary  gland.  It  usually  begins  about  that 
gland,  but  in  some  cases  seems  to  arise  about  the  sublingual  gland.  It  is 
usually  a  violent  process  from  the  start,  but  sometimes  it  is  first  an  indolent 
swelling  in  the  submaxillary  region  and  becomes  violent  and  begins  to  spread 
rapidly  after  a  few  days.  It  spreads  along  planes  of  connective  tissue  to  the 
subungual  region  of  the  mouth  and  to  the  pharynx. 

The  bacteria  reach  the  submaxillar}-  region  in  the  lymph.  A  lymph- 
gland  or  perhaps  several  glands  enlarge  and  are  rapidly  destroyed,  the  peri- 
glandular cellular  tissue  becomes  involved,  and  after  this  spread  takes  place 
along  connective-tissue  planes  and  not  by  lymph -glands,  and  other  h-mph- 
glands  seldom  enlarge. 

The  localization  in  the  submaxillar}-  region,  the  \-iolence  of  the  inflamma- 
tion, the  rapidity  of  the  spreading,  and  the  subsequent  involvement  of  the 
pharynx  and  floor  of  the  mouth  are  the  characteristic  features  of  Ludwig's 
angina  (see  T.  Turner  Thomas,  "Annals  of  Surger}-,"  February  and  March, 


Carbolic  Acid  Gangrene  197 

1908).  Thomas,  in  the  article  just  referred  to,  proves  by  anatomic  studies 
that  the  connective  tissue  in  the  submaxillary  fossa  is  directly  continuous  with 
that  in  the  floor  of  the  mouth.  The  disease  begins  as  a  painful  indurated 
swelling  beneath  the  body  of  the  jaw,  the  swelling  rapidly  increases  in  the  neck 
and  may  even  pass  to  the  level  of  the  sternum.  A  board-like  feel  of  this 
swelling  is  distinctive.  The  skin  may  be  pale  or  dusky  red.  There  may  or 
may  not  be  marked  tenderness. 

After  a  few  hours  or  a  day  or  two  the  floor  of  the  mouth  becomes  involved; 
as  a  result  of  this  the  tongue  is  raised  and  pushed  back,  the  mouth  is  kept 
from  closing,  swallowing  becomes  difficult,  speech  is  impaired,  the  saliva 
dribbles  constantly,  and  dyspnea  becomes  an  alarming  feature  of  the  case. 

In  some  cases  the  temperature  is  much  elevated,  but  in  most  it  is  moder- 
ately or  only  slightly  elevated. 

If  a  spontaneous  opening  should  occur  it  will  be  within  the  mouth.  Free 
suppuration  may  occur  or  only  a  little  watery  pus  may  form  and  the  pus  may 
be  brown  and  putrid.  In  many  cases  the  cellular  tissue  becomes  gangrenous. 
The  mortahty  is  high.  In  Thomas's  collection  of  106  cases  it  is  seen  that  43 
died  (ibid.),  though  with  the  prompt  intervention  which  is  now  advised  the 
mortality  should  be  much  below  this  figure  at  the  present  time.  I  have  had 
3  cases  and  2  of  them  died. 

Death  may  take  place  suddenly.  Death  is  seldom  due  to  septic  intoxica- 
tion or  pyemia,  but  may  be.  It  is  usually  due  to  edema  of  the  glottis  or  to 
bronchopneumonia. 

Treatment. — Operate  promptly  and  incise  freely.  If  there  is  an  infective 
focus  within  the  mouth,  remove  it.  Make  an  incision  through  the  swelling  in 
the  submaxillary  region,  carry  the  incision  forward  to  the  median  line  and 
divide  the  mylohyoid  muscle.  ''The  finger  should  be  passed  upward  in  the 
wound  until  only  mucous  membrane  intervenes  between  it  and  the  mouth. 
Gangrenous  tissue  is  cut  away,  the  wound  is  painted  with  pure  carbolic  acid, 
and  dusted  with  iodoform  "  (T.  Turner  Thomas,  ibid.).  Drainage-tubes  are 
inserted  and  the  part  is  dressed  with  antiseptic  fomentations.  If  edema  of 
the  glottis  exists,  tracheotomy  should  be  promptly  performed.  Stimulants 
are  given  with  a  free  hand  in  Ludwig's  angina. 

Carbolic  Acid  Gangrene. — Dressings  moistened  with  a  solution  of 
carbolic  acid  of  a  strength  of  from  3  to  5  per  cent,  if  wrapped  for  a  number 
of  hours  around  a  finger  or  toe,  a  hand  or  a  foot,  may  cause  dry  gangrene. 
There  is  but  little  danger  when  such  dressings  are  applied  to  the  tissues  of  the 
trunk,  because  these  thicker  tissues  are  better  nourished  and  cannot  be  com- 
pletely surrounded  by  the  wet  dressings.  When  a  dressing  wet  with  a  watery 
solution  of  carbolic  acid  is  wrapped  about  the  part  the  water  evaporates,  and 
as  it  does  so  the  carbolic  acid  becomes  more  and  more  concentrated.  A  well 
mixed  solution  seldom  causes  gangrene.  A  recent  aqueous  solution  often  con- 
tains free  globules  of  acid  and  is  particularly  apt  to  cause  gangrene  (Murphy) . 
It  is  claimed  that  a  solution  of  carbolic  acid  in  glycerin  never  causes  gangrene 
(Pautrier  in  "Presse  Medicale,"  March  2,  1907).  The  application  of  strong 
acid  rarely  causes  gangrene,  but  Levan  found  14  reported  cases  in  which  it  did 
(J.  Levan,  in  "Centralbl.  f.  Chir.,"  August  14,  1897),  and  Wallace  has  reported 
several  more  ("Brit.  Med.  Jour.,"  May  11,  1907).  The  continuous  application 
of  a  solution  of  a  strength  of  3  per  cent,  or  over  is  very  dangerous  and  ought 


198  Mortification,  Gangrene,  or  Sphacelus 

never  to  be  practised.  The  author  has  seen  5  cases.  Harrington  saw  1 8  cases  of 
gangrene  in  five  years  in  the  Massachussetts  General  Hospital,  and  collected 
132  cases  from  Hterature  ("Boston  Med.  and  Surg.  Jour.,"  May  2,  1901). 
Carbolic  acid  gangrene  is  due  to  great  exudation  into  the  cellular  tissue,  blocking 
the  circulation  (Housell),  and  the  production  of  arterial  thrombi,  a  condition 
to  which  the  patient  is  predisposed  by  the  injury  and  often  by  tight  bandaging. 
The  dressing  is  frequently  applied  by  a  druggist;  it  produces  anesthesia  of  the 
part,  and  the  dressing  may  perhaps  not  be  removed  for  days,  gangrene  per- 
haps progressing  beneath.  In  the  author's  5  cases  pain  was  absent  and  there 
was  no  smokiness  of  the  urine  or  any  other  e\ndence  of  absorption  of  the 
drug.  Dressing  of  lysol  and  of  alcohol  may  produce  gangrene,  but  the  necrosis 
is  more  superficial  than  that  due  to  carbolic  acid. 

Treatment. — If  the  gangrene  is  ven,-  superficial,  recovery  may  be  obtained 
by  using  hot  fomentations  and  picking  the  dead  parts  gradually  away.  In 
most  cases  the  finger  or  toe  is  completely  destroyed,  a  line  of  demarcation 
forms,  and  amputation  is  required. 

Post=febrile  Gangrene. — Dry  or  moist  gangrene  may  follow  any  fever, 
but  is  most  frequent  after  t_\-phoid  (may  follow  typhus,  influenza,  measles, 
scarlet  fever,  etc.).  Keen  tells  us  that  the  gangrene  resulting  from  arterial 
obstruction  is  apt  to  be  dry,  and  that  from  venous  obstruction  is  visually 
moist.  The  same  obsen-er  has  collected  203  cases.*  It  is  most  usual  in  the 
lower  extremities,  but  may  appear  in  the  upper  extremities,  cheeks,  ears,  nose, 
genitals,  lungs,  etc.  Some  writers  have  assigned  as  the  cause  weakness  of 
cardiac  action,  but  most  obser\-ers  believe  an  obstructing  clot  is  the  usual 
catise.  This  clot  may  come  from  the  heart,  but  is  in  most  cases  secondary  to 
endarteritis  due  to  the  action  of  the  toxins  of  the  bacilli  of  the  specific  fever. 
Keen  shows  that  in  some  cases  gangrene  is  due  to  obstruction  of  peripheral 
vessels  and  not  of  a  main  trunk.  In  rare  cases  gangrene  arises  after  throm- 
bophlebitis. Gangrene  may  begin  as  early  as  the  fourteenth  day  of  the  fever, 
but'  usually  appears  late  in  the  disease  and  may  arise  far  into  convalescence. 
In  the  course  of  a  continued  fever  frequent  examinations  should  be  made  to 
see  that  gangrene  is  not  arising.  Particular  examination  from  time  to  time 
should  be  made  of  the  lower  extremities,  and  in  young  girls,  of  the  genitals. 
If  gangrene  arises  in  an  extremity,  apply  antiseptic  dressings,  wait  for  a  fine 
of  demarcation,  and  then  amputate.  If  gangrene  occurs  in  other  regions, 
remove  the  dead  tissue  and  employ  hot  antiseptic  fomentations. 

Rules  when  to  Amputate  for  Gangrene.— In  dry  gangrene,  due  to 
obstruction  of  a  non-diseased  artery,  wait  for  a  fine  of  demarcation.  In  senile 
gangrene,  if  it  affect  only  one  or  two  toes,  let  the  dead  parts  be  cast  off  spon- 
taneously. If  a  greater  area  is  involved  or  the  process  spreads,  amputate 
above  the  knee  without  waiting  for  the  line.  In  ordinary  moist  gangrene,  if 
there  are  not  severe  s}-mptoms  of  sepsis,  and  if  the  gangrene  is  not  rapidly 
progressive,  wait  for  a  line  of  demarcation.  In  the  severer  cases  amputate 
at  once  high  up.  In  traumatic  spreading  gangrene  amputate  at  once.  In 
diabetic  gangrene  amputate  at  once,  high  up.  In  ergot  gangrene,  in  carbolic 
acid  gangrene,  in  post-jebrile  gangrene,  in  Raynaud's  gangrene,  and  in  jrost 
gangrene  wait  for  a  line  of  demarcation. 

*  Keen  on  the  "Surgical  Complications  and  Sequels  of  Typhoid  Fever." 


Causes  of  Thrombosis 


199 


IX.  THROMBOSIS  AND  EMBOLISM. 

Thrombosis  is  the  ante-mortem  coagulation  of  blood  in  the  heart  or  in  a 
vessel,  the  coagulum  remaining  at  its  point  of  origin  and  plugging  up  the 
vessel  partially  or  completely.  The  process,  and  also  the  condition  significant 
of  the  process,  is  known  as  thrombosis;  the  clot  is  called  the  thrombus.  This 
process  is  an  essential  part  in  the  arrest  of  hemorrhage;  it  occurs  in  phlebitis 
and  arteritis,  and  affords  a  frequent  basis  for  embolism.  The  thrombus  is  com- 
posed of  red  corpuscles,  white  corpuscles,  fibrin,  and  platelets  in  varjnng  pro- 
portions. Thrombi  may  form  in  the  veins,  in  the  arteries,  in  the  capillaries, 
or  in  the  heart.  Clotting  is  due  to  destruction  of  white  blood-cells,  fibrin 
ferment  being  set  free,  causing  the  union  of  calcium  and  fibrinogen  and 
thus  forming  fibrin.  Thromxbosis  is  more  common  in  the  veins  than  in 
the  arteries,  the  slow  blood-current  and  the  existence  of  valves  favor- 
ing the  deposit,  though  not  causing  it.  A  thrombus  forms  gradually^  being 
deposited  layer  by  layer;  hence  it  is  stratified  or  laminated.  Fig.  91  shows  a 
thrombus  in  a  vein.  All  thrombi  are  either  injections  or  simple,  the  latter 
being  also  called  aseptic  or  hland.  Thrombi  are  also 
spoken  of  as  fibrinous,  red,  hemostatic,  leukocytic,  etc. 

Causes  of  Thrombosis. — In  the  formation  of 
thrombi  four  conditions  are  to  be  considered,  viz.,  chemi- 
cal alterations  in  the  blood,  a  bacterial  attack  on  the 
intima,  tissue  changes  in  the  inner  coat  of  the  vessel,  and 
slowing  of  the  circulation.  One,  several,  or  all  of  these 
conditions  may  e.xist  in  a  case  of  thrombosis.  In  arteries 
the  chief  causes  are  disease  of  the  coats  and  embolism.  In 
veins  the  chief  causes  are  injury'  and  infectious  phlebitis. 
Capillary  thrombi  may  be  due  to  propagation  from  veins  or 
arteries  or  may  form  in  the  capillaries.  The  latter  condition 
is  seldom  seen.  The  essential  cause  of  all  intravascular 
thrombi  is  damage  to  the  endothelial  coat  and  in  most 
instances  the  damage  is  eft'ected  by  bacteria,  hence  most 
cases  of  thrombosis  seen  by  the  surgeon  are  infectious.  Any  condition  which 
causes  the  blood  to  contain  an  excess  of  fibrin-forming  elements  favors  throm- 
bosis, in  the  sense  that  a  slight  injur}'  of  the  vascular  endothelium  will  be  followed 
by  clot  formation.  Among  conditions  favoring  thrombosis  we  must  note 
particularly  slowing  of  circulation,  however,  caused.  A  special  predisposing 
condition  is  the  retarded  circulation  in  tuberculosis,  influenza,  and  fevers, 
the  blood  clotting  behind  the  vein-valves  after  the  endothehum  has  been 
damaged  by  toxins.  Among  other  favoring  states  are  inflammations; 
wounds;  fractures;  the  pressure  of  a  bandage  or  of  a  splint;  varicose  veins; 
hgation  of  a  vessel;  injur}-  of  a  vessel;  foreign  bodies  in  a  vessel;  atheroma 
in  arteries;  sutures  in  a  vessel;  certain  diseases,  such  as  gout,  t}'phoid  fever, 
pregnancy,  and  septic  processes;  phlebitis  or  arteritis  arising  in  the  vessel  or 
from  extension  of  surrounding  inflammation;  and  the  entrance  of  specific 
organisms. 

It  has  been  asserted  that  so  long  as  the  endothehum  of  a  vessel  is  unin- 
jured a  clot  does  not  form.    Slowing  of  the  blood-current  in  aseptic  conditions. 


Fig.  91.— Thrombus  inthe 
saphenous  vein  (Green). 


200  Thrombosis  and  Embolism 

it  is  now  taught,  will  not  cause  thrombosis.  One  of  the  functions  of  the  endo- 
thelial coat  is  to  keep  the  blood  fluid  by  preventing  corpuscular  disintegration. 
A  thrombus  can  form  only  when  fibrin  ferment  is  set  free,  and  fibrin  ferment 
can  be  set  free  only  when  white  corpuscles  disintegrate.  WTien  moving  blood 
coagulates,  the  third  corpuscles  or  platelets  first  settle  out  and  form  a  nucleus 
and  then  the  leukocytes  gather  about  it.  This  is  known  as  the  white  or  "ante- 
mortem"  thrombus— the  clot  of  moving  blood.  Thrombi  from  moving  blood 
are  rarely  pure  white;  they  contain  some  red  corpuscles,  forming  jnixed 
thrombi.  White  thrombi  and  mixed  thrombi  are  stratified  and  are  at  fii*st 
soft  but  harden  as  they  age.  The  red  thrombus  plugs  vessels  which  are  cut 
across  or  Hgated;  it  also  occurs  in  septic  processes  and  is  formed  after  death. 
A  primary  thrombus  remains  in  the  original  region  of  thrombosis.  A  secondary 
thrombus  forms  about  an  embolism.  A  propagating  or  spreading  thrombus 
extends  a  considerable  distance  from  the  seat  of  initial  disturbance.  A  throm- 
bus soon  undergoes  a  change.  An  aseptic  clot  usually  "organizes" — that  is, 
the  clot  is  absorbed  and  is  replaced  by  fibrous  tissue.  The  walls  of  the  injured 
vessel  become  filled  with  leukocytes,  leukocytes  invade  the  clot,  the  vascular 
endothehum  proliferates,  and  the  young  cells  follow  the  colonies  of  leukocytes 
into  the  thrombus.  The  thrombus  is  gradually  removed  by  leukocytes  and 
replaced  by  fibroblasts,  the  new  tissue  is  vascularized  and  becomes  granula- 
tion tissue,  the  granulation  tissue  is  converted  into  fibrous  tissue,  and  the 
fibrous  tissue  contracts.  In  some  instances  a  thrombus  is  implanted  on  the 
wall  of  the  vessel,  and  the  tube  is  not  permanently  occluded.  Such  a  con- 
dition may  be  obtained  by  the  application  of  a  lateral  ligature  about  a  small 
tear  in  a  large  vein.  In  most  instances,  after  the  formation  of  an  intravascular 
thrombus,  the  vessel  is  converted  into  a  narrow  cord 
of  fibrous  tissue.  A  thrombus  may  degenerate  and 
break  down  (fatty  degeneration),  giving  rise  to  em- 
boli or  a  thrombus  may  undergo  calcification.  A 
calcified  thrombus  in  a  vein  is  known  as  phleboJith. 
An  infected  thrombus  may  undergo  Hquefaction,  in- 
fective emboh  being  set  free  (Fig.  92) . 

A  clot  may  propagate  in  both  directions,  that  is, 

toward  the    periphery  and    toward   the    center.     It 

was  taught  for  many  years   that  when  an  artery  is 

,       ,  ,         ligated  a  thrombus  quickly  forms  and  reaches  to  the 

Fig.  92.-Infected  thrombus       ^      .         „    .         ,,  v       ,  T-u-        •  t 

of  a  vein  (schematic).  first  Collateral  branch  above.  Ihis  view  was  formu- 
lated in  preantiseptic  days.  It  is  now  known  that 
when  aseptic  ligation  is  performed  the  thrombus  is  small  and  rarely  reaches 
the  first  collateral  branch;  and  is  often  actually  absent,  vascular  obliteration 
being  obtained  by  proliferation  of  connective-tissue  cells  and  of  cells  from  the 
endothelial  coat.  If  any  infection  takes  place  the  clot  will  reach  the  first  col- 
lateral branch.  The  old  rule  of  surgery  was  as  follows:  If  an  arter\'  is  cut 
near  a  large  branch,  tie  the  branch  as  well  as  the  artery,  in  order  to  permit  oi 
the  formation  of  a  lengthy  clot.  This  rule  is  no  longer  followed  unless  infec- 
tion exists  or  is  anticipated. 

A  clot  in  a  vein  often  extends  a  long  distance.  The  author  has  seen  in  a 
post-mortem  examination  a  venous  thrombus  reaching  from  the  ankle  to  the 
vena  cava.    A  common  example  of  thrombus  in  a  vein  is  the  clot  formed  in  the 


General  Symptoms  of  Thrombosis  201 

uterine  sinuses  in  a  condition  of  puerperal  sepsis,  a  clot  which  tends  to  extend 
into  the  iliac  and  femoral  veins.  In  infectious  thrombosis  of  the  lateral  sinus, 
thrombophlebitis  arises  and  the  clot  tends  to  extend  up  to  the  torcular  and 
into  other  sinuses  and  down  into  the  jugular.  Phlegmasia  alba  dolens  or 
milk  leg  is  a  condition  in  which  the  leg  or  the  leg  and  thigh  are  swollen 
and  painful  because  of  venous  thrombosis  or  sometimes  lymphatic  throm- 
bosis. 

Lymphatic  Thrombosis. — Occasionally  occurs  in  the  thoracic  duct,  axillary 
lymphatics,  or  inguinal  lymphatics.  It  is  most  common  in  the  uterine  lymphat- 
ics during  puerperal  fever.  Lymphatic  thrombosis  may  be  due  to  infection, 
to  cancer,  to  tuberculosis,  or  to  change  in  the  lymph  itself. 

General  Symptoms. — The  symptoms  are  dependent  on  the  seat  of  the 
obstruction  and  the  presence  or  absence  of  infection.  An  organ  or  a 
part  of  an  organ  may  exhibit  functional  aberration.  The  local  signs  in 
a  vessel  accessible  to  touch  or  sight  are  the  presence  of  a  clot;  if  it  be 
in  an  artery,  anemia  and  the  absence  of  pulse  below  the  clot;  if  it  be  a 
vein,  swelling  and  edema  below  it.  There  is  usually  pain  at  the  seat  of 
trouble,  and  anesthesia  below  it.  Moist  gangrene  may  follow  venous  throm- 
bosis, and  dry  gangrene,  arterial  thrombosis.  Thrombosis  of  the  mesen- 
teric vein  is  followed  by  gangrene  of  the  bowel.  Infective  thrombophleb- 
itis is  a  spreading  inflammation  of  a  vein.  A  septic  thrombus  forms  and  the 
condition  is  an  early  step  in  pyemia.  We  see  this  condition  sometimes  in 
the  lateral  sinus  of  the  brain  as  a  result  of  suppuration  in  the  middle  ear;  in 
any  of  the  cerebral  sinuses  after  infected  compound  fracture  of  the  skull;  and 
in  the  uterine  veins  in  puerperal  sepsis.  Thrombo-arteritis  is  a  spreading 
inflammation  of  an  artery  in  which  a  septic  thrombus  forms  or  in  which  a 
septic  embolus  lodges.  It  occasionally  attacks  an  aneurysmal  sac.  In  in- 
fectious thrombophlebitis  and  in  arterial  pyemia  the  s^Tnptoms  are,  of  course, 
those  of  pyemia.  A  great  danger  of  thrombosis  is  embolism,  especially  pul- 
monary embohsm. 

Infectious  Thrombosis  of  the  Lateral  Sinus. — (See  page  823.) 

Thrombosis  of  the  Jugular  Vein. — This  condition  is  usually  infectious  and 
secondary  to  infectious  thrombosis  of  the  lateral  sinus  or  sometimes  of  the 
petrosal  sinus.  It  is  occasionally  due  to  cancer,  tuberculosis,  acute  rheu- 
matism, or  pyemia  taking  origin  from  a  distant  focus.  If  it  is  infectious, 
the  chills,  the  high  and  fluctuating  temperature,  and  the  great  exhaustion 
proclaim  the  existence  of  pyemia.  Locally  the  vein  feels  hard,  the  adjacent 
tissues  are  edematous,  the  branches  of  the  jugular  are  visibly  distended, 
there  may  be  linear  discoloration  over  the  course  of  the  jugular,  and  the  head 
is  held  stiffly  with  an  inclination  to  the  diseased  side. 

Thrombosis  of  the  Mesenteric  Vessels. — The  arteries  are  affected  much 
more  commonly  than  the  veins  and  the  superior  mesenteric  artery  far  more 
often  than  the  inferior.  Vascular  disease  is  the  cause  of  arterial  thrombosis 
and  arterial  thrombosis  occurs  chiefly  in  those  beyond  middle  life.  Venous 
thrombosis  may  be  primary  and  has  been  observed  after  splenectomy,  the 
clot  having  propagated  to  the  mesenteric  veins.  It  may  occur  as  a  result  of 
any  gastro-intestinal  or  general  infection  (pyemia,  appendicitis,  typhoid  fever). 
Secondary  venous  thrombosis  is  due  to  portal  obstruction  or  accompanies 
arterial  mesenteric  thrombosis. 


202  Thrombosis  and  Embolism 

Mesenteric  thrombosis  usually  produces  sooner  or  later  gangrene  of  the 
gut,  but  does  not  always  do  so. 

The  period  at  which  gangrene  develops  after  blocking  is  uncertain;  it 
may  arise  in  thirty-six  hours,  it  may  not  arise  for  two  weeks  or  more.  The  gut 
becomes  distended,  bloody  serum  exudes  into  the  peritoneal  cavity,  and  in 
most  cases  into  the  lumen  of  the  bowel.  The  mucous  membrane  undergoes 
necrosis  and  perforation  occurs.  The  area  involved  varies  greatly  in  differ- 
ent cases.  In  some  cases  it  is  very  Hmited,  and  is  rather  apt  to  be  in  the  large 
intestine.  In  other  cases  it  is  very  extensive,  and  is  apt  to  be  in  the  small 
intestine.  In  a  case  of  the  author's  in  the  Jefferson  College  Hospital  prac- 
tically the  entire  ileum  was  gangrenous  and  numerous  perforations  existed. 

In  mesenteric  thrombosis  pain  arises  rather  suddenly  and  rapidly  becomes 
severe.  It  is  a  persistent  pain  with  paroxysmal  exacerbations  and  is  usually 
generalized,  though  in  many  cases  it  has  an  area  of  pecuUar  intensity.  The 
pain  is  accompanied  by  rapid  pulse,  growing  exhaustion,  distention,  subnormal 
temperature,  tenderness,  a  mass  appreciable  by  palpation  in  the  region  of  the 
mesentery,  free  fluid  in  the  peritoneal  cavity,  nausea,  and  vomiting.  The 
condition  suggests  intestinal  obstruction.  The  vomited  matter  consists  first 
of  the  contents  of  the  stomach,  then  of  bile,  finally  becomes  stercoraceous, 
and  sometimes  contains  blood. 

In  nearly  one-half  of  all  cases  blood  in  considerable  quantity  passes  from 
the  rectum. 

Ballance  points  out  that  cardiac  disease  or  arterial  degeneration  suggests 
the  artery  as  the  seat  of  thrombosis. 

The  only  chance  for  recovery  without  operation  is  the  estabhshment  of 
the  collateral  circulation,  and  as  the  superior  mesenteric  vessels  are  terminal 
vessels  this  seldom  occurs  (in  only  about  5  per  cent,  of  cases). 

Thrombosis  after  Abdominal  Operations. — This  complication  is  occasionally 
encountered  and  is  most  often  met  with  in  the  left  side,  even  when  the  opera- 
tion was  in  the  middle  Une  or  the  right  side.  It  is  a  rare  complication,  occur- 
ring, according  to  Professor  Clark,  35  times  in  a  series  of  3000  operations. 

Many  explanations  have  been  given  of  it.  A  great  many  surgeons  regard  it 
as  infectious,  but  many  cases  certainly  are  not.  Clark  believes  it  is  due  to  injury 
of  the  deep  epigastric  vein,  forcible  and  prolonged  separation  of  the  wound 
edges  by  retractors  being  a  common  cause.  The  free  anastomosis  between 
the  epigastric  veins  of  the  two  sides  accounts  for  the  appearance  of  thrombosis 
on  one  side  after  operation  on  the  other.  It  probably  in  many  slight  cases  is 
not  recognized  and  it  will  not  be  recognized  unless  the  clot  reaches  the  femoral 
vein,  and  it  requires  one  or  two  weeks  to  reach  this  vein  if  it  does  so  at  all. 
When  a  clot  forms  in  the  femoral  vein  a  milk  leg  develops.  The  entire  ex- 
tremity swells  below  the  seat  of  thrombus,  the  temperature  is  usually  normal 
but  may  be  slightly  elevated. 

Thrombosis  in  General  Injections. — In  typhoid  fever  a  thrombus  may 
form  in  the  heart,  the  veins  or  the  arteries.  Thrombosis  may  occur  in  pneu- 
monia, in  influenza  and  in  other  fevers,  and  in  tuberculosis.  The  vessels  of 
a  limb,  a  lung,  the  brain  or  the  mesenteric  zone  may  suffer.  The  condition 
follows  bacterial  infection,  the  veins  are  most  prone  to  suffer  and  gangrene 
may  ensue. 

Thrombosis  in  Appendicitis. — In  about  2  per  cent,  of  cases,  according  to 


Embolism  203 

Sonnenberg,  this  complication  is  noted.  It  may  affect  the  femoral  or  saphenous 
vein  of  either  side  or  of  both  sides,  the  portal  vein  or  the  vena  cava,  and  may- 
occur  during  an  acute  attack  but  is  more  often  noted  in  an  interval. 

It  is  not  very  unusual  to  find  a  liver  abscess  follow  appendicitis,  the  in- 
fection being  carried  by  the  portal  vein  and  the  condition  being  known  as 
septic  pylephlebitis  (page  1017). 

Treatment. — If  an  aseptic  thrombus  forms  in  a  large  vessel  of  a  limb,  raise 
the  limb  a  few  inches  from  the  bed,  keep  it  perfectly  quiet  to  avoid  detachment 
of  fragments  (emboli),  apply  a  bandage  hghtly  from  the  toes  up,  and  place 
warm  bottles  around  the  extremity.  Maintain  rest  for  four  or  five  weeks.  The 
great  danger  is  the  formation  of  emboli,  hence  movements  and  rough  handling 
are  to  be  avoided.  Gangrene  is  another  danger,  hence  it  is  wise  to  favor  venous 
return  and  the  development  of  the  collateral  circulation  by  warmth,  elevation, 
and  bandaging.  In  infectious  thrombophlebitis,  if  the  vessel  is  accessible,  tie 
it  above  and  below  the  clot,  open  the  vessel,  remove,  irrigate,  and  pack  the 
wound  ^\'ith  iodoform  gauze.  The  general 
treatment  for  a  septic  condition  should  be  stimu- 
lating and  supporting.  Massage  is  unsafe  in 
any  condition  of  thrombosis,  and  is  particularly 
dangerous  in  septic  thrombosis.  In  thrombo- 
arteritis  treat  as  in  the  thrombo-phlebitis.  If 
gangrene  of  an  extremity  follows  thrombosis 
treat  as  previously  directed  (page  180).  Gan- 
grene of  the  intestine  in  mesenteric  thrombosis 
if  not  too  extensive  is  treated  by  resection. 

The  treatment  of  infectious  thrombosis  of        Fig.  93— Embolus  impacted  at  bi- 

,       ,  ...  r       ,  „  furcation  of  a  branch  of  the  pulmon- 

the  lateral  SmUS  is  set  forth  on  page  824.  ary  artery  (Green). 

Embolism  signifies  vascular  plugging  by  a 
foreign  body  (usually  a  blood-clot)  which  has  been  brought  from  a  distance. 
The  foreign  body  is  called  an  embolus.  An  embolus  usually  consists  of  a  sepa- 
rated or  ruptured  portion  of  a  thrombus,  atheromatous  material  from  a  dis- 
eased artery,  or  a  bit  of  fibrin  from  a  diseased  heart  valve.  In  some  cases  an 
embolus  consists  of  bacteria,  or  air,  or  fat,  of  a  fragment  of  a  tumor,  or  of 
parasites.  In  severe  burns  the  blood  undergoes  changes  and  jelly-Hke  matter 
is  often  precipitated  and  may  cause  embolism.  EmboH  vary  in  shape,  in 
size,  and  in  consistency.  Emboli  are  divided  into  simple,  bland  or  aseptic 
and  infectious,  toxic  or  septic.  Emboli  may  arise  either  in  the  venous  or  in 
the  arterial  system,  but  are  particularly  prone  to  arise  in  the  veins;  they  lodge 
in  an  artery,  in  capillaries,  or  in  the  veins  of  the  liver.  An  embolus  taking 
origin  in  one  of  the  systemic  veins  passes  through  the  right  heart  and  lodges  in 
a  terminal  branch  of  the  pulmonary  artery.  If  at  this  point  it  disintegrates, 
smaller  emboli  pass  to  the  left  heart  and  enter  the  arterial  circulation  to 
be  deposited,  as  are  emboli  originating  in  the  heart  or  arteries,  in  the  arteries 
of  an  extremity,  the  kidneys,  spleen,  or  brain.  Emboli  of  the  portal  circulation 
lodge  in  the  liver  or  perhaps  pass  through  that  organ  and  reach  the  lungs. 
An  embolus  is  arrested  when  it  reaches  a  vessel  whose  diameter  is  less 
than  its  own.  It  is  usually  caught  just  above  a  bifurcation.  When  an 
embolus  lodges,  it  at  once  partially  or  entirely  obstructs  the  circulation,  and 
increases  in  size  by  thrombosis.    Fig.  93  shows  an  impacted  embolus.    A  non- 


204 


Thrombosis  and  Embolism 


septic  embolus  when  lodged  usually  "organizes,"  as  does  a  thrombus,  and,  as 
described  on  page  132,  is  replaced  ultimately  by  fibrous  tissue.  A  soft  embolus 
may  disintegrate  and  permit  the  re-establishment  of  the  circulation.  An  em- 
bolus may  cause  an  aneurysm.  A  septic  embolus  breaks  down,  forms  a 
metastatic  abscess,  and  sends  other  emboli  onward  in  the  blood-stream. 

An  embolus  is  more  serious  than  a  thrombus:  it  causes  sudden  plug- 
ging, which  makes  dangerous  anemia  inevitable,  and  it  will  produce 
gangrene  if  the  collateral  circulation  fails.  Embolism  of  the  mesen- 
teric artery  causes  necrosis  of  the  intestine.  In  organs  with  terminal  arteries 
(spleen,  kidney,  brain,  and  lung)  there  is  no  collateral  circulation  and  embol- 
ism causes  injardion.  For  instance,  if  an  embolus  lodges  in  the  lung  it  pro- 
duces an  area  of  anemia;  the  removal  of  all  propulsion  upon  the  venous  blood 

causes  it  to  flow  back  and  stagnate,  and  vas- 
cular elements  exude,  forming  a  wedge- 
shaped  area  of  red  tissue,  the  embolus  being 
the  apex  of  the  w'edge.  This  is  known  as 
hemorrhagic  or  red  infarction,  and  is  often 
seen  in  the  lung  (Fig.  94)-  The  white  infarc- 
tion, seen  in  the  brain  and  kidney,  is  not  due 
to  retrogression  of  venous  blood,  but  is  due  to 
anemia  and  resulting  coagulation-necrosis. 
A  septic  embolus  causes  septic  thrombosis 
and  a  septic  infarction,  and  a  septic  in- 
farction is  followed  by  suppuration  and  the 
production  of  a  pyemic  abscess.  That 
emboh  of  the  systemic  venous  circulation 
usually  lodge  in  the  lungs  explains  the  occur- 
rence of  pulmonary  embolism  after  certain 
operations  upon  and  during  certain  diseases 
of  the  regions  drained  by  the  systemic  veins. 
EmboU  formed  in  vessels  of  the  systemic  circulation  lodge  most  often  in  the 
lungs,  brain,  kidney,  or  spleen.  It  is  because  emboli  which  pass  into  the  portal 
vein  lodge  in  the  liver  that  operations  upon  the  rectum  may  be  followed  by 
hepatic  embolism  and  abscess  of  the  Hver. 

General  Symptoms. — The  symptoms  depend  upon  the  organ  involved 
and  the  presence  or  absence  of  infection.  They  are  sudden  in  onset,  and 
are  due  to  loss  of  function,  which  may  be  permanent  or  which  may  be  fol- 
lowed by  inflammation,  softening,  or  gangrene.  In  a  septic  embolus  there 
are  symptoms  of  infection  and  abscess  forms  at  the  seat  of  lodgment.  In 
the  course  of  pyemia  a  chill  usually  means  the  occurrence  of  embolism. 
Embolism  of  the  cerebral  arteries  may  cause  aphasia,  paralysis,  or  coma.  Em- 
bolism of  the  pulmonary  artery  may  cause  almost  instant  death.  Embolism  of 
a  large  artery  of  a  limb  produces  symptoms  identical  with  thrombus,  except 
more  sudden  and  decided.  Below  the  obstruction  the  pulse  is  absent  and 
the  limb  is  swollen  with  edema,  is  cold,  and  is  discolored.  There  is  pain  at 
the  seat  of  obstruction.  This  condition  is  frequently  followed  by  gangrene. 
Embolism  of  the  superior  mesenteric  artery  produces  symptoms  similar  to 
those  caused  by  acute  intestinal  obstruction,  and  results  in  gangrene  of  a 
portion  of  the  intestine. 


Fig-  94- — Diagram  of  a  hemorrhagic 
infarct  :  a,  Artery  obliterated  by  an 
embolus  (e)  ;  v,  vein  filled  with  a 
secondary  thrombus  (th) ;  /,  center  of 
infarct,  which  is  becoming  disinte- 
grated ;  2,  area  of  extravasation ;  j, 
area  of  collateral  hyperemia  (O. 
Weber). 


Fat-embolism  205 

Pulmonary  Embolism. — This  condition  occasionally  follows  operations 
and  injuries  and  sometimes  develops  during  certain  diseases.  I  have  seen  a  case 
after  an  operation  for  appendicitis,  a  case  after  an  operation  for  varicocele, 
and  a  case  in  a  man  with  a  large  lumbar  contusion  to  which  massage  was  in- 
judiciously applied.  It  is  not  very  common.  Albanus  ("  Beitriige  klin.  Chir.," 
xl)  in  1 140  abdominal  operations  found  23  cases.  The  emboli  may  be  aseptic 
or  septic.  The  condition  is  most  common  as  a  result  of  thrombosis  of  the 
veins  of  the  lower  extremities,  appendicitis,  and  strangulated  hernia.  Cer- 
tain postoperative  pneumonias  are  embolic.  Very  small  aseptic  emboli  may 
cause  no  symptoms  or  sHght  symptoms.  When  aseptic  hemorrhagic  infarc- 
tion occurs  there  are  symptoms.  These  symptoms  are  a  chill  or  chilly  sensa- 
tions, moderate  fever  which  may  be  transitory,  dyspnea,  rapid  pulse,  pain  in 
the  chest,  sometimes  rapidly  advancing  signs  of  consolidation,  often  a  pleural 
friction  sound,  and  bloody  expectoration.  Sometimes  immediate  death  occurs. 
The  mortality  is  always  large  (80  per  cent.). 

A  septic  embolism  causes  metastatic  abscess  and  usually  suppurating 
pleuritis,  the  condition  being  known  as  septic  embolic  pneumonia.  Recovery 
is  rare  but  occasionally  occurs.  The  symptoms  are  those  of  pyemia  with  the 
physical  signs  of  consolidation  and  of  pleuritis. 

Embolism  of  the  Mesenteric  Arteries. — The  superior  mesenteric  is 
the  vessel  usually  afifected.  It  may  arise  in  pyemia,  septicemia,  arterial  or 
cardiac  disease.  The  symptoms  are  practically  identical  with  thrombosis  of 
the  mesenteric  vessels  (page  201). 

Treatment. — Murphy  removed  an  embolism  of  the  femoral  and  iliac 
arteries  through  an  incision  of  the  femoral,  and  then  sutured  the  incision 
("Jour.  Am.  Med.  Assoc,"  May  22,  1909).  The  operation  was  too  late  to 
prevent  gangrene,  but  it  emphasizes  the  truth,  that  an  aseptic  embolism  of  a 
large  artery  should  be  treated  by  incision  of  the  artery,  removal  of  the  clot, 
and  suture  of  the  vessel.  The  treatment  long  in  vogue  was  as  follows: 
In  a  limb,  keep  the  part  warm  in  order  to  stimulate  the  collateral  circu- 
lation, elevate  the  extremity  several  inches  from  the  bed,  apply  a  bandage 
lightly  from  the  periphery,  and  insist  on  perfect  quiet.  Massage  is  unsafe. 
If  gangrene  ensues,  await  a  line  of  demarcation  and  amputate.  In  septic 
embolic  arteritis  in  an  accessible  region  it  would  be  good  surgery  to  act  as 
in  septic  thrombophlebitis.  After  an  operation  upon  veins  (as  the  operation 
for  varicocele,  for  varix  of  the  leg,  or  for  hemorrhoids),  after  any  cutting 
operation,  and  after  the  infliction  of  a  fracture,  avoid  as  much  as  possible, 
and  for  some  time,  movements  or  handling,  as  fragments  of  thrombus  may 
be  detached. 

In  mesenteric  embolism  exploratory  laparotomy  may  disclose  a  perfora- 
tion which  can  be  closed  or  a  portion  of  gangrenous  gut  which  can  be  resected. 

In  aseptic  pulmonary  embolism  enforce  absolute  rest,  give  strychnin  and 
morphia  hypodermatically,  and  inhalations  of  oxygen. 

In  septic  embolic  pneumonia,  pursue  the  same  plan  of  treatment,  unless 
a  large  pulmonary  abscess  forms  or  an  empyema  arise.     In  either  case  operate. 

Fat=emboiism  in  the  human  being  was  first  noted  in  1856  by  MacGibbon, 
of  New  Orleans,  and  was  first  thoroughly  described  by  von  Recklinghausen  in 
1884,  although  Magendie,  in  1827,  and  Virchow,  in  1856,  developed  it  experi- 
mentally in  animals.     It  is  a  process  which  leads  to  an  accumulation  in  the 


206 


Thrombosis  and  Embolism 


capillaries  of  liquid  fat  after  injury  to  adipose  tissue,  high  tension  having 
forced  the  fat  into  the  open  mouths  of  veins.  Fat  may  be  forced  into  open 
veins  by  muscular  action,  by  efforts  at  repair,  or  by  concealed  bleeding.  Some 
little  fat  may  get  into  the  blood  by  means  of  the  lymphatics  and  it  can  also  enter 
by  way  of  the  synovial  membrane.  It  is  a  very  common  concUtion,  but  seldom 
produces  serious  trouble,  although  it  is  occasionally  fatal  and  is  responsible  for 
some  otherwise  inexpHcable  sudden  deaths  after  fractures.  Fat-embohsm  may 
arise  during  osteomyelitis,  after  extensive  bruises,  crushes,  lacerations,  amputa- 
tions, fractures,  resections,  or  rupture  of  the  liver.*  In  a  fatal  case  of  mine 
it  developed  as  a  result  of  manipulation  of  a  fracture  of  the  neck  of  the  femur. 
In  another  fatal  case  it  followed  amputation  for  cancer  of  the  breast  of  a  very 
fat  woman.  This  fluid  fat  accumulates  especially  in  the  capillaries  of  the  lungs 
and  brain.  It  may  plug  systemic  capillaries.  If  the  patient  recovers,  he  does 
so  because  the  fat  has  been  forced  through  the  vessels;  if  he  dies,  the  death 
results  from  mechanical  hindrance  to  function  and  nutrition.  When  the 
emboli  are  widely  scattered  and  not  large,  and  when  they  do  not  lodge  in  vital 
parts  of  the  brain  and  cord  they  may  produce  no  symptoms  and  do  no  real 
harm.  Normal  blood  contains  a  small  amount  of  finely  emulsified  fat  (from 
I  to  3  parts  per  looo).  In  a  number  of  physiologic  and  pathologic  conditions 
the  circulating  blood  contains  considerable  free  fat.  It  may  be  found  in  a  preg- 
nant woman,  a  nursing  baby,  a  fat  individual,  or  in  anyone  during  digestion. 

"It  has  been  noted  in  the  follow- 
ing conditions:  chronic  alcoholism; 
diabetes  meUitus;  certain  diseases 
of  the  liver,  heart,  and  pancreas; 
chronic  nephritis;  splenids;  tuber- 
culosis; malarial  fever,  typhus  fever; 
Asiatic  cholera;  and  poisoning  by 
phosphorus  and  by  carbon  mo- 
noxid.  Lipemia  commonly  occurs 
as  the  result  of  lacerated  wounds  of 
the  blood-vessels  situated  in  fatty 
tissue,  and  after  fractures  of  long 
bones  involving  injury  of  the  fatty 
matter"  ("Clinical  Hematology," 
by  John  C.  DaCosta,  Jr.).  In 
many  cases  of  fracture  in  adults  fat  is  found  in  the  urine.  I  have  had  this 
demonstrated  by  repeated  observations.  When  we  recall  how  rarely  simple 
fracture  causes  death  it  becomes  evident  that  a  moderate  amount  of  fat  in 
the  blood  is  not  dangerous  or  only  becomes  dangerous  if  it  fails  to  flow 
out.  In  lipemia  fatty  embolism  may  occur  if  the  amount  of  fat  becomes 
excessive  or  if  vascular  damage  favors  plugging.  At  my  suggestion,  Dr. 
Wm.  Carrington  conducted  an  invesdgation  to  determine  the  frequency  of 
lipuria  after  fractures  (Essay  Awarded  the  Surgical  Prize  in  Jefferson 
Medical  College  in  1908).  He  determined  that  fracture  of  long  bones  in- 
variably causes  lipuria,  fracture  of  small  bones  seldom  does;  that  after  frac- 
ture of  a  long  bone  fat  appears  in  the  urine  "on  different  days,  in  different 
amounts,  and  in  different  forms"  (this  curious  periodicity  was  first  observed 
*  G.  H.  Makins,  in  Heath's  Dictionary. 


Fig.  95.— Fat-embolism  of  the  lung  after  fracture 
of  the  femur.  The  fat-globules  and  masses,  stained 
black  with  osmic  acid,  lie  in  the  capillaries  of  the 
lung.     X  150.     (Hektoen.) 


Treatment  of  Fat-embolism  207 

by  Scriba,  in  1878) ;  that  when  fat  is  present  albumin  is  almost  always  present 
and  blood  is  occasionally  found;  that  the  urea  percentage  falls  as  the  fat 
content  rises  and  rises  as  the  fat  content  falls;  that  the  condition  is  rare  in 
young  children  and  that  fat-embohsm,  as  a  rule,  is  a  benign  process;  that 
about  the  fifteenth  day  after  a  fracture  fat  usually  disappears  from  the  urine. 
Carrington,  in  1908,  found  in  literature  276  reported  cases  of  fat-embolism. 

S)Tiiptoms. — Symptoms  arise  only  when  many  emboli  block  a  multitude 
of  the  capillaries  of  an  organ,  w'hen  a  large  embolism  lodges,  or  when  the  capil- 
laries of  a  vital  region  of  the  brain  or  medulla  are  blocked.  The  symptoms  are 
those  of  edema  of  the  lungs  and  exhaustion,  often  with  coma  or  delirium,  and 
sometimes,  in  the  beginning,  are  wrongly  thought  to  be  due  to  shock.  There  are 
restlessness,  dyspnea,  rapid  and  weakening  pulse,  and  rapid  respiration,  con- 
tracted pupils,  and  pallor  followed  by  cyanosis.  The  temperature  may  be  ele- 
vated, normal,  or  subnormal.  Many  coarse  rales  are  heard  in  the  chest,  but 
percussion  gives  a  clear  note.  If  pulmonary  edema  becomes  marked,  the  patient 
spits  up  a  bloody  froth.  If  life  is  prolonged  a  day  or  two,  oil  is  found  in  the 
urine.  Small  amounts  of  oil  may  be  found  in  the  urine  after  serious  injuries  or 
operations  when  no  symptoms  of  embolism  exist.  Nevertheless,  the  presence  of 
the  oil  is  always  a  cause  of  anxiety  and  is  often  a  warning.  It  is  maintained  by 
Groube  that  the  amount  of  fat  in  the  urine  is  in  inverse  ratio  to  the  amount  in 
the  blood;  the  greater  the  amount  excreted  in  the  urine,  the  less  the  amount 
retained  in  the  blood.  Hence,  fat  in  the  urine  makes  the  surgeon  anxious, 
and  a  sudden  diminution  of  the  amount  in  the  urine  is  a  sign  of  grave  danger 
if  there  develops  increasing  difficulty  in  respiration  ("Rev.  de  Chir.,''  July, 
1895).  The  inverse  ratio  said  to  be  maintained  between  fat  in  the  blood  and 
fat  in  the  urine,  if  it  really  exists,  is  similar  to  a  finding  of  Lepine  in  diabetes, 
that  is,  if  a  diabetic  is  given  diuretics,  the  sugar  in  the  urine  increases  and  the 
sugar  in  the  blood  decreases.  The  symptoms  of  fat-embolism  seldom  occur 
until  at  least  twelve  hours  after  an  accident,  and  rarely  before  the  third  day, 
but  may  occur  as  early  as  three  hours.  The  symptoms  occur  at  a  later  period 
than  those  of  shock  and  at  an  earlier  period  than  those  of  ordinary  embolism 
of  the  lung.  The  important  point  emphasized  by  Carrington  is  that  after 
the  reaction  from  shock,  if  there  were  shock,  and  for  hours  or  days  after  the 
injur>'  in  any  case,  there  is  a  period  of  freedom  from  all  alarming  symptoms, 
and  that  the  symptoms  of  fat-embolism  come  on  suddenly  and  without  warning. 
If  some  of  the  oil  is  forced  through  the  vessels  of  the  lung,  it  will  lodge  in  other 
regions  and  produce  other  symptoms.  Oil  may  appear  in  the  urine  as  above 
stated.  Urinary  suppression  may  occur.  Delirium  may  arise,  there  may  be 
twitching,  convulsions,  or  paralysis,  or  the  patient  may  pass  into  coma.  The 
eye-ground  may  show  choked  disk,  hemorrhage,  and  fat  in  the  vessels  (Con- 
nel's  case  and  Czemy's  case) .  Cases  of  fat-embolism  with  severe  symptoms 
are  commonly  fatal;  milder  cases  are  often  recovered  from.  In  mild  cases  the 
symptoms  last  but  a  few  hours,  in  severe  cases  the  condition  may  prove  fatal 
in  from  three  hours  to  seven  days  after  the  injury,  and  in  from  twenty-four  to 
forty-eight  hours  after  the  appearance  of  symptoms.  A  patient  may  have  tw'o 
or  three  attacks,  Connel's  case  had  three  attacks,  there  being  an  inter\-al  of  a 
week  between  the  first  and  second  and  between  the  second  and  third  attacks. 

Treatment. — The  treatment  consists  in  absolute  rest  of  the  diseased  or 
injured  part  and  the  administration  of  stimulants,  such  as  strjxhnin,  alcohol, 


2o8  Thrombosis  and  Embolism 

and  carbonate  of  ammonium,  the  use  of  external  heat;  the  employment  of 
oxygen  by  inhalation;  and  the  administration  of  diuretics  and  of  nitroglycerin 
hypodermatically.  Artificial  respiration  may  tide  a  patient  over  a  crisis. 
If  an  external  wound  exists,  free  drainage  must  be  established,  and  the  diseased 
or  damaged  part  should  be  thoroughly  immobilized  if  possilbe.  In  order  to 
prevent  fat-embolism  after  a  severe  injury  insist  on  rest.  Massage  used  early 
after  some  injuries  is  dangerous,  as  it  may  force  fluid  fat  into  the  vessels. 
When  severe  contusion  causes  the  formation  of  a  large  cavity  filled  with  blood, 
Groube  wisely  advises  incision,  to  lessen  the  danger  of  fat-embolism.* 

Air=embolism. — Air  may  enter  a  vein  during  a  surgical  operation  or  it 
may  be  injected  accidentally  while  giving  a  hypodermic  injection,  hypo- 
dermoclysis,  or  a  saline  infusion  into  a  vein.  It  may  follow  irrigation  of  the 
pleura  with  hydrogen  peroxid.  In  caisson  disease  it  is  taught  by  some  that 
nitrogen  is  set  free  in  the  blood.  It  may  occur  when  a  cerebral  sinus  is  opened, 
or  in  the  uterine  veins,  if  the  uterus  does  not  remain  contracted  after  delivery. 
It  is  very  seldom  that  any  symptoms  follow.  It  was  long  thought  that  such 
an  accident  must  be  extremely  dangerous.  The  e.xperiments  of  my  colleague, 
Professor  Hare,  indicate  that  quantities  of  air  may  be  injected  into  the  veins 
of  a  dog  without  apparent  harm.  The  entry  of  a  small  amount  of  air  into 
the  veins  of  a  human  being  will  not  be  apt  to  induce  dangerous  symptoms, 
but  it  may  be  fatal.  The  more  rapidly  it  is  introduced  and  the  greater  the 
amount,  the  greater  is  the  danger.  The  manner  in  which  it  can  induce  death 
is  doubtful.  Some  maintain  that  it  causes  blood  in  the  right  side  of  the  heart 
to  froth,  and  thus  prevents  normal  action  of  the  valves,  the  heart  becoming 
unable  to  propel  blood  through  the  lungs.  Others  maintain  that  air  reaches 
the  cerebral  capillaries  and  so  causes  cerebral  anemia.  Some  believe  cardiac 
failure  results  from  the  presence  of  air  in  the  pulmonary  capillaries.  The 
first  view  is  the  most  probable.  If  a  surgeon  divides  a  large  vein,  air  may  be 
sucked  in,  and  there  is  particular  danger  in  such  an  accident  if  a  vein  at  the 
root  of  the  neck  or  a  cerebral  sinus  is  torn  or  incised,  or  if  the  damaged  vessel 
lies  in  scar  tissue  and  cannot  collapse. 

Symptoms. — When  during  an  operation  air  enters  a  large  vein  there  is 
a  sucking  sound,  air  bubbles  may  be  noted  in  the  wound,  and  serious  symp- 
toms may  or  may  not  follow.  Twice  I  have  wounded  the  subclavian  vein  and 
have  heard  this  sound,  but  no  alarming  symptoms  developed.  If  serious 
symptoms  are  produced,  they  arise  suddenly,  and  consist  of  extreme  failure 
of  circulation,  a  curious  whirring  or  churning  sound  on  cardiac  systole  audible 
even  without  a  stethoscope,  deadly  pallor  or  cyanosis,  gasping  for  air,  convul- 
sions, and  possibly  death. 

Treatment. — Compress  the  vein  with  the  finger  and  clamp  it  quickly. 
Suspend  the  anesthedc,  lower  the  head,  employ  artificial  respii^ation,  and  give 
inhalations  of  oxygen,  and  strychnin  hypodermatically. 

*  Rev.  de  Chir.,  July,  1895.  ' 


Sapremia  209 


X.  SEPTICEMIA  AND  PYEMIA. 

Septicemia,  or  sepsis,  is  a  febrile  malady  due  to  the  introduction  into 
the  blood  of  pyogenic  organisms  or  the  products  of  pyogenic  organisms  or  of 
saprophytic  bacteria.  There  is  no  one  special  causative  organism,  and  any 
microbe  which  produces  inflammatory  and  febrile  products  may  cause  it. 
Either  streptococci  or  staphylococci  may  be  present.  Pneumococci  are  a 
not  very  unusual  cause.  Septicemia  arises  by  absorption  of  septic  matter 
by  the  lymphatics.  Clinically  we  distinguish  two  forms  of  septicemia:  (i) 
sapremia,  septic  or  putrid  intoxication;  and  (2)  septic  infection,  true  or  pro- 
gressive septicemia.  In  these  conditions  the  area  of  infection  is  usually  dis- 
covered by  the  surgeon;  but  when  it  cannot  be  located,  the  disease  is  called  by 
the  Germans  cryptogenetic  septicemia. 

Sapremia,  Septic  or  Putrid  Intoxication. — This  condition  is  due  to  the 
absorption  of  poisonous  ptomains  from  a  putrefying  area.  The  bacteria 
do  not  enter  the  blood,  but  their  toxins  do,  and,  as  these  toxins  are  active 
poisons,  the  condition  is  comparable  to  poisoning  by  successive  alkaloidal 
injections,  the  symptoms  and  prognosis  depending  upon  the  dose.  Not 
unusually  there  is  absorption  not  only  of  the  toxins  of  saprophytic  bacteria, 
but  also  the  toxins  of  pyogenic  micro-organisms.  Even  if  some  of  the  bacte- 
ria enter  the  blood,  they  do  not  multiply  in  this  fluid.  Slight  symptoms 
and  recovery  follow  a  small  dose;  grave  symptoms  and  death  follow  a  large 
one.  The  poison  does  not  multiply  in  the  blood,  and  a  drop  of  the  blood  of 
a  person  laboring  under  putrid  intoxication  will  not  produce  the  disease  when 
introduced  into  the  blood  of  a  well  person;  in  other  words,  the  disease  is  not 
infective.  Considerable  putrid  material  must  be  absorbed  to  cause  sapremia. 
What  is  known  as  surgical  fever  is  due  to  the  absorption  of  a  small  amount 
of  putrid  or  fermented  wound  fluid,  and  is  in  reality  a  mild  form  of  sapremia. 
If  sapremia  arises,  it  does  so  soon  after  the  infliction  of  a  wound,  and  after  a 
large  rather  than  small  wound,  when  a  considerable  amount  of  wound  fluid  is 
pent  up  under  pressure.  It  may  follow  labor  where  putrid  fluid  is  retained  in 
the  womb,  may  follow  an  injury  of  or  an  operation  upon  a  joint,  may  follow 
amputation  where  decomposing  blood-clot  or  wound  fluid  is  pent  up  within 
the  flaps,  or  may  ensue  upon  an  abdominal  operation  or  injury.  In  sapremia 
there  always  exist  a  considerable  absorbing  surface  and  a  large  amount  of 
dead  matter  which  has  become  putrid.  Roswell  Park  *  points  out  that 
sapremia  arises  from  putrefaction  of  a  blood-clot  or  wound  fluids  which  are 
retained  like  foreign  bodies  in  the  tissues,  and  does  not  arise  from  putrefaction 
of  the  tissues  themselves.  He  speaks  of  the  condition  as  due  to  the  absorption 
of  poison  from  a  "putrid  suppository."  Sapremia  will  not  occur  after  granu- 
lations form.  The  term  putrefaction  is  used  because  this  is  the  usual  change, 
but  any  fermentative  organism  may  cause  the  disorder.  Sapremia  is  a  malig- 
nant form  of  surgical  fever,  and  its  existence  means  an  ill-drained  wound,  and 
a  fermenting  and  probably  putrid  collection  of  blood-clot  or  wound  fluid. 

In  sapremia  there  is  congestion  of  the  stomach,  intestines,  and  other 
abdominal  viscera,  particularly  the  kidneys,  and  also  of  the  brain,  and  numbers 
of  red  blood-cells  disintegrate. 

*  "  Treatise  on  Surgery  by  American  Authors." 


2IO  Septicemia  and  Pyemia 

Symptoms. — The  patient  often  seems  to  react  incompletely  from  the 
injury;  he  feels  miserable,  complains  of  headache,  nausea,  and  pain  in  the 
back  and  limbs;  or,  he  may  react  and  in  a  day  or  two  develop  this  condition 
of  malaise.  In  some  cases  an  aseptic  fever  is  directly  succeeded  by  sapremia. 
In  most  cases  of  sapremia,  between  twenty-four  hours  and  two  or  three  days 
after  labor,  after  an  injury,  or  after  an  operation,  there  is  a  chill,  or  at  least  a 
chilly  sensation,  though  in  some  cases  this  is  wanting.  The  temperature 
rapidly  rises  to  103°  F.  or  even  more.  There  are  severe  headache,  dry  and 
coated  tongue,  rapid  and  weak  pulse,  nausea,  and  often  vomiting,  diarrhea, 
great  prostration,  restlessness,  muscular  twitching,  and  active  delirium.  The 
wound  is  found  to  be  foul,  and  commonly  there  is  drying  up  of  wound  discharge. 
There  is  diminution  or  suppression  of  urine,  and  a  strong  tendency  to  conges- 
tion of  various  organs.  Jaundice  is  not  unusual.  Petechial  spots  are  frequently 
noticed  upon  the  skin.  They  occur  also  upon  mucous  membranes  and  serous 
surfaces,  and  result  from  the  plugging  of  small  vessels  with  detritus  of  broken- 
down  red  corpuscles  and  consequent  vascular  rupture.  Great  elevation  of 
temperature  often  precedes  death.  In  some  cases  the  dose  of  poison  is 
so  large  that  the  patient  passes  into  rapid  collapse  without  preliminary  fever. 
Some  cases  recover  if  the  initial  dose  is  not  overwhelming  and  if  additional 
doses  are  not  absorbed.  Many  cases  die  of  exhaustion.  Some  become 
linked  with  fatal  pyemia  or  septicemia.  Hemoglobin  and  red  blood-corpus- 
cles are  rapidly  and  notably  diminished.  Distinct  leukocytosis  exists,  except 
in  those  cases  in  which  the  organism  is  ovenvhelmed  with  the  poison  and 
is  unable  to  react.  Cover-glass  preparations  do  not  show  organisms,  and 
cultures  from  the  blood  are  sterile. 

Treatment. — The  treatment  consists  in  at  once  draining  and  asepticizing 
the  putrid  area  and  administering  very  large  doses  of  alcohol  and  large  me- 
dicinal doses  of  strychnin  and  digitalis.  The  patient  should  be  purged  and 
diaphoresis  favored.  The  hot  bath  is  valuable  to  cause  sweating.  The 
action  of  the  kidneys  must  be  maintained  if  possible.  Purgatives,  diuretics, 
and  diaphoretics  are  given  to  aid  in  removing  the  toxin,  and  stimulants  are 
used  to  sustain  the  strength  of  the  patient  during  the  elimination  of  the  poison. 
Vomiting  is  allayed  by  champagne,  cracked  ice,  calomel,  cocain,  or  carbolic 
acid  with  bismuth.  Food  should  be  administered  every  three  hours.  The 
patient  is  fed  on  milk,  milk  and  lime-water,  liquid  beef-peptonoids,  beef- 
juice,  and  other  concentrated  foods.  Quinin  in  stimulant  doses  is  of  value. 
Antipyretics  are  useless.  The  use  of  saline  fluid  by  hypodermoclysis  or  intra- 
venous infusion  dilutes  the  poison  and  stimulates  the  heart,  skin,  and  kidneys 
to  activity.  Visceral  complications  must  be  watched  for  and  should  be 
promptly  treated  if  discovered.  Among  the  possible  visceral  complications 
are  nephritis,  cholecystitis,  enteritis,  hepatitis,  peritonitis,  pleuritis,  empyema, 
bronchopneumonia,  pericarditis,  and  endocarditis.  Antistreptococcic  serum 
is  useless  in  sapremia. 

Septic  Infection,  or  True  Septicemia. — This  condition  is  a  true  infective 
process.  In  sapremia  the  blood  contains  toxins  of  putrefactive  bacteria, 
but  not  the  bacteria  themselves.  In  septic  infection  the  blood  contains 
both  pyogenic  toxins  and  multiplying  pyogenic  bacteria,  the  bacteria 
perhaps  being  free  in  the  blood  or  in  white  cells.  In  sapremia  the  causative 
condition  is  putrid  material  lodged  like  a  foreign  body  in  the  tissues.     In 


Septic  Infection,  or  True  Septicemia  211 

septic  infection  the  tissues  themselves  are  suppurating,  and  both  bacteria 
and  toxins  are  being  absorbed  by  the  lymphatics.  Of  course,  septic  infection 
may  be  associated  with  septic  intoxication  or  may  follow  it.  In  suppurative 
fever  the  tissues  suppurate,  but  only  the  pyogenic  toxins  are  absorbed,  and 
not  the  pyogenic  bacteria.  In  septic  infection  both  the  pyogenic  bacteria 
and  toxins  enter  the  blood,  and  the  bacteria  multiply  in  the  blood  and  pro- 
duce continually  increasing  amounts  of  poison.  The  symptoms  of  sapremia 
depend  on  the  dose.  In  septic  infection  only  a  small  number  of  organisms 
may  get  into  the  blood,  but  they  multiply  enormously.  The  pus  microbes 
cause  true  septicemia,  and  reach  the  blood  chiefly  through  the  lymphatics, 
but  to  some  degree  by  penetrating  the  walls  of  vessels.  A  drop  of  blood  from 
a  man  with  septic  infection  will  reproduce  the  disease  when  injected  into  the 
blood  of  an  animal;  hence  the  disease  is  truly  infective.  The  wound  in  such 
cases  is  often  small,  but  may  be  large,  and  is  commonly  punctured  or  lacer- 
ated, and  the  disease  begins  later  after  the  infliction  of  a  wound  than  does 
sapremia.  No  wound  may  be  discoverable,  the  infection  having  arisen  from 
an  unrecognized  focus  of  suppuration — for  instance,  gonorrhea,  middle-ear 
disease,  dental  caries,  tonsillar  suppuration,  appendicitis,  etc.  Septicemia 
in  which  the  initial  atrium  of  infection  is  not  discovered  is  called  cryptogenetic 
septicemia. 

The  bacteria  which  exist  in  the  blood  and  organs  in  septicemia  are  usually 
staphylococci  or  streptococci,  often  both.  Pneumococci  or  colon  bacilli  in  some 
cases  are  causative.  The  blood  is  found  to  have  lost  much  of  its  coagulating 
power;  it  remains  fluid  for  some  time  after  death,  quantities  of  red  corpuscles 
are  destroyed,  and  minute  hemorrhages  take  place  in  the  brain,  mucous  mem- 
branes, skin,  serous  membranes,  muscles,  and  various  viscera.  There  may 
be  inflammation  of  synovial  and  serous  membranes.  There  is  congestion  of 
the  gastro-intestinal  tube  and  of  the  abdominal  viscera.  The  lymph-glands 
are  larger  than  normal  and  the  spleen  is  notably  enlarged.  The  wound  con- 
tains numbers  of  bacteria. 

Symptoms. — The  type  of  this  condition  is  met  with  in  puerperal  septicemia 
or  in  septicemia  from  an  infected  wound.  When  septicemia  arises  from  an 
infected  wound,  red  lines  due  to  l>Tnphangitis  are  usually  seen  about  the 
wound,  and  there  is  enlargement  of  related  lymphatic  glands.  In  some  cases, 
however,  the  wound  and  the  parts  about  it  look  normal.  A  supposed  aseptic 
fever  after  an  injury  may  continue  for  an  undue  time  and  the  surgeon  may 
find  that  septicemia  has  developed.  Septicemia  may  arise  during  the  exis- 
tence or  after  the  abatement  of  sapremia,  or  may  arise  when  the  aseptic  fever 
has  passed  away  and  when  there  has  been  no  putrid  intoxication.  It  begins 
in  from  four  to  seven  days  after  labor  or  an  injury,  usually  with  a  chill,  which 
is  followed  by  fever,  at  first  moderate,  but  soon  becoming  high.  In  some 
cases  there  is  a  chilly  sensation,  but  no  distinct  chill.  There  is  always  great 
prostration  even  before  the  chill.  The  fever  presents  morning  remissions  and 
evening  exacerbations,  and  may  occasionally  show  an  intermission.  \\'hen 
the  remission  begins  there  is  a  copious  sweat.  As  the  case  progresses  the 
temperature  may  fluctuate,  and  it  often  rises  verj^  high  before  death.  The 
pulse  is  small,  weak,  very  frequent,  and  compressible.  The  tongue  is  dry 
and  brown,  with  a  red  tip.  Sordes  gather  on  the  teeth  and  gums.  Vomiting 
is  frequent,  and,  as  a  rule,  there  is  diarrhea.     Low  delirium  alternates  with 


212  Septicemia  and  Pyemia 

stupor,  and  coma  is  usual  before  death.  The  great  prostration  is  a  noticeable 
and  characteristic  feature  of  the  sufferer  from  septicemia.  There  are  sub- 
siiltus  tendinum  (twitching  of  the  muscles  of  the  hands  and  feet)  and  carpho- 
logia  (picking  at  the  bedclothing).  Toward  the  end  the  face  often  becomes 
Hippocratic  (hollow  temples,  pinched  nose,  sunken  eyes,  livid  skin,  lead-colored 
and  cold  ears,  and  relaxed  lips).  Visceral  congestions  occur.  The  spleen  is 
enlarged,  ecchymoses  and  petechise  are  noted,  urinary  secretion  becomes  scanty 
or  is  suppressed,  and  the  wound  becomes  dry  and  brown.  Blood-examination 
detects  a  rapid  and  great  diminution  in  red  corpuscles  and  hemoglobin.  The 
anemia  is  in  many  cases  profound.  There  is  marked  leukocytosis  except  when 
the  system  is  ovenvhelmed  by  the  poison.  Cover-glass  preparations  made  from 
blood  may  show  bacteria,  but  often  fail  to  do  so.  Cultures  from  the  blood 
are  sterile  in  most  cases,  but  not  in  all.  A  negative  finding  does  not  disprove 
the  existence  of  septic  infection;  a  positive  finding  is  of  conclusive  diagnostic 
value.  Pneumococcic  septicemia  is  extremely  violent  in  manifestation.  In 
some  cases  death  ensues  before  the  lung  has  consolidated.  If  it  is  not  so 
rapid  endocarditis,  arthritis,  peritonitis,  meningitis,  or  osteomyelitis  may  de- 
velop. 

The  prognosis  of  true  septicemia  is  very  unfavorable,  and  in  some  malig- 
nant cases  death  occurs  within  twenty-four  hours,  but  mild  cases  often  recover. 
Welch  points  out  that  finding  the  staphylococcus  pyogenes  albus  in  the  blood 
is  not  particularly  ominous,  but  the  presence  of  other  pyogenic  cocci  is  exceed- 
ingly threatening.  Endocarditis,  pericarditis,  peritonitis,  plein-itis,  broncho- 
pneumonia, empyema,  nephritis,  arthritis,  cholecystitis,  hepatitis,  meningitis, 
and  pyelitis  are  among  the  comphcations  which  may  arise. 

Treatment. — The  treatment  in  general  is  the  same  as  for  septic  intoxica- 
tion. Antistreptococcic  serum  is  employed  by  some  surgeons,  but  the  value 
of  this  method  is  as  yet  doubtful.  It  does  not  do  any  harm.  It  may  do 
good.  It  is  proper  to  use  it,  but  not  to  the  exclusion  of  other  remedies.  The 
usual  dose  is  lo  c.c.  injected  into  the  abdominal  wall.  The  injection  may 
be  repeated  two,  three,  or  even  six  times  a  day,  and  may  be  used  for  a  num- 
ber of  days.  Because  oJ  uncertainty  as  to  the  causative  organisms  polyvalent 
serum  is  used  by  some.  Some  use  bacterial  vaccines.  Petre  has  injected 
fresh  warm  horse  serum  to  stimulate  leukocytosis.  Jayle  ("La  Presse  medi- 
cale,"  1905,  p.  722)  and  Federman  have  also  used  it.  All  sera  and  vaccines 
are  as  yet  of  undetermined  value  in  septic  infection.  Washing  the  blood  by  the 
intravenous  infusion  of  salt  solution  often  produces  distinct  improvement, 
which,  unfortunately,  is  usually  temporary.  Dr.  C.  C.  Barrows  commends 
formalin  used  intravenously.  The  strength  of  the  solution  is  i  part  of  formalin 
to  5000  parts  of  salt  solution.  The  dose  is  500  cc.  I  have  had  no  experience 
with  formalin  in  septicemia,  but  do  not  believe  that  any  reagent  can  be  safely 
introduced  which  would  rapidly  and  directly  kill  the  bacteria.  Even  if  such  an 
agent  could  be  found,  the  attempt  to  use  it  would  be  dangerous,  as  dead  bacteria 
liberate  a  poison,  and  the  rapid  death  of  immense  numbers  of  bacteria  would 
mean  the  entrance  into  the  blood  of  an  enormous  amount  of  toxic  matter. 

Pyemia. — Pyemia  is  a  condition  in  which  metastatic  abscesses  arise  as 
a  result  of  the  existence  of  septic  thrombophlebitis,  the  disease  being  char- 
acterized by  fever  of  an  intermittent  type  and  by  recurring  chills.  It  is  not 
actually  due  to  free  pus  in  the  blood,  but  to  the  passage  into  the  blood  of 


Symptoms  of  Pyemia  213 

clots  filled  with  toxins  or,  far  oftener,  of  clots  infected  by  streptococci,  staphy- 
lococci, or  both.  After  a  wound  is  inllicted  blood  clots  in  the  divided  veins. 
If  suppuration  occurs,  the  clots  may  become  filled  with  the  toxins  of  pyogenic 
bacteria  or  be  invaded  by  the  bacteria  themselves.  Thus  it  becomes  evident 
that  pyemia  may  develop  with  septicemia.  It  may  also  develop  when  there 
is  suppuration  in  a  wound,  but  not  septicemia,  no  lymphatic  absorption  of 
bacteria  or  toxins  having  occurred.  A  suppurating  focus  about  a  vein  may 
cause  thrombophlebitis  and  clot-formation  even  when  no  wound  exists.  This 
is  seen  in  thrombophlebitis  of  the  lateral  sinus  secondary  to  suppuration  of 
the  middle  ear. 

A  vessel  thrombus  runs  up  in  the  lumen  of  a  vein,  and  the  apex  of  the 
clot  softens,  a  portion  of  it  is  broken  off  by  the  blood-stream  and  carried  as 
an  embolus  into  the  circulation.  Many  of  these  poisonous  emboli  enter  into 
the  blood  and  lodge  in  some  vessels  which  are  too  small  to  transmit  them,  and 
at  their  points  of  lodgment  form  embolic,  secondary,  or  metastatic  abscesses. 
If  the  embolus  contains  only  pyogenic  toxins  the  danger  is  infinitely  less  than 
if  it  contains  bacteria.  The  secondary  abscess  if  caused  by  a  clot  containing 
only  toxins  may  not  lead  to  further  dissemination  of  disease.  If  the  embolus 
contains  bacteria,  thrombophlebitis  occurs  about  it,  and  new  infected  emboli 
form  and  are  sent  throughout  the  system.  Wounds  of  the  superficial  parts 
and  bones  produce  pyemic  infarctions  and  metastatic  abscesses  of  the  lungs. 
When  these  infarctions  break  into  fragments  particles  may  return  to  the  heart 
and  lodge,  or  may  be  sent  out  through  the  arterial  system  to  form  other  foci 
in  distant  organs.  Infected  areas  connected  with  the  portal  circulation 
(intestinal  injuries  or  suppurating  piles)  may  produce  abscess  of  the  liver. 
Wounds  of  bones  which  open  the  medullary  cavity  or  diploic  structure  are 
particularly  apt  to  be  followed  by  pyemia,  and  the  disease  may  follow  labor, 
phlegmonous  erysipelas,  and  other  conditions.  Malignant  endocarditis  is 
called  "arterial  pyemia, "  and  is  due  to  endocardial  embolic  infection.  In  this 
disorder  infected  emboli  lodge  in  the  kidneys,  the  spleen,  the  alimentary  tract, 
the  brain,  or  the  skin  (Osier).  Idiopathic  pyemia  is  a  misnomer.  Some 
primary  focus  of  infection  must  exist,  as  was  pointed  out  when  discussing 
septicemia. 

Symptoms. — The  wound  often  becomes  dry  and  brown,  and  sometimes 
also  offensive.  A  severe  and  prolonged  chill  or  a  succession  of  chills  ushers 
in  the  disease;  high  fever  follows,  and  drenching  sweats  occur.  The  chills 
recur  every  other  day,  every  day,  or  oftener.  A  chill  arises  from  the  libera- 
tion and  lodgment  of  emboli.  During  the  sweat  the  temperature  falls  and 
may  become  nearly  normal,  normal,  or  actually  subnormal.  The  tempera- 
ture often  oscillates  violently.  The  general  symptoms  of  vomiting,  wasting, 
etc.,  resemble  those  of  septicemia.  In  some  cases  the  mind  remains  clear,  in 
many  the  delirium  is  purely  nocturnal.  The  skin  frequently  becomes  jaun- 
diced, and  a  profound  adynamic  state  is  rapidly  established.  The  blood 
changes  are  like  those  of  septicemia.  The  spleen  is  enlarged.  The  lodgment 
of  emboli  produces  symptoms  whose  nature  depends  upon  the  organ  involved. 
Lodgment  in  the  lungs  causes  shortness  of  breath  and  cough,  with  slight  physi- 
cal signs.  Lodgment  in  the  pleura  or  pericardium  gives  pronounced  physical 
evidence.  Lodgment  in  the  spleen  produces  severe  pain  and  great  enlarge- 
ment.    The  parotid  gland  not  unusually  suppurates. 


214  Septicemia  and  Pyemia 

In  a  suspected  case  of  pyemia  always  examine  an  existing  wound,  and  if 
there  is  no  wound,  remember  that  the  infection  may  arise  from  gonorrhea, 
osteomyelitis,  suppuration  in  the  middle  ear,  appendicitis,  dental  caries,  ton- 
sillar suppuration,  abscess  of  the  prostate,  etc.  Chronic  pyemia  may  last 
for  months;  acute  pyemia  may  prove  fatal  in  three  days.  The  chief  com- 
plications are  joint-suppuration,  bronchopneumonia,  pleuritis,  empyemia, 
endocarditis,  pericarditis,  peritonitis,  nephritis,  cholecystitis,  pyelitis,  venous 
thrombosis,  and  abscesses. 

Treatment. — The  treatment  is  the  same  as  for  septicemia.  Open,  drain, 
and  asepticize  any  wound  and  any  accessible  secondar\'  abscess.  The  remarks 
made  as  to  the  use  of  sera  and  bacterial  vaccines  in  septicemia  apply  also  to 
pyemia. 

Erysipeloid  (reticular  lymphangitis,  crab  cellulitis)  was  described  by 
Rosenbach  in  1887,  although  like  cases  were  reported  nearly  fifteen  years  before 
by  Morrant  Baker  under  the  name  of  erythema  serpens.  Gilchrist,  in  1904, 
reported  329  Baltimore  cases.  I  have  seen  a  number  of  cases  in  the  Jefferson 
Hospital.  The  condition  is  due  to  infection  from  handling  putrid  animal 
matter,  especially  fish;  bites  of  crabs,  and  sticks  of  fish  fins.  Rosenbach 
claimed  to  find  a  special  organism  resembling  but  larger  than  a  staphylococcus, 
but  other  obsen^ers  fail  to  find  it.  The  period  of  incubation  is  from  a  few 
hours  to  two  days.  Jopson  describes  the  disease  as  follows  (''American  Jour. 
Med.  Sciences,''  May,  1908):  "It  appears  as  a  swelling  \\ith  elevated,  sharply 
defined  edges,  which  soon  affects  the  entire  circumference  of  the  finger;  and  is 
commonly  described  as  of  a  dark-red  color,  with  purplish  or  even  livid  edges. 
The  finger  is  tense  and  only  moderately  painful,  but  itching  and  burning  are 
prominent  symptoms.  Sections  of  tissue  excised  show  an  inflammation  of  the 
entire  corium  and,  to  a  slight  extent,  of  the  subcutaneous  tissue,  ^^^th  infiltra- 
tion of  polynuclear  leukocytes  and  small  lymph-cells;  edema  of  the  epithelial 
cells  of  the  epiderm ;  and  inflammatory  changes,  especially  marked  around  the 
sweat-glands  and  blood-vessels  (Gilchrist).  It  has  a  characteristic  tendency 
to  spread  from  its  usual  point  of  origin,  near  the  end  of  the  finger,  toward  the 
palm,  the  primarily  affected  area  fading  from  red  to  yellow,  and  thence  to 
normal.  Reaching  the  palm,  it  may  spread  over  it;  but  commonly,  it  soon 
affects  the  neighboring  finger;  and,  when  untreated,  it  may  gradually  spread 
to  all  the  fingers  and  to  the  back  of  the  hand.  There  is  no  fever  or  other 
constitutional  disturbance,  and  the  lymph-glands  are  almost  never  involved. 
It  is  more  or  less  self-limited,  commonly  lasting  from  ten  days  to  three  weeks; 
and  during  this  time  there  is  a  well-marked  tendency  to  relapse.  There  is  no 
suppuration,  pustulation,  or  vesiculation,  and  no  scaling  follows." 

It  is  treated  by  applications  of  lead-water  and  laudanum,  ichthyol  or  com- 
presses soaked  in  a  saturated  solution  of  Epsom  salt.  Jopson  applies  tincture 
of  iodine  and  Gilchrist  25  per  cent,  salicylic  acid  plaster. 


Erysipelas  215 

XI.  ERYSIPELAS    (ST.  ANTHONY'S  FIRE). 

Erysipelas  is  an  acute,  contagious,  spreading  capillary  lymphangitis 
due  to  the  streptococci  of  erysipelas,  which  grow  and  multiply  in  the  smaller 
lymph-channels  of  the  skin  and  its  subcutaneous  cellular  layers  and  also  in 
the  lymph-channels  of  serous  and  mucous  membranes.  Cutaneous  erysipelas 
is  characterized  by  a  rapidly  spreading  dermatitis,  by  a  remittent  fever  due 
to  absorption  of  toxins,  and  by  a  tendency  to  recurrence.  It  is  always  pre- 
ceded by  a  wound,  a  scratch,  or  an  abrasion,  which  may  have  been  trivial  and 
may  never  have  been  noticed.  The  so-called  idiopathic  erysipelas  is  pre- 
ceded by  a  breach  of  surface  continuity  so  small  as  to  escape  notice.  The 
initial  point  of  infection  may  be  in  the  mouth,  the  nostril,  the  pharynx,  the 
auditory  meatus,  between  the  fingers  or  toes,  at  the  margin  of  a  nail,  or  in  a 
cutaneous  furrow.  The  involved  area  in  cutaneous  erysipelas  seldom  suppu- 
rates but  sometimes  does,  very  thin  or  watery  pus  being  formed.  If  thick 
pus  forms  it  means  mixed  infection  with  staphylococci,  but  the  formation  of 
thin  pus  does  not  require  a  mixed  infection,  as  the  streptococcus  is  identical 
with  the  streptococcus  pyogenes.  In  some  cases  of  er}'sipelas,  staphylococcus 
infection  follows  and  even  actually  replaces  streptococcus  infection.  The 
rapid  spread  of  erysipelas  is  due  to  the  fact  that  the  streptococci  prevent  coagu- 
lation of  exudate  and  are  not  actively  attacked  by  leukocytes.  Erysipelas 
is  most  common  in  the  spring  and  fall,  and  is  most  usually  met  with  among 
those  who  are  crowded  into  dark,  dirty,  and  ill- ventilated  quarters;  it  attacks 
by  preference  the  debilitated  and  broken-down  (as  alcoholics  and  sufferers 
from  Bright's  disease).  The  disease  may  become  endemic  in  special  places 
or  localities.  The  poison  of  erysipelas  wiU  produce  puerperal  fever  in  a  lying- 
in  woman.  The  streptococcus  was  first  obtained  in  pure  cultures  by  Feh- 
leisen.  This  organism  is  widely  dififused.  The  question  of  identity  with  the 
streptococcus  pyogenes  is  discussed  on  page  48. 

Forms  of  Erysipelas. — Ambulant,  erratic,  migratory,  or  wandering  er}'sipe- 
las  is  a  form  which  tends  to  spread  widely  over  the  body,  leaving  one  part  and 
going  to  another.  Bullous  erysipelas  is  attended  by  the  formation  of  bullae. 
In  difjused  en-'sipelas  the  borders  of  the  inflammation  gradually  merge  into 
healthy  skin.  Erythematous  er}-sipelas  involves  the  skin  superficially.  Meta- 
static er>-sipelas  appears  successively  in  various  parts  of  the  body.  Puer- 
peral erysipelas  begins  in  the  genitals  of  lying-in  women,  producing  puerperal 
fever.  Erysipelas  simplex  is  the  ordinary  cutaneous  form.  Erysipelas 
neonatorum  begins  in  the  unhealed  navel  of  a  newborn  child  and  spreads 
from  this  point.  Typhoid  er}-sipelas  occurs  with  profound  adynamia.  Uni- 
versal erj-sipelas  involves  the  entire  body.  Celhditis  is  often  erysipelas  of  the 
subcutaneous  layers.  Phlegmonous  erysipelas  involves  the  skin  and  the 
cellular  tissues,  and  causes  suppuration,  and  often  gangrene.  Edematous 
erysipelas  is  a  variety  of  phlegmonous  erysipelas  with  enormous  subcutaneous 
edema.  Lymphatic  erysipelas  is  characterized  by  rose-red  lines  due  to  lym- 
phangitis. Venous  erysipelas  is  marked  by  the  dark  color  of  venous  congestion. 
Mucous  erysipelas  involves  a  mucous  membrane.  Erysipelas  may  attack 
the  fauces,  producing  the  very  grave  condition  known  as  jaucial  erysipelas. 


2i6  Erysipelas 

Clinical  Forms. — The  clinical  forms  are  cutaneous  erysipelas,  cellulo- 
cutaneous  or  phlegmonous  erysipelas;    cellulitis,  and  mucous  erysipelas. 

Cutaneous  erysipelas  most  frequently  attacks  the  face.  A  fever  sud- 
denly appears,  rises  rapidly,  reaches  a  considerable  height,  is  remittent  in 
type  and  sometimes  distinctly  fluctuating,  and  usually  terminates  in  four  or  five 
days  by  crisis.  At  the  time  of  febrile  onset  spots  of  redness  appear  on  the 
skin.  These  spots  run  together,  and  soon  a  large  extent  of  surface  is  found 
to  be  red  and  a  little  elevated.  Any  wound,  ulcer,  or  abrasion  which  exists 
becomes  dry  and  unhealthy,  and  its  edges  redden  and  swell.  The  erysipe- 
latous area  of  redness  and  swelling  extends  either  in  spots  with  intervening 
healthy  skin  or  in  an  uninterrupted  line.  The  margin  is  usually  sharply 
defined  from  the  healthy  skin,  and  the  color  fades  at  the  original  focus  as  the 
disease  advances  at  the  periphery  of  the  red  area.  The  color  fades  at  once 
on  pressure  and  returns  at  once  when  pressure  is  removed.  There  is  slight 
burning  pain,  which  is  increased  by  pressure.  In  the  hyperemic  area  vesicles 
or  bullae  form,  containing  first  serum  and  later  it  may  be  sero-pus,  but  there 
is  rarely  genuine  suppuration  in  cutaneous  erysipelas.  Edema  affects  the 
subcutaneous  tissues,  producing  great  swelling  in  regions  where  there  is  much 
loose  cellular  tissue  (as  in  the  eyelids).  The  anatomically  related  lymphatic 
glands  may  become  large  and  tender.  In  an  ordinarily  strong  person  the 
color  of  an  erysipelatous  area  is  bright  red  or  more  rarely  dark  red.  A  dusky 
color  precedes  suppuration.  A  blue  color  precedes  gangrene  or  indicates  pro- 
found cardiac  and  pulmonary  involvement.  Erysipelas  spreads  now  in  one 
direction,  now  in  another,  influenced,  acccording  to  Pfleger,  by  the  furrows 
of  the  skin.  When  the  disease  ceases  to  spread,  the  swelling  and  redness 
gradually  abate,  and  after  they  disappear  desquamation  takes  place,  and  the 
blebs  become  dry  and  crusted. 

In  strong  subjects  the  constitutional  symptoms  of  cutaneous  erysipelas  are 
usually  slight.  In  the  old  and  debilitated  the  symptoms  are  typhoidal,  there 
is  a  dry  tongue,  dyspnea,  and  hebetude,  delirium  comes  on,  and  death  is 
usual.  Possible  complications  are  meningitis,  pneumonia,  septicemia,  pleuri- 
tis,  pyemia,  endocarditis,  arthritis,  and  albuminuria.  Erysipelas  neonatorum 
is  generally  fatal.  In  some  instances  an  attack  of  erysipelas  will  cure  an  old 
skin  eruption,  a  new  growth,  an  ulcer,  or  an  area  of  lupus.  This  is  the  ery- 
sipUe  salutaire  of  our  French  confreres. 

Treatment. — Isolate  the  patient,  asepticize  the  wound,  if  there  be  a  wound, 
and  administer  a  purge.  Cases  of  cutaneous  erysipelas  occurring  in  a  fairly 
healthy,  young  or  middle-aged  subject,  tend  to  get  well  without  treatment. 
If  a  person  is  debilitated,  free  stimulation  is  necessary.  Tincture  of  chlorid 
of  iron  is  usually  administered  in  doses  of  from  20  to  40  ^^X  three  times  a 
day.  Tonic  doses  of  quinin  are  also  given.  Nutritious  food  is  given  at 
intervals  of  three  or  four  hours.  For  sleeplessness  or  delirium  use  chloral  or 
the  bromids;  for  very  high  temperature,  cold  sponging  is  required.  To  prevent 
spreading  some  have  advised  injection  of  the  healthy  skin  near  the  blush 
with  a  2  per  cent,  carbolic  solution  or  with  fluid  containing  gr.  -j^  of  corrosive 
sublimate.  A  band  of  iodin  painted  on  the  skin  may  arrest  the  progress  of 
the  disease,  and  so  may  a  ring  streaked  around  a  limb  or  about  an  erysipe- 
latous area  by  lunar  caustic.     Kraske  has  suggested  a  method  of  preventing  the 


Cellulocutancous  or  Phlegmonous  Erysipelas  217 

spread  of  cutaneous  erysipelas  which  is  often  effective.  The  y)atient  is  anes- 
thetized. At  about  two  inches  from  the  margin  of  the  redness  a  series  of 
cuts  are  made  into  the  skin,  to  a  sufficient  depth  to  cause  free  oozing.  Each 
cut  is  crossed  by  another  cut  and  a  ring  of  scarifications  is  made  to  surround 
the  region  of  the  erysipelas.  After  the  oozing  ceases  the  scarified  area  is 
soaked  for  one  hour  with  a  solution  of  carbolic  acid  (i  :  20)  or  corrosive 
sublimate  (i  :  2000).  The  part  is  dressed  with  pads  wet  with  carbolic  acid 
(i  :  40)  or  corrosive  sublimate  (i  :  2000).  This  operation  causes  the  forma- 
tion of  a  protective  barrier  of  leukocytes.  Locally,  paint  the  inflamed  area  with 
equal  parts  of  tincture  of  iodin  and  alcohol  and  apply  lead-water  and  lauda- 
num. The  iodin  is  germicidal  and  quickly  enters  the  lymph-spaces.  The  lead- 
water  and  laudanum  allays  the  burning  pain.  If  an  extremity  be  involved, 
bandage  it.  Some  advocate  a  daily  inunction  of  Crede's  soluble  silver.  A 
good  application  is  a  50  per  cent,  ichthyol  ointment  with  lanolin.  A  very 
useful  method  is  von  Nussbaum's.  The  author  applies  it  somewhat  modi- 
fied, as  follows:  wash  the  part  with  ethereal  soap,  irrigate  with  a  solution  of 
corrosive  sublimate  (i  :  1000),  dry  with  a  sterile  towel,  apply  an  ointment  of 
ichthyol  and  lanolin  (50  per  cent.),  and  dress  with  antiseptic  gauze.  Some 
use  iced-water  cloths.  Hot  fomentations  are  distinctly  harmful.  Some 
apply  borated  talc  or  salicylated  starch.  Ringer  advised  painting  every  three 
hours  with  a  mixture  composed  of  gr.  xxx  of  tannic  acid,  gr.  xxx  of  camphor, 
and  5  iv  of  ether.  J.  M.  DaCosta  recommended  pilocarpin  internally  in  the 
beginning  of  a  case.  The  Bier  treatment  is  often  useful.  Antistreptococcic 
serum  has  been  used  in  erysipelas,  and  most  beneficial  results  have  been  claimed 
for  it.  It  is  asserted  that  under  its  influence  the  temperature  soon  becomes 
normal.  My  personal  experience  with  the  serum  treatment  has  not  convinced 
me  of  its  value,  although  some  cases  seem  to  be  benefited.  Schorer  studied 
100  cases  of  erysipelas  in  Bellevue  Hospital  and  determined  the  opsonic  index 
and  its  relation  to  treatment  by  inoculation  of  dead  streptococci.  He  concluded 
that  the  vaccine  does  not  prevent  migration  or  recurrence,  but  seems  to  shorten 
the  duration  of  the  disease  ("Amer.  Jour.  Med.  Sciences,"  Nov.,  1907).  Ross 
and  Johnson  regard  treatment  by  a  specific  vaccine  as  very  efficient  ("Jour. 
Am.  Med.  Assoc,"  March  6,  1909). 

Cellulocutaneous  or  phlegmonous  erysipelas  is  characterized  by  high 
temperature  (io4°-io6°  F.),  the  rapid  onset  of  grave  prostration,  irregular 
chills,  sweats,  and  a  strong  tendency  to  delirium.  The  constitutional  condition 
may  be  one  of  suppurative  fever,  sapremia,  septicemia,  or  pyemia.  The  parts 
are  red,  as  in  cutaneous  erysipelas,  and  the  tumefaction  is  vastly  greater.  The 
swelling  is  brawny,  comes  on  early,  increases  with  exceeding  rapidity,  induces 
a  high  degree  of  tension,  and  frequently  becomes  associated  with  sloughing 
or  even  cutaneous  gangrene.  The  lymphatic  glands  are  swollen,  but  the  in- 
flamed lymphatic  vessels  are  hidden  by  the  tumefaction.  In  most  cases 
suppuration  occurs,  and  when  this  happens  the  parts  become  boggy  and  the 
pus  is  widely  disseminated  in  the  subcutaneous  and  intramuscular  tissues, 
and  even  into  muscle-sheaths  and  tendon-sheaths  (purulent  infiltration). 
When  the  disease  abates  sloughs  form,  which  leave  ulcers  upon  being  cast  off. 
In  bad  cases  muscles,  vessels,  tendons,  and  fascia  may  slough  away.  The 
commonest  complications  are  suppression  of  urine,  bronchopneumonia,  con- 


2i8  Erysipelas 

gestion  and  edema  of  the  lungs,  meningitis,  congestion  of  the  kidneys,  and 
acute  pleurisy.  Septicemia  or  pyemia  may  occur.  We  sometimes  meet  with 
this  form  of  erysipelas  after  extravasation  of  urine.  It  is  not  a  pure  strepto- 
coccus infection.  There  is  a  mixed  infection  with  other  pyogenic  cocci,  and 
often  with  organisms  of  putrefaction. 

Treatment. — At  once  asepticize  and  drain  any  existing  wound,  and  dress 
such  a  wound  with  hot  antiseptic  fomentations.  If  there  are  inflamed  lymph- 
vessels  or  glands  above  the  area  of  cellulocutaneous  infection,  paint  the  skin 
above  them  with  iodin  and  smear  it  with  blue  ointment  or  rub  in  Crede's 
ointment  of  soluble  silver.  IMake  numerous  incisions  into  the  inflamed 
tissues.  These  incisions  should  be  near  together,  and  each  cut  should  be 
two  or  three  inches  long.  Spray  the  wounds  with  hydrogen  peroxid  by  means 
of  an  atomizer,  wash  with  corrosive  subhmate  solution  (i  :  looo),  and  pack 
each  wound  with  iodoform  gauze.  Dress  with  many  layers  of  gauze  wet  with 
a  hot  solution  of  corrosive  subhmate.  The  gauze  is  covered  with  a  rubber  dam 
and  a  hot- water  bag  is  laid  upon  the  dressing.  If  sloughs  form,  cut  them  away 
and  employ  hot  antiseptic  fomentations.     Change  the  dressings  often.     In 


Fig.  96. — Acute  cellulitis  of  palm  and  forearm  following  a  slight  wound. 

some  cases  it  may  be  necessary  to  employ  continuous  irrigation  with  warm 
antiseptic  fluid,  or  continuous  immersion  in  a  hot  aseptic  or  antiseptic  bath. 
It  is  not  unusually  necessary  to  operate  for  the  removal  of  enlarged  lymphatic 
glands.  The  Bier  treatment  is  a  valuable  addition  to  our  resources.  In  rare 
cases  amputation  is  demanded.  When  granulations  begin  to  form,  treat  as  a 
healing  wound.  The  constitutional  treatment  is  that  previously  set  forth  as 
apphcable  to  septicemia,  viz.,  purgation,  the  use  of  diuretics  and  diaphoretics, 
the  administration  of  strychnin,  quinin,  digitahs,  alcoholic  stimulants,  and 
nourishing  food.  In  severe  cases  employ  hypodermoclysis  or  saline  infusion 
into  a  vein.     Antistreptococcic  serum  may  be  employed. 

Cellulitis. — Cellulitis  (Fig.  96)  is  a  microbic  inflammation  of  the  cellular 
tissue.  It  may  be  due  to  staphylococci,  to  streptococci,  to  other  pyogenic 
bacteria,  or  to  mixed  infection  with  two  varieties  of  pyogenic  organisms.     The 


Tetanus,  or  Lockjaw  219 

commonest  form  is  streptococcus  infection,  and  this  is  a  variety  of  erysipelas. 
A  streptococcus  infection  may  be  followed  and  replaced  by  a  staphylococcus 
infection.  Infection  with  the  Bacillus  aerogenes  capsulatus  causes  gangrenous 
cellulitis.  Cellulitis  is  prone  to  arise  in  damaged  tissues,  for  instance,  in 
a  crushed  part,  a  limb  the  seat  of  a  compound  fracture,  or  tissue  containing 
extravasated  urine.  In  tissue  the  resistance  of  which  has  been  lessened  by 
diabetes,  Bright's  disease,  irritating  discharges,  or  trophic  lesions,  cellulitis 
is  rather  apt  to  develop.  In  cellulitis  of  the  subcutaneous  tissue  the  micro- 
organisms find  entrance  by  means  of  a  wound.  Swelling  precedes  redness. 
The  sweUing  is  not  so  marked  as  in  phlegmonous  erysipelas,  and  the  redness  is 
darker  and  is  less  distinct  than  in  cutaneous  erysipelas.  The  redness  of 
cellulitis  is  about  the  wound;  it  spreads  but  does  not  fade  at  the  center  as  does 
ordinary  erysipelas;  red  lines  due  to  lymphangitis  ascend  the  limb  from  the 
infected  wound,  and  the  anatomically  associated  lymphatic  glands  enlarge. 
In  the  wound  and  its  neighborhood  there  is  severe  throbbing  pain.  The 
constitutional  symptoms  of  infection  develop  rapidly.  In  trivial  cases  the 
lymphatics  dispose  of  the  poison  and  suppuration  does  not  occur.  In  severe 
cases  pus  forms  about  the  wound  and  lymphatic  glands  may  suppurate.  Phleg- 
monous erysipelas  may  develop,  and  septicemia  or  pyemia  may  arise. 

Treatment. — Open,  disinfect,  and  drain  the  wound.  Paint  iodin  upon 
the  skin  over  inflamed  lymphatic  vessels  and  glands  and  cover  with  ichthyol 
ointment  or  rub  Credo's  soluble  silver  ointment  into  the  skin  over  the  inflamed 
lymph-glands  and  vessels.  Dress  the  wound  and  the  adjacent  inflamed  area 
with  hot  antiseptic  fomentations.  Secure  rest  of  the  part.  It  may  be  neces- 
sary to  make  incisions  as  in  phlegmonous  erysipelas.  In  some  cases  it  is 
necessary  to  remove  breaking-down  glands.  The  constitutional  treatment  is 
that  employed  for  septicemia. 


XII.  TETANUS,  OR  LOCKJAW. 

Tetanus  is  a  microbic  disease  invariably  preceded  by  some  injury  and 
characterized  by  spasm  of  the  voluntary  muscles.  The  wound  may  have  been 
severe,  it  may  have  been  so  slight  as  to  have  attracted  no  attention,  it  may 
have  been  inflicted  upon  the  alimentary  canal  by  a  fish-bone  or  other  foreign 
body,  or  may  have  been  situated  in  the  nose,  urethra,  vagina,  or  ear.  It  is 
possible  that  infection  can  occur  through  a  mere  abrasion  of  a  mucous  mem- 
brane. The  so-called  idiopathic  tetanus  is  either  not  tetanus  at  all,  or  the 
term  expresses  the  fact  that  we  have  not  found  the  traces  of  an  injury  which 
did  exist.  Tetanus  arises  most  frequently  after  punctured  and  particularly 
after  lacerated  wounds  of  the  hands  or  feet.  In  a  surgical  experience  of  over 
twenty  years  in  connection  with  the  Philadelphia  Fire  Department  I  have 
known  hundreds  of  firemen  to  injure  their  feet  by  stepping  on  nails  and  not  one 
developed  tetanus.  In  fact,  the  only  case  of  tetanus  among  them  since 
187 1  arose  in  a  man  who  lacerated  his  hand  with  glass.  Before  tetanus 
appears  a  wound  is  apt  to  suppurate  or  slough;  but  in  some  instances  the 
wound  is  found  soundly  healed  when  the  tetanus  begins.  The  toy  pistol 
produces  a  peculiarly  dangerous  wound.  In  the  United  States  many  cases 
of  tetanus  follow  the  celebration  of  the  Fourth  of  July,  a  large  per  cent,  of 


220  Tetanus,  or  Lockjaw 

the  causative  wounds  being  from  the  toy  pistol.  The  Fourth  of  July,  1903, 
was  responsible  for  466  reported  and  no  one  knows  for  how  many  unreported 
cases  in  the  United  States.  Since  that  date  the  prophylactic  use  of  antitetanic 
serum  has  become  the  rule  of  practice  in  suspected  injuries  and  there  has  been 
a  notable  diminution  in  the  number  of  cases.  The  fact  that  the  bacillus  of 
tetanus  is  anaerobic  explains  the  comparative  frequency  with  which  punctured 
and  lacerated  wounds  are  attacked,  for  in  such  wounds  the  bacilli  are  deeply 
lodged  in  recesses  or  cavities  into  which  air  does  not  penetrate  or  are  covered 
with  discharges  which  exclude  air.  Suppuration  favors  the  growth  of  tetanus 
bacilli  because  the  pyogenic  organisms  consume  oxygen.  Occasionally, 
though  fortunately  very  rarely,  tetanus  follows  vaccination.  It  is  essential 
that  vaccine  virus  should  be  carefully  selected  and  prepared.  When  care 
is  taken,  the  operation  is  absolutely  safe.  When  tetanus  follows  vaccination, 
it  arises  from  infection  of  the  wound  either  at  the  time  of  vaccination  or, 
as  is  far  more  common,  at  a  later  period  from  scratching  or  some  other 
fouling.  The  tetanus  organism  is  not  introduced  in  the  vaccine,  but  obtains 
entrance  during  or  subsequent  to  the  operation  of  vaccination  because  of 
utter  neglect  of  the  vaccine  lesion  and  in  consequence  of  the  accumulation 
of  filth  upon  and  about  it.  In  no  reported  case  have  the  symptoms  of 
tetanus  appeared  earlier  than  two  weeks  after  vaccination  (Wm.  N.  Welch, 
"N.  Y.  Med.  Jour.,"  Jan.  16,  1909),  The  organisms  or  its  spores  have  never 
been  discovered  in  tubes  or  in  points,  and,  as  Rosenau  points  out,  the 
organism  cannot  grow  and  cannot  form  toxins  on  dry  points  or  in  glyce- 
rinated  virus.  The  most  scrupulous  care  is  taken  to  prevent  contamination  of 
vaccine  virus  and  it  is  examined  for  tetanus  toxin  and  tetanus  bacilli  before 
it  is  placed  on  the  market.  Tetanus  has  followed  the  injection  of  gelatin. 
Commercial  gelatin  often  contains  the  bacilli  and  should  never  be  used  without 
careful  fractional  steriUzation  (page  420).  Tetanus  has  followed  a  bum,  a 
frost-bite,  a  hypodermatic  injection  of  quinin,  child-birth,  abortion,  and  the 
use  in  a  wound  of  contaminated  catgut.  Tetanus  may  appear  within  twenty- 
four  hours  after  an  accident,  but  it  may  not  arise  until  many  days  or  even 
several  weeks  have  elapsed.  Rose  reported  a  case  which  began  within  twenty- 
four  hours.  Kuhn  ("Berhner  klinische  Wochensch.,"  1901)  reports  a  fatal 
case  of  tetanus  beginning  twelve  hours  after  an  injection  of  gelatin.  Such  a 
rapid  case  could  only  be  due  to  the  gelatin  having  contained  a  large  quantity 
of  tetanus  toxin  (Schuckmann) .  Samuel  D.  Gross,  in  his  "System  of  Surgery," 
speaks  of  one  case  occurring  in  a  man  five  weeks  after  injury,  and  another  in  a 
girl  four  weeks  after  inujry.  Jacobson  and  Pease  are  of  the  opinion  that  "such 
cases  as  have  been  recorded  with  periods  of  incubation  under  three  days  must 
be  accepted  with  considerable  reserve"  ("Annals  of  Surgery,"  Sept.,  1906). 
Tetanus  prevails  more  in  certain  localities  than  in  others,  but  it  is  met  with 
all  over  the  world  from  the  Arctic  Zone  to  the  Tropics,  and  may  arise  in  either 
sex,  in  any  race,  and  at  any  age.  Colored  people  are  very  susceptible,  and  the 
disease  may  exist  endemically,  and  does  so  in  certain  portions  of  New  Jersey 
and  of  Cuba.  In  our  country  the  greatest  prevalence,  according  to  Anders,  is 
in  Pennsylvania,  Northern  New  York,  Long  Island,  Virginia,  Georgia,  and 
Louisiana.  Anders  collected  1201  cases  and  Pennsylvania  stands  first  on  his 
list  with  224  cases  ("Jour.  Am.  Med.  Assoc,"  July  29,  1905).  It  is  stated  that 
in  certain  districts  of  Nigeria  the  soil  contains  so  many  tetanus  spores  that  the 


Tetanus,  or  Lockjaw  221 

natives  poison  their  arrows  by  sticking  tliem  into  the  ground  (Allan  C.  Parsons 
in  "Brit.  Med.  Jour.,"  Jan.  23, 1909).  Tetanus  is  due  to  the  growth  in  a  wound 
of  a  bacillus  which  was  first  described  by  Nicolaier  and  was  first  cultivated  by 
Kitasato.  It  is  the  most  widely  distributed  of  all  the  pathogenic  bacteria. 
It  is  very  difficult  to  cultivate  and  cannot  be  cultivated  at  all  unless  air  is  ab- 
solutely excluded.  Tetanus  bacilli  or  their  spores  are  found  particularly  in 
garden  soil,  in  the  dust  of  walls,  walks,  and  cellars,  in  street  dirt,  and  in  the 
refuse  of  stables.  There  is  much  suggestive  evidence  that  virulent  tetanus 
bacilli  come  from  the  intestinal  canal  of  animals;  that  the  bacteria  lose  their 
virulence  when  they  have  been  long  outside  of  the  intestinal  canal;  and  that  the 
highest  degree  of  virulence  is  obtained  by  those  which  have  passed  frequently 
through  intestinal  canals.  The  above  view  is  known  as  the  fecal  theory  and 
is  strongly  advocated  by  Somani.* 

It  is  taught  that  in  tetanus  the  baciUi  do  not  enter  into  the  blood,  and  toxic 
products  produced  by  them  are  not  directly  absorbed  by  the  blood  or  lymph. 
Dr.  Porter,  of  Boston,  tells  me  that  in  a  recent  case  he  found  bacilli  in  adjacent 
lymph-glands,  a  highly  important  observation.  The  toxic  products  alone 
without  any  bacteria  enter  the  muscular  end  organs  of  motor  nerves,  ascend 
within  the  nerves,  and  reach  the  spinal  cord  and  medulla  (B runner,  Marie), 
become  fixed  in  the  nerve-cells  of  the  spinal  cord  and  medulla,  and  produce 
the  symptoms  of  the  disease.  Hence  tetanus  is  an  intoxication  and  not  an  in- 
fection, and  a  drop  of  blood  of  an  animal  with  tetanus,  if  injected  into  another 
animal,  will  not  produce  the  disease.  Tetanus  toxin  poisons  the  nervous 
system  as  would  strychnin  or  some  other  vegetable  alkaloid.  It  is  probably 
the  most  powerful  of  known  poisons.  It  has  been  estimated  that  27^  '-'^  ^ 
grain  is  sufficient  to  kill  an  adult  weighing  165  pounds  ("American  Medicine," 
Nov.  30,  1901).  The  great  power  of  the  poison  is  shown  by  the  report  of  Dr. 
Nicholas's  case  ("Comptes  rendu  de  la  Societe  de  Biologic,"  1893).  Dr. 
Nicholas  had  been  using  a  syringe  to  inject  filtered  cultures  of  the  baciUi  of 
tetanus  and  he  accidentally  pricked  his  finger  with  the  needle.  In  four  days 
tetanus  began,  and  he  barely  escaped  with  his  life  in  spite  of  the  fact  that 
the  fluid  was  free  of  bacteria  and  the  dose  of  toxin  was  extremely  minute. 
The  nature  of  the  virulent  poison  which  is  produced  at  the  seat  of  inoculation 
is  uncertain.  Some  beheve  it  to  be  alkaloidal,  like  the  vegetable  alkaloids; 
some  that  it  is  a  toxalbumin;  others  maintain  that  it  is  an  enzyme  or  ferment 
(Nocard,  Courmont,  and  others).  In  a  very  few  instances  the  injection  of 
perfectly  sterile  antidiphtheritic  serum  into  human  beings  has  caused  death 
with  all  the  symptoms  of  tetanus.  The  serum  must  have  been  obtained  from 
horses  in  whom  tetanus  was  incubating,  and  the  blood-serum  injected  must  have 
contained  a  fatal  dose  of  tetanus  toxin.  In  tetanus  an  ascending  neuritis 
occasionally,  though  seldom,  exists  in  the  peripheral  nerve  near  the  lesion. 
The  toxin  is  carried  to  the  cord  by  the  motor  nerves  only,  and  it  is  not  only 
absorbed  by  the  lymph-channels  of  the  nerve,  but  ascends  along  the  axis-cylin- 
ders of  the  nerve  itself  and  reaches  the  motor  cells  of  the  spinal  cord  (Meyer 
and  Ransom,  in  "Arch,  exper.  Path.  u.  Pharmakol.,"  1903).  On  reaching 
the  cord  it  attacks  the  motor  nerve-cells,  producing  changes  similar  to  those 
involved  in  certain  infections,  and  ascends  in  the  motor  tracts  of  the  cord  to 

*  "  Verhandl.  d.  lo.  internat.  med.  Cong.,"  Berlin,  1890,  Bd.  v,  Abth.  15,  p.  152. 


222  Tetanus,  or  Lockjaw 

the  medullary  nerve-centers.  While  toxin  is  ascending  the  axis-cylinders 
a  certain  amount  is  taken  up  by  tlie  lymphatics,  enters  the  blood,  and  reaches 
the  spinal  cord  by  other  nerve-fibers  (Jacobson  and  Pease,  in  "Annals  of 
Surgery,"  Sept.,  1906).  The  essential  basis  of  tetanus  is  spreading  irritation  of 
the  motor  portion  of  the  spinal  cord  accompanied  by  extreme  reflex  excitability 
which  is  due  to  poisoning  of  sensory  neurones  (Meyer  and  Ransom).  The 
irritation  of  the  motor  cord  produces  tonic  contraction  of  the  muscles;  the 
excitation  of  the  sensory  neurones  is  responsible  for  clonic  convulsions.  There 
are  no  instances  on  record  of  second  attacks  of  lockjaw,  but  it  is  not  believed 
that  one  attack  confers  any  prolonged  immunity. 

Local  Tetanus. — In  some  cases  local  symptoms  precede  widespread 
evidences  of  tetanus.  Experimental  tetanus  in  animals  "exhibits  almost 
without  exception  as  its  earliest  manifestations  those  of  a  purely  local  charac- 
ter and  which  are  at  first  restricted  to  the  neighborhood  of  the  inoculation. 
This  is  now  understood  to  be  due  to  the  absorption  of  the  toxin  by  the  motor- 
nerve  of  the  part.  The  conditions  favoring  the  local  appearance  of  tetanus 
are  a  short  motor  nerve  as  in  head  injuries;  an  injury  to  a  nerve-trunk  per- 
mitting the  rapid  atjsorption  of  a  large  amount  of  toxin;  the  production  of 
a  meager  amount  of  toxin  or  the  presence  of  something  which  prevents  the 
admission  of  a  large  amount  of  toxin  into  the  circulation  (Nathan  Jacobson 
and  Herbert  D.  Pease,  in  "Annals  of  Surgery,"  Sept.,  1906).  Cases  with  local 
symptoms  in  the  beginning  are  apt  to  have  had  long  periods  of  incubation, 
are  apt  to  be  cured,  and  usually  endure  a  considerable  time. 

Symptoms. — ^Acute  tetanus  begins  within  ten  days  of  an  accident. 
The  usual  period  of  incubation  is  from  three  to  five  days.  In  most  cases  the 
first  symptom  is  stiffness  of  the  jaw  on  opening  the  mouth.  In  some  cases 
the  first  symptom  is  stiffness  of  the  neck,  and  the  patient  believes  he  has 
"caught  cold."  In  any  case  the  neck  soon  becomes  stiff,  and  finally  both 
the  neck  and  jaw  become  as  rigid  almost  as  iron.  The  fixation  of  the  jaw  is 
called  trismus.  The  muscles  of  deglutition  become  rigid  on  attempts  at  swal- 
lowing. The  muscles  of  the  back,  legs,  and  abdomen  are  thrown  into  tonic 
spasm,  but  the  arms  rarely  suffer.  If  the  infected  injury  is  on  the  hand  or  foot, 
that  extremity  usually  is  found  to  be  rigid.  Spasm  of  the  face  muscles  causes 
the  risus  sardoniciis,  or  sardonic  smile  (contraction  particularly  of  the  miis- 
culus  sardoniciis  of  Santorini).  The  contraction  of  the  muscles  of  the  back 
is  often  so  powerful  as  to  bend  the  patient  into  a  curve  like  a  bow  and  allow 
him  to  rest  only  on  his  occiput  and  heels.  This  condition  is  known  as  opisthot- 
onos. If  he  is  bent  forward,  so  that  the  face  is  drawn  to  the  legs,  it  is  called  em- 
prosthotonos.  If  his  body  is  curved  sideways,  it  is  designated  pleurosthotonos. 
An  upright  position  is  orthotonos.  The  spasm  may  be  so  violent  as  to  cause 
muscular  rupture. 

The  characteristic  condition  in  tetanus  is  one  of  widely  diffused  tonic 
spasm,  aggravated  frequently  by  clonic  spasms  arising  from  peripheral  irri- 
tations. These  irritations  may  be  draughts,  sounds,  lights,  shaking  of  the 
bed,  attempts  at  swallowing,  contact  of  the  bed-clothing,  the  presence  of  urine 
in  the  bladder  or  of  feces  in  the  rectum,  or  various  visceral  actions.  The  clonic 
spasms  begin  early  in  the  case  and  become  more  frequent  and  more  violent 
as  the  disease  progresses.     The  muscles  become  more  rigid  and  the  attitude 


Chronic  Tetanus  223 

produced  by  tlic  tonic  contraction  of  the  muscles  is  temporarily  exaggerated. 
The  forcible  contraction  of  the  jaw  may  loosen  or  break  teeth.  The  spasms 
of  the  diaphragm,  of  the  glottis,  and  of  the  muscles  of  respiration  may  produce 
death  and  always  produce  great  dyspnea.  The  man  laboring  under  a  tetanic 
convulsion  presents  a  dreadful  picture;  he  is  bent  into  some  unnatural  atti- 
tude, the  face  is  cyanotic  and  wet  with  drops  of  sweat,  the  lips  are  covered 
with  froth  which  is  often  bloody,  the  eyes  bulge  and  are  suffused,  and  the 
countenance  expresses  deadly  terror  and  suffering.  The  agonizing  "girdle 
pain"  so  often  met  with  is  due  to  spasm  of  the  diaphragm.  Each  clonic  spasm 
causes  a  hideous  scream  by  the  constriction  of  the  chest  forcing  air  through 
a  contracted  glottis.  During  the  progress  of  the  disease  constipation  is 
persistent,  and  retention  of  urine  is  the  rule  (because  of  sphincter  spasm). 
The  mind  is  almost  invariably  entirely  clear  until  near  the  end — one  of  the 
worst  elements  of  the  disease.  In  very  rare  cases  delirium  arises.  I  have  seen 
it  twice,  due,  I  fancy,  in  each  case  to  the  drugs  employed.  It  might,  of  course,  be 
due  to  previous  alcohohsm.  Swallowing  in  many  cases  is  impossible.  Talk- 
ing is  very  difficult  and  it  is  impossible  to  project  the  tongue.  The  muscles 
throughout  the  body  feel  very  sore.  The  temperature  may  be  normal,  but  it  is 
usually  a  little  elevated,  and  always  arises  just  before  death.  Hyperpyrexia 
sometimes  occurs  (io8°-iio°  F.),  and  the  temperature  may  even  ascend  for  a 
time  after  death.  Insomnia  is  obstinate.  In  about  80  or  85  per  cent,  of  cases 
of  acute  tetanus  death  occurs  wathin  five  days,  and  many  of  these  patients  die 
within  two  or  three  days.  Very  few  puerperal  cases  recover  and  practically 
no  cases  which  follow  abortion  recover.  Of  late  years  the  mortality  in  acute 
tetanus  has  slightly  diminished.  If  a  patient  lives  a  week,  his  chance  of  re- 
covery is  good.  Death  may  be  due  to  exhaustion  or  to  carbonic-acid  narcosis 
from  spasm  of  the  glottis  or  fixation  of  the  respirator}'  muscles. 

Chronic  tetanus  comes  on  late  after  a  wound  (from  ten  days  to  several 
weeks) .  The  symptoms  are  not  so  severe  as  in  acute  tetanus.  The  muscular 
spasm  is  widespread,  but  it  may  not  be  persistent,  intervals  of  relaxation 
permitting  sleep  and  the  taking  of  food.  Chronic  tetanus  long  had  a  mor- 
tahty  of  40  or  50  per  cent.,  but  modern  methods  of  treatment,  it  has  been 
claimed,  have  considerably  reduced  it.  According  to  the  report  of 
Jacobson  and  Pease  it  is  still  from  35  to  50  per  cent.  ("Annals  of 
Surgery,"  Sept.,  1906).  The  disease  may  last  for  some  weeks.  Trismus 
neonatorum, ox  trismus  nascentium,  the  lockjaw  of  the  newborn,  is  due  to 
infection  of  the  stump  of  the  umbilical  cord,  and  is  practically  invariably 
fatal.  Hydrophobic  tetanus,  head  tetanus,  or  cephalic  tetanus,  is  a  condition 
in  which  the  spasms  are  confined  chiefly  to  the  face,  pharynx,  and  neck, 
although  the  abdominal  muscles  are  usually  also  rigid,  and  in  which  there 
is  palsy  of  the  seventh  nerve.  It  follows  head-injuries,  and  gives  a  better 
prognosis  than  does  general  tetanus. 

Two  other  forms  of  tetanus  have  been  produced  in  animals  by  experi- 
menters. One  is  cerebral  tetanus,  produced  by  injecting  tetanus  toxin  into 
the  brain  and  characterized  by  mental  symptoms  (Roux  and  Borrell,  in  "An- 
nals Ins.  Pasteur,"  July,  1897).  Another  is  tetanus  dolorosa,  produced  by 
injecting  toxin  into  the  posterior  roots  of  the  spinal  nerves,  and  characterized 
by  violent  spasms  of  pain  without  motor  symptoms. 


224 


Tetanus,  or  Lockjaw 


Diagnosis. — Tetanus  may  be  confounded  with  strychnin-poisoning, 
with  hysteria,  with  tetany,  or  with  hydrophobia.  Wood's  table  makes  the 
diagnosis  clear  between  tetanus,  strychnin-poisoning,  and  hysteria.* 


Tbtanus. 


Muscular  symptoms 
usually  commence  with 
pain  and  stiffness  in  the 
back  of  the  neck,  some- 
times with  slight  muscu- 
lar twitching;  comes 
on  gradually.  Jaw  one 
of  the  earliest  parts 
affected ;  rigidly  and  per- 
sistently set. 

Persistent  muscular 
rigidity  very  generally, 
with  a  greater  or  less 
degree  of  permanent 
opisthotonos,  empros- 
thotonos,  pleurosthoto- 
nos,  or  orthotonos. 

Consciousness  p  r  e- 
served  until  near  death, 
as  in  strychnin-poison- 
ing. 


Draughts,  loud  noises, 
etc.,  produce  convul- 
sions, as  in  strychnin- 
poisoning;  may  com- 
plain bitterly  of  pain. 

Eyes  open  and  rigidly 
fixed  during  the  convul- 
sion. 


Hysterical  Tetanus. 


Commences  with  blind- 
ness and  weakness. 


Muscular  symptoms 
commence  with  rigidity  of 
the  neck,  which  creeps 
over  the  body,  affecting  the 
extremities  last.  Jaws 
rigidly  set  before  a  convul- 
sion, and  remain  so  be- 
tween the  paroxysms. 


Persistent  opisthotonos 
and  intense  rigidity  be- 
tween the  convulsions  and 
after  the  convulsions  have 
ceased,  the  opisthotonos 
and  intense  rigidity  last- 
ing for  hours. 

Consciousness  lost  as 
the  second  convulsion 
comes  on,  and  lost  with 
every  other  convulsion,  the 
disturbance  of  conscious- 
ness and  motility  being 
simultaneous. 


Crying  spells  alternating 
with  convulsions. 


Eves  closed. 


Partial  spasm  in  the  leg, 
producing  in  Wood's  cases 
crossing  of  the  feet  and 
inversion  of  the  toes.  If 
all  the  muscles  were  in- 
volved, eversion  would  oc- 
cur, as  the  muscles  of  ever- 
sion are  the  stronger. 


Strychnin-poisoning. 


Begins  with  exhilaration  and  rest- 
lessness, the  special  senses  being 
usually  much  sharpened.  Dimness 
of  vision  may  in  some  cases  be 
manifested  later,  after  the  develop- 
ment of  other  symptoms,  but  even 
then  it  is  rare. 

Muscular  symptoms  develop  very 
rapidly,  commencing  in  the  extremi- 
ties, or  the  convulsion  when  the  dose 
is  large  seizes  the  whole  body  simul- 
taneously. Jaw  the  last  part  of  the 
body  to  be  affected;  its  muscles  re- 
lax first,  and  even  when,  during  a 
severe  convulsion,  it  is  set,  it  drops 
as  soon  as  the  latter  ceases. 

Muscular  relaxation  (rarely  a 
slight  rigidity)  between  the  convul- 
sions, the  patient  being  exhausted 
and  sweating.  If  recovery  occurs, 
the  convulsions  gradually  cease, 
leaving  merely  muscular  soreness, 
and  sometimes  stiffness  like  that 
felt  after  violent  exercise. 

Consciousness  always  preserved 
during  convulsions,  except  when  the 
latter  become  so  intense  that  death 
is  imminent  from  suffocation,  in 
which  case  sometimes  the  patient 
becomes  insensible  from  asphyxia, 
which  comes  on  during  the  latter 
part  of  a  convulsion  and  is  almost  a 
certain  precursor  of  death. 

The  "slightest  breath  of  air" 
produces  convulsion.  Patient  may 
scream  with  pain  or  may  express 
great  apprehension,  but  "ciying 
spells"  would  appear  to  be  impos- 
sible. 

Eyes  stretched  wide  open. 


Legs  stiffly  extended  with  feet 
everted,  as  the  spasms  affect  all  the 
muscles  of  the  leg. 


Tetany  is  distinguished  from  tetanus  by  the  milder  nature  of  the  spasms, 
by  the  greater  limitation  of  the  rigidity,  by  the  fact  that  spasms  begin  in  the 
hands  or  feet,  not  in  the  jaw  and  neck,  and  in  most  cases  by  periods  of  dis- 
tinct intermittence. 

*  "Nervous  Diseases,"  by  Prof.  H.  C.  Wood. 


Treatment  of  Tetanus  225 

In  hydrophobia  tonic  spasm  does  not  exist,  and  if  clonic  spasms  occur 
they  are  secondary  to  suffocative  attacks. 

Treatment. — Far  better  even  than  to  treat  tetanus  vi^ell  is  to  prevent  it. 
Careful  antisepsis  will  banish  it  as  a  sequence  of  surgical  operations  as  thor- 
oughly as  it  has  banished  septicemia.  Every  infected  w^ound  must  be  dis- 
infected with  the  most  scrupulous  care.  Every  punctured  wound  is  to  be 
incised  to  its  depths  and  thoroughly  cleaned  and  drained.  In  a  very  sus- 
picious wound,  such  as  a  Fourth  of  July  injury  or  a  wound  from  a  dung 
fork,  or  the  entrance  into  the  tissues  of  a  splinter  from  a  stable  floor,  after 
the  removal  of  foreign  bodies  and  thorough  antiseptic  cleansing,  dust  the  wound 
with  antitoxin  powder  or,  better,  give  2000  or  3000  units  of  antitetanus  serum 
hypodermatically.  It  seems  reasonably  certain  that  tetanus  antitoxin  has 
prophylactic  power,  in  fact,  Jacobson  and  Pease  say  that  "as  a  prophylactive 
measure  it  merits  our  fullest  confidence"  ("Annals  of  Surgery,"  Sept.,  1906). 
Obviously,  this  cannot  be  done  for  every  wound.  The  procedure  is  not  a 
certain  preventative.  Reynier  injected  antitoxin  into  a  patient  on  whom  he 
was  about  to  operate  because  there  was  a  case  of  tetanus  in  the  wards,  and  yet 
this  man  developed  tetanus  ("Gaz.  des  Hopitaux,"  July  16,  1901).  Thirty 
light  cases  have  been  reported  in  which  prophylactic  injections  failed  to  prevent 
the  disease.  When  in  spite  of  such  injections  the  disease  does  arise,  it  is  apt 
to  be  mitigated  in  violence.  Nevertheless  it  is  sure  that  animals  can  be  ren- 
dered immune  to  tetanus,  and  the  prophylactic  power  of  antitoxin  is  warmly 
advocated  by  many  eminent  men.  It  is  extensively  and  most  successfully 
used  by  veterinarians  to  prevent  tetanus  after  castration  of  horses,  and  this 
success  is  a  guide-post  to  us.  The  following  table  is  most  suggestive  (quoted 
by  Heineck  in  "Surgery,  Gynecology,  and  Obstetrics,"  Jan.,  1909,  from 
Scherck's  article  in  "Jour.  Am.  Med.  Assoc,"  1906,  vol.  xlvii,  p.  500). 
It  sets  forth  the  Fourth  of  July  injuries  treated  in  St.  Louis  dispensaries: 

v„„_„  XT„    „f    „  „  Antitetanic  serum  as      ta     .u  r 

Years.  No.  of  cases.  a  preventative.  Death  from  tetanus. 

1903  56  no  16 

1904  37  yes  none 

1905  84  yes  none 

1906  170  yes  none 

Puerperal  tetanus  is  prevented  by  antiseptic  midwifery,  and  tetanus  neo- 
natorum is  obviated  by  the  antiseptic  treatment  of  the  stump  of  the  cord. 
In  order  to  obviate  all  danger  of  the  development  of  tetanus  during  vaccinia, 
perform  the  little  operation  with  cleanliness  and  care  properly  for  the  wound 
and  for  the  pustule.  The  skin  should  be  cleansed  with  soap  and  water,  rubbed 
with  alcohol,  and  washed  with  boiled  water.  It  should  be  gently  scraped  with 
a  knife  (which  has  been  boiled)  until  serum  exudes.  The  virus,  taken  from 
a  hermetically  sealed  tube,  is  applied  to  the  raw  surface  and  allowed  to  remain 
exposed  to  the  air  until  dry.  A  piece  of  sterile  gauze  is  laid  over  the  part  and 
is  held  in  place  by  a  bandage.  This  dressing  is  changed  once  or  twice  a 
day,  as  may  be  necessary,  and  is  used  until  granulation  begins,  at  which  time 
the  use  of  any  simple  ointment  is  admissible.  Do  not  apply  a.  shield.  The 
evil  of  shields  is  pointed  out  by  Robert  N.  Willson  ("American  Medicine," 
Dec.  7,  1901). 

When  tetanus  exists,  always  look  for  a  wound,  and  if  one  is  found,  open 
15 


226  Tetanus,  or  Lockjaw 

it;  if  there  are  sloughs,  cut  them  away,  wash  the  wound  with  peroxid  of 
hydrogen  and  then  with  hot  normal  salt  solution,  dry  the  wound  with  gauze, 
paint  the  surfaces  of  the  wound  with  bromin,  and  secure  drainage  by  packing 
with  iodoform  gauze.  Dennis  disinfects  the  wound  with  a  solution  of  tri- 
chlorid  of  iodin  (0.5  per  cent.). 

Surgeons  of  a  former  day  were  accustomed  to  amputate  for  tetanus  if  the 
wound  was  upon  an  extremity.  When  we  reflect  that  the  poison-producers 
are  in  the  wound  and  not  in  the  circulation,  it  seems  a  reasonable  treatment. 
As  a  matter  of  fact,  it  never  does  any  good,  because,  when  the  symptoms 
begin,  the  toxin  has  already  entered  into  the  nerve-cells  and  become  fixed. 
Kitasato  has  shown  that  if  a  mouse  is  inoculated  with  tetanus  near  the  root  of 
the  tail,  excision  of  the  tail  and  cauterization  of  the  stump  will  not  prevent 
tetanus  unless  it  is  performed  within  one  hour  of  the  inoculation;  and  Nocard 
inoculated  sheep  near  the  root  of  the  tail  with  tetanus  spores,  and  although 
the  moment  symptoms  appeared  he  amputated  well  above  the  point  of  inocu- 
lation, the  animals  died  of  the  disease.  We  must  regard  amputation  as  a 
useless  method  of  treatment. 

Keep  the  sufferer  from  tetanus  in  a  darkened,  well-ventilated,  and  quiet 
apartment,  so  as  to  exclude  as  far  as  possible  peripheral  irritation.  Watch  for 
the  occurrence  of  retention  of  urine,  and  use  the  catheter  if  necessary.  Secure 
movements  of  the  bowels  by  administering  saHnes,  castor  oil,  croton  oil,  or 
enemas.  Stimulate  freely  with  alcohol.  Give  plenty  of  concentrated  liquid 
food  unless  swallowing  causes  convulsions,  then  feed  by  the  rectum,  and  give 
fluids  by  hypodermoclysis.  If  swallowing  causes  convulsions  some  surgeons 
give  an  inhalation  of  nitrite  of  amyl  before  an  attempt  is  made  to  swallow. 
If  this  treatment  does  not  make  swallowing  possible  then  partially  anesthetize 
the  patient  and  feed  him  by  means  of  a  pharyngeal  tube  passed  through  the 
nose.  Better  than  either  of  these  plans  is  to  abandon  mouth  feeding.  Large 
doses  of  the  bromid  of  potassium,  or  of  this  drug  with  chloral,  give  the  best 
results,  as  far  as  drug  treatment  is  capable  of  giving  results.  If  bromid  is 
used,  give  about  5j  every  four  to  six  hours.  Other  drugs  that  have  been 
used  with  some  success  are  gelsemium,  morphin,  curare,  injections  and  fomen- 
tations of  tobacco,  physostigmin,  anesthetics,  cocain,  and  cannabis  indica. 
An  ice-bag  to  the  spine  somewhat  relieves  the  girdle  pain.  Hot  baths  have 
been  advised.  It  is  said  that  venesection  followed  by  the  intravenous  infusion 
of  saline  fluid  does  good.  This  procedure  is  followed  by  a  free  flow  of  urine 
and  by  lessening  of  the  number  of  the  paroxysms.  It  may  be  repeated  several 
times  during  a  few  days  (E.  J.  McOscar,  in  "American  Medicine,"  Sept. 
14,  1901;   A.  V.  Moschcowitz,  in  "Med.  News,"  Oct.  13,  igoo). 

Yandell  says,  in  summing  up  Cowling's  report  on  tetanus:*  "Recoveries 
from  traumatic  tetanus  have  been  usually  in  cases  in  which  the  disease  occurs 
subsequent  to  nine  days  after  the  injury.  When  the  symptoms  last  fourteen 
days,  recovery  is  the  rule,  apparently  independent  of  treatment.  The  true 
test  of  a  remedy  is  its  influence  on  the  history  of  the  disease.  Does  it  cure 
cases  in  which  the  disease  has  set  in  previous  to  the  ninth  day?  Does  it  fail 
in  cases  whose  duration  exceeds  fourteen  days?  No  agent  tried  by  these 
tests  has  yet  established  its  claim  as  a  true  remedy  for  tetanus."  f 

*  "American  Practitioner,"  Sept.,  1870. 

f  Quoted  by  Hammond,  in  his  "Diseases  of  the  Nervous  S^-stem." 


Treatment  of  Tetanus  227 

It  is  now  claimed  by  some  observers  that  we  have  a  remedy  which  fulfils 
the  requirements  of  Yandell  in  the  tetanus  antitoxin  serum.  Behring's 
serum  is  said  to  be  six  times  as  strong  as  Tizzoni's,  but  it  is  difficult  or  impos- 
sible to  estimate  the  exact  power  of  either.  Behring  and  Kitasato  succeeded 
in  immunizing  animals  and  Tizzoni  and  Cattani  discovered  that  the  anti- 
toxin is  an  enzyme.  The  antitoxin  destroys  the  activity  of  the  toxin  and  is 
obtained  from  an  immunized  horse. 

If  injected  subcutaneously  it  is  absorbed  very  slowly  and  even  twenty- 
four  hours  or  more  after  such  an  injection  a  considerable  amount  remains 
unabsorbed  in  the  tissues.  It  is  not  absorbed  at  all  by  the  nervous  structures. 
It  is  ehminated  rapidly  and  unaltered  in  the  urine,  feces,  and  sweat.  It  seems 
to  be  harmless  and  its  immunizing  powers  are  certain.  Its  curative  power  is 
very  much  less  certain.  Hypodermatic  injections  are  practically  useless.  In- 
travenous injections  are  of  more  service,  but  even  then  the  antitoxin  only 
grasps  the  toxin  in  the  blood  and  fails  to  reach  that  in  the  nerves,  nerve-cells, 
and  nerve  tracts.  Some  practise  intramuscular  injections,  but  7  acute 
cases  so  treated  died,  a  mortality  of  100  per  cent.  (Jacobson  and  Pease,  "Annals 
of  Surgery,"  Sept.,  1906).  Injection  into  the  theca  of  the  cord  (intraspinal 
injection)  by  means  of  lumbar  puncture  is  an  attractive  method  but  the 
inability  of  nerve-elements  to  absorb  antitoxins  when  the  pia  intervenes,  is 
an  argument  against  it,  though  in  one  violent  acute  case  of  my  own,  occur- 
ring in  a  boy,  recovery  followed  this  method.  In  7  acute  cases  treated  by 
this  method  the  mortality  was  57.1  per  cent.  (Jacobson  and  Pease,  in  "Annals 
of  Surgery,"  Sept.,  1906).  John  Rodgers  injected  antitoxin  into  the  cauda 
equina  and  nerves  and  cured  two  apparently  hopeless  cases  ("Med.  Record," 
July  2,  1904).  Injection  into  a  nerve  (intraneural  injection)  is  a  more  rational 
method,  but  even  this  plan  is  only  of  service  in  localized  tetanus,  the  main 
nerve  above  the  part  tetanized  being  injected  (Kiister,  in  German  Surgical 
Congress  of  1905).  However  antitoxin  is  given  the  dose  must  be  large  if  any 
good  is  to  be  done.  Serum  is  usually  prepared  as  follows:  A  horse  is  injected 
repeatedly  with  the  toxins  obtained  from  cultures  of  tetanus  bacilli,  the  strength 
of  the  injections  being  gradually  increased.  Eventually  the  animal  becomes 
immune  to  tetanus.  Some  days  after  the  final  injection  a  cannula  is  placed 
in  the  jugular  vein  of  the  immunized  animal,  blood  is  drawn  into  a  sterile 
vessel  and  is  permitted  to  coagulate  during  twenty-four  hours,  and  at  the  end 
of  this  period  the  serum  is  separated  from  the  clot,  is  evaporated  to  dryness  in 
a  vacuum  over  sulphuric  acid,  and  the  powder  is  placed  in  hermetically  sealed 
glass  tubes.  In  order  to  use  the  serum,  dissolve  the  powder  in  sterile  water,  in 
the  proportion  of  i  gm.  to  10  c.c.  The  fluid  serum  sold  in  the  shops  bears 
this  proportion  to  the  powder.  The  serum  can  be  given  subcutaneously  or 
intravenously,  or  can  be  injected  into  the  brain  or  under  the  cerebral  dura  or  the 
spinal  arachnoid,  or  into  a  nerve.  If  used  subcutaneously,  from  20  to  30  c.c.  of 
the  fluid  serum  should  be  injected  into  the  abdominal  wall,  and  this  dose  should 
be  given  every  six  or  eight  hours  until  there  is  improvement.  Then  from  5  to  10 
c.c.  should  be  given  every  six  or  eight  hours.  As  the  symptoms  abate  the  dose 
is  lessened  and  the  intervals  between  the  doses  are  increased.  In  a  violent 
case  of  tetanus  the  first  dose  should  consist  of  40  to  50  c.c,  and  this  can  be 
repeated  in  four  or  five  hours.  In  a  case  of  tetanus  which  recovered,  reported 
by  Mixter,  enormous  doses  were  given.     This  patient  received  in  the  aggre- 


2  28  Tetanus,  or  Lockjaw 

gate  3400  c.c.  of  serum,  or  285  c.c.  a  day.*  In  47  acute  cases  treated  by 
subcutaneous  injection  the  mortality  was  82.6  per  cent.  In  30  acute  cases 
treated  by  a  combination  of  either  subcutaneous,  intraspinal,  intravenous,  or 
intracranial  injections  the  mortality  was  93.1  percent.  (Jacobson  and  Pease, 
in  "Annals  of  Surgery,"  Sept.,  1906).  Roux  and  Borrel  maintain  that  the 
toxins  of  tetanus  pass  from  the  blood  into  nervous  tissue  and  are  fixed  in  the 
ner\'e-cells.  As  the  antitoxin  when  given  hypodermatically  or  intravenously 
remains  in  the  blood,  it  can  only  antidote  the  poison  in  the  blood  and  not  that 
in  the  nerve-cells.  These  observers  advise  that  the  antitoxin  be  placed  where 
the  toxins  are  active — that  is,  that  it  be  thrown  into  the  cerebrum  (intracere- 
bral injections).  The  skull  is  trephined  or  opened  with  a  small  drill,  a  blunt 
needle  is  passed  to  the  depth  of  one  and  a  half  inches  into  the  frontal  lobe,  and 
the  serum  is  slowly  injected.  Abbe  follows  Kocher;  uses  a  local  anesthetic 
and  bores  a  very  small  hole  through  the  skull  midway  between  the. outer  angle 
of  the  orbit  and  the  middle  of  a  line  running  across  the  head  from  one  exter- 
nal auditory  meatus  to  the  other.  The  serum  should  be  concentrated.  One  gram 
of  dry  antitoxin  is  dissolved  in  5  c.c.  of  water,  and  this  amount  is  the  proper  dose. 
The  opposite  frontal  lobe  should  also  be  injected  either  at  once  or  the  next 
day.  Even  when  serum  has  been  injected  into  the  cerebrum  it  should  also 
be  given  subcutaneously.  Abbe  employed  intracerebral  injection  in  5  severe 
cases  and  3  of  them  recovered.  He  is  a  strong  believer  in  the  method  ('*  Annals 
of  Surgery,"  March,  1900).  Moschcowitz  has  collected  38  cases  so  treated 
and  claims  that  one-half  of  them  recovered.  Cerebral  abscess  followed  in  i  case 
("Med.  News,"  Oct.  13,  1900).  Tuffier  has  reported  a  successful  case  in 
which  he  injected  10  c.c.  of  serum  into  each  frontal  lobe  ("  Gaz.  heb.  de  Med. 
et  Chir.,"  July  4,  1901).  The  method  has  of  late  been  practically  aban- 
doned in  spite  of  the  early  favorable  reports. 

The  value  of  the  tetanus  antitoxin  in  acute  tetanus  is  more  than  doubtful. 
Under  its  use  the  mortality  from  acute  tetanus  is  said  to  fall  from  nearly  90 
per  cent,  to  75  per  cent.,  but  the  figures  above  given  do  not  sustain  this  con- 
tention. Neither  do  the  figures  indicate  that  the  mortality  in  chronic  tetanus 
has  been  greatly  influenced  by  it. 

Kitasato  has  shown  that  injections  of  iodoform  render  animals  immune, 
and  Sonnani  has  maintained  that  this  drug  placed  in  a  wound  prevents  the 
disease.  If  antitoxin  is  not  obtainable,  give  hj-podermatic  injections  of  iodo- 
form, 3  to  5  gr.  t.  i.  d. 

Bacelli's  treatment  consists  in  the  hypodermatic  injection  of  carbolic  acid, 
which  is  thought  to  grasp  tetanus  toxin  and  mitigate  its  virulence  or  even 
make  it  inert.  The  dose  is  isTll  of  a  3  per  cent,  solution  every  two  hours. 
Favorable  results  are  claimed  for  the  plan. 

The  h>TDodermatic  injection  of  an  emulsion  of  fresh  brain-matter  has  been 
advocated  on  the  ground  that  brain-matter  and  tetanus  toxin  have  a  mutual 
affinity  (Krokie^icz) .     The  results  are  not  conclusive. 

Mathews  reports  cure  in  2  cases  foUov/ing  the  very  gradual  introduction 
into  a  vein  of  a  solution  containing  sodium  chlorid,  sodium  citrate,  sodium  sul- 
phate, and  chlorid  of  calcium  ("Jour.  Am.  Med.  Assoc,"  August  29,  1903). 
Cure  of  acute  tetanus  has  followed  the  intraspinal  injection  of  a  solution  of 
magnesium  sulphate  (see  page  103),  which  drug,  Meltzer  has  shown,  strongly 
*  "  Boston  Med.  and  Surg.  Jour.,"  Oct.  6,  1898. 


Surgical  Tuberculosis  229 

stimulates  inhibition.  Blake  has  reported  such  a  case  ("Jour,  of  Surgery, 
Gynecology,  and  Obstetrics,"  May,  1906).  If  magnesium  sulphate  is  used, 
5  cc.  of  a  25  per  cent,  solution  are  injected  into  the  subarachnoid  space  of  the 
cord.  After  such  an  injection  there  is  marked  muscular  relaxation  lasting  a 
number  of  hours.  When  the  improvement  ceases  another  dose  is  given. 
Heineck  ("Jour,  of  Surgery,  Gynecology,  and  Obstetrics,"  Jan.,  1909)  reports 
a  successful  case  and  collects  12  other  cases  so  treated,  7  of  which  died. 

Murphy  reports  the  cure  of  a  case  by  spinal  puncture  and  injection  of 
morphin  and  eucain  into  the  theca  of  the  cord  ("Jour.  Am.  ]Med.  Assoc," 
August  13,  1904). 

XIII.    SURGICAL  TUBERCULOSIS. 

Tuberculosis  is  an  infective  disease  due  to  the  deposition  and  multipli- 
cation of  tubercle  bacilli  in  the  tissues  of  the  body.  The  term  surgical  tuhcr- 
cidosis  is  applied  to  all  of  those  numerous  tuberculous  lesions  that  demand 
surgical  treatment.  Such  lesions  may  exist  in  different  structures,  often  seem 
clinically  to  be  strictly  localized  processes,  and  in  many  instances  may  be  ex- 
tirpated, drained,  or  sterilized.  Among  the  conditions  placed  under  the 
heading  of  surgical  tuberculosis  are:  Tuberculosis  of  glands,  of  bones,  of 
joints,  and  of  the  skin.  These  lesions  are  most  common  in  children,  the 
majority  of  cases  are  curable,  and  they  are  not  so  often  associated  with  or 
followed  by  pulmonary  phthisis  as  are  some  other 
tuberculous  lesions.  They  tend  in  many  cases 
to  remain  local  and,  beyond  doubt,  a  considerable  ^^'^^"^^"^^.l 
number  of  them  are  due  to  infection  with  bovine  ^^■^<^Vjs>,^>c^'^^B^^^ 
bacilli.  Tuberculosis  is  characterized  either  by  ?^*^-^?'^-S'S^^<2'^« « 
the  formation  of  tubercles  or  by  widespread  cel- 
lular proliferation  (diffuse  tubercle)  or  by  fibrin- 
ous exudation,  which  is  very  rich  in  cells.  Tuber- 
culous conditions  tend  to  caseation,  sclerosis,  or 
ulceration. 

A  tubercle  is  a  non-vascular  infective  focus, 
appearing  to  the  unaided  vision  as  a  semi-trans- 
parent gray  or  yellowish  mass  the  size  of  a  mus- 
tard-seed. The  microscopic  tubercle  is  the  most 
characteristic  evidence  of  the  disease.   The  micro-  "'  **"  " 

scope    shows    that   a    gray    tubercle    consists   of    a         Fig.  97-- Synovial     membrane, 
,  f        11     1       ,  u      1      i  ^-^    li  showing  giant-cells  (Bowlby). 

number  of  cell-clusters,  each  cluster  constituting 

a  primitive  tubercle.  A  typical  primitive  tubercle  shows  a  center  consisting 
of  one  or  of  several  polynucleated  giant-cells  surrounded  by  a  zone  of  epi- 
thelioid cells  which  are  surrounded  by  an  area  of  lymphocytes.  When  the 
bacillus  obtains  a  lodgment  the  fixed  connective-tissue  cells  multiply  by 
karyokinesis,  forming  a  mass  of  nucleated  polygonal  or  round  cells.  These 
cells  are  connective-tissue  cells  and  derived  particularly  from  endothelium 
and  are  called  epithelioid  cells  from  their  resemblance  to  epithelial  cells. 
Early  in  the  development  of  a  tubercle  blood  channels  lined  with  epithelioid 
cells  exist,  but  continued  cell  proliferation  blocks  the  channels  and  at  the 
same  time  the  blood-supply  of  the  growth  is  further  limited  by  the  pressure 


J-SS^ 


230  Surgical  Tuberculosis 

of  proliferating  perivascular  cells  and  the  ])roliferation  of  the  endothelial  cells 
of  adjacent  vessels.  Some  of  the  epithelioid  cells  proliferate,  and  others 
attempt  to,  but  fail  for  want  of  blood-sup])ly.  Those  which  fail  to  multiply 
succeed  only  in  dividing  their  nuclei  and  enormously  increasing  their  bulk 
(giant-cells).  Giant-cells,  which  may  also  form  by  a  coalescence  of  epithe- 
lioid cells,  are  not  always  present.  Giant-cells  are  not  certain  evidence  of 
tuberculosis,  for  they  occur  in  syphilitic  lesions.  The  presence  of  irritant 
bacterial  j)roducts  induces  surrounding  inflammation  and  numbers  of  leuko- 
cytes gather  about  the  epithelioid  cells  (Fig.  gv"). 

The  bacilli,  when  found,  exist  in  and  about  the  epithelioid  cells,  and  some- 
times in  the  giant-cells.  When  bacilli  enter  the  tissues  they  are  often  killed. 
If  they  enter  in  large  numbers  or  are  peculiarly  virulent  they  induce  chronic 
inflammation,  granulation  tissue  forms,  and  the  cells  of  the  focus  often  have 
the  characteristic  arrangement  described  above.  The  bacilli  are  not  pyogenic 
and  suppuration  means  secondary  infection.  A  tuberculous  focus  tends 
strongly  to  degenerative  changes  because  of  the  local  anemia  and  the  pres- 
ence of  bacilli.  If  numerous  active  bacilli  are  present  caseation  takes  place. 
This  is  coagulation  necrosis  due  to  the  action  of  bacteria  updn  a  non-vascular 
area.  It  starts  at  the  center  of  a  tuberculous  focus  and  spreads  toward  the 
periphery  and  finally  forms  masses  like  cheese.  When  caseated  material  is 
mixed  with  scrum  tuberculous  pus  is  formed. 

A  caseated  focus  may  be  surrounded  or  encapsuled  by  fibrous  tissue. 
When  this  happens  the  tuberculous  process  may  remain  latent  for  months 
or  years,  perhaps  awakening  into  activity  as  the  result  of  a  traumatism  or 
lowered  general  resistance.  A  caseated  focus  may  be  cured  by  growth  of  fibrous 
tissue  which  replaces  the  tuberculous  focus.  This  is  cure  by  sclerosis.  A 
caseated  area  may  calcify.  Even  when  tuberculous  pus  forms  encapsulation 
may  occur,  the  fluid  being  absorbed,  and  the  remains  being  surrounded  by 
fibrous  tissue.  Whenever  tubercle  bacilli  consume  all  available  food  they  die  or 
remain  latent.  If  they  die  the  granulations  are  converted  into  fibrous  tissue  and 
the  part  is  healed.  If  they  remain  latent  they  may  at  any  time  become  again 
active.  Infiltrated  tubercle  is  due  to  the  running  together  of  many  minute 
infective  foci,  or  to  widespread  infiltration  without  any  formation  of  foci. 
Infiltrated  tubercle  tends  strongly  to  caseate.  The  description  of  a  tubercle 
previously  given  relates  to  the  common  reticulated  tubercle.  Two  other 
varieties  exist. 

The  fibrous  tubercle  is  much  richer  in  dense  connective  tissue  than  is  the 
ordinary  tubercle.  It  forms  when  bacilli  are  greatly  weakened  or  killed. 
When  this  happens  embryonal  cells  cease  to  degenerate,  and  ordinary  inflam- 
mation results  in  fibrous  tissue  formation.  Fibrous  tubercle  is  evidence  of 
an  effort  at  cure. 

Hyaline  tubercle  results  from  hyaline  degeneration  o'f  the  reticulum  of  an 
ordinary  tubercle  and  is  the  early  stage  of  coagulation  necrosis. 

The  Incidence  of  Tuberculosis.— Tuberculosis  is  the  most  wide- 
spread of  diseases,  being  particularly  common  in  northern  countries,  in 
civilized  regions,  and  in  great  cities.  Both  men  and  domestic  animals  suffer 
from  it,  and  it  is  occasionally  met  with  in  captive  wild  animals.  It  may 
even  occur  in  cold-blooded  animals.  It  is  rare  in  savage  races  and  extremely 
rare  in  wild  animals  dwelling  under  natural  conditions. 


The  Bacillus  of  Tuberculosis  231 

How  many  persons  die  of  tuberculosis  is  a  much  debated  point.  Some 
writers  claim  that  consumption  of  the  lungs  alone  kills  one-third  of  all  that 
die;  and  if  the  deaths  from  various  other  tuberculous  lesions  are  added  to 
this,  it  will  be  seen  what  an  enormous  part  the  disease  plays  in  the  mortality 
tables.  Many  observers  hold  that  one-third  of  the  human  race  suffer  with 
tuberculosis,  and  that  in  every  country  the  remaining  two-thirds  free  from 
the  disease  are  every  moment  in  danger  of  acquiring  it.  Evans  has  main- 
tained that  of  the  35,000,000  deaths  that  occur  yearly  in  the  world,  5,000,000 
are  the  result  of  tuberculosis.  Pliiigge  thinks  that  one-seventh  of  the  race  dies 
of  tuberculosis.  Sherman  G.  Bonney,  in  his  work  on  Pulmonary  Tuberculosis, 
asserts  that  "from  85  to  95  per  cent,  of  the  human  race  have  been  at  some 
period  of  life  the  subject  of  tuberculous  infection"  and  that  i  person  in  7 
dies  of  the  disease. 

This  enormous  incidence  of  the  disease,  however,  is  disputed  by  some 
authorities;  notably,  by  G.  Cornet  (Nothnagel's  "Encyclopedia  of  Practical 
Medicine  ") .  This  distinguished  observer  states  that  one-seventh  of  all  deaths 
result  from  tuberculosis,  and  that  some  pathologists  have  reported  that  in 
one-third  of  all  necropsies  tuberculous  lesions  are  found;  but  that  these  sta- 
tistics are  obtained  from  institutions  where  only  the  very  poor  are  cared  for, 
and  that  the  percentage  of  tuberculosis  is  vastly  lower  in  the  better  classes  of 
the  community.  The  exact  figures,  however,  are  hard  to  determine.  It  is 
certain  that  enormous  numbers  of  people  are  affected  with  tuberculosis. 
I  believe  many  affected  ones  recover,  for  Naegeli  points  out  that  almost  all  who 
perish  after  thirty  from  non-tuberculous  conditions  show  healed  lesions  of 
tubercle.  Von  Behring  maintains  that  all  of  us  are  "a  little  tuberculous" 
(Jonathan  Wright,  in  "New  York  Med.  Jour.,"  April  2,  1904).  Pflugge 
maintains  that  from  50  to  70  per  cent,  of  the  human  race  are  predisposed 
to  tuberculous  infection,  and  if  infected  would  die  of  it  unless  an  intercur- 
rent malady  destroyed  them. 

The  Bacillus  of  Tuberculosis. — The  tubercle  bacillus  was  discovered  by 
Robert  Koch  in  1882.  It  is  a  little  rod  with  a  length  about  equal  to  one-half  the 
diameter  of  a  red  corpuscle.  It  is  non-motile,  does  not  form  spores,  and  requires 
oxygen  in  order  to  grow,  but  it  may  obtain  oxygen  from  body-cells  or  fluids. 
Tubercle  bacilh  exist  in  all  active  tuberculous  lesions,  and  the  more  active  the 
process  the  greater  their  numbers.  They  may  not  be  found  in  a  tuberculous 
area,  having  once  existed,  but  died  out  for  want  of  nourishment.  For  instance, 
in  a  cold  abscess  they  are  frequently  absent.  Bacilh  may  be  destroyed  by  a 
secondary  infection,  for  example,  by  a  pyogenic  infection.  Even  when  present, 
tubercle  bacilh  may  be  overlooked.  Differential  staining  may  exhibit  the 
bacilli.  In  the  material  from  an  active  tuberculous  lesion,  even  if  bacilh  are 
not  found,  injection  of  the  tuberculous  matter  into  a  guinea-pig  will  be  followed 
by  the  production  of  the  disease,  and  in  these  lesions  bacilli  can  be  demonstrated. 
Bacilli  may  be  widely  distributed  throughout  the  body.  It  has  long  been 
taught  that  they  may  occasionally  though  seldom  be  demonstrated  in  the  blood 
in  cases  of  acute  miliary  tube'rculosis.  Rosenberger  ("xA.merican  Jour,  of  the 
Med,  Sciences,"  Feb.,  1909)  seems  to  prove  that  bacilh  are  invariably  present  in 
the  blood  in  all  cases  of  tuberculosis.  We  have  failed  to  find  them  in  the  past 
because  of  defective  methods  emplo3'ed  in  the  search.  He  finds  them  in  cases 
of  acute  miliary  tuberculosis,  cases  of  advanced  tuberculosis  with  cavity  forma- 


232  Surgical  Tuberculosis 

tion,  and  cases  of  incipient  tuberculosis.  In  other  words,  if  Rosenberger  is 
correct,  and  I  l)elieve  he  is,  tuberculosis  in  all  its  forms  is  a  bacteremia.  The 
method  employed  by  Rosenberger  will  be  found  in  the  article  previously  re- 
ferred to.  This  method  promises  to  be  of  enormous  importance  in  diagnosti- 
cating incipient  tuberculosis.  We  have  discussed  the  tubercle  bacillus  on 
page  51.  The  bacillus  of  leprosy,  the  smegma  bacillus,  and  the  tubercle 
bacillus  are  similar,  but  not  identical.  Each  is  an  acid-fast  bacillus;  that  is, 
if  st-ained  with  an  aniUn  color,  mineral  acids  will  not  wash  out  the  stain. 
All  acid-fast  bacilli  are  capable  of  producing  lesions  that,  to  some  extent  at 
least,  resemble  tuberculous  lesions;  but  the  lesions  produced  by  all,  except 
the  tubercle  bacillus  and  the  leprosy  bacillus,  tend  to  cure.  It  is  possible  that 
all  acid-fast  bacilli  are  branches  from  a  common  stem. 

The  tubercle  baciUi  obtained  from  different  animals  differ  considerably, 
both  in  morphology  and  in  virulence.  Koch  asserted,  in  1901,  that  the  bacilli 
of  human  tuberculosis  differ  radically  from  those  of  bovine  tuberculosis, 
that  human  tuberculosis  cannot  be  given  to  cattle  at  all,  and  that  it  is  so 
difficult  to  transfer  bovine  tuberculosis  to  the  human  being  that  the  danger 
from  infected  cattle  is  utterly  trivial  and  may  be  disregarded.  Ravenal 
and  others  have  positively  opposed  this  view  of  Koch's  and  there  have  been 
reported  what  appear  to  be  undoubted  cases  of  the  transference  of  tuberculosis 
from  animals  to  man.  There  is  still  dispute  upon  this  point,  but  most  writers 
believe  that  bovine  tuberculosis  and  human  tuberculosis  are  essentially  the 
same,  although  the  bacilli  present  temporary  differences  due  to  altered  en- 
vironment. The  bacilli  of  bovine  tuberculosis  are  certainly  far  less  danger- 
ous to  man  than  are  the  bacilli  of  human  tuberculosis,  and  the  bacilli  of 
human  tuberculosis  are  vastly  less  dangerous  to  cattle  than  are  the  bacilli  of 
bovine  tuberculosis.  The  bacilli  of  bovine  tuberculosis,  when  they  find 
lodgment  in  human  tissues,  are  apt  to  produce  local  lesions  and  seldom  dis- 
seminate, and  vice  versa.  It  has  been  proved  that  many  cases  of  tubercu- 
lous cervical  adenitis  are  due  to  bovine  bacilli.  In  some  cases  cattle  have 
been  successfully  infected  with  human  bacilli.  Human  infection  with  bovine 
bacilli  is  most  common  in  the  young,  and  such  infections  tend  to  spontaneous 
cure.  The  histologic  lesions  seen  in  man  and  cattle  are  identical  and  so 
are  the  degenerative  changes,  and,  as  Baumgarten  showed,  cattle  react  to 
tuberculin  obtained  from  human  bacilli. 

Nocard  reports  2  cases  of  individuals  who  wounded  themselves  while 
cutting  the  flesh  of  tuberculous  cattle.  Both  developed  generalized  lesions 
and  died.  Ravenel  strongly  opposes  the  view  of  Koch  and  maintains  that 
the  bacillus  of  bovine  tuberculosis  is  highly  pathogenic  for  man  ("University 
of  Penn.  Med.  Bull.,"  xiv,  238,  igoi).  The  same  author  has  reported  4  cases 
of  undoubted  inoculation  tuberculosis  in  the  hands  of  veterinarians.  Similar 
cases  have  been  placed  on  record  by  other  observers.  The  entire  question  is 
one  of  immense  importance.  If  Koch  is  right,  there  is  practically  no  danger 
to  man  in  eating  tuberculous  meat  or  in  drinking  tuberculous  miUc.  Most 
observers  endorse  the  words  of  the  report  of  the' British  Commission  of  1904. 
This  commission  positively  maintained  that  bovine  tuberculosis  can  be  com- 
municated to  man. 

Distribution  of  the  Bacilli. — These  baciUi  are  parasites,  and  not  sapro- 
phytes; and  the  real  source  of  infection  is  a  tuberculous  person  or  animal. 


Routes  of  Infection  233 

Wherever  there  are  tuberculous  men  or  animals  the  bacilli  get  into  the  air. 
The  number  that  get  into  the  air  depends  upon  the  number  of  animals 
affected,  the  seat  of  the  tuberculous  lesion  in  each,  the  care  taken  by  the 
victims,  and  the  control  exercised  by  the  community. 

Tubercle  bacilli  from  an  infected  indi\idual  may  get  into  the  atmosphere 
from  the  urine,  the  sputum,  the  feces,  the  sweat,  the  milk,  or  caseous  or 
purulent  material.  The  bacilli  from  dried  sputum  enter  the  dust,  in  which, 
fortunately,  they  are  usually  destroyed  quickly  by  the  complete  dn-Tiess,  the 
oxygen  of  the  air,  and  the  sunHght;  but  under  some  circumstances  they  may 
retain  their  \-irulence  for  weeks  or  even  for  months.  The  infected  area  itself 
is  usually  the  direct  source  of  the  bacteria  from  a  given  case  of  tuberculosis, 
but  this  is  not  invariably  so;  for  a  tuberculous  v\"oman  with  a  healthy  mammar}' 
gland  may  secrete  milk  containing  tubercle  bacilli,  a  consumptive  free  from 
genito-urinar}'  tuberculosis  may  occasionally  pass  urine  containing  bacteria,  a 
cow  may  give  tuberculous  milk  when  the  udder  is  not  diseased,  and  tubercle 
bacilli  may  enter  the  bile  of  a  tuberculous  patient.  The  Third  Interim  Report 
of  the  Royal  Commission  on  Tuberculosis  states  positively  that  the  milk  of 
tuberculous  cows  may  contain  bacilli  even  when  the  udder  is  not  diseased. 
It  is  probable  that  flies  and  insects  may  transmit  infection  (Lord,  in  "Boston 
Med.  and  Surg.  Jour.,"  1904,  cli) ;  and  it  is  certain  that  putrefaction  does 
not  surely  destroy  tubercle  bacilli.  This  is  proved  by  the  fact  that  lining 
bacilli  may  be  passed  in  the  feces  of  an  animal  that  has  been  fed  on  tuberculous 
meat,  and  that  they  may  be  found  in  the  feces  of  an  indi^•idual  suffering  with 
intestinal  tuberculosis.  We  are  thus  justified  in  concluding  that  slaughter- 
house waste,  if  improperly  disposed  of,  is  a  danger  to  the  communit}". 

Routes  of  Iniection. — An  indi\'idual  may  acquire  tuberculosis  by  inhaling 
tuberculous  material  {inhalation  tuberculosis),  by  swallowing  tuberculous 
material  (ingestion  tuberculosis),  a.nd  by  inoculation  with  tuberculous  material 
(inoculation  tuberculosis) .  Infection  of  the  lungs  is  commonly  brought  about 
by  the  inhalation  of  dried  tuberculous  sputum  or  dust  carr}ing  tubercle  bacilli. 
Ingestion  tuberculosis  may  follow  the  eating  of  tuberculous  meat,  the  drinking 
of  tuberculous  milk,  or  the  consumption  of  uncooked  articles  on  which  tubercle 
bacilli  have  gathered.  It  has  been  shown  that  the  lacteals  may  take  up  tubercle 
bacilli  from  the  intestine,  even  if  there  is  no  intestinal  lesion:  and  that  bacilli  can 
pass  through  the  thoracic  duct  and  into  the  blood,  and  lodge  in  some  tissue, 
particularly  the  pulmonar\-  tissue,  so  inducing  tuberculosis.  They  tend  to 
lodge  at  any  point  of  least  resistance;  and  if  not  caught  up  in  the  lungs,  will 
tend  to  be  arrested  in  some  other  region  that  has  been  the  seat  of  a  trifling 
injur}' — for  instance,  in  an  epiphysis  that  has  been  strained.  It  is  a  peculiar 
fact  that  a  tri\nal  injur}'  constitutes  a  point  of  least  resistance;  but  a  severe  in- 
jury, such  as  a  fracture  of  a  bone,  does  not  do  so.  Baumgarten  was  a  strong 
believer  in  the  idea  that  bacilU  enter  the  organism  with  the  food  and  von 
Behring  now  warmly  advocates  the  same  \-iew,  teaching  that  bacilli  enter  the 
organism  of  even.'  person  in  early  life.  They  may  be  destroyed  by  tissue  re- 
sistance, but  if  not  destroyed  have  a  period  of  latency  and,  finaUy,  perhaps 
after  years,  become  active  and  cause  the  disease  ("Deutsche  Med.  Woch.," 
Sept.  24,  1903). 

It  is  certain  that  inoculation  may  be  followed  by  tuberculosis.  The  inocu- 
lation of  tubercle  bacilli  in  the  intestine  may  produce  intestinal  ulceration.     It 


234  Surgical  Tuberculosis 

has  been  shown  experimentally  that  rubbing  the  baciUi  into  the  nasal  mucous 
membrane  may  produce  a  local  area  of  disease.  Inoculation  of  the  skin  may 
result  from  a  wound,  the  bacilli  being  carried  into  the  wound  itself.  The  vic- 
tims of  cutaneous  inoculation  are  usually  butchers,  physicians  who  have  made 
post-mortem  examinations,  and  workmen  who  handle  hides.  In  these  cases, 
as  a  rule,  an  ulcer  promptly  forms  at  the  point  of  inoculation;  but  in  some 
few  cases  the  wound  heals  soundly  and  tuberculous  lesions  develop  in  its 
neighborhood.  In  still  rarer  instances  no  apparent  inflammation  or  ulcera- 
tion occurs  in  or  around  the  seat  of  inoculation;  but  the  anatomically  related 
lymph-glands  become  tuberculous. 

A  number  of  cases  of  inoculation  tuberculosis  have  been  reported.  I 
have  treated  one,  a  physician,  who  inoculated  his  finger  while  making  cul- 
ture studies  with  tuberculous  material.  In  this  case  the  axillary  glands  be- 
came tuberculous.  I  have  also  seen  a  tuberculous  ulcer  of  the  forearm  in  an 
attendant  of  a  lunatic  asylum,  who  had  been  bitten  by  a  tuberculous  patient. 
Inoculation  tuberculosis  occasionally  follows  circumcision,  as  practised  by  an 
orthodox  rabbi,  the  operator  having  been  tuberculous.  There  have  been  re- 
ported apparent  cases  of  direct  inoculation  of  the  geni to-urinary  tract  during 
sexual  intercourse.  If  there  has  been  some  definite  injury  of  the  tissues,  in- 
oculation may  follow  a  simple  rubbing  of  tubercle  bacilli  into  a  part. 

When  the  mother's  ovum  is  tuberculous,  the  disease  may  be  directly  trans- 
mitted to  the  fetus,  producing  the  condition  known  as  congenital  tuberculosis. 
Rosenberger  found  bacilli  in  the  blood  from  the  umbilical  cord  of  the  placenta 
of  a  tuberculous  mother.  This  proves  that  congenital  tuberculosis  may  exist 
even  when  the  ovum  is  not  known  to  be  tuberculous,  and  also  that  a  child 
born  by  a  tuberculous  mother  is,  if  not  immune  to  the  bacteria,  tuberculous 
from  the  moment  circulation  is  established  between  embryo  and  mother. 
Baumgarten  believes  that  bacilli  may  pass  the  placenta,  enter  the  fetus,  and 
remain  latent  for  years.  Latent  bacilU  have  been  found  in  normal  lymph- 
nodes  (Harbitz,  in  "Jour.  Infect.  Diseases,"  vol.  ii,  1904);  this  proves  that 
latency  is  possible.  However  common  the  direct  transmission  of  bacilli  may 
be,  the  direct  transmission  of  the  disease  is  unusual,  but  the  transmission  of  an 
hereditary  predisposition  to  infection  is  not  unusual.  In  spite  of  recent  asser- 
tions to  the  contrary,  I  believe  that  there  is  such  a  thing  as  hereditary  predis- 
position to  tuberculosis.  The  experience  of  the  human  race  uniformly  con- 
firms the  behef  in  predisposition.  In  some  cases  of  tuberculosis  we  can  satisfy 
ourselves  clinically  as  to  the  cause  of  the  infection.  For  instance,  when  an  in- 
dividual is  injured  with  an  object  known  to  carry  tubercle  bacilli,  if  an  ulcer 
of  the  skin  forms,  and  the  adjacent  lymphatic  glands  enlarge,  the  deduction  is 
obvious.  In  other  cases,  it  is  impossible  to  make  up  our  minds  as  to  the  cause 
of  a  tuberculous  lesion.  For  instance,  we  can  only  guess  that  a  person  has 
inhaled  tuberculous  material  or  has  eaten  tuberculous  food.  If  in  inoculation 
tuberculosis  no  lesion  arises  at  the  point  of  entry,  the  opinion  as  to  the  causa- 
tion will  be  founded  merely  upon  guess-work. 

It  seems  sure  that  when  the  baciUi  of  tuberculosis  enter  into  the  body,  if 
they  are  not  destroyed  by  the  body-resistance,  they  either  produce  a  local 
lesion  at  the  site  of  inoculation,  or  pass  to  the  nearest  lymphatic  glands  or  to 
some  point  of  least  resistance,  and  there  establish  disease.  The  first  lesion  is 
known  as  the  primary  focus,  and  from  this  focus  the  disease  may  be  dissemi- 


Products  of  the  Tubercle  Bacilli  235 

nated  to  the  most  distant  parts.  The  bacilli  enter  readily  if  there  is  a  wound 
or  an  abrasion;  but  in  exceptional  circumstances  they  may  enter  through  un- 
broken skin  and  undamaged  mucous  membrane.  Any  structure  may  become 
tuberculous,  but  some  structures  are  much  more  liable  to  do  so  than  others. 
The  lungs  are  very  liable;  the  conjunctiva  is  very  resistant. 

We  have  })reviously  quoted  Rosenl:)erger's  view  that  tuberculosis  is  a 
bacteremia  in  all  cases.  The  bacilli  which  enter  the  blood  may  pass  out  in  the 
urine  or  feces,  may  produce  local  lesions,  or  may  induce  advancing  and  wide- 
spread tuberculosis.  Dissemination  by  the  lymph-stream  is  known  clinically 
to  occur,  and  it  means  slowly  advancing  tuberculosis  with  localization  of 
lesions.  In  dissemination  by  the  lymph-stream,  the  dissemination  is  usually 
in  the  normal  direction  of  the  lymph-current;  but  if  the  lymph-vessels  become 
blocked,  lymph-regurgitation  may  occur,  and  then  the  dissemination  takes 
place  in  a  direction  opposite  to  the  normal  flow  of  the  lymph-current. 

Products  of  the  Tubercle  Bacilli. — A  great  variety  of  products  are 
formed  by  the  tubercle  bacilli,  and  among  them  we  may  mention  alkaloids, 
toxalbumins,  fatty  acids,  and  ferments.  Experimental  injection  of  the  toxal- 
bumins  produces  inflammation;  and  of  the  alkaloids,  fever.  It  has  been  shown 
by  Maragliano  that  injection  of  the  toxalbumins  actually  lowers  the  tempera- 
ture. Beyond  any  doubt,  the  culture-material  in  which  tubercle  bacilli  are 
growing  contains  poison;  and  the  bodies  of  the  bacilli  themselves  contain  poison. 
The  poisons  in  the  culture-medium  are  called  extracellular  poisons,  and  those 
within  the  bacilli  are  called  intracellular  poisons.  It  is  quite  probable  that  the 
former  poisons  are  identical  with  the  latter,  and  have  merely  passed  from  the 
bacilli  into  the  culture-medium. 

Tuberculin. — It  was  proved  some  time  ago  that  dead  bacilli  are  toxic 
and,  if  experimentally  injected,  induce  a  toxic  condition  in  the  animal,  cause 
inflammation  of  the  kidneys,  and  sometimes  produce  cold  abscess  subsequently 
at  the  seat  of  injection.  In  1890  Koch  collected  the  poison  from  dead  bacteria 
in  the  form  of  a  liquid,  which  he  called  tuberculin.  A  number  of  different 
methods  of  extracting  such  poison  have  been  suggested;  hence,  there  are  a  num- 
ber of  different  tuberculins.  Koch  has  made  several  himself.  His  early 
tuberculin  was  made  by  making  a  glycerin-bouillon  culture  of  tubercle  bacilli, 
evaporating  on  a  water-bath  to  one-tenth  of  its  volume,  and  filtering  out  the 
dead  bacilli.  The  filtrate  contained  tuberculin  mixed  with  glycerin.  Later 
Koch  prepared  tuberculin  from  virulent  cultures  of  bacilli,  dried,  ground  up,  and 
mixed  with  water,  the  fluid  being  centrifuged  for  forty-five  minutes.  When 
centrifuged,  two  layers  separate.  The  upper  layer,  which  is  white  and  opal- 
escent, contains  the  elements  soluble  in  glycerin,  is  like  the  old  tuberculin,  and 
is  called  TO.  The  lower  layer  contains  an  emulsion  of  insoluble  elements  of 
high  immunizing  power,  and  is  called  TR.  In  1901  Koch  presented  another 
tuberculin  (BE)  of  dried  bacilli  in  equal  amounts  of  glycerin  and  water. 

It  was  discovered  by  Koch  that  tuberculous  animals  are  much  more  strongly 
affected  by  an  injection  of  tubercuHn  than  are  healthy  animals.  The  most 
positive  reaction  is  noted  in  the  tuberculous  area;  but,  as  a  rule,  there  is  also 
a  reaction  in  the  area  where  the  injection  is  made.  We  get  no  reaction  from 
the  administration  of  tuberculin  by  the  stomach,  but  occasionally  can  obtain 
it  by  the  inhalation  of  the  dried  material.  If  a  moderate  dose  of  tubercuUn 
is  injected  into  a  non-tuberculous  animal,  there  may  be  a  trivial  redness  at  the 


236  Surgical  Tuberculosis 

point  of  injection  and  a  slight  and  temporary  rise  of  temperature;  or  there 
may  be  no  evidence  of  reaction  whatever.  An  injection  in  a  tuberculous  ani- 
mal, however,  is  followed  by  distinct  inflammation  at  the  seat  of  injection,  and 
a  positive  reaction  in  the  tuberculous  area.  This  area  undergoes  congestion 
or  inflammation,  leukocytes  collect  around  it,  and  the  part  tends  to  necrosis 
and  is  liable  to  break  down. 

In  addition  to  the  changes  already  mentioned,  there  is  elevation  of  tempera- 
ture. If  the  dose  has  been  small,  there  may  be  only  a  slight  feeling  of  coldness 
to  usher  in  the  rise  of  temperature;  but  if  the  dose  has  been  large,  there  is 
usually  a  distinct  chill.  This  chill  comes  on  eight  to  twelve  hours  after  the  in- 
jection and  is  accompanied  and  followed  by  elevated  temperature.  The  fever 
lasts  from  four  to  twenty-four  hours,  and  the  temperature  may  be  elevated  to 
from  two  to  five  degrees  Fahrenheit.  The  febrile  condition  is  accompanied 
with  pain  in  the  head,  limbs,  and  back,  and  with  increased  rapidity  of  the 
circulation,  restlessness,  weakness,  and  usually  nausea.  As  the  temperature 
passes  to  normal  all  the  symjitoms  disappear.  The  slight  elevation  of  tem- 
perature which  may  be  noted  after  tuberculin  has  been  injected  into  a  non- 
tuberculous  animal  is  not  ushered  in  by  a  chill,  and  does  not  exceed  one  degree 
Fahrenheit,  unless  a  very  large  dose  has  been  given.  We  thus  note  that  the 
injection  of  tuberculin  may  be  of  the  greatest  possible  value  in  diagnosis. 

A  good  many  observers  have  grown  fearful  of  injecting  tuberculin,  believ- 
ing that  it  is  liable  to  cause  the  tuberculous  focus  to  spread,  or  actually  to 
lead  to  the  development  of  disseminated  tuberculosis.  Virchow  was  of  this 
opinion.  That  such  a  condition  may  follow  the  use  of  large  doses  seems  cer- 
tain, but  moderate  or  small  doses  appear  to  be  entirely  safe.  Flick  has  pointed 
out  that  if  a  blister  is  applied  to  a  tuberculous  person  a  distinct  febrile  reaction 
appears  a  number  of  hours  after  the  application.  This  is  due  to  the  absorption 
of  toxic  material,  probably  tuberculin,  from  the  blister.  It  is  known  that  in  a 
tuberculous  animal  certain  excretions  (urine)  and  serous  exudates  contain 
tuberculin.  Merieux  and  Baillon  show  that  if  a  tuberculous  person  is  blistered 
the  fluid  of  the  blister,  injected  into  a  tuberculous  animal,  produces  a  definite 
reaction.  This  proceeding  is  of  diagnostic  value.  The  tuberculin  comes 
from  the  tuberculous  person  and  he  is  proved  to  be  tuberculous  by  injecting 
the  tuberculin  into  another  tuberculous  animal. 

Professor  Behring  (Paris  Congress  of  Tuberculosis,  Oct.,  1905)  main- 
tains that  there  is  a  curative  principle  not  identical  wdth  antitoxin.  He  ob- 
tains a  substance  from  tuberculous  material,  which  he  calls  T.  C.  and  he  in- 
troduces this  substance  into  the  living  body.  When  T.  C.  is  acted  on  by  the 
cells  of  the  living  body,  it  is  altered;  and  the  hypothetical  material,  T.  X.,  is 
formed.  This  distinguished  laboratory  worker  says  that  the  T.  C.  is  the 
vital  principle;  and  that  when  cattle  are  immunized  by  inoculating  attenuated 
bacilli,  the  T.  C,  by  acting  on  the  body-cells,  is  responsible  for  the  diagnostic 
reaction  to  tuberculin  and  for  the  protective  action  towards  tuberculosis. 
Some  try  by  means  of  supposed  antitoxins  to  immunize  the  body-fluids,  but 
he  tries  instead  to  immunize  the  body-cells.  He  is  unwilling  to  inject  living 
tubercle  bacilli  into  human  beings;  so  he  frees  the  tubercle  bacilli  of  certain 
substances,  leaving  an  organism  that  resembles  the  tubercle  bacillus,  which  he 
calls  the  rest  bacillus.  This  lest  bacillus  is,  by  certain  methods,  converted 
into  an  amorphous  material  identical  with  the  T.  C.  formed  by  the  action  of 


Predisposition  237 

the  body-cells  upon  the  virus.  This  T.  C.  is  taken  up  by  lymph-cells;  and 
it  so  changes  these  cells  that  they  are  converted  into  eosinophiles  or  oxy- 
philes,  and  the  change  in  these  cells  makes  the  body  immune.  T.  C.  may 
safely  be  injected,  as  it  is  not  a  living  material;  and,  whereas  it  may  produce 
tubercles,  they  do  not  tend  to  caseate.  Professor  Behring  believes  that  this 
material  may  be  used  in  the  treatment  of  human  tuberculosis. 

Resistance  of  Bacilli. — Among  the  antagonistic  elements,  we  have 
mentioned  oxygen,  dryness,  and  sunlight.  ^loist  heat,  at  the  temperature  of 
boiling  water,  is  rapidly  fatal.  A  5  per  cent,  solution  of  carbolic  acid  is  one 
of  the  most  powerful  of  germicides.  Full-strength  alcohol  is  next  in  point 
of  power.  Corrosive  sublimate  is  not  a  satisfactory  germicide.  Formalde- 
hyde is  fatal  only  after  long  exposure.  Iodoform  and  ether  is  a  reasonably 
powerful  mixture. 

That  the  virulence  of  tubercle  bacilli  varies  under  different  circumstances 
is  sure.  Under  some  circumstances  they  may  be  extremely  powerful;  under 
others  nearly  innocuous.  The  liability  to  infection  depends,  perhaps,  in 
part,  on  individual  predisposition,  and  certainly,  to  a  great  extent,  on  the  num- 
ber and  the  virulence  of  the  bacteria. 

Immunity. — It  seems  likely  that  some  persons  are  immune  to  tuberculo- 
sis. Such  persons  may  come  from  an  ancestral  line  in  which  all  the  predis- 
posed have  died  off,  so  that  the  immediate  ancestors  of  the  Une  were  non- 
susceptible.  The  tendency  to  immunity  may  be  strengthened  by  proper  mar- 
riages, and  may  be  weakened  by  improper  marriages;  or  immunity  in  a  Hne 
may  be  destroyed  by  the  continuance  of  unfavorable  conditions.  It  is  some- 
times noticed  that  during  the  progress  of  a  locahzed  tuberculous  infection  a  deep- 
seated  tuberculosis  (for  instance,  phthisis)  improves.  This  exhibits  a  progres- 
sive development  in  the  powers  of  the  organism  to  resist  infection  by  stimula- 
tion of  the  apparatus  for  opposing  infection.  That  numbers  of  people  get 
entirely  well  of  tuberculosis  is  certain  and  that  such  people  have  secured 
prolonged  immunity  in  many  cases  is  probable.  Paretic  ailments  seem  to 
possess  a  high  degree  of  immunity  to  tuberculosis  (Rosanoff,  in  "Jour.  Amer. 
Med.  Assoc,"  February  13,  1909).  Of  course,  the  term  immunity  is  only  rela- 
tive. No  one  can  be  absolutely  immune;  for  when  subjected  to  extremely 
unfavorable  circumstances,  or  when  a  number  of  virulent  bacilli  are  intro- 
duced, anyone  may  become  tuberculous. 

Predisposition. — Personally,  I  beUeve  that  there  is  such  a  thing  as  a 
predisposition  toward  tuberculosis,  just  as  there  is  toward  many  other  diseases. 
Such  a  predisposed  indi\-idual  possesses  temporarily  or  permanently  a  condi- 
tion of  the  body-cells,  body-fluids,  or  both,  that  either  makes  easy  the  entrance 
of  the  bacilli  or  prevents  strong  opposition  to  their  multiplication  when  they 
have  entered,  A  person  is  predisposed  to  an  infectious  disease  when  the 
opsonic  index  is  low,  for  this  indicates  lack  of  phagocytic  power  in  the  leuko- 
cytes. Predisposition  may  be  increased  by  some  extraneous  circumstance, 
such  as  occupation,  residence,  etc.,  that  brings  the  individual  into  frequent 
or  prolonged  contact  with  virulent  bacteria. 

There  is  certainly  such  a  thing  as  congenital  tuberculosis,  and  any  tissue 
may  be  involved  in  the  congenital  trouble.  Rosenberger  showed  that  blood  in 
umbihcal  veins  from  the  placenta  of  a  tuberculous  mother  contained  bacilli 
("Amer.  Jour.  Med.  Sciences,"  1909).     Young  children  are  very  liable  to 


238  Surgical  Tuberculosis 

tuberculosis  of  the  acquired  form.  According  to  Professor  Behring,  many 
children  become  infected  with  tuberculosis  in  their  early  years  by  eating  tuber- 
culous food;  but  such  a  tuberculosis  often  remains  latent  for  a  considerable 
length  of  time,  and  then  develops.  This  theory  obtains  probably  from  the 
fact  that  the  digestive  organs  of  the  child  are  not  strongly  protective  against 
bacteria  as  are  those  of  the  adult. 

A  question  is,  Do  certain  individuals  possess  a  special  predisposition  to 
develop  tuberculosis,  and  is  this  hereditar)'?  Hereditar}-  predisposition  was 
once  regarded  as  practically  the  only  cause  of  the  disease,  but  many  thinkers 
now  regard  it  as  of  shght  importance,  although  I  do  not  see  how  we  can  deny 
its  existence.  To  do  so  is  to  run  counter  to  the  experience  of  the  human  race 
in  all  countries  and  at  all  times.  We  all  see  how  common  is  tuberculosis  in  the 
descendants  of  tuberculous  persons.  Hutley  studied  432  cases  of  tuberculosis. 
In  23.8  per  cent,  one  or  both  parents  had  the  disease  (the  father  alone  in  11.5 
per  cent.,  the  mother  alone  in  9.9  per  cent.,  and  both  in  2.4  per  cent.).  Some 
maintain  that  in  30  per  cent,  of  consumptives,  one  parent  or  both  parents  have 
been  consumptives,  and  in  60  per  cent,  a  parent  or  a  grandparent  has  suffered 
with  tuberculosis.  Because  of  the  extreme  frequency  of  the  disease,  however, 
this  statement  does  not  prove  that  the  cases  in  the  family  are  due  to  heredity; 
but  that  there  must  be  such  a  thing  as  hereditary  predisposition  is  indicated 
by  the  fact  that  there  are  many  families  living  under  similar  conditions  to  the 
tuberculous  families,  without  there  having  occurred,  through  several  genera- 
tions, a  single  case  of  tuberculosis  among  their  members.  A  feature  that  makes 
us  unable  to  reach  a  certain  conclusion  is  that  tuberculosis  is  contagious 
and  several  members  of  a  family  may  be  infected  from  one  member,  even 
when  there  is  no  predisposition  to  the  trouble  by  heredity.  The  mere  living 
in  one  house  may  account  for  the  infection.  A  fact  strongly  in  favor  of  the 
hereditary  influence  is  that  in  a  family  whose  ancestors  have  been  tuberculous 
and  whose  members  have  not  lived  together,  but  have  been  scattered  widely 
over  the  earth,  member  after  member  may  die  of  the  disease. 

Unhealthy  environment  particularly  predisposes  to  tuberculosis;  and 
the  element  of  poverty — leading  as  it  does  to  taking  improper  or  insufficient 
food,  dwelling  in  an  unhygienic  room  or  in  an  overcrowded  building,  pursuing 
an  exhausting  occupation,  working  for  long  hours,  and  obtaining  insufficient 
amusement  and  outdoor  exercise — also  has  a  most  powerfully  unfavorable 
effect.  As  a  class  the  poor  dislike  ventilation,  take  insufficient  exercise  in 
the  open  air,  do  not  get  enough  sunlight,  work  in  a  dusty  atmosphere,  take 
insufficient  nourishment  and  eat  improper  food,  live  in  damp  and  dirty  rooms, 
are  subjected  to  grinding  competition  and  cruel  anxieties,  and  many  of  them 
drink  quantities  of  whiskey.  City  life  is  a  predisposing  cause  of  tuberculosis 
for  many  of  the  foregoing  reasons,  and  particularly  because  many  city  workers 
follow  an  indoor  occupation.  The  enemies  of  tuberculosis  are  sunlight,  fresh 
air,  nourishing  food,  and  outdoor  exercise,  and  the  limiting  of  any  of  these 
factors  favors  the  development  of  the  disease. 

Tuberculosis  may  occur  in  any  region  that  man  inhabits;  although  in 
some  regions  it  is  rare,  and  in  others  it  is  excessively  common.  Its  great  fre- 
quency in  some  regions  is  probably  due  less  to  climate  than  to  environment, 
occupation,  and  heredit}-;  and  the  greatest  predisposition  is  found  in  the  town 
dweller.     There  is  much  more  tuberculosis  among  males  than  among  females. 


The  Term  Scrofula  239 

An  injury  may  be  followed  by  the  development  of  tuberculosis  at  the  seat 
of  injury,  the  injury  creating  a  point  of  least  resistance  in  which  bacilli  may 
lodge.  A  slight  injury  of  a  joint  or  a  bone  is  the  most  common  traumatic 
predisposition;  although  a  chest  injury  may  be  followed  by  tuberculous 
pleuritis,  and  a  head  injury  by  tuberculous  meningitis.  The  injury  that  pre- 
disposes, as  previously  stated,  is  a  trivial,  and  not  a  severe  one.  In  some  cases 
in  which  tuberculosis  develops  after  injury,  the  injury  has  been  a  mere  coinci- 
dence; in  others,  a  region  the  seat  of  an  undeveloped  tuberculosis  ha^  been 
affected  by  the  injury,  and  the  tuberculous  process  has  thus  been  awakened  into 
activity.  If  there  is  no  tuberculous  focus  at  the  seat  of  injury,  we  are  justified 
in  concluding,  when  tuberculosis  develops,  that  a  point  of  least  resistance  has 
been  created.  Such  points  are  more  common  in  those  that  have  a  focus  of 
tuberculosis  somewhere  about  the  body,  but  may  apparently  occur  in  those 
that  have  no  such  focus.  Many  diseases  and  conditions  predispose  to  tuber- 
culosis. Tuberculosis  is  very  common  in  chronic  drunkards,  in  the  insane, 
in  the  occupants  of  prisons,  almshouses,  and  reformatories;  among  negroes  in 
the  north,  particularly  those  engaged  in  indoor  occupations;  among  American 
Indians  subjected  to  the  blighting  influences  of  civiUzation  by  formula  and 
routine;  and  in  the  sufferers  from  tertiary  syphilis,  diabetes,  and  Bright's 
disease.     Any  exhausting  malady  may  be  followed  by  tuberculosis. 

The  Term  Scrofula. — Many  surgeons  positively  oppose  the  useof  the  term 
scrofula,  but  I  believe  that  there  is  clinical  value  in  retaining  it.  The  surgeons 
that  have  entirely  abandoned  it  think  that,  after  all,  it  is  exactly  synonymous 
with  tuberculosis.  I  use  it  to  designate  the  persons  that  are  predisposed  to 
tuberculosis  through  possessing  a  type  of  tissue  of  low  resisting  power.  These 
tissues  fall  a  ready  prey  to  the  bacteria  of  tuberculosis.  Such  tissue-vulner- 
abihty  is  usually  hereditary;  and,  as  a  rule,  one,  or  even  both  parents  are 
tuberculous,  are  in  ill  health,  or  are  themselves  predisposed.  Occasionally 
this  type  of  tissue  is  acquired,  a  child  having  at  first  been  apparently  entirely 
healthy;  and  later,  owing  to  poor  food,  insufficient  air,  and  bad  hygienic 
surroundings,  developing  scrofula. 

That  scrofula  is  not  simply  osseous,  articular,  or  glandular  tuberculosis  is 
proved  by  the  fact  that  a  person  that  we  recognize  as  scrofulous  may  never 
throughout  his  life  develop  a  tuberculous  lesion.  Some  surgeons  think  that 
scrofula  is  latent  tuberculosis,  and  will,  under  the  influence  of  some  exciting 
cause,  burst  into  activity.  This  is  possible,  but  unproved.  We  do  know 
that  some  so-called  scrofulous  lesions  are  not  tuberculous ;  for  instance,  facial 
eczema,  corneal  ulceration,  granular  lids,  and  mucous  catarrh.  These 
lesions  are  rather  expressive  of  poor  health,  improper  food,  and  deprivation  of 
fresh  air. 

The  subjects  of  scrofula,  besides  being  prone  to  the  non-tuberculous  lesions 
above  mentioned,  are  particularly  prone  to  develop  tuberculous  lesions;  and 
such  a  lesion  may  arise  in  any  part  that  has  been  the  seat  of  a  shght  injury  or 
of  a  non-tuberculous  inflammation.  The  parts  most  apt  to  become  tubercu- 
lous are  the  bones,  the  joints,  and  the  glands. 

There  are  two  types  of  the  so-called  scrofulous,  that  is,  two  t\^es  of  those 
that  are  predisposed.  The  common  type  is  known  as  the  phlegmatic,  or 
lymphatic;  and  it  is  this  type  that  is  particularly  described  by  our  surgical 
forefathers.     In  the  phlegmatic  type,  the  individual  is  stohd  of  expression; 


240  Surgical  Tuberculosis 

and  has  thick,  coarse  skin,  a  muddy  complexion,  dark,  coarse  hair,  a  thick 
neck,  thick  lips,  a  thick  nose,  and  a  heavy  lumbering  gait.  He  is  dull  of 
apprehension,  with  feeble  emotional  reaction,  and  but  Httle  capacity  for  con- 
centration or  interest.  The  other  type  is  much  more  seldom  met  with.  It  is 
what  is  called  the  sanguine  type,  or  what  the  elder  Gross  spoke  of  as  the  an- 
gelic type.  Such  a  child  is  frequently  beautiful,  and  graceful  in  its  movements. 
Its  skin  is  transparent  and  clear,  and  the  color  comes  and  goes.  The  eyes 
are  blue,  the  lashes  long,  and  the  hair  silky.  The  tendency  is  to  thinness, 
rather  than  fat;  and  the  mind  is  not  dull,  but  precocious  and  the  temperament 
is  nervous.     In  both  these  types  of  scrofula,  the  condition  of  h-mphatism  exists. 

Lymphatism,  or  the  Lymphatic  Constitution  (Status  Lymphati= 
CUSj. — This  term  was  introduced  by  Potain  to  designate  a  condition  in  child- 
hood in  which  there  is  a  very  strong  disposition  to  the  development  of  disease 
of  the  lymphatic  structures,  or  in  which  at  birth  there  was  excessive  develop- 
ment of  these  structures.  The  enlarged  glands  may  be  tuberculous  Irom 
the  beginning;  but,  as  a  rule,  they  are  not  so  in  the  beginning,  but  tend  to 
become  so.  Inflammation  of  a  mucous  membrane  is  followed  by  enlarge- 
ment of  the  anatomically  related  lymphatic  glands.  These  enlarged  glands 
are  frequently  met  with  in  the  neck.  We  find  them  associated  with  enlarged 
tonsils  and  pharyngeal  adenoids. 

Usually  lymphatism  is  congenital,  but  it  may  be  acquired  when  children 
are  placed  under  unfavorable  conditions.  Lymphatic  children  frequently 
have  rickets  and  are  invariably  anemic.  In  infancy  it  is  the  bronchial  and 
mesenteric  glands  that  are  particularly  apt  to  enlarge;  in  childhood,  it  is  the 
glands  of  the  neck.  In  lymphatic  children  it  is  not  uncommon  to  have  a  per- 
sistent thymus  gland.  The  gland,  however,  is  not  obvious,  but  rather  hides 
at  the  root  of  the  neck  (Humphry,  in  "Lancet,"  Dec.  26,  1908),  and  may 
be  missed  at  necropsy.  In  some  cases  a  goiter  appears.  As  the  child  in- 
creases in  age,  the  lymphatic  enlargements  are  likely  to  disappear  unless 
tuberculous  infection  has  occurred.  After  a  child  has  reached  the  age  of 
seven  or  eight  years  non-tuberculous  glands  of  the  neck  cease  to  enlarge;  and 
by  the  time  of  puberty  they  have  usually  disappeared.  I  do  not  believe  that 
the  condition  can  be  diagnosticated  during  life. 

If  an  operation  is  performed  on  the  victim  of  lymphatism  the  wound  is 
very  liable  to  become  infected,  and  the  bleeding  from  the  wound  is  very  trivial. 
The  \'ictims  of  lymphatism  are  more  apt  than  other  persons  to  die  under  a 
general  anesthetic,  and  occasionally  one  of  them  dies  during  natural  sleep 
(see  Dr.  Geo.  Blumer,  in  the  "Bulletin  of  the  Johns  Hopkins  Hospital," 
Oct.,  1903).  This  disease  accounts  for  most  other\^^se  inexpHcable  cases  of 
sudden  death  in  children  and  young  persons,  and  such  deaths  are  respiratory 
and  not  cardiac  (Humphry,  in  "Lancet,"  Dec.  26,  1908). 

The  Diagnosis  of  Tuberculosis. — Whenever  he  sees  a  persistent 
area  of  chronic  inflammation  in  any  structure  of  the  body  the  surgeon  must 
think  of  the  possibility  of  its  being  tuberculous.  A  thorough  investigation 
must  be  made  into  the  local  disease  and  the  body  generally;  and  it  is  of  par- 
ticular importance  to  determine  whether  there  is  any  other  diseased  locality, 
and  whether  there  is  any  evidence  of  tuberculous  disease  anywhere  in  the  body. 
The  patient's  history  must  be  investigated,  and  any  possible  tendencies  or 
predispositions    inquired    into.     Tuberculosis    does    not   cause    leukocytosis 


The  Tuberculin  Test  241 

except,  perhaps,  occasionally  and  moderately  in  tuberculosis  of  serous  mem- 
brane, and  even  in  this  condition  there  is  no  increase  in  p()lymor{)honuclear  cells. 
A  mixed  infection  causes  only  a  trivial  increase  in  polynuclear  leukocytes. 

In  many  cases  of  tuberculosis,  the  diagnosis  can  be  made  from  purely 
clinical  investigation.  This  is  the  case,  for  instance,  in  many  tuberculous 
ulcers,  abscesses,  and  glands.  In  some  cases  the  diagnosis  can  be  made  only 
by  making  differential  stains  of  material  obtained  from  the  suspected  focus, 
or  by  removing  a  section  of  the  inflammatory  area  with  a  Mixter's  canula, 
and  studying  it  carefully  under  the  microscope.  Cultiu-es  may  be  taken  from 
any  material  obtained  from  the  suspected  focus. 

In  doubtful  cases,  animal  inoculation  is  necessary  to  make  a  diagnosis. 
The  material  is  injected  into  a  guinea-pig;  and  if  it  be  tuberculous,  the  animal 
will  develop  miliary  tuberculosis  within  a  few  weeks.  With  apparently  sterile 
fluid  obtained  from  a  tuberculous  focus,  the  disease  can  be  induced  in  guinea- 
pigs  by  inoculation.  Blistering  a  tuberculous  person  causes  elevated  tempera- 
ture (page  236).  If  the  fluid  of  the  bhster  be  injected  into  a  tuberculous 
animal  a  distinct  reaction  occurs  (page  236). 

In  a  suspected  case  of  tuberculous  meningitis  of  the  brain  or  of  tuberculous 
disease  of  the  membranes  of  the  cord,  the  theca  of  the  cord  should  be  tapped 
(lumbar  puncture),  and  the  fluid  obtained  should  be  carefully  examined.  Of 
course,  if,  in  a  case  of  tuberculous  cerebral  meningitis,  the  foramina  in  the  floor 
of  the  fourth  ventricle  have  been  blocked  by  exudate,  no  characteristic  fluid 
will  be  obtained  by  tapping.  It  is  usually  found,  however,  that  even  in  tuber- 
culous cerebral  meningitis,  there  is  increased  tension  of  the  fluid  in  the  sub- 
arachnoid space  of  the  cord,  that  this  fluid  is  present  in  unnaturally  large  quan- 
tity, and  that  it  is  turbid  through  the  presence  of  pus  and  white  blood-cells. 
Sometimes  it  contains  bits  of  fibrin  and  sometimes  blood;  and  in  many  cases 
the  bacilli  of  tuberculosis.  Exploratory  abdominal  incision  is  sometimes  nec- 
essary to  determine  the  existence  of  tuberculous  peritonitis. 

The  -Y-rays  are  of  great  aid  in  making  a  diagnosis  of  osseous,  articular,  and, 
perhaps,  certain  forms  of  pulmonary  tuberculosis.  The  area  of  tuberculosis 
is  lighter  than  the  surrounding  healthy  structures  when  seen  by  the  jc-rays. 

The  Tuberculin  Test. — The  tuberculin  test  may  sometimes  be  used  to 
very  great  advantage  in  making  an  early  diagnosis  of  recent  lesions.  Some 
physicians  will  not  use  it,  beUeving  that  it  is  very  dangerous.  However 
tuberculin  is  jused,  it  is  much  more  reliable  diagnostically  in  children  than  in 
adults.  In  many  adults  free  from  demonstrable  signs  of  tuberculosis,  tuberculin 
gives  a  distinct  reaction  probably  because  many  adults  have  or  have  had  the 
disease.  I  have  already  expressed  the  belief  that  if  given  in  moderate  doses 
it  is  safe;  that  is,  it  is  safe  if  the  disease  is  not  too  far  advanced.  Very  large 
doses,  or  the  gi^^ng  of  the  remedy  at  all  in  greatly  advanced  tuberculosis,  would 
not  be  safe.  Some  conditions  contraindicate  its  use,  among  them  are  the 
following:  .\ddison's  disease,  recent  pulmonary  hemorrhage,  and  suspected 
bilateral  renal  tuberculosis  (Howes  and  Floyd  in  "Publications  of  Mass. 
Gen.  Hospital,"  1908).  It  should  only  be  given  when  other  diagnostic 
methods,  fail  to  give  certain  informa-tion,  and  is  only  to  be  used  by  a  man 
trained  in  its  use.  Too  large  a  dose  may  cause  a  severe  chill,  high  fever,  and 
great  exhaustion,  may  arouse  a  latent  focus  to  activity,  and  may  actually  cause 
dissemination  of  the  disease.  There  is  no  use  in  trying  the  test  if  fever  exists. 
16 


242  Surgical  Tuberculosis 

A  temperature  of  99.5°  F.  or  over,  when  the  patient  is  quiet  in  bed,  contra- 
indicates  the  employment  of  the  test.  The  test  should  \)t  used  as  directed  by 
John  B.  Howes  and  Cleveland  Floyd  ("Publications  of  the  Mass.  General 
Hospital,"  1908).  These  rules  are  as  follows:  Koch's  old  tuberculin  is  used 
and  the  preparation  must  not  be  over  two  months  old.  One  cc.  (100  mg.)  of 
the  material  is  drawn  up  in  a  pipet  and  is  dropped  into  10  cc.  of  a  2  per  cent, 
solution  of  carbolic  acid.  Each  cubic  centimeter  of  this  solution  contains 
10  mg.  of  tuberculin;  i  cc.  of  solution  No.  i  is  mixed  with  9  cc.  of  a  ^  P^r 
cent,  solution  of  carboHc  acid.  Each  cubic  centimeter  of  solution  No.  2 
contains  i  mg.  of  tuberculin. 

One  cc.  of  solution  No.  2  is  mixed  with  9  cc.  of  the  very  dilute  carboHc  solu- 
tion.    Each  cubic  centimeter  of  solution  No.  3  contains  .1  mg.  of  tubercuHn. 

The  patient  is  kept  in  bed  for  three  days  before  beginning  the  test,  and  also 
during  the  test,  and  during  all  of  this  time  the  temperature  is  taken  every  two 
hours.  The  injection  is  to  be  made  at  an  indifferent  point.  The  first  dose  is 
I  mg.  of  tuberculin  (i  cc.  of  solution  No.  3).  If  there  is  no  reaction,  wait  for 
three  days  and  then  give  i  mg.  (i  cc.  of  solution  No.  2).  If  No.  2  gives  no 
reaction,  wait  three  days  and  give  10  mg.  (i  cc.  of  No.  i  solution) ;  if  it  gave  a 
slight  reaction,  inject  5  mg.  (^  cc.  of  No.  i  solution) .  The  reaction  sought  for 
is  not  only  rise  of  temperature,  but  local  signs  and  constitutional  symptoms. 

We  have  previously  described  the  tubercuhn  reaction;  that  is,  the  temporary 
local  congestion  or  inflammation  in  the  tuberculous  area,  and  the  chilly  sensa- 
tion or  chill,  followed  by  marked  elevation  of  temperature.  The  local  reaction 
is  the  most  important.  In  certain  tuberculous  lesions  we  can  see  the  local 
reaction;  for  instance,  in  lupus.  In  joint  tuberculosis  the  skin  over  the  joint 
becomes  red.  In  a  tuberculous  ulcer  of  the  mouth  we  can  see  the  changes; 
and  in  a  lesion  of  the  larynx  the  laryngologist  can  observe  them  with  the  laryn- 
goscope. By  means  of  a  cystoscope  the  local  reaction  can  be  seen  in  a  tuber- 
culous ulcer  of  the  bladder. 

Troudeau  pointed  out  that  redness  at  the  seat  of  injection  is  a  common 
reaction.  The  constitutional  signs  of  reaction  are  chilly  sensations  or  chills, 
sweats,  skin  eruptions,  headache,  pain  in  the  back  and  joints,  diarrhea, 
nausea,  malaise,  cardiac  palpitation,  and  dyspnea.  Howes  and  Floyd  regard 
even  h°  F.  of  fever  as  significant  of  reaction  if  there  are  also  constitutional 
symptoms  and  local  signs. 

The  tuberculin  test  should  not  be  used  in  advanced  pulmona^  tuberculosis 
because  it  is  unsafe.  In  advanced  cases  it  fails  to  cause  any  reaction  because 
the  tissues  are  unable  to  produce  antibodies  when  acted  on  by  toxin  (Howes 
and  Floyd,  in  "Publications  of  the  Mass.  General  Hosp.,"  1908).  As  a  matter 
of  fact,  there  is  never  any  need  of  using  the  test  in  an  advanced  case,  because  the 
diagnosis  is  perfectly  clear  without  it.  We  never  should  give  extremely  large 
doses  in  making  the  tuberculin  test,  because  an  extremely  large  dose  may 
obtain  a  positive  reaction  even  in  a  healthy  man.  A  person  with  actinomy- 
cosis or  secondary  syphilis  may  show  a  reaction  to  tuberculin  which  confuses 
our  results.  There  may  be  no  reaction  to  tuberculin  when  a  tuberculous 
focus  is  encapsuled  with  thick  walls.  If,  after  the  careful  use  of  tuberculin, 
there  is  no  reaction,  it  is  usually  a  safe  conclusion  that  there  is  no  tuberculosis. 

The  Ophthalmo-tuberculin  Reaction. — It  was  pointed  out  that  when 
tuberculin  is  injected  into  a  tuberculous  individual  a  reaction  arises  at  the  seat 


Finding  Bacilli  in  the  Blood  243 

of  injection.  It  has  been  shown  that  if  tuberculin  is  placed  in  the  conjunctival 
sac  of  a  tuberculous  individual  a  reaction  occurs,  and  this  method  is  valuable 
because  even  a  trivial  reaction  is  easily  observed.  The  introduction  of  tuber- 
culin into  the  conjunctival  sac  is  usually  spoken  of  as  Calmette's  method. 
This  test  can  be  used  even  if  fever  exists  and  even  if  a  skin  eruption  exists. 
It  is  not  as  satisfactory  in  surgical  as  in  medical  cases.  The  old  tubercuHn  of 
Koch  is  used.  It  is  carefully  freed  from  irritant  materials,  a  i  per  cent,  solu- 
tion is  made  in  normal  salt  solution,  and  i  drop  of  this  is  placed  in  the  eye. 
Baldwin  regards  i  per  cent,  as  dangerously  strong  and  uses  ^  per  cent.  No 
constitutional  symptoms  develop,  but  in  four  or  five  hours,  if  the  subject  be 
tuberculous,  the  conjunctiva  of  the  lids  becomes  injected,  the  corneal  vessels 
distend,  lachrymation  arises,  and  the  lids  may  swell  (Howes  and  Floyd,  in 
"Pubhcations  of.  Mass.  General  Hospital").  The  reacdon  attains  its  height 
in  from  twelve  to  twenty-four  hours  and  disappears  in  from  forty-eight  to 
seventy-two  hours  after  its  first  appearance.  In  a  non-tuberculous  person  no 
redness,  or  only  a  trivial  and  temporary  redness,  is  noted.  There  is  never  a 
constitutional  reaction  even  in  a  case  of  advanced  tuberculosis.  Of  course,  this 
test  is  contraindicated  if  there  is  a  tuberculous  lesion  of  the  hds  or  eye,  if  there 
is  ulceration  of  the  cornea,  or  if  conjunctivitis  exists,  I  have  never  become  con- 
vinced that  the  method  is  entirely  free  from  danger  to  the  eye,  and  I  own  that  I 
rather  fear  to  use  it.  Cases  of  permanent  ocular  injury  are  on  record.  Bald- 
win ("  Jour.  Am.  Med.  Assoc,"  February  20,  1909)  made  over  1000  tests.  He 
says  that  the  test  has  some  value  in  diagnosis,  no  value  in  prognosis,  and  as  yet 
cannot  distinguish  "active  latent"  from  healed  tuberculosis.  He  says  danger 
to  the  eye  is  slight. 

Von  Pirquet's  Cutaneous  Tuberculin  Reaction. — After  the  skin  has 
been  rawed  or  scarified,  i  drop  of  Koch's  tuberculin  is  put  upon  the  abraded 
surface.  In  a  tuberculous  individual  local  redness  will  appear  in  ten  or  twelve 
hours,  and  in  twelve  hours  more  the  area  will  be  swollen  and  perhaps  edematous. 
This  condition  disappears  in  a  few  days,  leaving,  perhaps,  as  a  legacy  a  trivial 
induration.     There  is  almost  never  a  febrile  reaction. 

Moro's  Cutaneous  Tuberculin  Reaction. — The  material  used  is  5  cc. 
of  old  tubercuHn  and  5  gm.  of  lanoHn.  It  is  rubbed  into  the  abdominal  skin 
and  if  the  individual  is  tuberculous  a  crop  of  red  papules  appears  in  the  area 
where  the  inunction  was  made.     There  is  no  febrile  reaction. 

Blistering  a  Tuberculous  Person. — See  page  236. 

Injecting  a  Tuberculous  Animal  with  Blister  Fluid  from  a  Person 
Suspected  to  be  Tuberculous. — See  page  236. 

Massage  of  a  Tuberculous  Focus. — Wright  has  shown  that  gentle  mas- 
sage of  a  tuberculous  focus  may  be  followed  by  a  reaction  like  that  which  fol- 
lows the  diagnostic  use  of  tuberculin.  In  such  a  case  the  massage  drives 
tuberculous  products  into  the  blood  and,  perhaps,  if  the  massage  is  frequently 
repeated,  auto-immunizes  the  individual. 

Animal  Inoculations. — This  method  of  diagnosis  is  seldom  employed 
and  only  in  unusually  obscure  cases. 

The  Agglutination  Test. — The  agglutination  test,  as  appUed  to  the 
blood-serum  of  a  tuberculous  individual,  is  decidedly  uncertain. 

Finding  Bacilli  in  the  Blood  (Rosenberger's  Method). — The  finding 
of  tubercle  bacilli  in  the  blood  by  the  method  of  Rosenberger  is  proof  of  the 


244  Surgical  Tuberculosis 

existence  in  the  body  of  the  bacilli  of  tuberculosis.  The  method  is  entirely- 
free  from  danger  or  unpleasantness  to  the  patient,  and,  if  Rosenberger's 
favorable  conclusions  secure  confirmation,  it  is  the  method  of  all  methods  for 
making  the  diagnosis.  About  5  cc.  of  blood  are  drawn  from  a  vein  in  the 
arm  and  it  is  placed  at  once  in  an  equal  quantity  of  a  2  per  cent,  solution  of 
sodium  citrate  in  normal  salt  solution.  The  mixture  is  shaken  thoroughly 
and  is  placed  in  a  refrigerator  for  twenty-four  hours.  Some  of  the  sediment  is 
then  removed  by  means  of  a  pipet,  a  thick  preparation  is  made  upon  a  glass 
slide,  and  the  slide  is  dried  upon  a  copper  plate  at  a  moderate  heat,  and  is  then 
placed  in  distilled  water  until  complete  laking  occurs.  The  dehcate  film  which 
remains  is  dried  and  fixed  by  passing  through  the  flame  of  a  Bunsen  burner  and 
is  then  stained  by  the  technic  in  common  use  to  stain  tubercle  bacilli  ("Am. 
Jour.  Med.  Sciences,"  Feb.,  1909).  Rosenberger's  studies  upon  cases  in  my 
wards  in  the  Jefferson  Hospital  have  proved  most  helpful  to  me,  and  I  beUeve 
that  his  views  are  correct. 

Prognosis, — Many  cases  of  tuberculosis  are  cured.  This  is  indicated 
by  the  frequency  with  which  we  find  healed  tuberculous  lesions  in  necropsies 
on  individuals  dead  of  other  diseases.  We  reach  the  same  conclusion  from 
the  clinical  study  of  many  cases.  The  prognosis  of  a  single  tuberculous  focus, 
especially  if  it  can  be  extirpated  or  sterilized,  is  very  good;  provided  that  the 
general  health  is  good,  that  there  is  not  much  anemia,  that  the  digestive 
processes  are  well  performed,  that  mixed  infection  is  absent,  that  there  are  no 
albuminoid  changes  in  the  viscera,  and  that  the  patient  is  able  and  willing  to 
live  the  life  that  is  necessary  for  his  welfare.  Of  course,  the  prognosis  is  in- 
fluenced by  the  patient's  temperament,  his  willingness  to  brook  control,  his 
monetary  status,  and  his  habits.  The  danger  is  greatly  increased  by  multiple 
lesions.  The  dangers  of  mixed  infection  and  of  albuminoid  disease  have  been 
previously  discussed. 

In  very  young  children  the  prognosis  is  most  unfavorable;  but  in  older 
children  it  is  very  much  better;  in  fact,  it  is  better  in  them  than  in  adults. 

Tuberculosis  of  the  skin  gives  a  very  fair  prognosis ;  and  glandular,  bony, 
and  articular  tuberculosis  are  frequently  recovered  from:  but,  of  course,  any 
tuberculous  lesion,  however  limited  in  area,  is  a  profound  menace. 

Another  fact  to  be  borne  in  mind  is  that  many  cases  apparently  cured  are 
not  really  cured;  and  that  the  disease  strongly  tends  to  reappear  in  the  same 
region  or  in  a  nearby  region,  or  to  reappear  later  in  another  part  of  the  body. 
We  should,  further,  remember  that  in  many  cases  in  which  there  is  apparently 
one  lesion  only,  there  are,  in  reality,  distant  lesions  undiscoverable  by 
cHnical  methods.  In  any  case  of  tuberculosis  the  higher  the  opsonic  index  the 
better  the  prognosis,  the  lower  the  opsonic  index  the   worse  the  prognosis 

(page  41). 

Another  important  fact  is  that  when  an  individual  has  a  latent  focus  of 
tuberculosis,  especialy  if  this  latent  focus  is  in  the  lungs,  should  a  surgical 
operation  be  performed  for  some  other  purpose,  and  the  patient  be  kept  in 
bed  for  a  considerable  length  of  time,  the  latent  focus  may  become  active.  I 
have  always  believed  that  in  latent  pulmonary  tuberculosis  the  administration 
of  ether  or  chloroform  might  waken  the  disease  into  activity.  It  therefore 
becomes  evident  that  in  such  persons  operations  of  necessity  are  the  only 
ones  that  should  be  undertaken.     Such  an  operation,  if  possible,  should  be 


Treatment  of  Tuberculosis  245 

done  under  a  local  anesthetic;  and  the  patient  should  be  got  about  again  at 
the  earliest  possible  moment. 

Treatment. — One  of  the  first  thoughts  of  the  surgeon  is  to  provide  against 
the  contamination  of  healthy  individuals  by  the  infected.  Any  infected  ex- 
cretion or  suspicious  discharge  from  the  patient  must  be  disinfected  at  once  and 
dressings  that  are  removed  from  the  patient  should  be  burned. 

We  are  not  in  this  section  discussing  the  treatment  of  tuberculosis  of  the 
lungs,  which  belongs  to  the  medical  man,  and  in  which  climate  is  of  the  first 
importance.  In  cases  of  surgical  tuberculosis,  however,  the  patient  may  do 
better  in  some  climates  than  in  others;  and  the  change,  by  stimulating  the 
appetite  and  causing  him  to  sleep  and  giving  him  renewed  hope,  will  be  bene- 
ficial. In  surgical  tuberculosis,  climate  is  not  the  factor  that  it  is  in  tuberculo- 
sis of  the  lungs;  but  if  there  is  pure  atmosphere,  an  equable  temperature,  and 
plenty  of  sunhght,  the  climate  will  lure  the  patient  out-of-doors,  and  will  thus 
be  greatly  to  his  advantage. 

A  life  in  the  open  air  is  the  most  essential  thing  in  the  treatment  of  surgical 
tuberculosis;  but,  as  Professor  Halsted  points  out,  it  is  not  of  much  use  to  tell  a 
great  many  persons  to  live  in  the  fresh  air.  They  will  not  do  it,  unless  they  are 
made  to;  and  it  is  hard  to  make  them  unless  they  live  in  quarters  especially 
built  with  this  object  in  view.  Therefore,  other  things  being  equal,  if  the  pa- 
tients with  surgical  tuberculosis  have  the  means,  it  is  a  good  plan  to  send  them 
to  a  sanitarium  in  the  mountains  or  at  the  seashore,  where  they  can  obtain  the 
persistent,  unbroken  life  in  the  open  air  that  is  the  cure  of  the  disease.  The 
patient  should  spend  his  days  in  the  fresh  air,  and  he  should  sleep  at  night 
directly  exposed  to  the  air;  and  if  the  atmosphere  is  free  from  dust  and  foul 
odors,  so  much  the  better.  The  poorer  patients  must  get  the  fresh  air  at  home, 
if  they  cannot  be  sent  to  some  camp  or  colony.  In  large  cities  adjacent  to  the 
seaside  resorts,  poor  people  can  usually  be  sent  for  a  short  time,  at  least,  to 
the  seaside;  and  I  am  a  very  great  believer  in  the  beneficial  effects  of  Atlantic 
City  and  other  seashore  resorts. 

It  is  frequently  necessary  to  do  an  operation  in  a  great  city,  although  we 
operate  much  less  than  formerly  for  these  conditions.  If  an  operation  is  done 
in  a  great  city,  the  patient  is  kept  in  the  fresh  air  as  much  as  possible  during 
his  convalescence.  If  it  is  feasible,  he  is  sent  away  to  a  colony  or  sanitarium 
to  recuperate.  It  would  be  an  excellent  thing  if,  in  many  of  those  cases  in 
which  operation  is  necessary,  the  operation  could  be  performed  at  the  camp  or 
the  sanitarium.  One  advantage  of  the  camp  or  sanitarium  is  that  the  patient  is 
watched  and  regulated  daily,  and  is  led  to  do  things  that  otherwise  he  would  ne- 
glect. Many  patients  endeavor  to  evade  going  out  when  they  should,  because 
they  are  afraid  of  taking  cold;  and  many  of  them  are  just  neglectful  and  do  not 
want  to  take  the  trouble  to  do  it. 

It  cannot  be  too  strongly  insisted  on  that  in  surgical  tuberculosis  fresh  air 
is  of  as  much  importance  as  in  tuberculosis  of  the  lungs.  It  increases  the  vital 
resistance,  it  stimulates  opsonic  power,  and  it  causes  the  patient  to  eat  more 
nourishing  food  and  to  sleep  better  at  night.  Frequently  we  see  children 
that  have  had  sinuses  for  months  get  rapidly  well  when  they  adopt  an  open-air 
life;  and,  although  albuminoid  changes,  when  they  once  exist,  will  never  pass 
away,  further  albuminoid  changes  may  not  take  place  if  the  patient  lives 
properly. 


246  Surgical  Tuberculosis 

A  patient  with  surgical  tuberculosis  can  have  no  more  injurious  environ- 
ment than  a  dark,  damp  room,  especially  if  it  is  in  a  crowded  tenement  and  up 
a  narrow  court.  The  value  of  sunshine  is  also  beginning  to  be  appreciated. 
We  know  that  it  limits  the  growth  of  tubercle  bacilli.  It  is  not  the  heat  that 
benefits  the  person,  but  the  chemical  rays  of  sunlight.  These  rays  have  some 
germicidal  influence,  have  considerable  penetrating  power,  and  seem  to  influ- 
ence decidedly  the  nutritive  processes.  Excessive  sunlight  is,  however,  not 
beneficial.  In  summer  it  exhausts  the  patient  and  even  in  winter  it  pro- 
duces eye-strain  and  headache.  Major  Woodruff,  U.  S.  A.,  insists  that 
excessive  sunlight  is  actually  harmful,  particularly  to  blondes  ("  The  Effects 
of  Tropical  Light  on  White  Men") .  Tuberculosis  is  dreadfully  fatal  in  certain 
tropical  countries  and  is  more  fatal  to- blondes  than  to  brunettes.  Open  air 
treatment  is  more  valuable  in  winter  than  in  summer,  perhaps  because  cold 
stimulates  respiration  and  because  the  sunlight  is  not  debihtating. 

The  area  of  tuberculosis  requires  rest.  We  have  long  known  how  disas- 
trous it  is  to  confine  a  person  to  bed  in  a  dark,  ill-lighted,  and  improperly 
ventilated  room.  We  can,  however,  confine  a  person  to  bed  with  perfect  safety 
if  there  is  a  free  flow  of  fresh  air.  We  must  confine  certain  cases  to  bed;  for 
instance,  cases  of  tuberculous  peritonitis,  and  some  cases  of  bone  tuberculosis, 
and  of  joint  tuberculosis.  A  patient  with  tuberculosis  who  has  fever  ought  to 
be  in  bed.  We  can  put  such  patients  to  bed  without  any  fear  of  the  disease 
becoming  worse  or  spreading  if  the  supply  of  fresh  air  is  plentiful  and  if  the 
patient  is  kept  warmly  covered  and  wears  a  skull-cap.  Of  course,  a  draft  -is  to 
be  avoided.  Patients  that  are  confined  to  bed  do  excellently  in  a  tent,  in  a 
cottage  sanitarium,  or  on  a  porch  that  has  been  altered  for  the  purpose. 

At  the  very  first  possible  moment  the  patient  should  be  got  out-of-doors; 
and  in  many  cases  of  tuberculous  disease  (for  instance,  vertebral  disease), 
the  tuberculous  part  is  supported  by  means  of  a  brace  or  a  splint. 

We  thus  see  the  two-fold  nature  of  the  modern  treatment  of  surgical  tuber- 
culosis: rest  for  the  tuberculous  part  and  a  life  in  the  open  air.  Exercise  is 
of  importance  also,  although  it  should  never  be  taken  in  excess.  If  the  patient 
is  confined  to  bed,  he  should  be  massaged  and  rubbed  with  alcohol,  the  tuber- 
culous part  being  usually  avoided.  Forcible  manipulation  must  never  be 
applied  to  a  focus  of  tuberculosis,  because  it  may  lead  to  dissemination.  Gentle 
massage  of  a  tuberculous  part  may  do  good.  Wright  has  shown  that  it  is  fol- 
lowed by  a  reaction  like  that  produced  by  tuberculin  and  is  due  to  the  absorption 
of  tubercuHn  from  the  seat  of  disease.  If  a  person  has  fever  he  must  not  at- 
tempt active  exercise,  but  must  be  confined  to  bed. 

One  should  overfeed  tuberculous  patients,  if  the  stomach  tolerates  it; 
but  not  on  any  single  article,  or  even  on  any  particular  one.  The  diet  should 
contain  a  sufficiency  of  fats,  proteids,  and  carbohydrates;  and  the  food  should 
be  agreeable  to  the  taste  and  readily  assimilable.  Otherwise,  disgust  will  be 
engendered;  and  with  disgust  comes  indigestion  and  loss  of  appetite.  The 
very  life  of  the  patient  may  depend  on  his  remaining  able  to  take  a  sufficiency 
of  nourishing  food. 

There  is  no  specific  diet  for  tuberculosis,  although  many  have  been  sug- 
gested. One  of  the  most  valuable  foods  is  milk,  taken  raw  or  mixed  with 
other  articles,  such  as  lime  water  or  sodium  carbonate,  and  frequently  with 
brandy.     The  use  of  an  exclusive  diet  of  boiled  milk  is  to  be  deprecated,  and  in 


Treatment  of  Tuberculosis  247 

children  it  sometimes  leads  to  tiic  development  of  scurvy.  Practically  anyone 
can  take  milk,  if  proper  efforts  are  made. 

Soft  boiled  eggs  are  useful;  and  bread  or  toast  should  be  eaten  with  plenty 
of  butter,  ^vh^ch  is  an  agreeable  form  of  fat.  Vegetables  and  fruits  are  desirable. 

If  the  patient  can  take  cod-liver  oil  without  impairing  his  appetite  or  di- 
gestion, it  should  be  given;  provided  the  weather  is  not  too  hot.  Cod-liver 
oil  produces  diarrhea  in  very  hot  weather.  Children  learn  to  take  it  very  well. 
To  many  adults,  however,  it  is,  and  remains,  absolutely  abhorrent.  The 
chief  value  of  cod-liver  oil  is  that  it  is  a  fat,  and  it  seems  improbable  that  it 
contains  any  elements  specifically  antagonistic  to  tubercle.  If  used,  large 
doses  should  not  be  given;  as  they  will  not  be  digested.  The  common  dose 
for  an  adult  is  a  teaspoonful  two  or  three  hours  after  meals.  Thirty  drops  three 
times  a  day  is  usually  given  a  child,  and  an  infant  should  receive  15  drops 
three  times  a  day. 

We  know  of  no  drug  or  medicine  that  can  with  safety  be  used  at  the  present 
time  with  any  real  hope  that  it  \\'ill  specially  destroy  tubercle.  Drugs  are, 
of  course,  given,  but  they  are  of  secondary  importance. 

Tonics  are  used,  and  in  children  the  syrup  of  the  iodid  of  iron  has  con- 
siderable reputation.  Remedies  may  be  needed  to  improve  digestion  or  con- 
trol night-sweats,  etc.  I  do  not  believe  that  beechwood  creosote  or  carbonate 
of  guaiacol  internally,  or  iodoform  inunctions,  or  painting  the  surface  with 
guaiacol  confer  any  real  benetit  in  tuberculosis. 

Alcohol  is  often  required.  It  is  not  needed  in  all  cases,  but  is  in  many. 
We  should  avoid  it  in  children,  however,  unless  there  is  a  particular  indication 
for  its  use.  When  a  tuberculous  patient  is  weak,  milk-punch  or  egg-nog  is 
of  service:  and  in  any  case  of  mixed  infection  alcohol  is  required  in  full  doses. 
If  fever  exists,  and  the  administration  of  alcohol  makes  the  pulse  more  rapid 
and  the  deUrium  worse,  and  causes  tiushing  of  the  face,  the  dose  is  too  large 
and  should  be  diminished.  Any  patient  that  smells  strongly  of  alcohol  is  get- 
ting an  overdose.  ^lany  able  investigators  in  many  lands  are  stri\'ing  to 
work  out  a  safe  and  satisfactory  specific  treatment  for  tuberculosis.  Landerer 
proved  that  immunity  to  tuberculosis  can  be  produced  in  the  lower  animals 
by  injection  of  hving  bacilli.  Injections  of  tuberculin  finally  produce  immunity 
to  that  product.  Just  at  present  we  are  witnessing  a  revival  of  faith  in  tuber- 
cuhn. 

One  set  of  clinicians  begin  with  very  small  doses  and  by  a  very  gradual 
increase  of  dose  finally  reach  full  doses.  The  object  is  to  produce  an  immunit}' 
to  tuberculin. 

When  an  animal  becomes  immune  to  tuberculin  the  body  cells  resist  and 
finally  destroy  the  tubercle  baciUi  (Braun,  in  "Boston  Med.  and  Surg.  Jour.," 
July,  23,  1908).  The  treatment  is  begun  with  doses  of  .0001  mg.  of  the  new 
tuberculin  emulsion  of  Koch  (B.  E.)  or  .oci  mg.  of  the  old  tuberculin  (T.  O.). 
The  dose  is  gradually  but  very  slowly  increased,  the  effort  being  always  to  in- 
crease with  the  smallest  possible  disturbance.  Finally,  full  doses  are  given. 
From  six  months  to  a  year  is  required  for  the  treatment.  If  the  bacillar}^ 
emulsion  is  used,  no  reaction  need  be  obtained  throughout  treatment.  The 
essence  of  treatment  is  the  very  small  dose  and  the  ver}-  gradual  increase. 
The  utterly  reckless  use  of  tuberculin  when  it  was  first  introduced  lead  to  most 
disastrous  results  and  consequent  abandonment  of  the  treatment  until  three  or 


248  Surgical  Tuberculosis 

four  years  ago.  It  was  not  that  tuberculin  treatment  was  wrong,  but  that  too 
large  doses  were  given  and  were  given  indiscriminately  to  any  and  all  tuber- 
culous patients. 

Wright  gives  very  small  doses  of  emulsion  of  powdered  bacilli,  not  with  the 
idea  of  causing  body  immunity  to  tuberculin,  but  to  produce  immunity  by 
strengthening  the  phagocytic  power  of  the  leukocytes. 

When  this  plan  is  followed  the  dose  is  determined  by  the  opsonic  index, 
and  the  dose  is  only  raised  to  a  sufficient  degree  to  establish  the  posidve  phase 
without  producing  even  the  most  trivial  subjective  symptoms.  One  dose 
causes  an  increase  of  immunizing  power  in  the  body  for  about  a  fortnight  and 
then  another  dose  is  given.  Many  clinicians  deny  the  need  of  even  giving  the 
dose  by  the  opsonic  index.  When  tuberculin  is  given  by  either  of  the  above 
plans  it  is  entirely  safe,  and  I  believe,  beyond  doubt,  is  of  value  in  suitable  cases. 
It  is  not  to  be  used  in  advanced  cases  or  in  febrile  conditions.  It  must  be  given 
in  doses  so  small  that  it  causes  no  reaction  and  no  marked  local  reaction  at 
the  seat  of  disease.  For  tuberculous  glands,  tuberculous  bones,  or  tuberculous 
joints,  one  dose  a  w-eek  is  given.  It  is  injected  hypodermatically  beneath  the 
skin  of  the  back.  If  we  get  a  general  or  local  reaction,  the  dose  is  too  large. 
When  given  in  this  way  it  is  safe,  never  produces  trouble  at  the  site  of  injection, 
seems  to  arrest  some  cases  of  tuberculosis,  improves  the  local  trouble  in  many, 
and  benefits  the  general  condition  of  most.  According  to  Trudeau,  tuberculin 
strengthens  the  individual's  immunity  to  tuberculosis.  According  to  Wright 
it  causes  an  increase  in  deficient  opsonins.  Tuberculin  is  of  unquestionable 
value  in  some  cases  of  lupus. 

Ringer  has  recently  strongly  advocated  the  use  of  tuberculin  ("Jour.  Am. 
Med.  Assoc,"  May  2,  1908).  Maragliano  treats  tuberculosis  with  the  serum 
of  animals  which  have  been  injected  with  dead  bacilli  and  toxins,  and  he  be- 
lieves that  this  serum  contains  quantities  of  antibodies  and  antitoxins.  The 
animal  is  injected  many  times  until  its  serum  becomes  highly  agglutinative. 
Maragliano  believes  that  this  highly  agglutinative  serum  when  introduced  into 
the  human  body  causes  the  protective  mechanism  of  the  body  to  produce 
quantities  of  antibodies  and  antitoxins.  Most  clinicians  do  not  favor  the  use  of 
Maragliano's  serum. 

The  Local  Treatment  of  Tuberculosis. — When  certain  drugs  are  directly 
inserted  into  a  tuberculous  focus,  they  do  possess  an  antagonistic  influence. 
Iodoform  is  the  most  powerful  of  these  drugs;  guaiacol,  balsam  of  Peru  (Lan- 
derer) ,  bismuth,  and  chlorid  of  zinc  (Lannelongue)  have  a  similar  action.  Iodo- 
form has  little  or  no  influence  when  placed  on  a  free  surface  exposed  to  the 
air,  but  when  in  the  form  of  an  emulsion  it  is  injected  into  a  tuberculous  area, 
the  air  being  excluded  (page  30),  this  drug  is  powerfully  antituberculous. 
Chlorid  of  zinc  seems  to  act  by  causing  the  development  of  quantities  of 
fibrous  tissue,  which  encapsulates  or,  perhaps,  replaces  the  tuberculous  focus. 
Some  surgeons  inject  tuberculous  nodules  with  camphorated  naphthol.  Every 
region  of  tuberculosis  requires  local  rest,  perhaps  by  the  use  of  a  splint,  or  a 
brace. 

Special  Methods  of  Surgical  Treatment. — The  surgeon  may  endeavor 
to  extirpate  a  tuberculous  focus,  or  to  drain  it  thoroughly  and  to  sterilize  the 
area.  Extirpation  is  sometimes,  although  not  very  frequently,  possible.  Com- 
plete extirpation  is  a  valuable  method,  but  partial  extirpation  is  dangerous. 


Tuberculosis  Ulcerosa  249 

If  a  part  only  of  a  tuberculous  focus  is  extirpated,  many  lymph-tracts  and  blood- 
vessels are  oi)ened;  and  the  incomplete  operation  may  lead  to  the  dissemination 
of  the  disease.  The  methods  of  surgical  treatment  suited  to  different  forms 
of  tuberculous  disease  will  be  discussed  in  different  sections  of  this  book. 

Bier's  Method  by  Congestive  Hyperemia  (see  page  116). — Bier  believes  that 
p)assive  hyperemia  is  of  the  greatest  ])ossible  benefit.  Active  hyperemia  is 
obtained  by  heat,  and  is  especially  valuable  to  induce  the  absorption  of  the  prod- 
ucts of  a  non-tuberculous  chronic  inflammation.  Passive  hyperemia  is  par- 
ticularly useful  in  tuberculosis  of  joints,  tuberculous  ulcers,  cold  abscesses, 
and  tuberculous  disease  of  the  tarsus  and  carpus  and  phalanges.  If  a  limb 
is  afifected,  it  is  obtained  by  placing  a  rubber  band  around  the  limb  above  the 
part,  the  band  being  apphed  with  sufficient  firmness  to  interfere  with  venous 
return,  but  not  so  tightly  as  to  block  arterial  entry.  This  band  should  be  ap- 
plied daily,  and  should  be  kept  in  place  for  an  hour  or  so  at  each  applica- 
tion. In  the  intervals  between  the  treatments  the  Hmb  should  be  at  rest. 
Bier  uses  special  apparatuses  for  obtaining  congestive  hyperemia  in  various 
parts  of  the  body. 

I  have  seen  cure  or  very  great  improvement  follow  this  treatment  in  a  num- 
ber of  cases.  It  is  founded  on  the  old  idea  of  Laennec  that  cyanosis  and 
tubercle  are  antagonistic.  Why  this  method  is  beneficial  is  much  debated. 
Some  think  that  the  imprisoned  blood  takes  on  increased  bactericidal  power; 
some,  that  the  number  of  leukocytes  is  greath'  increased;  some,  that  quantities 
of  leukocytes  migrate;  and  some,  that  the  amount  of  bactericidal  blood-serum 
is  increased.  Bier  believes  that  it  depends  upon  phagocytosis.  It  would  seem 
possible  that  the  cells  in  this  locality,  under  the  influence  of  the  congestive 
hyperemia,  may  form  powerful  antitoxins. 

The  Finsen  Light. — Finsen  pointed  out  that  the  chemical  rays  in  sunlight 
are  powerfully  germicidal,  and  that  this  germicidal  power  can  be  notably  in- 
creased if  the  rays  are  concentrated  on  a  part  by  the  use  of  particular  apparatus. 
He  also  showed  that  enormous  numbers  of  chemical  rays  can  be  obtained  from 
electric  light.  The  Finsen  treatment  to-day  consists  in  applying  the  actinic 
rays  obtained  from  electric  light.  They  act  most  powerfully  on  lupus,  but  re- 
quire a  very  long  time  to  effect  a  cure. 

The  X-Rays. — The  :v-rays  are  of  value  in  treating  certain  tuberculous 
conditions.  They  are  of  most  use  in  lupus,  their  effects  in  this  disease  being 
nearly  as  powerfully  curative  as  those  of  the  Finsen  light,  and  much  more  rapid. 

Tuberculous  Abscess. — For  description  of  this  see  page  155. 

Tuberculosis  of  the  Skin. — Tuberculosis  of  the  skin  m.ay  arise  from 
inoculation  with  material  derived  from  a  bovine  or  human  source.  It  is  fre- 
quently found  that  some  other  member  of  the  family  labors  under  tuberculous 
disease  or  that  some  family  predecessor,  direct  or  collateral,  suffered  from  it. 
Stelwagon  ("Diseases  of  the  Skin")  includes  all  cases  under  five  heads:  (i) 
tuberculosis  ulcerosa;  (2)  tuberculosis  disseminata;  (3)  tuberculosis  verru- 
cosa;  (4)  scrofuloderma;   (5)  lupus  vulgaris. 

Tuberculosis  Ulcerosa. — The  disease  arises  by  a  mucous  outlet  and  is 
usually  secondary  to  internal  tuberculous  disease.  Small  mihary  tubercles 
form  which  caseate  and  are  converted  into  ulcers.  The  ulcers  are  shallow, 
round  or  oval  in  outline,  with  soft  edges,  the  floor  being  composed  of  sluggish  or 
edematous  granulations  covered  with  a  crust.     The  discharge  is  scanty  and 


250  Surgical  Tuberculosis 

seropurulent.  In  some  cases  there  is  but  one  ulcer;  in  others  there  are  two 
or  several,  and  the  fusion  of  ulcers  produces  a  serpiginous  outline.  The  ulcers 
do  not  tend  to  heal,  but  gradually  and  steadily  advance.  Such  ulcers  are  met 
with  about  the  mouth,  the  genital  organs,  and  the  anus. 

Tuberculosis  Disseminata. — This  occurs  only  in  children;  it  is  acute  in 
onset  and  widespread.  One  type  is  polymorphic:  spots,  papules,  pustules, 
and  crusted  ulcers  existing,  and  lymphatic  glands  being  enlarged.  Another  type 
follows  one  of  the  exanthemata  and  presents  "a.rough  resemblance  to  flat  lupus 
tubercles,  to  sluggish  acne  papules,  and  to  lichen  scrofulosum"  (Stelwagon). 

Tuberculosis  Verrucosa. — Anatomical  tubercle,  the  verruca  necrogenica 
of  Wilks,  is  due  to  local  inoculation  with  tuberculous  matter.  It  may  be  met 
with  in  surgeons,  the  makers  of  post-mortems,  leather- workers,  and  butchers, 
usually  upon  the  backs  of  the  hand  and  fingers.  It  consists  of  a  red  mass  of 
granulation  tissue  having  the  appearance  of  a  group  of  inflamed  warts.  Pus- 
tules often  form. 

Scrofulodermata  or  tuberculous  gummata. — By  scrofulodermata  we 
mean  chronic  inflammations  of  the  skin,  the  granulation-tissue  product  of 
which  caseates,  mixed  infection  occurs,  and  small  abscesses,  sinuses,  or  ulcers 
form.  A  tuberculous  ulcer  has  a  floor  of  a  pale  color,  and  has  no  granulations 
at  all,  or  is  covered  with  large,  pale,  edematous  granulations.  The  discharge 
is  thin  and  scanty.  The  ulcer  is  surrounded  by  a  considerable  zone  of 
purple,  tender,  and  undermined  skin,  which  is  apt  to  slough.  When  healing 
occurs,  the  skin  puckers  and  usually  inverts. 

Lupus. — Lupus  begins  usually  before  the  age  of  twenty- five,  but  is  met  with 
often  in  individuals  in  middle  life.  It  is  most  usual  upon  the  face,  especially  the 
nose.  It  is  a  very  chronic  and  extremely  destructive  disease.  Three  forms  are 
recognized:  (i)  lupus  vulgaris,  in  which  pink  nodules  appear  that  after  a  time 
ulcerate  and  then  cicatrize  partly  or  completely.  These  nodules  resemble 
jelly  in  appearance;  (2)  lupus  exedens,  in  which  ulceration  is  very  great;  and 
(3)  lupus  hypertrophicjis,  in  which  large  nodules  or  tubercles  arise.  Lupus 
may  appear  as  a  pimple,  as  a  group  of  pimples,  or  as  nodules  of  a  larger  size. 
The  ulcer  arises  from  desquamation,  and  is  surrounded  by  inflammatory 
products  which,  by  progressively  breaking  down,  add  to  the  size  of  the  raw 
surface.  The  ulcer  is  usually  superficial,  is  irregular  in  outline,  the  edges 
are  soft  and  neither  sharp  nor  undermined,  the  sore  gives  origin  to  a  small 
amount  of  thin  discharge,  the  parts  about  are  of  a  yellow-red  color,  the  edges 
are  solid  and  puckered  and  scar-like  and  there  is  no  pain.  The  sore  is  often 
crusted,  the  crusts  being  thin  and  of  a  brown  or  black  color;  it  may  be  pro- 
gressing at  one  point  and  healing  at  another;  it  is  slow  in  advancing,  but  often 
proves  hideously  destructive.  The  scars  left  by  its  healing  are  firm  and 
corrugated,  but  are  apt  to  break  down.  Clinically  it  is  separated  from  a  ro- 
dent ulcer  by  several  points.  The  rodent  ulcer  is  deep,  its  edges  are  everted, 
and  the  parts  about  filled  with  visible  vessels.  It  is  not  crustea,  has  not  a  puck- 
ered edge,  its  edges  and  base  are  hard  and  rarely  show  any  tendency  to  healing. 

Tuberculosis  of  Subcutaneous  Connective  Tissue.— In  this  form 
of  tuberculosis  tuberculous  nodules  form  and  break  down  (tuberculous  ab- 
scesses). In  the  deeper  tissues  these  abscesses  are  usually  associated  with 
bone,  joint,  or  lymphatic  gland  disease  (see  Cold  Abscess,  page  155). 

Tuberculosis  of  the  Mammary  Gland. — (See  page  163.) 


Peritoneal  Tuberculosis  251 

Tuberculosis  of  Blood=vessels. — It  is  certain  that  bacilli  in  the  blood 
or  in  tuberculous  emboli  may  establish  intravascular  tuberculosis. 

Tuberculosis  of  nerve  is  excessively  rare.  Tuberculous  neuritis  may 
arise  in  the  course  of  general  tuberculosis.  A  nerve  lying  in  a  tuberculous 
area  may  itself  become  tuberculous.  It  rarely  does  so,  however.  In  fact, 
nerves  resist  infections  though  in  the  midst  of  them,  and  for  this  reason  have 
been  called  the  ''aristocrats  of  the  body." 

Pulmonary  Tuberculosis. — In  adults  the  lungs  are  more  commonly 
affected  than  any  other  structure.  The  lung  affection  may  be  primary  or 
may  be  secondary  to  some  distant  tuberculous  process.  Pulmonary  tubercu- 
losis belongs  to  the  province  of  the  physician  and  requires  no  description  here. 

Tuberculosis  of  the  Alimentary  Canal. — A  tuberculous  ulcer  of  the 
lip  occasionally  arises,  and  may  be  mistaken  for  a  cancer  or  a  chancre.  A 
tuberculous  ulcer  of  the  tongue  is  commonly  associated  with  other  foci  of  dis- 
ease. Such  ulcers  are  separated  from  cancer  by  their  soft  bases  and  edges 
and  by  the  rarity  of  glandular  enlargements,  and  from  syphilitic  processes 
by  the  therapeutic  test.  Confirmation  of  the  diagnosis  is  obtained  by  culti- 
vations and  inoculations.  Tubercle  may  affect  the  pharynx,  palate,  tonsils, 
and,  very  rarely,  the  stomach. 

Gastric  Tuberculosis. — It  is  thought  that  the  acid  gastric  juice  must 
protect  the  stomach  from  tubercle,  because  tubercle  bacilli  are  frequently 
introduced  into  the  stomach,  but  the  organisms  very  rarely  lodge  and  multiply 
in  the  stomach-wall.  Furthermore,  bacilli  when  introduced  into  the  stomach 
are  retained  but  a  short  time  and  the  stomach- walls  contain  few  lymph-follicles 
(Barchasch,  in  "Beit.  Z.  klin.  d.  Tuberculose,"  vii,  Part  III,  1907).  It  may 
be  assumed  that  gastric  catarrh  and  motor  impairment  are  predisposing  causes. 
Gastric  tuberculosis  may  be  primary,  but  is  usually  secondary  to  pulmonary 
tuberculosis,  infected  sputum  having  been  repeatedly  swallowed  ("Jour.  Am. 
Med.  Assoc,"  Dec.  28,  1907).  Gastric  tuberculosis  may  cause  cicatricial 
stenosis  of  the  pylorus,  ulcer  (of  which  I  reported  an  instance),  a  tumor-Hke 
thickening,  solitary  tubercle,  and  miHary  tuberculosis  (Barchasch,  Ibid.). 

Intestinal  tuberculosis  may  follow  pulmonary  tuberculosis,  but  it  may 
arise  primarily  in  the  mucous  membrane  of  the  bowel  or  result  from  tubercu- 
lous peritonitis.  Intestinal  tuberculosis  causes  diarrhea  and  fever,  may  re- 
semble appendicitis,  and  may  cause  abscess  and  perforation.  True  tubercu- 
lous disease  of  the  appendix  occasionally  occurs.  Tuberculosis  of  the  cecum 
is  by  no  means  as  rare  as  we  used  to  believe  (page  996).  Fistula  in  ano  is 
frequently  tuberculous,  and  when  it  is,  the  lungs  are  very  often  involved,  the 
pulmonary  lesion  being  usually  primary  (page  251). 

Tuberculosis  of  the  Liver. — Tuberculous  disease  of  the  hver  causes 
cold  abscess  or  cirrhosis. 

Peritoneal  tuberculosis  (page  1008)  may  be  primary,  infection  having 
been  by  way  of  the  blood,  may  be  part  of  a  diffused  process,  or  may  follow  intes- 
tinal tuberculosis,  the  serous  and  muscular  coats  of  the  bowel  having  been  at 
some  point  in  contact  or  a  follicular  ulcer  having  perforated  (Abbe) .  The  germ 
may  have  entered  by  the  Fallopian  tube.  Tuberculous  peritonitis  may  be  due 
to  ovarian  or  Fallopian  tuberculosis,  or  to  ulceration  of  a  tuberculous  appendix. 
It  usually  causes  ascites,  tympany,  and  tumor-like  formations  composed  of 
adherent  bunches  of  bowel  or  omentum  or  distended  mesenteric  glands  (page 
1008). 


252  Surgical  Tuberculosis 

The  heart  muscle  is  rarely  attacked  by  tuberculosis.  In  fact,  valvular 
lesions  of  the  left  side  of  the  heart  actually  protect  the  individual  from  pul- 
monary tuberculosis.  Non-tuberculous  endocarditis  may  arise  in  the  course 
of  a  tuberculous  process  elsewhere.  Tuberculous  endocarditis  does  very 
rarely  occur. 

The  pericardium  may  be  attacked  with  primary  tuberculosis,  or  the 
process  may  be  secondary  to  pleural  tuberculosis. 

Tuberculosis  of  the  pleura  is  not  uncommon.  Tuberculous  pleurisy 
may  be  acute  or  chronic.  In  some  instances  mi.xed  infection  takes  place  and 
suppuration  occurs.  The  tuberculosis  may  be  primary,  but  is  usually  secon- 
dary to  pulmonary  tuberculosis,  and  may  be  due  to  direct  extension  or  to 
rupture  of  an  area  of  pulmonary  softening.  A  primary  pleurisy  not  due  to 
traumatism  is  very  apt  to  be  tuberculous. 

Tuberculosis  of  the  brain  induces  meningitis  and  hydrocephalus 
(page  819). 

Tuberculosis  of  the  membranes  of  the  spinal  cord  is  seen  alone 
or  in  association  with  tuberculous  intiammation  of  the  brain. 

Tuberculous  disease  of  fascia  is  common;  in  fact,  fascia  is  pecu- 
liarly prone  to  infection.  Fascia  may  be  attacked  primarily,  and  when  it  is, 
the  disease  is  apt  to  spread  rapidly  and  widely  and  to  produce  most  disastrous 
results.  The  elder  Senn  regards  tuberculosis  of  the  intermuscular  septa  of  the 
thigh  as  a  very  grave  condition,  which,  if  extensive,  demands  amputation  of 
the  Hmb.  Secondary  tuberculosis  of  fascia  is  far  more  common  than  the 
primary  form,  the  original  focus  of  disease  being  in  bone,  joint,  tendon-sheath, 
or  lymph-gland. 

Tuberculosis  of  muscle  is  rare.  Instances  of  primary  tuberculosis 
have  been  reported.  Secondary  tuberculosis  is  more  common,  but  even  this 
condition  is  rare,  muscle  seeming  to  have  a  high  degree  of  resistance. 

Tuberculous  disease  of  bone  (page  501)  is  very  common  in  youth,  and 
usually  a  sprain  or  a  contusion,  which  is  oftener  shght  than  severe,  precedes 
any  signs  of  the  disease.  The  injury  establishes  a  point  of  least  resistance,  and 
in  the  damaged  area  the  bacilh  are  deposited  and  multiply,  or  else  a  latent 
area  of  tuberculosis  is  roused  into  activity  by  the  traumatism.  The  organisms 
may  be  deposited  directly  from  the  blood,  or  may  arrive  in  an  embohsm  from 
a  distant  tuberculous  focus  (lung  or  lymph-gland),  which  embolus  is  caught 
in  a  terminal  artery  in  the  end  of  a  long  bone  and  causes  a  wedge-shaped 
infarction. 

Tuberculous  osteomyelitis,  as  a  rule,  begins  just  beneath  the  articular 
cartilage  or  in  the  epiphysis.  There  may  be  one  focus,  several  foci  or  m-any 
foci  in  the  same  bone.  The  products  of  the  tuberculous  inflammation  con- 
stitute tuberculous  nodules  which  destroy  the  medullary  tissue  and  hence 
cut  off  the  nutrition  of  adjacent  bone.  Bone  trabeculae  are  destroyed,  and 
tuberculous  granulations  take  their  place,  and  here  and  there  small  dead 
portions  of  bone  trabeculae  lie  as  sequestra  among  the  granulations.  In  some 
bones,  for  instance,  the  vertebrae  and  the  bones  of  the  corpus  and  tarsus,  the 
tuberculous  process  spreads  widely;  in  some  it  tends  to  remain  localized. 
Tuberculous  granulations  may  be  absorbed,  may  be  encapsuled,  may  be 
replaced  by  fibrous  tissue,  or  may  caseate  (page  230).  When  an  osseous 
tuberculous  focus  spreads  and  finally  reaches  the  surface  of  the  bone  the 


Tuberculosis  of  the  Cervical  Lymph-glands  253 

stimulated  periosteum  produces  new  bone,  while  bone  destruction  is  still 
going  on  within.  Under  such  circumstances  the  bone  enlarges  and  becomes 
spindle  shaped,  as  is  seen  in  a  phalanx,  the  seat  of  tuberculous  osteomyelitis, 
the  condition  known  as  spina  ventrosa. 

Tuberculous  disease  of  the  joints  (page  500)  is  called  ''white 
swelling'^  and  also  pulpy  degeneration  of  the  synovial  membrane.  Joints  are 
especially  Hable  to  tuberculosis  in  youth,  although  the  wrist  and  shoulder  not  in- 
frequently suffer  in  adult  Ufe.  Joint-tuberculosis  is  often  preceded  by  an  injury. 
The  tuberculous  process  may  begin  in  the  synovial  membrane.  Primary 
synovial  tuberculosis  is  most  often  met  with  in  the  knee-joint.  Usually  the 
disease  begins  in  the  head  of  a  bone,  dry  caries  resulting,  necrosis  ensuing,  or  an 
abscess  forming,  which  may  break  into  the  joint. 

Tuberculosis  of  lymphatic  glands  is  known  as  ''tuberculous  adeni- 
tis.'' It  is  the  most  typical  lesion  of  scrofula.  Tuberculous  adenitis  is  most 
frequent  between  the  third  and  fifteenth  years.  A  person  not  of  the  tuberculous 
type  may  acquire  tuberculosis  of  the  glands,  but  the  disease  is  unquestionably 
of  much  greater  frequency  in  those  who  are  recognized  as  predisposed  to  tuber- 
culosis. Tuberculous  glands  may  get  well,  may  even  calcify,  but  usually 
caseate  if  left  alone.  Long  after  heaUng  they  may  break  down  and  soften 
{residual  abscess  oj  Paget) .  They  very  frequently  suppurate  because  of  mixed 
infection.  Though  at  first  a  local  disease,  tuberculous  glands  may  prove  to  be 
a  dangerous  focus  of  infection,  furnishing  bacteria  which  are  carried  by  blood  or 
lymph  to  distant  organs  or  throughout  the  entire  system.  Glandular  enlarge- 
ment is  in  rare  instances  widely  diffused,  but  it  is  far  more  commonly  locahzed. 
Enlargement  of  the  cervical  glands  is  most  common.  Tuberculous  disease  of 
the  mesenteric  gland  is  known  as  tabes  mesenterica.  Tuberculosis  of  lymph- 
glands  may  be  due  either  to  bovine  bacilh  or  to  human  baciUi. 

Tuberculosis  of  the  cervical  lymph=glands  is  a  very  common  condi- 
tion. It  is  most  common  in  young  children  and  is  quite  often  seen  in  young 
adults.  It  is  rare  in  those  of  middle  age.  In  the  majority  of  cases  infection 
takes  place  from  the  tonsils,  pharynx,  or  posterior  part  of  the  oral  cavity  and  in 
these  cases  the  first  glands  to  enlarge  are  those  just  below  the  parotid  saUvary 
gland.  In  a  number  of  cases  enlargement  begins  in  the  submaxillary  or  sub- 
mental glands  and  in  these  cases  infecdon  originates  from  the  teeth,  mouth, 
or  face  (Dowd,  in  "Surgery,  Gynecology',  and  Obstetrics,"  March  1909).  A 
tuberculous  lesion  of  the  scalp  may  be  followed  by  tuberculosis  of  the  parotid 
lymph-glands.  Cervical  adenitis  may  be  unilateral  or  bilateral  and  is  a  very 
chronic  condition.  It  is  predisposed  to  by  enlargement  of  the  tonsils,  ade- 
noids, and  nasopharyngeal  catarrh.  In  30  per  cent,  of  cases  the  bacilli  of 
bovine  tuberculosis  may  be  found  (Dowd,  Ibid.) .  The  enlargements  usually 
arise  insidiously,  but  sometimes  (after  whooping-cough,  measles,  or  scarlet 
fever)  they  come  on  more  rapidly.  When  first  observed  the  enlargements  are 
small,  round,  firm,  isolated,  painless  and  somewhat  movable.  As  they  enlarge 
they  fuse  into  an  irregular  sweUing  which  may  be  quite  tender  and  is  always 
anchored  to  surrounding  parts.  As  the  glands  caseate  the  mass  softens,  the 
skin  over  it  becomes  adherent  and  red,  and  finally  breaks  open.  Cold  abscess 
may  form  or  mixed  infection  with  pus  cocci  may  take  place. 

Cervical  lymphadenitis  may  be  confused  with  lymphadenoma.  The 
former,  as  a  rule,  first  appears  in  the  submaxillary  triangle;  the  latter,  in  the 


254  Surgical  Tuberculosis- 

occipital  or  sternomastoid  glands.  The  former  are  more  tender,  softer,  and 
less  movable  than  the  latter.  Tuberculous  glands  weld  together,  they  are 
apt  to  remain  localized  for  a  considerable  time,  and  they  tend  to  soften. 
They  may  be  accompanied  by  other  tuberculous  manifestations.  Lymph- 
adenoma  from  the  start  affects  many  glands;  it  may  arise  simultaneously  in 
several  regions,  although  in  some  cases  there  is  a  distinct  beginning  in  one 
region.  Lymphadenoma  shows  very  little  tendency  to  suppurate,  and  does 
not  break  down  except  late  in  the  course  of  the  disease,  and  is  accompanied 
by  great  debility  and  anemia.  Tuberculin  tests  may  aid  in  the  diagnosis,  but 
a  difficulty  is  that  Hodgkin's  disease  and  tuberculosis  may  coexist.  Malignant 
gland-tumors  infiltrate  adjacent  glands  and  other  structures,  binding  skin, 
muscles,  and  glands  into  one  hard,  firm  mass. 

Tuberculous  cer\ical  adenitis  is  in  most  instances  a  reasonably  curable 
condition.  Some  cases  can  be  cured  by  open-air  treatment,  food,  medicine, 
and  hygienic  care.  In  most,  however,  operation  is  indicated  in  addition  to  such 
treatment,  and  these  operations  are  usually  successful  if  thoroughly  performed. 
When  possible  operation  should  be  performed  when  the  patient  is  at  the  sea- 
side, or,  at  least,  the  patient  should  convalesce  there  if  circumstances  permit. 
Thorough  extirpation  is  the  proper  operative  treatment  and  any  diseased  con- 
dition of  scalp,  face,  mouth,  tonsil,  or  nasopharynx  is  to  be  corrected.  My 
belief  is  that  about  75  per  cent,  of  cases  are  permanently  cured  by  thorough 
operation.  If  a  patient  is  well  five  years  after  operation  the  cure  may  be  re- 
garded as  permanent.  Cured  cases  seldom  die  subsequently  of  any  tubercu- 
lous lesion. 

It  is  not  uncommon  after  removal  of  infected  glands  and  healing  of  the 
wound  to  have  several  or  numerous  small  hard  nodules  form  beneath  the  skin 
in  the  area  operated  upon.  Dowd  extirpated  some  of  these  nodules  and 
found  they  were  not  tuberculous,  but  were  fibrous.  I  have  been  able  to  con- 
firm Dowd's  statement  in  several  of  my  own  patients. 

Medical  treatment  is  not  nearly  so  valuable  as  surgical  treatment  in  this 
form  of  tuberculosis.  If  medical  treatment  alone  is  relied  on,  many  of  these 
cases  develop  pulmonary  tuberculosis.  Attridge,  quoting  Demme  and  Dowd 
("Surgery,  Gynecology,  and  Obstetrics,"  Dec,  1908),  sets  the  number  which 
develop  it  when  medical  treatment  is  relied  on  at  21  per  cent.,  and  the  number 
developing  other  distant  tuberculous  lesions  at  8.2  per  cent.  A  total  of  29.2 
per  cent.,  and  these  figures  do  not  include  bone  infections  and  late  infections 
of  the  lymph-nodes.  Even  in  cases  supposed  to  have  been  cured  by  medical 
means  it  will  be  found  that  most  of  them  react  to  tuberculin,  showing  that 
lesions  are  latent  rather  than  cured.  Wohlgemuth  shows  that  complete 
removal  cures  75  per  cent,  of  cases;  curetting  and  drainage  cures  63  per  cent.; 
general  treatment,  24  per  cent.  (Attridge,  Ibid.) .  In  a  series  of  100  cases  oper- 
ated upon  by  Dowd,  pulmonary  tuberculosis  arose  in  but  i  case  and  bone 
tuberculosis  in  3  cases.  If  miliary  tuberculosis  exists,  if  the  patient  is  much 
exhausted,  if  the  infection  is  not  definitely  localized,  or  if  an  internal  organ  is 
the  seat  of  active  tuberculosis,  operation  is  not  indicated. 

Death  seldom  follows  operation.  The  mortality  without  operation  is 
probably  10  per  cent.  Complete  extirpation  of  the  involved  group  of  glands  is 
practised  when  the  disease  is  well  localized.  If  it  is  not  well  localized  I  follow 
Attridge's  plan  (Ibid)  and  wait  until  it  becomes  so,  treating  the  patient  in  the 


Rickets  255 

interval  by  open-air  life,  nourishing  food,  medicine,  and  the  .r-rays.  If 
softening  occurs,  the  area  should  be  incised  and  curetted  and  the  exposed  sur- 
face should  be  treated  by  repeated  applications  of  tincture  of  iodin.  When 
healing  occurs,  extirj)ation  is  to  be  performed.  If  sinus  formation  exists 
mixed  infection  has  occurred  or  will  occur  and  the  sinuses  must  be  curetted 
and  treated  \\-ith  iodin  until  they  heal ,  when  the  glands  may  be  extirpated.  I 
do  not  believe  in  a  bilateral  extirpation  at  one  seance.  The  operation  on 
one  side  only  is  prolonged  and  bloody  and  is  all  the  patient  is  fit  to  stand. 
If  both  sides  of  the  neck  are  involved  an  interval  of  several  weeks  should  be 
insisted  on  before  the  other  side  is  attacked. 

In  chronic  cases  of  cervical  lymphadenitis  it  is  invariably  necessary  to 
search  for  intraoral  or  nasophar}'ngeal  disease,  and  if  such  disease  exists  it 
must  be  treated  before  the  glands  are  removed.  After  operation  rigid  open-air 
life  is  insisted  on. 

Tuberculosis  of  tendon=sheaths  (tuberculous  tenosynovitis)  is  dis- 
cussed on  page  736. 

Tuberculosis  of  the  Kidney.— (See  page  1287.) 

Tuberculosis  may  attack  the  Fallopian  tubes,  ovaries,  or  uterus. 

Tuberculosis  of  the  urethra,  prostate  gland,  seminal  vesicles, 
and  bladder  is  considered  in  the  section  on  Regional  Surgery. 

Tuberculosis  of  the  Testicle  (page  1389). — This  disease  is  not  rare. 
It  is  sometimes  primary,  but  is  usually  preceded  by  tuberculosis  of  the  kidney, 
bladder,  or  prostate.  But  one  testicle  is  affected  in  the  beginning,  but  the 
other  gland  is  apt  to  be  attacked  later.  The  tuberculous  mass  softens,  be- 
comes adherent  to  the  scrotum,  and  breaks  or  bursts,  exposing  the  damaged 
testicle  (fungus  of  the  testicle).  The  cord  is  apt  to  be  involved  in  tuberculosis 
of  the  testicle. 


XIV.  RACHITIS,  OR  RICKETS. 

Rickets  is  a  chronic  disorder  of  nutrition  arising  during  the  early  years 
of  life  (the  first  two  or  three)  as  a  result  of  insufficient  or  of  improper  diet, 
aided  and  abetted  in  many  cases  by  bad  hygienic  surroundings.  A  deficiency 
of  fat  and  phosphate  in  the  food  or  the  use  of  a  diet  which,  by  inducing  gastro- 
intestinal catarrh,  prevents  assimilation,  causes  rickets.  It  is  characterized 
by  incomplete  osteogenesis  and  other  nutritive  failures.  The  disease  is  not 
common  in  nursing  children  unless  breast-feeding  has  been  unduly  prolonged, 
and  children  fed  upon  artificial  food  are  particularly  apt  to  develop  it.  Holt 
says  such  diet  is  ver\'  deficient  in  fat  and  often  in  proteids,  and  contains  an 
excess  of  carbohydrates  ("Diseases  of  Infancy  and  Childhood").  J.  Bland 
Sutton  made  some  valuable  experiments  to  indicate  the  injury  done  animals 
by  denying  them  natural  diet.  He  fed  lion  cubs  in  the  London  Zoological 
Gardens  on  raw  horse  meat  only  and  the  animals  developed  rickets.  The 
rickety  animals  rapidly  recovered  on  feeding  them  with  milk  and  powdered 
bones  mixed  with  cod-hver  oil.  The  disease  is  essentially  a  city  malady, 
"being  principally  seen  in  children  living  in  crowded  tenements  where  the 
effects  of  improper  food  are  most  strikingly  show^n;  yet  even  here  the  disease 
is  rare  in  those  who  get  a  plentiful  supply  of  good  breast-milk  "  (Holt).     Rick- 


256  Rachitis,  or  Rickets 

ets  must  not  be  regarded  as  a  bone  disease.  It  is  true  the  bones  are  aflFected, 
but  so  are  various  structures  and  organs,  all  of  the  disorders  being  due  to  an 
underlying  nutritive  defect.  Some  maintain  that  lactic  acid,  produced  in  the 
intestinal  canal,  causes  bone  inflammation,  but  most  obser\-ers  do  not  beheve 
the  bone  changes  are  inflammatory.  Children  are  very  seldom  born  with 
rickets,  but  develop  it  later,  the  period  of  greatest  Uability  being  between  the 
seventh  month  and  the  fifteenth  month.  So-called  congenital  rickets  is  usually 
sporadic  cretinism.  A  child  with  rickets  may  become  scorbutic  (scuny  rickets). 
Some  regard  rickets  as  the  result  of  an  infection.  Others  think  it  results 
from  thymus  atrophy  (Mendel). 

Whatever  may  be  the  cause  of  rickets,  the  essential  condition  in  the  bones 
is  an  insufficient  deposit  of  mineral  matter  in  the  new  bone  cells.  The  new 
bone  is  soft  and  vascular  and  bone  lamellae  toward  the  medullary-  canal 
are  actually  absorbed.  There  is  excessive  proliferation  of  cartilage  which 
results  in  enlargement.  The  proliferating  and  imperfectly  ossified  cells 
cause  enlargements  at  the  ends  of  long  bones  and  at  the  sternal  ends  of  the 
ribs  and  various  bones  bend  and  are  distorted.  The  parietal  bone  bulges 
on  each  side,  the  fontanels  remain  long  open;  there  may  be  unossified  gaps 
in  the  occipital  bone,  membrane  only  filling  them  {craniotabes) .  There  may 
be  pigeon-breast,  bent  long  bones,  cun-ed  spine  and  distorted  pelvis.  The 
bones  later  may  become  firmly  ossified  in  deformity.  In  rickets  the  spleen 
and  liver  are  enlarged  and  the  th}Tnus  is  atrophied. 

Evidences  of  Rickets. — The  condition  is  one  of  general  ill-health;  the 
child  is  ill-nourished,  pallid,  flabby;  it  has  a  tumid  belly  and  suffers  from 
attacks  of  diarrhea  and  sick  stomach;  it  is  disinclined  for  exertion  and  has  a 
capricious  appetite;  it  is  hable  to  night-sweats;  enlarged  glands  are  often 
noted,  the  teeth  appear  behind  time,  and  the  fontanels  close  late.  In  health 
the  posterior  fontanel  closes  in  the  second  month  and  the  anterior  fontanel  in 
the  eighteenth  month.  In  rickets  the  anterior  fontanel  is  often  open  when 
the  child  is  three  years  of  age.  The  sutures  are  often  open  at  the  end  of  the  first 
year.  The  head  is  square  in  shape,  the  cranial  bones  are  thick,  and  areas  of 
thickening  known  as  bosses  appear  over  the  parietal  bones.  The  head  is  large 
and  the  forehead  bulges.  The  long  bones  become  much  cur\-ed,  the  upper  part 
of  the  chest  sinks  in,  curv-ature  of  the  spine  appears,  and  the  pelvis  is  distorted. 
The  ligaments  are  relaxed  and  lengthened  and  the  joints  are  wobbly.  The 
muscles  are  feeble  and  ill-developed.  Infantile  convulsions  are  common. 
Nocturnal  restlessness  and  night  terrors  are  the  rule.  Laryngismus  stridulus 
and  tetany  may  occur.  Swelling  appears  in  the  articular  heads  of  long  bones, 
by  the  side  of  the  epiphyseal  cartilages,  and  in  the  sternal  ends  of  the  ribs, 
forming  in  the  latter  case  rachitic  beads.  The  lesions  of  rickets  are  due  to 
imperfect  ossification  of  the  animal  matter  which  is  prepared  for  bone-forma- 
tion, and  the  soft  bones  gradually  bend.  The  sweUings  at  the  articular 
heads  are  due  to  pressiu-e  forcing  out  the  soft  bone  into  rings.  Rachitic 
children  rarely  grow  to  full  size,  and  the  disease  is  responsible  for  many  dwarfs. 
Most  cases  recover  without  distinct  deformity,  but  the  time  lost  during  the 
period  when  active  development  should  have  gone  on  cannot  be  made  up,  and 
some  sUght  deficiency  is  sure  to  remain.  Bowlegs,  knock-knees,  and  spinal 
curvatures  are  usually  rachitic  in  origin.  The  disease  may  be  associated  with 
scurvy,  inherited  s}-philis,  or  tuberculosis.     In  appearance  the  rickety  child  is 


Scorbutus  257 

pot-bellied,  pale  and  anemic,  and  usually  fat  and  flabby,  though  occasionally 
thin.  There  is  great  liabiUty  to  enlargement  of  the  tonsils,  gastro-intestinal 
catarrh,  and  bronchial  catarrh.  The  blood  is  deficient  in  red  corpuscles 
and  hemoglobin,  and  sometimes  there  is  leukocytosis.  The  disease  lasts  for 
many  months  and  is  usually  recovered  from.  It  does  not  directly  produce 
death,  but  is  a  powerful  indirect  cause  of  infant  mortality  because  it  lessens 
resistance  and  predisposes  to  many  diseases.  It  is  almost  always  afebrile; 
rarely  congenital;  and  in  unusual  cases  known  as  late  rickets  develops  be- 
tween the  fifth  and  tenth  year.  The  so-called  acute  rickets  is  practically 
always  scurvy  (Holt).  The  \'ictims  of  rachitis  are  \ery  liable  to  fracture  the 
bones  from  shght  force  and  green-stick  fractmres  are  particularly  prone  to 
occur.     After  fracture  of  a  rickety  bone  union  is  usually  delayed. 

Treatment. — The  treatment  consists  in  having  the  child  Hve  as  much  as 
possible  in  the  open  air  and  simshine.  Salt-water  baths  are  useful.  Sea  air 
is  very  beneficial.  Fresh  food  (milk,  cream,  and  meat-juice)  should  be 
ordered.  Cod-hver  oil,  s}Tup  of  the  iodid  of  iron,  arsenic,  and  some  form 
of  phosphorus  are  to  be  administered.  It  is  absolutely  necessary  to  improve 
the  primary  assimilation.  Shght  deformities  of  the  extremities  require  no 
special  treatment  unless  they  increase.  If  the  deformity  is  marked  or  is  in- 
creasing, use  braces;  employ  massage,  manipulation,  and  faradism.  Holt 
points  out  that  by  the  time  the  child  is  two  years  of  age  the  bones  are  so  firm 
that  the  pressure  of  a  brace  cannot  cure  the  deformity.  Hence  after  this  age 
braces  are  useless.  Pronounced  estabhshed  deformities  of  the  extremities  are 
usually  treated  surgically.  K}'phosis  is  treated  by  making  the  patient  lie  upon 
a  hard  bed  without  a  pillow.  The  child  sits  up  a  few  hours  each  day,  the 
shoulders  being  held  back  and  support  applied  to  the  body.  In  bad  cases, 
during  the  time  the  child  is  erect  it  should  wear  a  brace  or  plaster-of-Paris 
jacket.  Daily  manipulation,  the  child  lying  prone,  is  helpful.  Friction  and 
electricity  to  the  spinal  muscles  do  good. 

Scorbutus  (Scurvy). — This  disease  is  rare  to-day  in  adults,  but  was  at 
one  time  very  common  among  those  who  took  long  voyages,  or  who  engaged 
in  campaigns,  or  were  the  victims  of  sieges.  Of  recent  years  it  is  very  uncom- 
mon, and  has  occurred  chiefly  among  voyagers  in  the  Arctic  regions  or  those 
who  were  beleaguered.  Some  years  ago  I  saw  several  cases  in  a  large  alms- 
house. It  is  important  to  remember  that  though  scur\y  is  rare  in  adults,  it  is 
by  no  means  uncommon  in  ill-nourished  infants.  (A  most  graphic  picture  of 
scurvy  as  it  used  to  occur  will  be  found  in  "A  Voyage  Around  the  World," 
by  Lord  Anson.     Compiled  by  the  Rev.  R.  Walter.) 

Scurvy  is  a  constitutional  malady  due  to  the  consumption  of  improper  diet, 
and  especially  to  the  emplo}-ment  of  a  diet  characterized  by  the  absence  of 
vegetables. 

The  use  of  salt  meat  as  a  staple  article  seems  to  favor  the  production  of 
the  disease.  Garrod  considered  absence  of  potassium  salt  to  be  the  real 
cause.  Absence  of  variety  in  diet,  bad  water,  poorly  ventilated  quarters,  and 
insufficient  exercise  favor  the  development  of  the  disease.  Some  believe 
that  an  organic  poison  derived  from  tainted  food  is  responsible  (Torup). 
A  bacterial  origin  has  been  suggested  by  Berthenson,  Babes,  and  others. 
Certain  studies  made  in  the  Transvaal  suggest  the  bacterial  origin  of 
scur\y.  Myer  Coplans  ("  Lancet,"  June  18,  1904)  states  that  it  occurred 
17 


-:)« 


Rachitis,  or  Rickets 


in  those  getting  excellent  rations  and  began  as  inflammation  of  the  gums, 
the  constitutional  symptoms  following.  If  the  gum  condition  was  early 
recognized  and  cured  simply  by  cleanhness  and  antiseptics,  that  is,  by  pure 
local  treatment,  constitutional  trouble  did  not  develop. 

Scurvy  begins  with  weakness,  drowsiness,  muscular  pains,  and  great 
susceptibiHty  to  cold.  The  skin  is  pallid  or  dirty  w^hite,  and  is  occasionally 
mottled  and  often  peels  off.  The  patient  is  breathless  on  the  slightest  exer- 
tion. The  pulse  is  excessively  weak  and  slow.  There  is  no  fever.  The 
gums  may  be  tender  and  inflamed  from  the  start,  but  in  most  cases  they  are 
not.  After  two  or  three  weeks,  usually  the  gums  become  tender,  painful,  and 
swollen,  and  bleed  at  frequent  inter\-als;  the  breath  becomes  offensive,  the 
teeth  loosen  and  even  drop  out;  subcutaneous  hemorrhages  take  place,  giWng 
rise  to  petechia?  or  extensive  extravasations;    the  vision  l^ecomes  dim;   the 


Fig.  9^1. —  I  he  gums  in  scurvy. 

urine  becomes  scanty  and  of  low  specific  gravity;  cutaneous  vesicles  form, 
rupture,  and  give  rise  to  bleeding  ulcers,  and  ulcers  hkewise  arise  from  break- 
ing do\Mi  of  blood  extravasations;  hemorrhages  take  place  into  and  between 
the  muscles,  and  in  severe  cases  beneath  the  periosteum  and  into  joints,  and 
blood  may  flow  from  the  nose,  lungs,  kidneys,  stomach,  and  intestines.  Deep 
hemorrhages  are  felt  as  hard  lumps.  Bleeding  at  an  epiphyseal  hne  may 
separate  the  epiphysis  from  the  shaft.  If  an  inflammation  or  ulceration  arises 
at  any  point,  fever  is  observed.  It  was  observed  by  DeHaven,  who  com- 
manded the  Grinell  expedition  in  search  of  Sir  John  Franklin,  that  scuny 
causes  old  and  soundly  healed  wounds  to  ulcerate.  The  same  observation 
was  made  years  before  in  Lord  Anson's  voyage.  A  sailor  of  the  "  Centurion" 
had  been  wounded  fifty  years  before  at  the  battle  of  the  Boyne.  He  developed 
scurv)^  and  the  old  w^ound  opened.  Most  cases  of  scurvy  get  wxll  under  proper 
treatment,  but  complete  recovery  is  not  attained  for  a  long  time.  Sudden 
death  is  Uable  to  occur  if  any  exertion  is  made. 


Contusions  259 

Captain  Cools,  succeeded  in  preventing  scurvy  among  his  sailors  by  [)ro- 
viding  plenty  of  fresh  water;  guarding  them  against  fatigue,  wet,  and  extremes 
of  heat  and  cold;  attending  to  cleanliness  and  ventilation,  and  stimulating 
cheerfulness.  This  great  navigator  lost  no  men  from  scurvy.  After  the 
time  of  Captain  Cook,  the  British  Admiralty,  acting  on  the  suggestions  of 
Lind  and  Blane,  provided  ships  with  lime-juice  or  lemon-juice  with  the 
most  beneficial  results  in  preventing  the  disease.  Scurvy  is  prevented  at  the 
present  time  by  employing  a  proper  diet  and  by  maintaining  cleanliness  and 
hygienic  conditions. 

The  following  agents  are  believed  to  be  especially  useful  as  preventatives: 
fresh  meat,  lemon-juice,  cider,  vinegar,  milk,  eggs,  onions,  cranberries,  cab- 
bages, pickles,  potatoes,  and  lime-juice.  When  the  disease  develops,  give 
vinegar,  lemon-juice,  onions,  scraped  apples,  cider,  nitrate  of  potassium, 
whiskey  or  brandy,  and  plenty  of  nourishing  food.  Antiseptic  mouth-washes 
are  necessary  and  strychnin  is  a  valuable  stimulant  to  the  circulation.  Sleep 
must  be  secured  and  ulcers  are  treated  by  antiseptic  dressings  and  com- 
pression. 

Infantile  scurvy  or  Barlow's  disease  may  exist  alone  or  with  rickets 
(scurvy  rickets).  It  occurs  most  often  in  the  children  of  the  well-to-do,  those 
who  have  been  brought  up  on  artificial  foods.  It  occurs  between  the  eighth  and 
eighteenth  months  of  life.  The  child  is  anemic,  suffers  from  gastro-intestinal 
disorders,  spongy  and  bleeding  gums,  weakness  of  the  legs,  general  muscular 
tenderness,  night-sweats,  and  often  febrile  attacks  (Rotch),  bleeding  from  the 
nose,  bleeding  beneath  the  skin  (blue  spots),  bloody  urine  and  stools,  bleeding 
beneath  the  periosteum,  into  joints,  viscera,  or  muscles.  In  some  cases  hema- 
turia is  the  first  and  perhaps  the  only  symptom  (J.  Lovett  Morse,  "Jour. 
Am.  Med.  Assoc,"  Dec.  17,  1904).  A  subperiosteal  hemorrhage  is  very 
dense,  is  tender,  is  fusiform  in  outline,  and  does  not  fluctuate.  It  is  some- 
times mistaken  for  sarcoma.  In  one  case  seen  by  the  author  a  hemorrhage 
beneath  the  periosteum  of  the  femur  was  mistaken  for  a  sarcoma.  The 
Umb  attacked  is  flexed,  and  the  child  will  not  move  it.  Separation  of  an 
epiphysis  may  result  from  hemorrhage  between  it  and  the  bone.  Infantile 
scurvy  is  often  unrecognized.  If  promptly  treated,  recovery  is  the  rule,  other- 
wise death  may  occur  from  exhaustion. 

Treatment. — Keep  the  child  quiet  in  bed  and  give  liberal  amounts  of  cow's 
milk  and  beef-juice.  Administer  orange-juice,  grape-juice,  scraped  apples, 
and  tonics.  To  children  over  one  year  of  age  give  potatoes.  Antiseptic 
mouth-washes  are  necessary. 


XV.  CONTUSIONS  AND  WOUNDS. 

Contusions. — A  contusion  or  bruise  is  a  subcutaneous  laceration,  due  to 
the  application  of  blunt  force,  the  skin  above  it  being  uninjured  or  damaged 
without  a  surface-breach  and  blood  being  effused.  Punches,  kicks,  blows 
from  a  blackjack,  etc.,  cause  contusions.  In  intra-abdominal  contusions 
the  skin  of  the  abdomen  is  frequently  not  damaged.  In  contusions  of  struc- 
tures overlying  a  bone  the  skin  suffers  with  the  deeper  structures.  If  a  large 
vessel  is  ruptured,  hemorrhage  is  profuse  and  much  blood  gathers  in  the 


26o  Contusions  and  Wounds 

tissue.  If  only  small  vessels  suffer,  hemorrhage  is  moderate.  An  ecchymosis 
is  diffuse  hemorrhage  over  a  large  area,  the  blood  lying  in  the  spaces  of  the 
subcutaneous  or  submucous  areolar  tissue,  A  very  small  ecchymosis  is 
known  as  a  petechia;  a  very  large  ecchymosis  is  called  a  suffusion  or  extrav- 
asation. A  hematoma  is  a  blood-tumor  or  a  circumscribed  hemorrhage, 
the  blood  lying  in  a  distinct  cavity  in  the  tissue.  In  extremely  severe  con- 
tusions tissue  vitality  may  be  destroyed  or  so  seriously  impaired  that  gangrene 
follows.  Suppuration  rarely  occurs,  but  occasionally  does  so,  and  is  most  apt 
to  in  a  drunkard  or  a  person  of  dilapidated  constitution.  When  hemorrhage 
arises  in  the  tissues  after  a  contusing  force  it  soon  ceases  unless  a  very  consid- 
erable vessel  is  ruptured.  The  arrest  of  hemorrhage  is  brought  about  by  the 
resistance  of  the  tissues,  the  contraction  and  retraction  of  the  vessels,  coagu- 
lation of  blood,  and  in  some  cases  of  severe  injury  coagulation  is  favored 
by  syncope.  Blood  in  the  tissues,  as  a  rule,  soon  coagulates,  the  fluid  ele- 
ments being  absorbed  and  the  red  corpuscles  breaking  up  and  setting  free 
pigment,  which  pigment  may  be  carried  away  from  the  seat  of  injury  or  may 
crystallize  and  remain  there  as  hematoidin.  In  some  cases  inflammation 
occurs  about  the  extravasated  blood,  a  capsule  of  fibrous  tissue  being  formed, 
and  the  blood  being  slowly  absorbed,  or  the  fluid  elements  remaining  un- 
absorbed  (blood-cyst),  or  the  blood  becoming  thicker  and  thicker,  finally  cal- 
cifying. Blood  in  serous  sacs  (joints,  pleura,  pericardium)  coagulates  very 
slowly.  As  blood  is  being  absorbed  it  undergoes  chemical  changes  and 
color-changes  ensue,  the  part  being  at  first  red  and  then  becoming  purple, 
black,  green,  lemon,  and  citron.  The  stain  following  a  contusion  is  most 
marked  in  the  most  dependent  area.  After  a  bruise  of  the  periosteum  a 
blood-clot  forms,  much  tissue-induration  occurs,  and  a  hard  edge  can  be 
detected  by  palpation  at  the  margin  of  the  clot. 

Symptoms. — The  symptoms  are  tenderness,  swelling,  and  numbness 
followed  by  some  aching  pain  or  a  feeling  of  soreness.  The  pain  rarely  per- 
sists beyond  the  first  twenty-four  hours.  Cutaneous  discoloration  appears 
quickly  in  superficial  contusions,  but  only  after  days  in  deep  ones.  In  some 
regions — the  scalp,  for  instance — it  can  scarcely  be  detected;  in  others,  as  in 
the  eyelid  and  vulva,  discoloration  is  early,  widespread,  and  marked.  Dis- 
coloration and  swelling  are  very  marked  in  regions  where  loose  cellular  tissue 
abounds  (eyelids,  prepuce,  scrotum).  The  discoloration  is  at  first  red,  and 
becomes  successively  purple,  black,  green,  lemon,  and  citron.  The  swelling  is 
primarily  due  to  blood,  and  is  added  to  by  inflammatory  exudation.  In  a  more 
severe  contusion  a  hematoma  may  form.  A  recent  hematoma  fluctuates,  but 
gradually,  because  of  cell-proliferation,  the  edge  becomes  hard  and  the  center 
continues  to  fluctuate.  The  mass  gradually  grows  smaller  and  finally  dis- 
appears. A  subperiosteal  hematoma  of  the  scalp  may  be  mistaken  for  depressed 
fracture  of  the  skull.  Any  form  of  hematoma  of  the  scalp  may  be  mistaken 
for  an  abscess,  but  differs  from  it  in  the  absence  of  inflammatory  signs.  It 
occasionally,  though  rarely,  suppurates.  In  a  case  in  which  suppuration  occurs 
an  abrasion,  which  may  be  very  minute,  often  exists  on  the  skin.  In  any 
severe  contusion  there  is  considerable  and  possibly  grave,  or  even  fatal,  shock. 
Treatment. — In  a  severe  injury  bring  about  reaction  from  the  shock. 
Local  treatment  consists  in  rest,  elevation,  and  compression  to  arrest  bleeding, 
antagonize  inflammation,  and  control  swelling.     Cold  is  useful  early  in  most 


Shock  261 

oases,  but  it  is  not  suited  to  very  severe  contusions  nor  to  contusions  in  the 
debilitated  or  aged,  as  in  such  cases  it  may  cause  gangrene.  In  very  severe 
contusions  employ  heat  and  stimulation.  When  inflammation  is  subsiding 
after  a  contusion,  compression  and  inunctions  of  ichthyol  should  be  employed. 
Massage  and  passive  motion  are  imperatively  needed  after  contusion  of  a 
joint.  If  the  amount  of  blood  is  very  large,  massage  must  not  be  used  because 
it  may  cause  embolism  or  fat-embolism.  If  a  distinct  cavity  exists,  aspiration 
or  incision  lessens  the  danger  of  fat-embolism.  A  contusion  should  never 
be  incised  unless  the  amount  of  blood  is  large  and  a  distinct  cavity  ex- 
ists, or  hemorrhage  continues,  or  infection  takes  place,  or  a  lump  remains 
for  some  weeks,  or  gangrene  is  threatened.  For  persistent  bleeding  freely 
lay  open  the  contused  area,  turn  out  clots,  ligate  vessels,  insert  drainage- 
strands  or  a  tube,  and  close  the  wound.  If  gangrene  is  feared,  make  incisions 
and  apply  heat  to  the  part.  If  a  slough  forms,  employ  antiseptic  fomentations. 
The  constitutional  treatment  for  contusion,  after  the  patient  has  reacted  from 
shock,  is  the  same  as  that  for  inflammation.     (See  Abdomen,  etc.) 

Wounds. — A  wound  is  a  breach  of  surface  continuity  effected  by  a  sudden 
mechanical  force.  Wounds  are  divided  into  open  and  subcutaneous,  septic 
and  aseptic,  incised,  contused,  lacerated,  punctured,  gunshot,  stab,  and 
poisoned  wounds. 

The  local  phenomena  of  wounds  are  pain,  hemorrhage,  loss  of  func- 
tion, and  gaping  or  retraction  of  edges. 

Pain  is  due  to  the  injury  of  nerves,  and  it  varies  according  to  the  situation 
and  the  nature  of  the  injiu-y.  It  is  influenced  by  temperament,  excitement, 
and  preoccupation.  It  may  not  be  felt  at  all  at  the  time  of  the  injury.  At 
first  it  is  usually  acute,  becoming  later  dull  and  aching.  In  an  aseptic  wound 
the  pain  usually  remains  slight,  but  in  an  infected  wound  it  always  becomes 
severe. 

The  nature  and  amount  of  hemorrhage  vary  with  the  state  of  the  system, 
the  vascularity  of  the  part,  and  the  variety  of  injury. 

Loss  of  function  depends  on  the  situation  and  extent  of  the  injury. 

Gaping  or  retraction  of  edges  is  due  to  tissue-elasticity,  and  varies  according 
to  the  tissues  injured  and  the  direction,  nature,  and  extent  of  the  wound. 

The  constitutional  condition  after  a  severe  injur)-  is  a  state  known  as 
shock. 

Shock. — The  name  shock  was  introduced  in  1795  by  James  Latta  to 
designate  the  condition  ensuing  upon  severe  injury.  (See  G.  C.  Kinnaman, 
in  "Annals  of  Surg.,"  Dec,  1903.)  Shock  is  a  depression  of  the  xxtaX  powers 
arising  from  an  injury  or  a  profound  emotion  acting  on  the  ner\-e-centers 
and  inducing  exhaustion  or  inhibition  of  the  vasomotor  mechanism.  Ex- 
haustion is  gradually  induced;  inhibition  is  suddenly  produced.  By  over- 
stimulation of  sensory  nerves  violent  impressions  are  conveyed  to  the  ner\-e- 
centers,  the  vasomotor  center  is  exhausted  or  inhibited,  vasoconstrictor 
power  is  lost,  the  arteries  and  capillaries  are  depleted  or  nearly  emptied 
of  blood,  and  the  blood  is  largely  transferred  to  the  veins.  The  blood-pres- 
sure is  lowered,  the  cardiac  action  is  impaired,  the  respiratory  action  is  impeded, 
and  quantities  of  dark-colored  blood  gather  in  the  somatic  veins,  but  espe- 
cially in  the  veins  of  the  splanchnic  area.  (See  the  masterly  study  of  "Sur- 
gical Shock"  by  Crile.)     In  shock  the  abdominal  veins  are  greatly  distended 


262  Contusions  and  Wounds 

and  the  other  veins  of  the  body  may  also  be  overfull,  the  arteries  contain  less 
blood  than  normal,  and  an  insufficient  amount  of  blood  is  sent  to  the  heart 
and  to  the  vital  centers  in  the  brain.  In  other  words,  in  shock  there  is  a 
deficiency  in  the  circulating  blood.  The  term  collapse  is  used  by  some  to 
designate  a  severe  condition  of  shock,  and  is  employed  by  others  as  a  name 
for  a  condition  produced  by  functional  depression  of  the  vasomotor  center  the 
result  of  mental  disturbance,  cardiac  failure,  respiratory  failure,  or  vasomotor 
insufficiency,  rather  than  of  physical  injury.  Crile  regards  collapse  as  inhibi- 
tion of  the  vasomotor  center,  in  contrast  to  shock,  which  is  exhaustion  of  the 
center.  As  a  matter  of  fact,  shock  and  collapse  are  often  both  present.  That 
the  bombardment  of  the  nerve-centers  by  a  tumult  of  peripheral  impressions 
causes  shock  is  shown  by  the  fact  that  if  the  nerves  from  a  part  are  thoroughly 
cocainized  so  that  they  will  not  transmit  sensation,  operation  upon  the  part 
produces  practically  no  shock.  Crile  calls  such  cocainization  the  introduction 
of  a  physiological  block.  Shock  may  be  sUght  and  transient,  it  may  be  severe 
and  prolonged,  it  is  usually  sudden  in  onset,  but  may  come  on  gradually, 
and  it  may  even  produce  almost  instant  death.  I  agree  with  Bloodgood  that 
even  a  violent  injury  does  not  of  necessity  at  once  produce  it.  Every  now  and 
then  we  see  a  man  with  a  crushed  limb  who  does  not  exhibit  shock,  the  condi- 
tion gradually  coming  on  from  pain,  hemorrhage,  terror,  etc.  During  an 
operation  if  shock  arises  it  is  apt  to  do  so  gradually,  but  this  is  not  always  the 
case,  for  sometimes  it  comes  on  with  great  suddenness,  for  instance,  when 
traction  is  made  upon  the  pedicle  of  the  spleen,  when  the  bone  of  the  thigh  is 
sawed  through,  or  when  there  is  a  burst  of  blood  from  a  large  vessel.  Sudden 
death  from  shock  is  due  to  reflex  stimulation  of  the  pneumogastric  nuclei  and 
arrest  of  cardiac  action.  It  is  known  as  death  by  inhibition.  Shock  is  more 
severe  in  women  than  in  men,  in  the  nervous  and  sanguine  than  in  the  lym- 
phadc,  in  those  weakened  by  suffering  than  in  those  who  are  strangers  to  illness. 
It  is  predisposed  to  by  fear,  by  disease  of  the  kidneys,  diabetes,  chronic  cardiac 
disease,  and  alcohoHsm.  Injuries  of  nerves,  of  brain,  of  the  intrathoracic 
viscera,  of  the  intra-abdominal  viscera,  of  the  urethra,  or  of  the  testicle  pro- 
duce extreme  shock.  Anything  which  extracts  the  body-heat  favors  the  de- 
velopment of  shock  (exposure  to  cold  air,  insufficient  covering,  chilling  the 
body  by  solutions  or  wet  towels).  Cerebral  concussion  is  shock  plus  other 
conditions.  Sudden  and  profuse  hemorrhage  causes  shock;  so  does  prolonged 
anesthetization.  Great  shock  may  occur  after  the  removal  of  a  large  tumor 
or  a  quantity  of  fluid  from  the  abdomen.  In  such  a  case  shock  is  brought 
about  by  the  sudden  removal  of  pressure  and  the  consequent  rapid  distention 
of  intra-abdominal  veins.  Exposure  of  tissue  and  vital  parts  to  air  aggra- 
vates shock. 

Symptoms. — The  symptoms  of  ordinary  shock  {torpid  or  apathetic  shock) 
are  subnormal  temperature;  irregular,  weak,  rapid,  and  compressible  pulse; 
cold,  pallid,  clammy,  or  profusely  perspiring  skin;  shallow,  irregular,  and  often 
gasping  respiradon.  Consciousness  is  usually  maintained,  but  there  is  an  ab- 
sence of  mental  originating  power,  the  injured  person  answering  when  spoken 
to,  but  volunteering  no  statements  and  lying  with  partly  closed  lids  and  expres- 
sionless countenance  in  any  position  in  which  he  may  be  placed.  The  an- 
swers to  questions  though  apparently  intelligent  are  utterly  unreliable.  There 
is  great  motor  weakness.     The  pupils  are  dilated  and  react  but  slowly  to  Hght. 


The  Prevention  of  Shock  in  Operations  263 

The  sphincters  arc  relaxed.  Pain  is  slightly  or  not  at  all  ai)])rcciated.  Nausea 
is  absent  and  vomiting  may,  as  in  concussion,  {)resage  reaction,  (iastric 
regurgitation,  after  a  considerable  duration  of  shock,  is  not  unusual,  and  is  a 
bad  omen.  Shock  is  not  rarely  followed  by  suppression  of  urine.  Whereas 
the  victim  of  shock  is  usually  stupid  and  indifferent,  he  may  become  delirious. 
If  delirium  arises,  the  condition  is  very  grave.  I'ravers  called  shock  with 
delirium  crctliislic  or  delirious  shock.  As  a  matter  of  fact,  such  a  State  is  not 
genuine  shock,  but  is  either  a  traumatic  or  a  toxic  delirium.  It  is  usually  due 
to  uremia  or  sepsis.  Delirious  shock  is  seen  after  a  person  has  been  bitten  by 
a  i)ois()nous  snake.  Many  years  ago  Travers  described  a  secondary  or  delayed 
form  of  shock,  which  comes  on  several  hours  after  an  injury  or  violent  emotional 
disturbance.  This  form  of  shock  is  seen  not  unusually  in  those  who  have 
passed  through  a  railroad  accident.  It  may  be  a  sign  of  hemorrhage,  and  is 
sometimes  met  with  after  the  administration  of  ether  or  chloroform.  The 
statements  made  by  a  person  who  has  recovered  from  a  severe  shock  are  always 
unreliable  as  to  events  which  occurred  while  shock  existed,  and  are  often 
doubtful  as  to  the  details  of  the  accident.  Not  unusually  the  memory  of 
the  accident  is  perverted  or  even  destroyed. 

Diagnosis. — Concealed  hemorrhage  is  difficult  to  differentiate  from  shock. 
It  produces  impairment  of  vision  (retinal  anemia) ,  irregular  tossing,  frequent 
yawning,  great  thirst,  nausea,  and  sometimes  convulsions.  In  shock  the 
hemoglobin  is  unaltered;  in  hemorrhage  it  is  enormously  reduced  (Hare  and 
Martin).  In  hemorrhage  recurrent  attacks  of  syncope  are  met  with.  In 
pure  shock  such  attacks  do  not  occur.  In  concealed  hemorrhage  the  abdomen 
may  exhibit  physical  signs  of  a  rapidly  increasing  collection  of  fluid.  Shock 
and  hemorrhage  are  often  associated.  The  essential  characteristic  of  shock 
is  rapid  onset,  which  separates  it  distinctly  from  exhaustion.  It  arises  at  a 
much  earlier  period  after  an  injury  than  does  fat-embolism. 

The  Prevention  of  Shock  in  Operations. — Examine  the  patient  with 
care  before  operating,  giving  special  attention  to  the  condition  of  the  kidneys. 
The  amount  of  urine  passed  and  the  amount  of  urea  it  contains  should  always 
be  determined  when  possible.  The  amount  of  urea  should  be  estimated  from 
the  twenty-four  hours'  urine.  The  normal  amount  of  urine  in  the  twenty- 
four  hours  is  about  fifty  ounces  and  the  normal  amount  of  urea  2  per  cent. 
Less  urea  is  significant  of  danger  from  shock  and  subsequent  kidney  complica- 
tions. If  the  condition  of  the  patient  leads  us  to  fear  that  there  will  be  dan- 
gerous shock,  do  not  purge  him  severely  before  operation,  and  just  previous 
to  operation  give  a  rectal  injection  of  hot  saline  fluid  and  a  hypodermatic  in- 
jection of  YFS"  of  ^  grain  of  atropin.  It  is  also  a  good  plan  in  some  cases  to  give 
a  hypodermatic  injection  of  gr.  |  of  morphin  twenty  minutes  before  operation. 
It  tranquillizes  the  patient  and  less  ether  will  be  needed  to  anesthetize  him. 
Examine  the  patient  thoroughly  and  prepare  him  carefully  beforehand  and 
decide  if  he  should  take  a  general  anesthetic  at  all,  and,  if  so  which  one.  In 
some  cases  a  local  anesthetic  should  be  used,  for  instance,  some  cases  of 
typhoid  perforation  and  strangulated  hernia. 

Occasionally  the  nerves  from  the  damaged  part  should  be  infiltrated  with 
cocain  (Crile).  This  prevents  the  ascent  of  peripheral  impressions,  makes 
what  Crile  calls  a  "physiological  block,"  and  so  prevents  shock.  After  this 
infiltration  a  limb  can  be  amputated  below  the  infihrated  area  without  pain 


264  Contusions  and  Wounds 

and  without  depression  of  the  vital  powers.  In  some  few  cases  in  which  we 
fear  shock  spinal  anesthesia  is  used;  in  others  scopolamin  and  morphia. 
If  a  general  anesthetic  is  used  it  must  be  skillfully  given  and  not  a  drop  is 
given  beyond  the  amount  necessary  to  maintain  thorough  anesthesia.  Cover 
every  part  but  the  field  of  operation  with  hot  blankets  and  put  cans  of  hot 
water  about  the  patient,  or  put  him  on  a  bed  composed  of  hot-water  pipes 
covered  with  blankets.  Prevent  bleeding  with  the  greatest  possible  care. 
Operate  as  rapidly  as  is  consistent  with  safety  and  thoroughness.  If  shock 
develops  during  an  operation  hasten  on  the  work,  lessen  the  amount  of  ether, 
and  apply  active  treatment.  Return  the  patient  to  bed  as  soon  as  possible 
and  without  exposure  in  cold  halls  or  a  windy  elevation.  Occasionally  it 
becomes  necessary  to  suspend  an  operation  in  order  to  prevent  death  on  the 
table. 

Treatment. — In  treating  ordinary  apathetic  shock  raise  the  feet  and  lower 
the  head,  unless  this  position  causes  cyanosis.  At  least  place  the  head  flat 
and  the  body  recumbent.  Wrap  the  patient  in  hot  blankets  and  surround  him 
with  hot  bottles,  hot  bricks,  hot-water  bags,  or  cans  of  hot  water.  Always 
wrap  a  can,  a  bottle,  or  a  bag  in  flannel,  to  avoid  burning  the  patient.  Ordi- 
nary stimulants  seem  of  but  little  value  and  drugs  given  by  the  stomach  are  not 
absorbed.  Salt  solution  may  be  thrown  into  a  vein  {intravenous  infusion), 
may  be  given  by  the  rectum  {enterodysis) ,  or  subcutaneously  {hypodermodysis). 
Intravenous  infusion  does  good,  but,  unfortunately,  the  benefit  is  very  tem- 
porary except  in  cases  associated  with  hemorrhage.  In  hemorrhage  it  should 
always  be  given,  and  it  should  be  given  mixed  with  adrenalin  chlorid  (i  tea- 
spoonful  of  the  1 :  1000  solution  of  adrenalin  chlorid  is  added  to  i  liter  of  salt 
solution).  The  operation  of  intravenous  infusion  is  described  on  page  465. 
The  custom  of  giving  salt  solution  in  a  vein  has  become  so  common  that 
resident  physicians  are  apt  to  resort  to  it  as  a  routine.  It  is  to  be  remembered 
that  if  given  rapidly  or  in  too  great  quantity  it  may  gather  in  the  chambers  of  a 
dilated  right  heart  and  arrest  a  heart  so  weakened  that  it  has  almost  reached 
its  Hmit  of  function.  I  am  satisfied  that  the  rapid  administration  of  salt  solu- 
tion intravenously  is  responsible  for  some  deaths.  Crile  maintains  that  the 
only  way  "to  increase  and  sustain  the  blood-pressure  when  the  vasomotor 
center  is  exhausted"  is  to  "create  a  peripheral  resistance  either  by  a  drug 
acting  on  the  blood-vessels  themselves  or  by  mechanical  pressure."*  In  order 
to  accomplish  this  he  used  adrenalin  chlorid.  Because  of  the  rapidity  with 
which  this  drug  is  oxidized  he  gives  it  intravenously,  slowly  and  continuously 
from  a  buret,  using  a  solution  of  a  strength  of  from  i  in  50,000  to  i  in  100,000 
in  salt  solution.  The  rate  of  flow  should  be  "controlled  by  a  screw-cock 
attached  to  the  rubber  tube."  Crile  also  places  the  patient  in  a  rubber  suit 
and  distends  the  suit  by  means  of  an  air  pump  and  thus  obtains  equable  pres- 
sure upon  the  cutaneous  surface  and  an  increase  of  peripheral  vascular  resist- 
ance. The  difficulty  with  giving  the  solution  in  a  vein  is,  the  drug  first  comes 
in  contact  with  "the  vessels  having  the  least  power  of  influencing  blood-pres- 
sure," and  before  a  notable  rise  can  be  affected  by  arterial  action  "it  is  necessary 
that  the  solution  should  pass  through  the  right  heart,  the  lungs  on  its  way  to 
the  aorta,  then  finally  affecting  the  coronary  arteries"  (Crile,  in  " .\m.  Jour. 

*  George  Crile,  in  Boston  Med.  and  Surg.  Jour.,  March  5,  1903. 


Treatment  of  Shock  265 

Med.  Sciences,"  Jan.,  1909).  The  best  way  to  use  adrenalin  solution  in  severe 
shock  is  to  introduce  it  as  Crile  now  advises,  that  is,  into  the  arterial  system  and 
toward  the  heart.  Occasionally,  by  this  means,  resuscitation  from  apparent 
death  may  be  accomplished.  Crile  calls  this  method  centripetal  arterial  trans- 
fusion.    It  is  applied  as  follows  ("Am.  Jour.  Med.  Sciences,"  April,  1909) : 

"In  human  resuscitation  the  technic  is  as  follows:  The  patient  in  the 
|)ronc  posture  is  subjected  at  once  to  rapid  rhythmic  pressure  upon  the  chest, 
with  one  hand  on  each  side  of  the  sternum.  This  pressure  produces  artificial 
respiration  and  a  moderate  artificial  circulation.  A  cannula  is  inserted  toward 
the  heart  into  an  artery.  Normal  saUne,  Ringer's,  or  Locke's  solution,  or,  in 
their  absence,  sterile  water,  or,  in  extremity,  even  tap  water,  is  infused  by  means 
of  a  funnel  and  rubber  tubing.  But  as  soon  as  the  flow  has  begun  the  rubber 
tubing  near  the  cannula  is  pierced  with  the  needle  of  a  hypodermic  syringe 
loaded  with  i  :  1000  adrenahn  chlorid  and  15  to  30  minims  are  at  once  in- 
jected. Repeat  the  injection  in  a  minute  if  needed.  Synchronously  with  the 
injection  of  the  adrenalin  the  rhythmic  pressure  upon  the  thorax  is  brought  to 
a  maximum.  The  resulting  artificial  circulation  distributes  the  adrenalin  that 
spreads  its  stimulating  contact  with  the  arteries,  bringing  a  wave  of  powerful 
contractions  and  producing  a  rising  arterial,  hence  coronary,  pressure.  When 
the  coronary  pressure  rises  to,  say,  40  mm.  or  more,  the  heart  is  likely  to  spring 
into  action.  The  first  result  of  such  action  is  to  spread  still  further  the 
blood-pressure-raising  adrenalin,  causing  a  further  and  vigorous  rise  in  blood- 
pressure,  possibly  even  doubling  the  normal.  The  excessively  high  pressure  is 
most  favorable  to  the  resuscitation  of  tissue,  especially  of  the  central  nervous 
system  (Stewart) .  Just  as  soon  as  the  heart-beat  is  estabUshed  the  cannula 
should  be  withdrawn,  first,  because  it  is  no  longer  needed,  and  second,  because 
the  rising  blood-pressure  will  drive  a  torrent  of  blood  into  the  tube  and  fun- 
nel. Unless  there  has  been  hemorrhage,  the  only  object  in  the  use  of  saline 
infusion  is  to  serve  as  a  means  of  introducing  the  adrenalin  into  the  arterial 
circulation  toward  the  heart.  Bandaging  the  extremities  and  abdomen  tightly 
over  masses  of  cotton  is  very  useful." 

In  prolonged  shock  direct  transfusion  of  blood  should  be  employed  (page 
463).  The  use  of  hot  and  stimulating  rectal  enemata  is  important.  The 
rectum  may  absorb  fluids  when  the  stomach  refuses  to  do  so.  Enemata  of  hot 
normal  salt  solution  are  beneficial  (enteroclysis) .  The  tube  is  carried  to  the 
sigmoid  flexure  and  the  injection  is  introduced  so  as  to  distend  the  colon. 
Hypodermodysis  is  given  as  follows :  Insert  an  aspirator  tube  into  the  cellular 
tissue  of  the  loin,  scapular  region,  or  under  the  mamma,  cleansing  the  part  first. 
The  tube  is  attached  to  a  fountain  syringe,  which  is  filled  with  normal  salt 
solution,  and  is  hung  at  a  height  of  two  or  three  feet  above  the  bed  (Fig.  99). 
In  an  hour's  time  a  pint  or  more  of  fluid  will  enter  the  tissue  and  be  absorbed. 
It  is  the  custom  to  give  hypodermatic  injections  of  ether,  brandy,  strychnin, 
digitahs  or  atropin,  or  inhalations  of  amyl  nitrite.  Crile  has  demonstrated 
experimentally  that  strychnin  i^  perfectly  futile  in  pure  shock  and  may  actually 
aggravate  the  condition.  In  collapse  it  is  of  some  value.  We  believe  this 
statement  is  true  clinically.  Strychnin  goads  a  heart  to  increased  action 
when  that  organ  has  not  suflficient  blood  passing  into  it  to  enable  it  to  firmly 
and  strongly  contract;  the  use  of  strychnin  in  shock  has  been  compared  by 
Hare  to  beating  a  dying  horse  to  make  it  pull.     I  believe  that  atropin  is  of 


266 


Contusions  and  Wounds 


great  benefit  in  shock,  especially  if  the  skin  is  very  muist.  This  drug,  according 
to  my  colleague,  Prof.  Hobart  A.  Hare,  is  a  sedative  to  the  vagus;  but  what 
makes  it  particularly  valuable  is  that  it  acts  upon  the  vasomotor  system, 
combats  the  dilatation  of  the  blood-vessels,  maintains  vascular  tone,  prevents 
stagnation  of  blood  in  any  vessels,  and  increases  the  amount  of  moving  blood. 
If  the  skin  is  very  moist,  atropin  is  particularly  indicated.  Senn  recommends 
the  hypodermatic  injection  of  sterile  camphorated  oil,  a  syringeful  every 
fifteen  minutes,  until  reaction  begins.     Inhalation  of  oxygen  is  often  of  much 


Fig.  99. — Subcutaneous  saline  infusion  (Senn). 


service,  and  ardficial  respiration  may  be  necessary.  Opiates  are  contra- 
indicated  in  shock.  Mustard  plasters  should  be  placed  over  the  heart,  spine, 
and  shins.  A  turpentine  enema  is  useful.  An  enema  of  hot  coflfee  and 
whisky  is  valuable.  In  severe  cases  of  shock,  bandage  the  extremities. 
Bandaging  for  the  relief  of  shock  is  called  autotransfusion.  This  procedure 
increases  peripheral  resistance  and  enables  the  body  to  utilize  to  the  best 
advantage  the  small  amount  of  circulating  blood,  and  sends  most  of  it  to  the 
brain,  where  it  will  maintain  the  activity  of  the  vital  centers  and  keep  up  cir- 
culation and  respiration.  For  this  purpose  ordinary  muslin  bandages  may 
be  used,  or  gauze  bandages,  or  the  bandages  of  Esmarch.  Crile's  rubber 
suit  accomplishes  the  object  more   satisfactorily  than  does  bandaging   the 


Treatment  of  Wounds  267 

extremities.  Abdominal  massage  helps  drive  out  the  imprisoned  blood, 
and  after  massage  sets  free  the  abdominal  blood  apply  a  compress  and  binder. 
In  serious  cases  artificial  respiration  and  stimulation  of  the  diaphragm  with 
a  galvanic  current  may  be  used.  If  shock  comes  on  during  an  operation, 
the  operation  must  be  hurried  or  even  abandoned,  and  proper  treatment  must 
be  instituted  at  once.  The  anesthetist  should  give  very  little  ether  when 
shock  becomes  at  all  evident.  Should  we  operate  during  shock  ?  We  should 
only  do  so  when  death  without  instant  operation  is  inevitable. '  We  must 
operate,  if  it  is  necessary  to  do  so,  to  arrest  hemorrhage,  to  relieve  strangu- 
lated hernia,  intestinal  obstruction,  obstruction  of  the  air-passages,  compound 
fractures  of  the  skull,  extravasated  urine,  or  intraperitoneal  extravasations 
from  ruptured  viscera.  If  hemorrhage  can  be  temporarily  controlled  by 
pressure  or  a  clamp,  so  much  the  better,  and  the  permanent  arrest  can  be 
effected  after  the  reaction  from  shock.  It  is  not  wise,  in  the  author's  opin- 
ion, to  amputate  during  shock.  A  tourniquet  or  Esmarch  bandage  should  be 
applied,  and  attempts  be  made  to  bring  about  reaction,  and  when  reaction 
is  obtained  the  amputation  should  be  performed.  It  is  only  just  to  say  that 
some  eminent  surgeons  oppose  this  rule.  Roswell  Park  says  that  "shock  is 
often  alleviated  by  the  prompt  removal  of  mutilated  limbs  which,  when  still 
adherent  to  the  trunk,  seem  to  perpetuate  the  condition."  The  same 
teacher  believes  in  operating  at  once  upon  severe  compound  fractures.* 
After  ever}-  operation  keep  careful  watch  upon  the  amount  of  urine  passed, 
see  to  it  that  the  patient  takes  sufficient  fluid,  and  if  the  urine  becomes  scanty 
put  a  hot-water  bag  over  the  kidneys,  give  diuretics  by  the  mouth,  secure 
cutaneous  activity,  give  saline  purgatives,  and  administer  hot  saline  enemata. 
If  the  condition  is  not  soon  benefited,  the  custom  is  to  infuse  hot  saline  fluid 
into  a  vein.  I  am  doubtful  if  intravenous  infusion  of  saline  fluid  is  benefi- 
cial in  suppression,  and  I  even  fear  it  may  do  harm  (see  the  studies  of  Widal, 
Marie  and  Crouzon,  Merklen,  and  others).  In  urinary  suppression  following 
accident  or  surgical  operation  (post-operative  suppression  or  anuria)  the  condi- 
tion is  so  dreadfully  grave  that  it  is  justifiable  to  expose  each  kidney  and  split 
the  capsule  in  order  to  relieve  tension  and  in  the  hope  of  thus  abatingcongestion. 
Post-operative  suppression  of  urine  is  almost  invariably  fatal.  Rossle  ("Cen- 
tralb.  f.  Chir.,"  1907,  xxxiv.)  says  that  in  certain  cardiac  and  renal  conditions 
salt  solution  damages  the  capillaries  and  does  actual  harm.  Delayed  shock  is 
treated  in  the  same  manner  as  apathetic  shock  if  hemorrhage  can  be  excluded. 
If  hemorrhage  is  the  cause,  the  bleeding  must  be  arrested,  and  blood  be  trans- 
fused, or  saline  fluid  be  infused  into  a  vein.  If  delirious  shock  is  due  to  sepsis, 
the  treatment  is  that  of  sepsis.  If  it  is  a  nervous  delirium,  give  morphin  and 
(jther  sedatives.     If  due  to  uremia,  the  treatment  is  obvious. 

Fat=embolism.— (See  page  205.) 

Fever. — (See  Fevers,  page  133.) 

Treatment  of  Wounds. — All  wounds,  other  than  those  made  by  the 
surgeon,  are  regarded  as  infected.  The  rules  for  treating  such  wounds  are: 
(i)  arrest  hemorrhage;  (2)  bring  about  reaction;  (3)  remove  foreign  bodies; 
(4)  asepticize;  (5)  drain,  coaptate  the  edges,  and  dress;  and  (6)  secure  rest 
to  the  part  and  combat  overaction  of  the  tissues.  Constitutionally,  allay 
pain,  secure  sleep,  maintain  the  nutrition,  and  treat  inflammatory  conditions. 
♦Park's  "Surgery  by  American  Authors." 


268  Contusions  and  Wounds 

Arrest  of  Hemorrhage.— To  arrest  hemorrhage  the  bleeding  point  must  be 
controlled  by  an  Esmarch  band  or  digital  pressure  until  ready  to  be  grasped 
with  forceps;  it  is  then  caught  up  and  tied  with  catgut  or  aseptic  silk.  Slight 
hemorrhage  ceases  spontaneously  on  exposure  of  the  bleeding  point  to  air, 
and  moderate  hemorrhage  ceases  permanently  after  the  temporary  applica- 
tion of  a  clamp.  An  injured  vessel  when  not  of  the  smallest  size  must  be 
ligated,  even  if  it  has  ceased  to  bleed.  Capillary  oozing  is  checked  by  hot 
water  and  compression.  If  a  large  artery  is  divided  in  a  limb,  apply  a  tourni- 
quet before  ligating  (see  Wounds  of  Vessels). 

Bringing  about  of  Reaction. — (See  Shock.) 

Removal  oj  Foreign  Bodies. — Remove  all  foreign  bodies  visible  to  the  eye 
(splinters,  bits  of  glass,  portions  of  clothing,  gun-wadding,  grains  of  dirt,  etc.) 
with  forceps  and  a  stream  of  corrosive  sublimate  solution,  sterile  water,  or 
normal  salt  solution.  In  a  lacerated  or  contused  wound  portions  of  tissue 
injured  beyond  repair  should  be  regarded  as  foreign  bodies  and  be  removed 
with  scissors. 

Cleaning  the  Wound. — To  clean  the  wound  shave  the  surrounding  area, 
if  it  is  hairy;  scrub  the  surface  about  the  wound  with  ethereal  soap,  green 
soap,  or  castile  soap,  wash  with  water,  scrub  with  alcohol,  and  then  with 
corrosive  sublimate  solution  (i  :  looo).  An  accidental  wound  is  infected, 
and  must  be  well  washed  out  with  an  antiseptic  solution.  In  every  wound  in 
which  we  have  reason  to  suspect  tetanus  infection  a  preventive  dose  of  anti- 
toxin should  be  given.  We  have  particular  occasion  to  apprehend  tetanus  if 
the  wound  is  contaminated  with  feces,  street  dirt,  stable  dustj  or  stable  refuse, 
or  if  it  was  infected  with  a  toy  pistol  such  as  boys  use  to  celebrate  the  Fourth  of 
July.  A  clean  wound  made  by  the  surgeon  need  not  be  irrigated;  in  fact, 
irrigation  with  an  antisepdc  fluid  leads  to  necrosis  of  tissue,  causes  a  profuse 
flow  of  serum,  and  necessitates  drainage.  If  clots  have  gathered  in  a  wound, 
they  must  be  removed,  as  their  presence  will  prevent  accurate  coaptation  of  the 
edges.  In  an  infected  wound  they  are  washed  out  with  a  stream  of  corrosive  sub- 
limate solution.  In  a  clean  wound  they  are  washed  out  with  hot  salt  solution. 
If  dirt  is  ground  into  a  wound,  as  is  often  seen  in  crushes,  pour  sweet  oil  into 
the  wound,  rub  it  into  the  tissues,  and  scrub  the  wound  with  ethereal  soap. 
The  oil  entangles  the  dirt,  and  the  soap  and  water  remove  both  oil  and  dirt. 
After  the  rough  cleansing  irrigate  with  corrosive  sublimate  solution.  In 
some  cases,  especially  in  bone-injuries,  it  is  necessary  to  scrape  the  wound 
with  a  curet.  If  a  fissure  of  the  skull  is  infected,  enlarge  the  fissure  with 
a  chisel  in  order  to  clean  it.  In  a  badly  infected  wound  one  of  the  most 
valuable  agents  for  use  in  producing  disinfection  is  pure  carbolic  acid.  After 
cleaning  the  wound,  it  is  necessary  in  certain  regions  to  examine  in  order 
to  determine  if  tendons  or  considerable  nerves  have  been  cut.  If  such  struc- 
tures have  been  divided,  they  must  be  sutured  with  fine  silk,  chromic  gut, 
or  kangaroo-tendon. 

Drainage,  Closure,  and  Dressing. — Superficial  wounds  require  no  special 
drainage,  as  some  wound-fluid  will  find  exit  between  the  stitches  and  the  rest 
will  be  absorbed.  A  large  or  deep  wound  requires  free  drainage  for  at  least 
twenty-four  hours  by  means  of  a  tube,  strands  of  horsehair,  silk,  or  catgut, 
or  bits  of  iodoform  gauze.  An  infected  wound  must  invariably  be  drained. 
Good  drainage  may,  to  a  considerable  extent,  compensate  for  imperfect  anti- 


Treatment  of  Wounds  269 

sepsis.  If  capillary  drains  be  employed,  apply  a  moist  dressing.  Approxi- 
mate the  edges  with  interrupted  sutures  of  silk  or  silkworm-gut  if  the  wound 
is  deep  and  considerable  tension  is  inevitable.  Catgut  is  used  for  suj^crficial 
wounds  and  for  those  where  tension  is  slight.  If  there  is  decided  tension, 
silver  wire  may  be  used.  In  very  deep  wounds  buried  sutures  must  be  used. 
These  sutures  may  consist  of  absorbable  material  (kangaroo-tendon  or  cat- 
gut) or  unabsorbabic  material  (silver  wire)  or  very  fine  silk.  Of  late  I  have  been 
following  the  Johns  Hopkins  custom  and  have  closed  all  clean  wounds  with 
sutures  of  very  fine  iron  dyed  silk  passed  by  small  and  very  sharp  sewing 
needles.  By  the  use  of  these  fine  sutures  a  minimum  amount  of  tissue  necrosis 
occurs,  the  risk  of  infection  is  greatly  lessened,  and  the  resulting  scar  is  the 
smallest  that  can  be  obtained.  As  is  well  known,  tight  sutures  cause  tissue 
necrosis  and  hence  predispose  to  infection.  It  is  impossible  to  tie  the  fine 
black  silk  very  tight,  because  if  we  do  so  it  breaks.  It  requires  considerable 
practice  to  learn  to  tie  the  sutures  without  breaking.  This  fine  silk  can  be 
buried  without  fear,  as  it  never  causes  a  sinus,  and  it  is  used  for  layer  sutures 
with  perfect  confidence.  I  learned  this  plan  from  Dr.  Harvey  Gushing,  and 
am  much  pleased  with  it.  If  the  wound  is  infected,  dress  with  warm,  moist 
antiseptic  gauze.  If  it  is  not  infected,  dress  with  dry  sterile  gauze.  The 
custom  once  was  to  cover  even  dry  gauze  with  a  rubber  dam  to  diffuse  the  fluids, 
but  we  now  prefer  to  omit  the  rubber  dam  and  use  plentiful  dressings.  A  dry 
dressing  absorbs  wound  fluids  quickly  and  is  less  likely  to  become  infected. 
Change  the  dressings  in  twenty-four  hours  or  sooner  if  they  become  soaked 
with  discharge.  Dressings  are  changed  for  cause,  but  not  according  to 
scheduled  time.  They  must,  of  course,  be  changed  when  they  become  soaked 
with  wound-fluid,  and  soaking  may  occur  in  a  few  hours,  but  may  not  occur 
for  days.  As  long  as  the  temperature  remains  normal,  and  the  wound  free 
from  pain,  if  the  dressing  is  not  wet  with  discharge,  it  can  be  left  in  place  unless 
removal  is  necessary  to  take  out  a  drainage-tube.  If  pus  forms,  open  the  wound 
at  once.  Many  surgeons  sprinkle  wounds  before  approximation  and  wound 
surfaces  after  approximation  with  a  drying-powder.  These  powders  are  of 
great  use  in  infected  wounds,  but  are  not  necessary  in  clean  wounds.  Among 
the  substances  employed  are  saUcylic  acid,  boric  acid,  calomel,  acetanilid,  aris- 
tol,  iodoform,  subiodid  of  bismuth,  and  glutol.  In  large  wounds  which  can- 
not be  approximated  it  is  occasionally  advisable  to  skin-graft  by  Thiersch's 
method.  A  small  wound  which  cannot  be  sutured  is  dusted  with  an  anti- 
septic powder  and  dressed.  A  granulating  wound  is  dressed  as  is  a  healing 
ulcer.  In  recent  infected  wounds  rest  associated  with  Bier's  treatment  com- 
])rise  the  means  of  local  treatment.  Incision  is  usually  required.  In  later  in- 
fections or  severe  infections  the  wound  must  be  opened  widely  and  drained. 
A  sloughing  wound  is  opened,  is  dusted  with  iodoform  or  acetanilid,  and  is 
dressed  with  hot  antiseptic  fomentations. 

Rest. — Severe  wounds  require  the  confinement  of  the  patient  to  bed. 
Bandages,  splints,  etc.,  are  used  to  secure  rest.  In  a  closed  wound  rest  need 
not  be  protracted,  in  fact,  our  former  custom  was  to  insist  upon  it  for  too  long 
a  period.  The  slight  irritation  of  moderate  motion  stimulates  repair.  We 
no  longer  feel  it  necessary  to  keep  laparotomy  cases  in  bed  for  three  full  weeks, 
but  we  get  them  up  in  from  seven  to  ten  days.  By  doing  this  we  secure  just  a§ 
firm  a  cicatrix,  greatly  lessen  the  annoyance  from  constipation  and  flatulence, 


270 


Contusions  and  Wounds 


and  diminish  notably  tlie  number  of  cases  of  post-operative  pneumonia  and 
phlebitis.  I  do  not,  however,  advocate  getting  such  padents  up  in  twenty- 
four  to  thirty-six  hours,  as  is  advised  by  some  surgeons.  A  paUent  with  an 
infected  wound  or  an  open  drainage  wound  should  be  confined  to  bed.  The 
methods  of  combating  inflammation  have  previously  been  set  forth. 

Constitutional  Treatment. — Bring  about  reaction  from  depression,  but  y)re- 
vent  undue  reaction.  Feed  the  patient  well,  stimulate  him  if  necessary, 
attend  to  the  bowels  and  bladder,  secure  sleep,  and  allay  pain.     Watch  for 


Fig.  loo. — Muscle  suture:  .4,  Transverse  wound  of  biceps  muscle,  showing  marked  retraction 
of  muscle-ends  and  mattress  suture  in  place;  B,  muscle  suture  completed  (Senn). 


complications,  namely,  inflammation,  suppuration,  gangrene,  tetanus,  er}'- 
sipelas,  suppression  of  urine,  and  pneumonia.  Observe  the  temperature 
closely;  it  may  be  a  danger-signal  of  urgent  importance. 

Incised  "Wounds. — An  incised  wound  is  a  clean  cut  inflicted  by  an  edged 
instrument.  Only  a  thin  film  of  tissue  is  so  devitalized  that  it  must  die. 
These  wounds  have  the  best  possible  chance  of  union  by  first  intention. 

The  pain  may  be  very  severe;  but  if  the  instrument  is  sharp  and  used 
quickly  it  may  be  trivial.  The  pain  is  less  severe  than  that  caused  by  some 
other  varieties  of  wounds.  The  acute  pain  does  not  last  long,  and  is  followed 
by  smarting.  The  hemorrhage  is  profuse,  var>'ing,  of  course,  with  the  region 
cut.     Bleeding  from  the  scalp  is  violent,  because  there  are  numerous  vessels 


Incised  Wound 


271 


which  lie  in  fibrous  tissue  and  cannot  retract  nor  contract.  The  edges  of 
incised  wounds  retract  because  of  tissue-elastricity,  and  the  wound  "gapes." 
If  the  skin  or  fasciae  are  divided  at  a  right  angle  to  the  muscle  beneath,  there 
is  wide  ga|)ing.  If  the  cut  is  parallel  to  the  muscle- fibers,  the  gaping  is 
slight. 

When  the  skin  is  violently  pulled  upon,  it  tends  to  split  in  a  certain  line. 
Langer  and  Kocher  speak  of  this  as  the  line  of  cleavage,  and  point  out  the 
direction  of  these  lines  in  various  situations.  A  cut  across  the  line  of  cleavage 
is  followed  by  wide  gaping.  A  cut  in  the  direction  of  the  line  of  cleavage  pro- 
duces slight  gaping,  and  is  followed  by  a  trivial  scar. 

W^hen  a  muscle  is  cut  across,  the  wound  edges  widely  separate.  When  a 
tendon  is  completely  cut  across,  extensive  separation  occurs. 


Fig. 


-Suturing  of  tendons  and   nerves  in  incised  wounds:   a.  Primary  tendon  suture; 
b,  primary  nerve  suture  (Senn). 


An  incised  wound  can  be  thoroughly  inspected,  all  divided  structures  can 
be  identified,  foreign  bodies  can  be  easily  removed,  and  disinfection  can  be 
satisfactorily  carried  out. 

Treatment. — According  to  general  principles.  Arrest  hemorrhage,  asep- 
ticize, etc. 

Examine  the  wound  carefully  to  see  if  a  nerve,  a  tendon,  or  a  muscle  is 
divided,  and  if  such  injury  is  discovered,  suture  at  once  (Figs.  100  and  loi). 
If  the  wound  is  extensive  or  deep,  it  may  be  necessary  to  use  buried  sutures 
in  order  to  keep  the  sides  of  the  wound  in  contact.  If  the  surface  of  a  wound 
is  approximated,  but  the  depths  are  not,  the  dead  space  or  cavity  becomes 
filled  with  fluid,  and  infection  almost  certainly  occurs.  If  buried  sutures  have 
not  been  used,  such  a  cavity  must  be  obliterated  by  the  judicious  application 
of  pressure  upon  the  surface.  This  is  secured  by  the  adaptation  of  a  mass  of 
loose  or  fluffed-up  gauze,  and  the  firm  application  of  a  bandage  or  binder.    An 


272 


Contusions  and  Wounds 


incised  wound  is  usually  closed  with  interrupted  sutures  (Figs.  102  and  103). 
In  adjusdng  the  sutures,  see  that  the  edges  of  the  wound  are  not  inverted,  but 


Th'  right  way. 


Fig.  103. — Tying  an  interrupted  suture. 
The  knot  is  placed  to  the  side  of  the  wound 
as  shown  in  Fig.  102. 


M°f^  TAf  wrong  way. 


Fig.    102. — The    interrupted    suture    (after 
Bryant) 


Fig.  104. — Continuous  suture. 


rests  to  the  side  of  it.    Tie  the  stitches  firmly  but  not  tightly.    If  a  stitch  is  tied 
too  tightly  it  will  make  a  furrow,  as  shown  in  Fig.  102,  and  undue  tightness  is 


Fig.  105. — Ford's  suture:  a  square  knot,  a 
single  knot,  a  double  or  friction  knot,  and 
the  first  method  of  passing  the  needle  to  tie 
a  single  knot  immediately. 


Fig.  106. — Ford's  suture:  showing  two 
square  knots,  a  single  knot,  and  the  method 
of  completing  a  square  knot. 


sure  to  cause  necrosis,  and  is  often  productive  of  a  stitch-abscess.     As  pre- 
viously stated,  I  usually  close  wounds  with  sutures  of  very  fine  black  silk. 


Incised  Wounds 


273 


This  will  break  if  wc  try  to  tie  it  tightly  and  as  it  never  causes  a  sinus  when 
retained  in  the  tissues  it  can  be  used  for  buried  sutures  as  well  as  for  the  skin. 
A  silk  suture  and  catgut  suture  should  be  tied  with  the  reef  knot;  a  suture  of 
silkworm-gut  may  be  tied  with  either  a  surgeon's  knot  or  a  reef  knot.  If  a 
wound  is  on  the  face,  pardcular  care  must  be  employed  in  closing  it,  in  order 
to  limit  the  amount  of  disfigurement.  Fine  silk  sutures  are  passed  with  a 
small  sharp  needle  or  a  subardcular  sdtch  is  used.  In  a  clean  wound  sdtches 
can,  as  a  rule,  be  removed  in  from  six  to  eight  days.  In  a  large  wound  one- 
half  the  stitches  are  removed  at  one  sitdng,  and  in  a  day  or  two  the  rest 
are  removed.  Sdtches  are  promptly  removed  if  they  begin  to  cut  out  or  if 
infection  occurs. 

The  old  continued  suture  is  rarely  used  for  skin-wounds  at  the  present 
time.  This  suture  is  employed  to  suture  the  dura  after  division,  to  suture 
the  two  layers  of  pleura  together 
before  an  abscess  of  the  lung  is 
opened,  to  suture  the  peritoneum 
after  laparotomy,  and  to  suture 
the  mucous  membrane  after  cer- 
tain operations  upon  the  stomach. 
The  continued  suture  is  shown  in 
Fig.  104.  A  continuous  suture 
knotted  after  each  emergence  was 

devised  by  Ford.  It  is  very  useful  in  suturing  the  parietal  peritoneum  (Figs. 
105  and  106). 

Halsted's  subcuticular  stitch  (Fig.  107)  makes  a  most  perfect  closure  of  the 
skin-wound,  and  is  followed  by  the  smallest  possible  scar.  In  closing  a  deep 
wound  the  muscles  and  fasciae  are  sutured  in  layers  by  buried  sutures  before 
the  subcuticular  stitch  is  inserted.  It  is  only  used  in  wounds  which  are  almost 
certainly  clean,  as  those  made  by  the  surgeon,  and  in  wounds  which  do  not 
require  drainage.  The  suture  material  should  be  of  silver  wire  caught  upon 
a  curved  Hagedorn  needle  or  silkworm-gut  carried  by  a  long,  straight,  round 


Fig. 


107. — Halsted's    subcuticular   suture: 
the  true  skin. 


Fig.  108.— The  quilled  suture. 


needle.  The  suture  is  passed  through  the  corium  on  each  side  of  the  wound, 
as  shown  in  Fig.  107.  The  curved  needle  must  be  held  in  the  bite  of  a 
needle-holder.  When  the  suture  has  been  passed  the  ends  are  pulled  upon, 
and  the  skin-wound  closes  neatly. 

Halsted's  suture  does  not  penetrate  the  cuticle;  hence,  in  passing  it  the 
white  staphylococcus  is  not  carried  through  stitch-holes  and  into  the  wound, 
an  accident  which  might  be  followed  by  infection  of  a  stitch-hole  or  even  of 
18 


274 


Contusions  and  Wounds 


Fig.  no.— The  twisted  suture. 


Fig.  109.— Button 
suture. 


the  wound.  When  it  is  desired  to  vdthdraw  this  suture,  take  one  end  in  the 
bite  of  the  forceps,  cut  it  off  short  with  scissors,  catch  the  free  end  with  forceps, 
and  pull  steadily  upon  it. 

In  very  deep  wounds  or  wounds  in  which  there  is  much  tension  after 
approximation  the  quilled  suture  (Fig.  108)  or  the  button 
suture  (Fig.  109)  may  be  used.  The  twisted  suture  or 
hare-lip  suture  is  shown  in  Fig.  no. 

Problems  of  drainage,  dressing,  etc.,  are  discussed  on  pages 
76,  77,  and  78. 

If  infection  occurs,  the  wound 
becomes  swollen,  tender,  pain- 
ful, and  discolored,  and  the 
temperature  of  the  patient 
soon  becomes  elevated.  In 
such  a  condition  cut  the 
stitches,  disinfect,  and  drain. 

Wounds  of  Mucous  Mem- 
branes.— If  the  surgeon  intends 

to  inflict  a  wound  upon  a  mu-  , 

cous  surface,  he  should  see  to  it  that  the  patient's  general 
condition  is  good.  Thorough  asepsis  is  impossible,  and  a 
good  result  depends  largely  upon  the  vital  resistance  of  the  tissues. 
Before  operating,  irrigate  the  part  frequently  with  boric  acid,  peroxid 
of  hydrogen,  or  normal  salt  solution.  When  ready  to  sew  up  the  wound 
be  sure  that  all  irritant  fluids  are  removed  (saliva  in  the  mouth,  etc.). 
Cleanse  the  wound  with  hot  normal  salt  solution.  The  stitches  must  include 
submucous  tissue  as  well  as  the  mucous  membrane,  and  consist  of  silver  wire, 
silk,  chromic  catgut,  or  silkworm-gut.  After  sewing  up  a  wound  in  the 
mouth,  wash  the  cavity  at  frequent  intervals  with  salt  solution,  and  follow 
each  washing  with  an  insufflation  of  iodoform. 

In  accidental  wounds  irrigate  with  salt  solution,  dust  with  iodoform,  and 
close  as  directed  above.  Corrosive  sublimate  is  so  irritant  that  it  does  harm 
when  applied  to  a  mucous  membrane. 

Contused  and  Lacerated  Wounds. — A  contused  wound  results  from  a 
blow  or  a  squeeze  which  bruises  and  crushes  the  tissues  and  splits  or  ruptures 
the  skin.  It  is  a  common  injury  when  force  is  applied  to  tissues  over  a  bone. 
The  blow  of  a  blackjack  may  cause  either  a  contusion  or  a  contused  wound 
of  the  scalp.  A  contused  wound  is  irregular  in  outhne,  with  jagged  edges,  and 
is  surrounded  by  a  broad  zone  of  contusion.  The  worst  form  of  contused 
wound  is  a  crush  of  an  extremity  produced  by  being  run  over.  The  skin  is 
often  widely  separated  from  the  tissues  beneath. 

A  lacerated  wound  results  from  tearing  apart  of  the  tissues.  It  too  is 
irregular  and  jagged,  and  is  accompanied  by  more  or  less  contusion.  A 
brush-burn  is  a  contused-lacerated  wound  due  to  friction.  Both  lacerated 
and  contused  wounds  contain  masses  of  partly  detached  and  damaged  tissue, 
the  vitality  of  which  is  endangered.  Nerve-trunks,  muscles,  and  great 
vessels  may  be  torn  across.  Hence,  such  wounds  are  apt  to  slough,  fre- 
quently suppurate,  and  are  occasionally  followed  by  cellulitis  or  even  by 
gangrene.     There  is  more  danger  of  tetanus  than  in  incised  wounds.     A  wound 


Punctured  Wounds  275 

especially  apt  to  be  followed  by  tetanus  is  made  by  the  toy  pistol.  In  con- 
tused and  lacerated  wounds  the  edges  are  discolored  and  cold  to  the  touch, 
and  there  is  little  primary  hemorrhage  unless  a  cerebral  sinus  is  opened 
or  a  great  vessel  is  torn.  There  is  considerable  danger  of  secondary 
hemorrhage  if  large  vessels  have  been  bruised.  In  wounds  of  this  nature  the 
pain  is  often  slight,  but  it  may  be  violent.     Shock  is  very  severe. 

Avulsion  of  a  limb  is  a  dreadful  form  of  lacerated  wound.  The  thumb 
or  a  finger  may  be  torn  off  or  the  arm  may  be  wrenched  from  the  body  with 
or  without  the  scapula.  In  such  cases  the  wound  is  large,  jagged,  and  irreg- 
ular, long  strings  of  muscle  or  tendon  hang  from  the  gap,  the  wound  edges 
are  cold,  but  the  bleeding  is  trivial.     The  shock  is,  of  course,  profound. 

Avulsion  0}  the  scalp  may  be  produced  when  the  hair  is  caught  in  machin- 
ery. The  American  Indian  inflicts  this  injury  when  he  scalps  a  conquered 
foe.  In  some  cases  of  avulsion  of  the  scalp  the  periosteum  is  removed  with 
the  flap;  in  most  it  is  not.  The  flap  usually  consists  of  skin  and  aponeurosis. 
In  this  form  of  laceration  there  is  severe  bleeding. 

Treatttient. — The  surgeon  brings  about  reaction  and  endeavors  to  asepticize 
the  wound  and  skin  about  it  (page  268),  arrests  hemorrhage,  and  ligates  any 
visible  damaged  vessel  whether  it  bleeds  or  not.  Hopelessly  damaged  tissue 
should  be  cut  away,  doubtful  tissue  being  retained.  In  some  cases  amputation 
is  necessary.  If  we  apprehend  tetanus,  give  an  injection  of  antitetanic  serum 
as  a  preventive.  Secure  thorough  drainage,  in  some  situations  making 
counter-openings  if  necessary.  Tube-drainage  may  be  necessary  or  iodoform 
gauze  in  strands  may  be  used.  Contused  wounds  and  lacerated  wounds, 
except  when  on  the  face,  are  seldom  closed  by  sutures.  They  are  rarely  closed, 
because  the  damage  is  so  great  and  the  blood-supply  so  interfered  with  that 
primary  union  will  not  occur.  In  the  face  the  blood-supply  is  so  good  that 
primary  union  may  be  obtained  in  part  or  entirely,  and  it  is  worth  while  to  try 
to  obtain  it.  Cold  must  not  be  appUed  to  a  region  of  lowered  vitahty  because 
it  might  cause  gangrene.  Heat  is  useful.  Hence,  it  is  advisable,  even  from 
the  start,  to  dress  with  hot  antiseptic  fomentations,  and  this  mode  of  dressing 
becomes  imperative  if  sloughing  begins.  Of  course,  the  part  must  be  kept  at 
rest. 

If  suppuration  occurs,  the  surgeon  sees  to  it  that  the  pus  has  free  exit,  and 
if  necessary  secures  free  exit  by  making  excisions.  Bier's  treatment  and  rest 
are  useful  for  infections. 

After  avulsion  of  a  limb  the  patient  is  reacted  from  shock,  large  vessels  are 
sought  for  and  tied,  damaged  tissue  is  cut  away,  the  wound  is  packed  with 
gauze  and  is  partly  approxime.ted  by  sutures.  After  avulsion  of  the  scalp 
bleeding  vessels  are  carefully  ligated.  A  portion  of  the  scalp  may  be  torn 
away,  but  a  pedicle  may  connect  it  with  the  balance  of  this  structure.  In  such 
a  case  cleanse  the  parts  thoroughly  and  suture  the  flap  in  place  (W.  T. 
Bivings,  "Phila.  Med.  Jour.,"  June  7,  1902).  If  the  portion  of  scalp  is 
entirely  separated,  adopt  Gussenbauer's  suggestion  when  possible  and  graft 
pieces  of  the  avulsed  scalp.  In  any  case  the  ulcer  resulting  from  avulsion 
must  be  repeatedly  grafted.  Abbe  obtained  healing  in  a  case  after  four  years 
by  the  use  of  12,000  grafts. 

Punctured  Wounds. — Punctured  wounds  are  made  wth  pointed  instru- 
ments, as  needles,  splinters,  etc.     The  depth  of  a  punctured  wound  greatly 


276  Contusions  and  Wounds 

exceeds  its  surface  area.  After  the  withdrawal  of  the  instrument  inflict- 
ing the  injury  the  wound  partly  closes  at  points,  blood  and  wound-fluid  can- 
not find  exit,  and  if,  as  is  probably  the  case,  bacteria  were  deposited  in  the 
tissues,  infection  with  pus  organisms  is  very  likely  to  occur,  and  if  it  does  occur 
suppuration  spreads  widely.  There  is  also  danger  of  infection  with  tetanus 
bacilli.  Such  a  wound  may  involve  an  important  blood-vessel,  and  in  such  a 
case  profuse  hemorrhage  may  occur;  otherwise  hemorrhage  is  slight.  A  great 
cavity  of  the  body  may  be  penetrated  or  an  important  organ  may  be  wounded. 
Large-sized  foreign  bodies  may  be  driven  into  the  tissues  or  a  portion  of  the 
instrument  may  break  off  and  lodge.  Pain  is  rarely  severe  unless  a  consid- 
erable nerve  has  been  damaged.  If  both  a  large  vein  and  artery  are  punctured, 
varicose  aneurysm  or  aneurysmal  varix  may  arise. 

Treatment. — When  possible,  inspect  the  instrument  which  did  the  dam- 
age to  see  if  a  piece  has  been  broken  ofif.  If  there  is  severe  hemorrhage, 
enlarge  the  wound  and  tie  the  bleeding  vessels.  In  a  puncture  not  made  by  the 
surgeon,  the  wound  must  be  regarded  as  infected.  If  a  wound  is  made  by  a 
dirty  instrument  through  skin  known  to  be  unclean,  it  is  proper  that  the  skin 
about  the  puncture  be  sterilized,  that  the  wound  be  enlarged,  that  foreign  bodies 
be  removed,  that  the  wound  be  irrigated  with  an  antiseptic  solution,  or  be  painted 
with  pure  carbolic  acid,  and  be  drained  with  a  tube  or  a  strip  of  gauze.  Such 
treatment,  though  painful,  and  appearing  unnecessarily  severe  or  even  cruel  to 
the  sufferer  from  a  trivial  puncture,  is  necessary,  and  may  save  the  patient  from 
serious  illness  or  from  death.  Every  deep  puncture  inflicted  by  an  instrument 
not  surgically  clean,  and  every  puncture  inflicted  by  a  nail,  a  splinter,  a  meat 
hook,  a  rusty  pin,  a  tooth  of  a  cat  or  dog,  etc.,  must  be  regarded  as  grossly 
infected  and  must  be  treated  by  incision,  sterilization,  drainage,  hot  antiseptic 
fomentations,  and  rest.  If  the  puncture  is  superficial  and  is  made  with  a 
smooth  pointed  instrument  like  a  needle,  when  the  instrument  was  not  grossly 
infected  the  parts  may  be  dressed  with  hot  antiseptic  fomentations,  but  they 
should  be  inspected  daily  for  evidence  of  infection  and  at  the  first  sign  of 
trouble  an  incision  must  be  made.  If  a  foreign  body  is  retained  in  the  tissue, 
it  must  be  removed. 

Pure  carbolic  acid  is  a  most  efficient  agent  to  sterilize  a  punctured  wound. 

If  an  important  cavity  of  the  body  has  been  invaded  by  a  puncture,  ex- 
ploratory incision  is  necessary  (see  Brain,  Thorax,  Abdomen).  In  punctures 
with  contaminated  instruments  the  antitetanic  serum  finds  a  valuable  place  as 
a  preventive  of  tetanus. 

Stab-wounds. — Stab-wounds  were  formerly  considered  with  punctured 
wounds,  but  Senn  wisely  placed  them  in  a  class  by  themselves.  Stab-wounds 
are  inflicted  by  penetrating  the  tissues  with  a  pointed  or  narrow  instrument — 
for  instance,  a  dagger,  a  knife,  the  blades  of  scissors,  a  bayonet,  or  a  sword. 
Such  wounds  are  narrow  and  very  deep.  A  stab-wound  may  cause  rapid 
death  by  penetration  of  a  large  blood-vessel.  Some  great  cavity  of  the  body 
may  be  penetrated  and  internal  hemorrhage  will  then  occur.  The  body  may 
be  transfixed  by  a  sword  or  bayonet.  Bone  is  rarely  injured  unless  the  skull 
is  perforated  or  the  chest  entered.  In  stab-wounds  there  is  usually  great 
hemorrhage  and  shock. 

Treatment. — Wherever  possible,  look  at  the  instrument  which  did  the 
damage  and  see  if  a  piece  is  broken  off.     If  no  great  cavity  is  entered,  treat  by 


Gunshot-wounds  277 

general  rules:  arrest  bleeding,  react  from  shock,  etc.  The  treatment  of 
penetrating  wounds  of  the  abdomen,  thorax,  and  cranium  is  discussed  in  the 
special  sections. 

Arrow-wounds. — Arrow-wounds  might  be  considered  under  the  head  of 
punctured  wounds  or  stab-wounds.  When  hostiUties  with  the  red  men  were 
frequent  and  before  mercenary  traders  had  fitted  out  the  savages  with  rifles, 
arrow-wounds  were  common  among  the  men  of  the  frontier.  They  are  now 
very  rare.  Military  surgeons  still  encounter  them,  especially  in  some  parts  of 
Africa  and  in  the  Philip[jine  Islands.  An  arrow-wound  may  be  a  trivial  punc- 
ture of  the  skin,  a  deep  wound  of  the  soft  parts  with  or  without  bone  injury,  a 
penetration  of  a  joint,  or  of  one  of  the  body  cavities.  The  skull  cavity  may  be 
entered  by  an  arrow.  In  some  of  these  cases  there  is  a  puncture  of  the  bone 
without  the  formation  of  fissures,  but  usually  when  bone  is  punctured  there 
is  fissure  formation,  splintering,  or  depression.  A  large  blood-vessel  may  be 
divided  by  an  arrow  and  violent  bleeding  result  or  fatal  concealed  hemorrhage 
may  take  place  from  a  wounded  \iscus.  Some  tribes  poison  arrows.  It  is  said 
that  the  Piutes  were  the  only  tribe  of  North  American  Indians  which  did  this. 

Some  tribes  in  South  America  use  curare,  others  use  snake-poison,  others 
use  decomposed  meat.  In  Northern  Nigeria  some  form  of  strophanthus 
plays  a  part  in  nearly  all  the  poisons  used  (Allan  C.  Parsons,  in  "British  Aled. 
Jour.,"  Jan.  23,  1909).  The  same  author  points  out  that  the  poison  used  is 
generally  complex  and  contains  also  various  animal  and  vegetable  ingredients, 
particularly  decomposed  organic  matter,  plant  juice  containing  strychnin,  and 
soil  contaminated  with  tetanus  organisms. 

Treatment. — An  arrow  is  always  septic  and  should  be  extracted.  Some- 
times when  it  has  been  buried  deeply  in  a  part  it  should  be  pushed  across  and 
extracted  through  a  counter-opening  after  the  protruding  shaft  has  been  cut 
off.  An  arrow  head  cannot  be  pulled  out  by  the  shaft.  The  barbs  on  the  head 
catch  and  prevent  extraction  and  the  neck  of  the  shaft  is  apt  to  break.  The 
tissues  should  be  freely  divided  down  to  the  head  of  the  arrow  and  on  each  side 
of  it,  when  it  can  usually  be  withdrawn  by  forceps.  If  imbedded  in  bone,  the 
head  must  be  gently  rocked  from  side  to  side  to  loosen  it,  every  care  being  taken 
to  avoid  breaking  a  stone  or  bending  an  iron  arrow  head.  If  an  arrow  has 
penetrated  the  abdomen,  a  laparotomy  should  be  performed.  If  it  has  entered 
a  joint,  the  joint  should  be  freely  opened.  If  it  has  entered  the  chest,  one  or 
more  ribs  will  require  resection.  If  it  has  entered  the  skull,  trephining  is 
indicated.  Any  bleeding  vessels  are  to  be  caught  and  tied.  The  track  of  the 
arrow  should  be  disinfected  ^Aith  pure  carbolic  acid  and  drainage  should 
be  inserted.  It  is  particularly  important  to  remove  a  poisoned  arrow  at  once. 
After  removing  a  poisoned  arrow,  if  the  nature  of  the  poison  is  known,  proper 
treatment  should  be  appUed  to  antidote  the  poison.  The  French  Colonial 
surgeons  fill  wounds  inflicted  by  poisoned  arrows  with  tannic  acid.  The  same 
custom  is  followed  by  English  surgeons  in  West  Africa  (Allan  C.  Parsons,  Ibid.) . 

Gunshot-wounds. — Gunshot-wounds  are  contused  or  contused-lacerated 
wounds  inflicted  by  materials  projected  by  explosives.  A  bit  of  rock  or  a 
crowbar  hurled  by  dynamite  inflicts  a  gunshot-wound,  as  does  a  shell-frag- 
ment, a  pistol-ball,  small  birdshot,  a  rifle  bullet,  pieces  of  a  hand  grenade, 
a  flying  cap,  a  piece  of  wadding,  grains  of  powder,  a  buckshot,  a  fragment  of 
metal  broken  off  a  shell,  grapeshot  and  canister,  or  a  cannon-ball.     Injuries 


278  Contusions  and  Wounds 

by  shell-fragments,  portions  of  a  bursted  boiler,  pieces  of  masonry  or  wood, 
are  either  lacerated  or  punctured  wounds,  and  need  no  special  consideration 
here.  In  this  article  we  treat  of  injuries  caused  by  bullets  and  shot,  that  is, 
by  missiles  propelled  from  firearms. 

Firearms  are  instruments  by  means  of  which  missiles  are  projected  to  a 
distance  by  the  expanding  gases  of  burning  gunpowder.  There  are  many 
different  sorts  of  firearms.  Artillery  includes  various  sizes  of  guns  upon  sup- 
ports, from  the  great  1 2-inch  guns  of  a  battleship,  which  fire  shells  weighing 
850  pounds,  to  machine-guns,  which  fire  ordinary  rifle  bullets.  Field  artillery 
uses  little  but  shrapnel-shells.  Such  a  shell  is  a  case  of  steel,  cyUndroconoidal 
in  shape,  containing  a  number  of  bullets  and  a  charge  of  explosive,  the  shell 
exploding  by  means  of  a  time-fuse.  Canister  is  an  iron  casing  containing 
bullets  unassociated  with  an  explosive  discharge  within  the  casing.  The 
canister  breaks  when  fired,  and  the  balls  separate  over  a  large  area.  It  is 
used  only  at  close  range — that  is,  three  or  four  hundred  yards. 

Among  small  arms  may  be  mentioned  muskets,  revolvers,  shot-guns,  and 
rifles.  Wounds  from  the  old-time  musket  ball  are  now  never  met  with  except 
in  warfare  against  barbarous  tribes.  The  musket  has  a  smooth  bore  and 
fires  round  bullets  of  soft  lead.  This  round,  soft  bullet,  being  large,  moving 
with  comparative  slowness,  and  flattening  easily,  is  very  liable  to  glance,  to 
deform,  and  to  lodge.  When  a  musket  is  fired  at  close  range  and  the  bullet 
strikes  the  tissue  at  a  right  angle,  it  produces  a  punched-out  entrance  wound. 
If  the  velocity  is  low  or  the  impact  is  not  at  a  right  angle  to  the  tissues,  the  en- 
trance wound  may  "be  formed  of  triangular  flaps,"  the  comers  of  which  are 
inverted.*  The  entrance  wound  is  surrounded  by  a  bruised  area.  The  track 
of  the  bullet  is  larger  than  the  bullet,  and  is  so  badly  contused  and  lacerated 
that  some  tissue  is  devitalized;  and  the  shaft  of  a  bone,  if  struck,  is  likely  to 
be  splintered.  If  the  ball  emerges,  the  wound  of  exit  is  larger  than  the  bullet, 
and  forms  triangular  and  everted  flaps.  Heahng  by  first  intention  seldom 
occurs  in  such  wounds.  The  old  smooth-bore  musket,  firing  a  round  bullet, 
has  been  displaced  by  the  rifle  propeUing  a  conical  projectile. 

In  the  firearms  of  civilians,  as  a  rule,  the  bullets  are  made  of  lead,  hardened 
and  shaped  by  compression,  or  hardened  by  an  admixture  with  tin.  The 
conical  or  cylindroconoidal  rifle  bullet  has  much  greater  velocity  and  pene- 
trating power  than  the  round  bullet.  Hence,  it  is  more  liable  to  penetrate  and 
less  likely  to  deflect  and  to  lodge.  The  track  of  this  bullet  is  less  devitalized 
than  is  the  track  of  the  round  bullet.  The  cutaneous  surface  is  not  so  much 
contused.  The  wound  of  entrance  is  smaller  than  the  bullet,  and  is  punched 
out  or  inverted;  and  the  wound  of  exit  is  larger  than  that  of  entrance  and  is 
often  everted.  The  bones  are  more  seriously  comminuted  than  by  the  round 
bullet,  and  osseous  fragments  may  be  driven  widely  into  the  dssues.  In  fact, 
"an  explosive  effect"  may  occur  at  close  range.  Delorme  lays  it  down,  as 
a  rule,  that  comminution  of  bone  makes  the  wound  of  exit  larger;  and  he 
asserts  that  a  wound  of  exit  larger  in  diameter  than  the  thumb  means  com- 
minution of  bone. 

Gunshot-wounds  Seen  in  Civil  Life. — Wounds  are  occasionally  inflicted 
with  the  sporting  rifle  or  the  shot-gun,  and  frequently  with  blank  cartridges; 

*  "Wounds  in  War,"  by  Surgeon  Col.  W.  F.  Stevenson. 


Gunshot-wounds  279 

but  the  vast  majority  of  such  wounds  seen  by  the  civilian  surgeon  are  inflicted 
with  the  revolver. 

Wounds  from  the  Sporting  Rifle. — In  the  sporting  rifle  a  large  charge  of 
powder  is  cm])loyed.  Some  sporting  rifle  bullets  have  no  hard  jackets.  Others 
have  an  inct)mplete  hard  jacket.  In  a  bullet  with  a  partial  hard  jacket  the 
"nose"  of  the  bullet  is  exposed  and  soft.  The  bullets  are  usually  larger  than 
those  used  in  the  military  rifle.  Such  bullets  deform  in  the  dssues,  and 
inflict  dreadful,  tearing  wounds.  If  such  a  bullet  strikes  a  limb,  amputation 
may  be  recjuircd.  If  it  strikes  the  head  or  trunk,  it  will  almost  certainly 
produce  a  fatal  wound. 

Wounds  from  the  Shot-gtm. — The  degree  of  injury  is  in  direct  ratio  to  the 
adjacency  of  the  wounded  individual  to  the  gun  when  the  discharge  takes 
place;  to  the  size  and  number  of  the  shot;  and  to  the  charge  of  powder.  Single 
shot  may  bruise  the  surface  and  fail  to  enter  the  tissues  or  may  enter  the  tissues. 
When  many  shot  enter  together,  they  strike  as  a  solid  body.  Single  shot  are 
usually  deflected  from  vessels  and  nerves,  and  seldom  lodge  in  bone;  but, 
rather,  flatten  on  the  bone  surface.  Even  a  single  shot  lodged  in  the  eyeball 
is  apt  to  produce  violent  inflammation  which  may  destroy  the  eye.  Numerous 
shot  entering  together  at  close  range  produce  extensive  contusion  of  the  surface 
and  fearful  lacerations  of  the  tissues,  and  often  inflict  irreparable  damage. 
Bone  may  be  fractured  and  bits  of  clothing  or  other  foreign  bodies  may  be 
carried  into  the  wound  with  the  shot.  At  close  range  toes  or  fingers  may  be 
blown  ofi',  an  eye  may  be  blown  out,  or  portions  of  tendon  or  muscle  may 
be  shot  away.  Primary  hemorrhage  is  seldom  severe  because  the  wound  is 
lacerated;  but  secondary  hemorrhage  is  to  be  feared,  and  serious  infection 
usually  follows  such  injuries.  Buckshot  at  close  range  inflict  grave  or  dread- 
ful wounds.  The  United  States  Army  is  supplied  with  a  cartridge  for  use  in 
riots.     This  cartridge  contains  two  shot,  each  about  the  size  of  a  buckshot. 

The  Treatment  of  Shot-gun  Wounds. — If  the  shot  be  scattered  and  lodged 
it  is  seldom  necessary  to  remove  them.  As  a  rule,  such  cases  require  only 
cleansing  of  the  skin  and  aseptic  dressings.  If  shot  lodge  in  a  joint,  they 
impair  function;  if  in  the  face,  they  produce  deformity.  In  both  of  these 
cases  removal  is  necessary.  When  a  shot  lodges  in  the  eye  it  usually,  but  not 
always,  causes  blindness.  If  the  eye  is  gravely  damaged  it  must  be  enucleated. 
In  serious  lacerations  produced  by  shot  at  close  range  the  hopelessly  damaged 
tissue  must  be  cut  away,  hemorrhage  must  be  arrested,  foreign  bodies  must  be 
removed  (though  no  protracted  search  is  either  necessary  or  desirable  to  re- 
move grains  of  shot),  the  wound  must  be  disinfected  as  well  as  possible,  and 
free  drainage  must  be  employed.  It  is  wise  to  give  a  prophylactic  dose  of 
antitetanic  serum. 

Blank-cartridge  Injuries. — These  injuries  can  occur  only  at  close  range. 
They  consist  of  bums  and  lacerations,  frequently  a  wad  or  a  bit  of  clothing 
lodges  in  the  tissues,  and  tetanus  is  a  not  unusual  sequence.  The  explosive 
used  in  the  toy  pistol  is  a  fulminate,  and  bits  of  the  envelope  of  the  explosive 
may  be  driven  quite  deep  into  the  tissues.  There  is  considerable  danger  of 
tetanus  after  injuries  inflicted  by  the  toy  pistol.  What  in  the  United  States 
is  called  "Fourth  of  July  tetanus"  is  tetanus  following  such  an  injury,  the  small 
boy  being  prone  to  employ  a  toy  pistol  to  contribute  noise  to  the  celebration 
of  the  nation's  birthday  (see  page  219). 


28o  Contusions  and  Wounds 

Blank-cartridge  wounds  and  toy-pistol  wounds  are  treated  by  cleansing 
the  skin,  enlarging  the  wound,  removing  foreign  bodies,  disinfecting,  and 
draining.     A  prophylacdc  dose  of  antitetanus  serum  should  always  be  given. 

Wounds  Inflicted  by  the  Revolver  Bullet. — The  revolver  varies  in  caliber 
from  .22  to  .45.  Whereas  it  is  true  that  certain  military  revolvers  of  the  auto- 
matic type  fire  a  hard-jacketed  rifle  bullet,  the  revolvers  of  civil  life  propel 
cylindroconoidal  unjacketed  bullets  at  a  velocity  of  about  700  feet  a  second. 
A  revolver  bullet  never  produces  an  explosive  effect.  It  is  liable  to  deform 
in  the  tissues,  is  often  deflected  from  bone  or  tendon,  and  is  very  apt  to  lodge. 
The  shape  of  the  bullet,  the  velocity  with  which  it  is  propelled  and  with  which 
it  rotates,  and  its  hardness,  make  it  unlikely  that  at  any  near  range  the  bullet 
will  merely  contuse,  and  not  enter,  the  skin.  Unless  striking  at  an  angle  to  the 
perpendicular,  it  will  almost  always  enter.  In  some  cases,  however,  a  pistol 
bullet,  like  a  spent  rifle  bullet,  may  fail  to  enter  the  tissues.  It  then  grazes  the 
surface  and  inflicts  a  brush  burn  or  simply  contuses  the  part.  Sometimes  it 
perforates,  more  often  it  lodges.  Whereas  it  may  be  deflected,  it  comparatively 
seldom  is;  and  it  often  deforms,  though  it  dDes  not  do  so  to  anything  hke  the 
degree  that  the  soft,  round  bullet  does.  If  a  bullet  enters  the  dssues,  a  cavity, 
or  an  organ,  and  lodges  there,  it  causes  a  penetrating  wound.  If  it  enters  and 
emerges,  it  causes  a  perforating  wound.  The  bullet  may  not  enter  alone,  but 
may  carry  with  it  bits  of  clothing  or  other  foreign  bodies;  though  this  complica- 
tion is  much  rarer  in  injury  with  the  conical  bullet  than  with  the  round  ball. 
On  one  occasion  I  removed  a  piece  of  coat  from  the  interior  of  the  lung,  to 
which  it  had  been  carried  by  a  pistol  bullet.  In  another  instance  I  removed 
a  piece  of  shirt  from  the  interior  of  the  abdomen,  to  which  it  had  been  carried 
by  a  similar  bullet.  A  revolver  bullet  may  break  bones,  though  it  is  not  nearly 
so  liable  to  do  so  as  is  a  rifle  bullet. 

In  studying  a  gunshot-wound  one  must  consider  the  wound  of  entrance, 
the  tissue  track,  and,  if  the  bullet  has  emerged,  the  wound  of  exit.  If  a  revolver 
bullet  fired  from  a  distance  of  ten  feet  or  more  from  the  person  struck  hits  the 
skin  at  a  right  angle,  it  makes  a  wound  of  entrance  that  is  smaller  than  the 
bullet  because  the  skin  is  elastic.  It  is  a  certain  fact  that  one  cannot  assert 
from  an  inspecdon  of  the  wound  of  entrance  what  size  bullet  a  man  was  struck 
with.  A  .22  often  leaves  a  most  trivial  opening.  The  shape  of  the  wound  of 
exit  is  somewhat,  but  not  regularly,  circular,  because  a  certain  amount  of  tissue 
is  destroyed.  The  margins  are  also  somewhat  depressed.  It  has  a  punched- 
out  look,  and  the  edges,  as  Draper  tells  us,  are  frayed  in  appearance  ("  Text- 
book of  Legal  Medicine,"  by  Frank  Winthrop  Draper).  The  edges  of  the 
wound  look  thickened  and  are  contused,  this  discoloration  being  noted  for  a 
distance  of  an  inch,  or  even  two  inches,  from  the  margin  of  the  wound.  The 
skin  surface  is  distinctly  Ijlackened;  but  unless  the  weapon  were  fired  at  very 
close  range,  this  is  not  due  to  burning,  but  rather  to  staining  with  a  mixture  of 
burnt  gunpowder  and  the  grease  of  the  outer  surface  of  the  bullet.  The  ap- 
pearance of  the  wound  of  entrance  will  be  very  different  if  the  bullet  strikes 
the  surface  at  an  acute  instead  of  a  right  angle.  Then  the  wound  will  not  be 
round,  but  oval  or,  perhaps,  linear.  When  a  bullet  is  fired  very  near  to  the 
surface  of  the  body  the  hair  of  the  skin  will  be  burned,  there  will  be  some 
staining  with  gunpowder  around  the  wound,  and  powder-grains  will  be  found 
lodged  in  the  skin.     Whether  the  weapon  inflicting  the  wound  was  close  or 


Gunshot-wounds  281 

distant  there  is  bruising  of  the  skin,  but  when  the  powder  is  found  in  the  tissues 
or  on  the  surface,  it  means  that  the  weapon  was  close  at  the  time  of  discharge. 
The  absence  of  imbedded  powder,  however,  does  not  prove  that  the  shot 
was  not  close,  because  the  wea{)on  employed  might  have  been  one  using 
smokeless  powder.  If  the  weapon  were  fired  at  close  range  the  skin  may 
have  been  burnt  by  burning  gases  or  the  clothing  may  have  been  burnt  and  the 
skin  scorched  by  the  burning  clothing.  Staining  of  the  skin  with  powder  can 
be  washed  off,  but  when  the  skin  has  been  burnt  it  is  dry  like  parchment. 
When  unexploded  powder-grains  are  lodged  in  the  skin  the  resulting  condition 
is  spoken  of  as  tattooing,  and  this  always  means  a  very  close  shot.  It  has 
been  held  by  some  that  powder-grains  are  never  found  in  the  skin  unless  the 
bullet  has  been  fired  from  a  distance  of  less  than  3  feet,  but  this  is  too 
arbitrary  a  statement  to  make  in  a  court  of  law.  In  any  medicolegal  case 
experiments  should  be  made  with  a  weapon  and  ammunidon  similar  to 
those  used  in  inflicting  the  wound  in  order  to  determine  the  real  facts  of 
the  case.  Draper  ("Text-book  of  Legal  Medicine")  makes  the  following 
important  statement  relating  to  burns  of  the  skin,  which,  I  am  convinced, 
is  corrects  *Tf  the  weapon  is  held  in  the  hand  in  the  ordinary  way,  hammer 
and  sight  on  the  barrel  directed  upward,  the  wound  in  the  skin  will  show, 
immediately  above  its  orifice,  a  brand  or  scorching  caused  by  a  shght  recoil 
in  the  act  of  firing.  The  location  of  this  brand  will  change  as  the  posi- 
tion of  the  hammer  is  changed.  If  the  weapon  is  held  in  a  vise  and  fired, 
this  relation  of  the  brand  to  the  wound  is  obliterated.  This  observation,  first 
made  and  published  by  Dr.  D.  B.  N.  Fish  in  1883,  suppMes  an  accurate  index 
of  the  position  in  which  the  pistol  is  held  in  firing."  In  passing  through  the 
tissues  the  revolver  bullet  makes  a  contused  lacerated  wound,  and  we  may 
find  along  this  wound  powder-grains  (if  the  bullet  has  been  fired  at  close  range) 
and  portions  of  clothing,  pieces  of  the  bullet  itself  or  perhaps  of  bone.  A  bul- 
let may  pass  directly  through  both  walls  of  the  skull,  traversing  the  brain  in  its 
passage.  It  may  pass  through  a  line  of  the  side  of  the  skull  and  lodge  within 
the  cavity  of  the  cranium.  In  some  cases  it  makes  an  opening  of  entrance  that 
is  smallest  on  the  external  surface  of  the  bone  and  largest  on  the  inner  table. 
In  other  cases  it  makes  extensive  comminuted  fractures.  When  a  bullet 
tracks  its  way  through  a  muscle  it  makes  a  jagged,  contused,  lacerated  wound. 
It  does  the  same  in  the  brain.  In  both  cases  the  track  of  the  bullet  is  larger 
than  the  bullet,  and  the  tissue  for  a  considerable  distance  wide  of  the  track 
is  contused  or  actually  destroyed.  In  passing  through  an  aponeurosis  or  a 
serous  membrane  the  bullet  may  make  a  round  orifice  or  a  slit-like  tear.  Of 
course,  the  nature  of  the  wound  in  the  tissues  will  be  greatly  affected  if  the  bul- 
let is  deformed  by  having  struck  bone,  or  if  it  carries  bits  of  bone  along  with  it. 
The  deflection  of  a  bullet  from  an  aponeurosis,  fascia,  or  bone  so  alters  its 
course  that  the  missile  becomes  very  difficult  to  locate  and  remove.  In  some 
cases  a  bullet  has  entered  near  the  front  of  the  body  and  passed  around  the 
wall  of  the  chest  until  it  has  almost  reached  its  point  of  entrance,  or  else  has 
emerged  at  some  point  of  this  course — in  either  case  constituting  what  is 
known  as  a  contour  wound.  Contour  wounds  are  not  infrequently  seen  upon 
the  head.  For  instance,  a  bullet  may  strike  the  frontal  region,  pass  around  un- 
der the  scalp,  and  lodge  in  or  emerge  from  the  occipital  region. 

When  the  buflet  does  not  lodge,  but  emerges  from  the  body,  the  wound  of 


2»2 


Contusions  and  Wounds 


exit  must  be  studied.  If  an  undeformed  IniUet  passes  straight  through  the 
body  it  makes  a  wound  of  exit  that  is  somewhat  larger  than  the  bullet.  It  has 
a  torn-out  appearance,  but  without  distinct  destruction  of  tissue,  and  exhibits 
an  irregular  outline  and  eversion  of  the  edges.  The  margins  of  such  a  wound 
are  bruised,  but  are  never  scorched  and  never  show  powder-grains.  If  a  bullet 
has  been  deformed  by  hitting  bone,  or  if  it  has  driven  bone  before  it,  a  very 
large  lacerated  wound  of  exit  may  be  formed.  It  is  important  to  remember 
that  the  presence  of  a  number  of  wounds  on  the  surface  of  the  body  does  not 
in  itself  prove  that  a  number  of  different  bullets  have  been  fired,  for  in  certain 
circumstances  one  bullet  may  make  several  wounds.  A  few  years  ago  I  saw 
a  case  in  which  a  bullet  had  penetrated  the  right  hand  and  the  right  thigh, 
and  had  lodged  in  the  left  thigh.  There  were  three  wounds  of  entrance 
and  two  wounds  of  exit.  Many  very  extraordinary  cases  of  this  sort  have  been 
reported. 

Symptoms  of  a  Gunshot-wound.— Hemorrhage  is  often  considerable, 
but  ceases  spontaneously  unless  a  large  vessel  has  been  divided.  If  hemor- 
rhage is  profuse,  the  consdtutional  symptoms  of  hemorrhage  exist  (page  435)- 
These  symptoms  are  of  great  importance  in  abdominal  wounds.  A  pistol  ball 
seldom  causes  severe  primary  hemorrhage,  because  it  will  not  often  penetrate 
a  large  artery.  It  is  apt  to  push  aside  a  vessel,  and  secondary  hemorrhage 
is  not  unusual.  Even  if  a  large  vessel  is  wounded  and  a  succession  of  violent 
hemorrhages  occur,  a  man  may  live  for  several  days.  Secondary  hemorrhage 
may  follow  a  gunshot-wound  because  of  contusion  of  vessels  or  of  infection. 

Pain  is  often  not  noticed  at  first.  The  injured  individual,  if  greatly  pre- 
occupied or  excited,  may  not  know  that  he  has  been  struck  by  a  bullet. 
There  may  be  only  a  feeling  of  numbness,  but  usually  there  is  a  dull  or 
stinging  pain.  If  a  large  nerve  has  been  injured  there  may  be  violent  pain. 
Even  trivial  gunshot-wounds  frequently  produce  profound  shock,  and  yet  it 
may  happen  that  severe  wounds  may  be  accompanied  by  but  slight  shock. 
In  most  gunshot- wounds  of  the  brain,  abdomen,  and  spinal  cord  the  shock 
is  very  great. 

General  Considerations  as  to  Treatment. — The  dangers  are  shock, 
hemorrhage,  and  infection.  Bullets  are  aseptic  when  they  enter  a  part,  and 
if  infection  is  not  inserted  in  the  track  of  the  ball  the  wound  will  in  most 
instances  heal  kindly.  "The  fate  of  a  wounded  man  is  in  the  hands  of  the 
surgeon  who  first  attends  him"  (Nussbaum).  The  danger  of  a  wound  depends 
upon  the  size  and  velocity  of  the  bullet,  the  part  struck,  "and  the  degree 
of  asepsis  observed  during  the  first  examination  and  dressing"  (Nancrede). 
The  rules  of  treatment  are:  bring  about  reaction,  arrest  hemorrhage,  pre- 
serve asepsis,  and,  in  some  cases,  remove  the  ball.  Always  notice  if  a  wound 
of  exit  exists.  It  is  a  good  plan,  when  endeavoring  to  determine  the  extent 
of  injury,  to  put  the  parts  in  the  position  they  were  in  when  the  injury  was 
inflicted.  We  should  try  to  ascertain  the  size  and  nature  of  the  weapon,  and 
the  range  at  which  it  was  fired.  Examine  the  clothing  to  see  if  any  fragments 
are  missing  and  could  have  been  carried  in.  Such  fragments  render  sepsis 
almost  inevitable.  The  surgeon  must  not  feel  it  his  duty  to  probe  in  all  cases. 
In  many  cases  it  is  better  not  to  probe  at  all.  Explore  for  the  ball  when  sure 
that  it  has  carried  with  it  foreign  bodies;  when  its  presence  at  the  point  of 
lodgment  interferes  with  repair;   when  it  is  in  or  near  a  vital  region  (as  the 


General  Considerations  as  to  Treatment  283 

brain);  and  when  it  is  necessary  to  know  the  position  of  the  bullet  in  order 
to  determine  the  question  of  amputation  or  resection.  If  the  wound  is  large 
enough,  the  finger  is  the  best  probe. 

FluJjrer's  aluminum  probe  is  a  valuable  instrument  (Fig.  113),  It  is 
employed  especially  in  brain-wounds,  and  is  allowed  to  sink  into  the  track  of 
the  ball  by  the  influence  of  gravity  after  the  part  has  been  placed  in  a  proper 
position.  If  a  lead  bullet  is  deeply  imbedded,  it  is  possible  to  distinguish  the 
hard  projectile  from  a  bone  by  inserting  the  asepticized  stem  of  a  clay  pipe,  a 
bit  of  pine  wood,  or  Nelaton's  porcelain-headed  probe  (Fig.  in).  On  any 
one  of  these  appliances  lead  will  make  a  black  mark.  No  such  test  can 
be  applied  to  a  military  bullet,  for  this  has  a  hard  metal  jacket,  and  will  not 
make  a  black  mark  on  a  white  substance. 

Though  Nekton's  probe  will  not  show  the  difference  between  a  hard 
projectile  and  bone,  it  is  a  valuable  instrument  to  follow  the  track  of  a  wound. 
The  porcelain  head  ought  to  be  larger  than  it  is  usually  made — in  fact,  it 
should  be  nearly  the  size  of  the  bullet  (Senn)  (Fig.  112). 

In  passing  a  probe  use  no  more  force  than  in  passing  a  catheter. 


Fig.  III.— Nelaton's  bullet  probe. 


Fig.  112. — Senn's  bullet  probe. 


Fig.  113. — Fluhrer's  aluminum  gravitation  probe  (natural  size,  except  the  length,  which  is  twelve 

inches). 

The  indudion  balance  of  Graham  Bell  has  been  employed  to  determine 
the  situation  of  a  bullet.  The  bullet  may  be  located  by  Girdner's  telephonic 
probe.  In  order  to  construct  this  instrument,  take  a  telephone  receiver,  fasten 
one  of  the  wires  to  a  metal  plate  and  the  other  one  to  a  metallic  probe.  Mois- 
ten a  portion  of  the  patient's  body  and  place  the  metal  plate  in  contact  with  it. 
The  surgeon  places  the  receiver  to  his  ear  and  inserts  the  probe  into  the  wound. 
If  the  probe  strikes  metal,  a  click  is  heard  with  distinctness.  A  bullet  may 
be  located  by  LilienthaVs  probe.  This  apparatus  consists  of  a  mouth-prece, 
two  insulated  copper  wires,  and  a  probe.  The  mouth-piece  is  composed  of 
two  plates,  one  of  copper  and  one  of  zinc,  which  are  applied  to  the  sides  of  the 
tongue.  An  insulated  wire  runs  from  each  plate  and  into  the  metal  probe. 
The  tip  of  the  probe  is  composed  of  two  or  four  pieces  of  metal,  is  separated 
from  the  shank  by  a  washer  of  rubber,  and  is  attached  to  the  wires.  The 
operator  closes  the  teeth  upon  the  mouth-piece,  and  inserts  the  probe  into  the 
wound.  If  the  probe  touches  the  bullet,  a  distinct  and  continuous  metallic 
taste  is  appreciable. 

The  best  means  of  discovering  a  bullet  is  to  use  the  fiuoroscope  or  take  a 


284  Contusions  and  Wounds 

skiagraph.  In  order  to  locate  it  accurately,  view  it  through  a  series  of  squares, 
insert  guide-pins,  or,  better  than  either  of  these  plans,  employ  Sweet's  appa- 
ratus. Bullets  are  readily  seen  by  the  fluoroscope  in  the  superficial  soft  parts, 
and  are  discovered  in  deeper  structures  (bone,  abdomen,  lung,  brain,  etc.) 
by  taking  skiagraphs. 

In  extracting  the  ball  use  very  strong  forceps  (Fig.  114).  The  old  Amer- 
ican bullet-forceps  is  useless  for  the  extraction  of  the  hard-jacketed  ball,  as  the 
points  will  not  penetrate  and  the  instrument  will  not  hold. 

If  hemorrhage  is  severe  in  a  gunshot-wound,  enlarge  the  wound,  find  the 
bleeding  vessel,  and  tie  it.  Before  handling  a  gunshot-wound  asepticize  the 
parts  about  it  and  irrigate  the  wound  with  hot  sterile  salt  solution.  In  some 
situations  a  wound  should  be  drained  with  a  short  tube  or  a  bit  of  iodoform 
gauze;  in  other  regions  this  is  unnecessary.  The  dressing  should  be  anti- 
septic. Primary  union  rarely  takes  place  after  a  wound  inflicted  by  a  pistol- 
ball  or  an  ordinary  rifle-ball,  because  of  the  inevitable  necrosis  of  damaged 
tissue  in  the  track  of  the  ball,  but  in  some  cases  it  can  be  obtained.     Primary 


Fig.  114. — Bullet-forceps. 

union  is  frequent  after  injury  by  the  small  hard-jacketed  modern  projectile 
Healing  begins  in  the  depths  of  the  wound  and  extends  toward  the  wound  of 
entrance,  or,  if  there  be  also  a  wound  of  exit,  toward  both.  Radical  opera- 
tions may  be  demanded:  laparotomy,  trephining,  rib-resection,  joint-resec- 
tion, or  amputation. 

Amputation  is  sometimes  demanded  because  of  great  injury  to  the  soft 
parts  (as  by  a  shell-fragment),  the  splintering  of  a  bone,  injury  of  a  joint, 
damage  to  the  chief  vessels  or  nerves,  or  the  destruction  of  a  considerable 
part  of  a  limb.  Perform  a  primary  amputation  if  possible,  and  make  the  flaps 
through  tissue  that  will  not  slough.  In  civil  practice,  with  careful  antisepsis, 
more  questionable  tissue  can  be  admitted  into  a  flap  than  in  military  practice, 
where  transportation  will  become  necessary  and  antisepsis  may  be  imperfect 
or  wanting.  It  has  been  shown  in  recent  years  that  even  when  a  large  joint 
has  been  perforated  by  a  small  hard-jacketed  projectile,  amputation  or  resec- 
tion is  rarely  required  if  the  wound  was  treated  aseptically  from  the  begin- 
ning, but  this  is  scarcely  true  of  the  revolver  bullet. 

Wounds  by  Cannon-balls, — A  cannon-ball  weighing  five  or  six  pounds 
may  be  imbedded  in  tissues.  A  ball  or  sheU  fragments  may  tear  oft"  a  limb 
or  lacerate  it  extensively.  In  some  cases  of  injury  by  spent  balls  the  bone  is 
destroyed  and  the  muscles  disorganized  while  the  skin  is  intact. 

Wounds  in  War  Inflicted  by  Rifle-bullets. — During  the  last  few  years 
frequent  and  notable  improvements  have  been  made  in  the  miUtary  rifle. 
The  range  and  rapidity  of  firing  have  been  vastly  increased,  the  velocity  of  the 
projectile  and  its  penetrating  power  have  been  enormously  added  to,  and  the 
trajectory  has  been  decidedly  lowered.     Hence,  the  zone  dangerous  to  an 


Wounds  in  War  Inflicted  by  Rifle-bullets  285 

enemy  has  been  lengthened.  In  order  to  accomplish  these  things,  changes  have 
been  made  in  the  gun,  the  explosive,  and  the  projectile.  It  is  a  far  cry  from 
the  old  Brown  Bess,  of  song  and  story,  to  the  modern  Lee-Enfield  of  the 
British  army,  or  the  Springfield  of  the  United  States  army.  All  modern 
military  rifles  are  of  small  caliber;  that  is,  less  than  .35  in.  The  Springfield 
rifles  of  the  days  of  the  war  between  the  States  had  a  caliber  of  .45  in.  The 
old  Sjiringfield  [)rojected  a  bullet  at  an  initial  velocity  of  1300  feet  a  second; 
whereas  the  modern  rifle  sends  a  projectile  on  its  way  with  an  initial  velocity  of 
from  2000  to  2300  feet  a  second,  the  bullet  rotating  on  its  long  axis  2500  times 
during  the  first  second  of  translation.  At  a  range  of  50  feet,  such  a  bullet  will 
penetrate  54  inches  of  pine  wood;  and  at  1000  yards,  it  will  penetrate  over  13 
inches  of  pine  wood  (Surgeon-General  O'Reilly,  of  the  United  States  Army,  in 
"Keen's  Surgery,"  Vol.  lY.) .  Up  to  5000  yards  a  modern  rifle  can  inflict  a  fatal 
wound,  and  it  can  be  used  point-blank  at  a  range  of  from  500  to  600  yards.  A 
bullet  from  a  modem  military  rifle,  even  after  having  struck  some  solid,  hard 
body,  may  grievously  injure  a  man  by  ricochet.  With  a  magazine  rifle,  at  2500 
yards,  from  5  to  10  per  cent,  of  the  balls  will  ricochet  from  turf.  At  3000  yards, 
they  will  bury  in  turf,  but  may  ricochet  from  ver}^  hard  ground.  The  United 
States  army  now  uses  a  magazine  Springfield  that  weighs  less  than  9  pounds. 
The  barrel  is  24  inches  in  length,  and  the  diameter  of  the  bore  is  .30  inch. 
The  rifling  makes  one  complete  turn  in  every  10  inches.  With  this  weapon, 
by  magazine  fire,  25  aimed  shots  may  be  fired  in  a  minute;  and  when  used  as 
a  single-loader,  23  aimed  shots  (Surgeon-General  O'Reilly,  U.  S.  A.,  in 
"Keen's  Surgery,"  Vol.  IV.). 

Old-fashioned  Black  Gunpowder  as  Compared  with  Smokeless  Powder. — 
There  are  many  difi'erent  varieties  of  smokeless  powder,  but  each  is  essentially 
a  nitro-powder.  Among  these  smokeless  powders  are  melenite,  used  by  the 
French;  lyddite,  employed  by  the  British;  and  shimose,  adopted  by  the  Japa- 
nese. The  United  States  forces  use  cellulose  nitrate  in  perforated  cylindrical, 
amber-colored  grains.  Nitro-powder  is  very  nearly  smokeless  because  all 
the  products  of  its  combustion  are  gases.  Of  the  products  of  the  combustion 
of  black  gunpowder,  57  per  cent,  by  weight  settle  out  from  the  atmosphere 
in  solid  form  on  cooling. 

There  are  great  advantages  in  the  use  of  smokeless  powder.  It  is  much 
more  powerful  than  black  gunpowder;  hence,  a  smaUer  charge  can  be  em- 
ployed. The  modern  Springfield  requires  a  charge  of  44  grains;  and  at  the 
time  of  the  discharge  the  pressure  in  the  chamber  is  about  49,000  pounds  to 
the  square  inch.  Smokeless  powder  gives  the  bullet  a  greater  velocity,  causes 
less  recoil,  and  fouls  the  barrel  infinitely  less  than  black  powder;  and  the  ab- 
sence of  smoke  maintains  a  clearer  atmosphere  for  observation,  and  also  fur- 
nishes no  sign  of  location  which  might  prove  of  advantage  to  the  enemy. 

Projectiles. — The  bullet  of  a  modem  rifle  is  conical,  has  a  lead  core,  and  is 
hardened  by  being  covered  with  a  mantle  or  jacket  of  copper,  steel,  or  nickel, 
or  of  alloys  of  copper  and  nickel,  or  of  copper,  nickel,  and  zinc.  The  hard 
jacket  is  absolutely  essential,  because  the  speed  of  the  projectile  is  so  great  that 
no  soft  bullet  would  take  the  rifling.  Fragments  would  be  torn  off  from  the 
bullet  in  the  gun,  and  the  grooves  of  the  gun  would  soon  be  filled  ^^^th  metal, 
the  gun  becoming  useless.  The  projectile  of  a  modern  Springfield  rifle  is 
elongated,  and  has  an  ogival  head  of  infinite  radius.     The  air-resistance  is 


286 


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Wounds  in  War  Inflicted  by  Rifle-bullets 


287 


least  in  a  bullet  of  this  shape.     The  core  is  composed  of  lead  hardened  with 
tin,  and  its  jacket  is  of  nickel  and  copper. 

The  military  surgeon  deals  with  wounds  inflicted  with  these  small,  dense, 
hard,  conical  projectiles,  impelled  with  great  velocity,  and  carried  long  dis- 
tances. The  old  bullet  was  liable  to  lodge,  was  often  deflected  in  the  tissues, 
was  flattened  out  on  meeting  with  resistant  structures,  such  as  bone  or  cartil- 
age, and,  after  flattening,  became  larger,  tearing  and  lacerating  the  soft  parts 
and  comminuting  the  bone.  The  modem  projectile  is  likely  to  penetrate,  is 
rarely  deflected,  and  is  so  hard  that  its  shape  is  often  but  little  altered  on 
meeting  with  resistant  structures.  Hence,  it  was  thought  that  the  new  bullet 
would  prove  more  humane  than  the  old  projectile  and  inflict  wounds  that  would 


Fig.  IIS- — I,  Krag-Jorgensen  ;   2,  new  Springfield. 


be  more  easily  treated,  because  the  bullet  would  be  unapt  to  lodge  and  ex- 
tensive damage  w'ould  seldom  be  inflicted.  This  \iew  has  proved,  to  a  great 
extent,  correct. 

With  the  modern  rifle  of  small  cahber  and  the  hard  projectile  propelled 
by  smokeless  powder  the  range  has  been  notably  increased,  the  trajectory 
of  the  bullet's  flight  has  been  greatly  lowered,  and  the  danger-zone  to  an  enemy 
has  been  correspondingly  lengthened. 

Mechanics  of  Projectiles. — If  a  moving  bullet  were  acted  upon  by  no  force 
but  propulsion,  it  would  continue  to  move  in  the  direction  that  it  was  pursuing 
when  it  left  the  muzzle  of  the  gun  and  its  course  would  be  a  straight  line, 
but  it  is  acted  upon  by  other  forces.  Even  in  a  vacuum  its  course  would  not 
be  a  straight,  but  a  cur\-ed  line,  because  gra\-itation  would  draw  it  toward  the 
earth.     Under  ordinar}'  circumstances  the  air  also  resists  its  forward  progress. 

A  mo\-ing  bullet  is  urged  onward  by  the  force  of  the  exploding  powder. 
This  onward  movement  is  called  the  motion  of  translation.     The  rate  of  for- 


288  Contusions  and  Wounds 

ward  movement  is  the  velocity,  and  this  is  expressed  in  feet  per  second.  Air- 
resistance  causes  the  velocity  to  lessen  rapidly,  and  the  farther  av^^ay  from  the 
gun  the  projectile  is,  the  greater  is  its  loss  of  velocity.  For  instance,  on  leaving 
the  muzzle  of  the  Lee-Enfield  rifle,  a  bullet  has  a  velocity  of  2060  feet  a  second 
(muzzle  velocity);  at  700  yards,  it  has  a  velocity  of  1039  feet  a  second;  at  2000 
yards,  571  feet  a  second;  at 3000 yards,  369 feet  a  second  ("Gunshot-wounds," 
by  Major  C.  G.  Spencer) .  The  velocity  of  a  bullet  at  any  particular  portion 
of  its  flight  is  called  remaining  velocity. 

A  bullet  fired  from  a  rifle  rotates  on  its  long  axis.  This  rotation  is  called 
spin  or  the  movement  of  rotation  and  is  in  the  direction  of  the  groove  of  the 
rifling.  It  is  this  motion  that  keeps  the  point  of  the  bullet  toward  the  front 
and  prevents  rotation  on  its  short  axis,  which  would  be  responsible  for  increased 
air-resistance,  diminished  striking  force,  and  lessened  range.  If  a  cylindro- 
conoidal  bullet  were  fired  from  a  smooth  bore,  it  would  rotate  on  its  short  axis 
at  even  as  short  a  range  as  9  yards,  and  would  strike  a  target  in  its  length 
(Stevenson's  "Wounds  in  War  "). 

The  diminution  in  the  transverse  diameter  of  bullets  has  necessitated 
an  increase  in  length  in  order  to  maintain  their  weight  and  sectional  density. 
{Sectional  density  is  the  weight  divided  by  the  area  of  the  cross-section.)  The 
increase  in  length  makes  an  increased  rapidity  of  rotation  indispensable.  The 
higher  the  pitch  of  the  rifling,  the  more  rapid  the  rate  of  rotation  imparted 
to  the  bullet.  The  Minie  rifle  had  a  complete  turn  in  78  inches.  The  United 
States  Army  Springfield  has  a  complete  turn  in  10  inches.  The  velocity  of 
spin  as  the  bullet  leaves  the  barrel  of  a  Springfield  is  about  2500  times  a  second. 
The  velocity  of  rotation  changes  as  the  velocity  of  translation  changes;  and 
when  translation  ceases,  because  the  energy  of  propulsion  has  expended  itself, 
rotation  also  ceases.  "But  when  the  motion  of  translation  is  suddenly  and 
completely  arrested  by  contact  wdth  an  obstacle,  then,  if  the  bullet  is  not  broken 
up,  the  motion  of  rotation  continues  until  its  energy  is  expended  "  ("  Wounds 
in  War,"  by  Surgeon-General  W.  F.  Stevenson,  C.  B.,  A.  M.  S.).  A  rifle  bullet 
in  its  flight  deviates  a  little  laterally,  and  in  the  direction  of  the  groove  of  the 
rifling.  In  the  U.  S.  Army  rifle  the  groove  of  the  rifling  is  toward  the  right 
when  the  gun  is  held  with  the  butt  toward  one;  hence,  the  deviation  of  the 
bullet  is  toward  the  right.     This  lateral  deviation  is  called  drift. 

Influence  of  Gravity  and  Air-resistance. — We  have  previously  stated  that, 
even  if  moving  in  a  vacuum,  the  line  of  flight  of  a  bullet  (the  trajectory)  would 
be  a  curved  and  not  a  straight  line,  because  of  the  influence  of  gravity, 
which  pulls  the  bullet  toward  the  earth.  The  bullet  would  fall  16  feet  the  first 
second,  48  feet  the  second  second,  80  feet  the  third  second,  and  so  on.  A 
bullet  moving  forward  in  a  vacuum  would  advance  through  equal  distances  in 
equal  periods  of  time,  and,  as  gravity  would  draw  it  toward  the  earth  vdth  in- 
creasing rapidity,  the  trajectory  would  be  a  parabola  (Fig.  116,  line  A-E-F-G) . 

Air-resistance  strongly  retards  the  advance  of  a  bullet  and  causes  it  to  lose 
its  velocity  rapidly,  and  a  bullet  fired  in  air  does  not  advance  through  equal 
distances  in  equal  periods  of  time.  Because  of  air-resistance  a  bullet  falls  to 
the  earth  sooner  than  it  would  under  the  influence  of  gravity  alone.  Hence, 
the  trajectory  of  a  bullet  in  air  is  not  a  true  parabola,  but  the  line  of  descent  is 
much  nearer  to  the  vertical  than  would  be  the  case  in  a  vacuum  (Fig.  116,  line 
k-e-hg). 


Wounds  in  War  Intlicted  l)y  Ri lie-bullets 


289 


Air-resistance  depends  upon  the  velocity  of  the  bullet,  the  cross-secdon  area 
of  the  bullet,  the  shape  of  the  head  of  the  bullet,  the  atmospheric  density,  and 
the  steadiness  of  flight  ("Gunshot- wounds,"  by  Major  C.  G.  Spencer). 
Air-resistance  is  least  in  the  bullet  that  tapers  raj)idly.  A  bullet  begins  to  lose 
its  steadiness  of  flight  about  1000  yards  from  the  muzzle  of  the  rifle. 


b     B 


c    d 


Fig.  116. — Trajectories  in  vacuo  and  in  air  (Stevenson). 

The  Danger  Zone. — Owing  to  the  fact  that  the  trajectory  is  a  curved  line 
elevation  must  be  given  to  rifles  except  at  point-blank  range;  and  the  degree  of 
elevation  must  be  increased  according  to  the  range.  Point-blank  range  for  a 
Springfield  is  about  600  yards.  By  this  term  is  meant  that  when  a  gun  is  aimed 
horizontally  the  entire  course  of  the  bullet  up  to  600  yards  is  dangerous  for 
infantry.  For  longer  ranges  the  rifle  must  be  elevated  and  the  bullet  "shot  into 
the  air."  It  becomes  evident  that  when  a  rifle  is  elevated  the  bullet  rises  far 
above  a  man's  head,  and  continues  to  rise  to  what  is  known  as  the  culminating 
point,  when  it  begins  to  descend.  It  does  not  become  dangerous  to  men  undl 
it  gets  near  to  the  earth.     The  point  at  which  it  becomes  dangerous  to  cavalry 


A'  B'  D 

Fig.  117. — Trajectorj',  showing  dangerous  zones  :  A-B-D,  Trajectory  of  bullet ;  D,  point 
of  termination  of  the  bullet's  flight  ;  A-B,  point  of  first  catch  for  cavalry  ;  B,  point  of  first 
catch  for  infantry  ;  A'-D,  dangerous  zone  for  cavalry  ;  B'-D,  dangerous  zone  for  infantry 
(Spencer). 

is  called  "///e  point  of  first  catch  for  cavalry''''  (Fig.  117).  The  point  at  which 
it  becomes  dangerous  for  infantry  is  called  ^Hhe  point  of  first  catch  for  infantry  " 
(Fig.  117).  The  dangerous  zone  (Fig.  117)  is  from  the  point  of  first  catch  to  the 
termination  of  the  bullet's  flight,  because  anywhere  in  this  zone  men  may  be 
struck,  but  between  the  point  of  first  catch  and  the  man  firing  the  gun,  soldiers 
are  perfectly  safe.  The  point  of  first  catch  for  cavalry  is  about  8^  feet  and  for 
infantry  about  6  feet  above  the  ground. 

The  more  nearly  vertical  the  line  of  the  bullet's  descent,  the  shorter  is  the 
danger  zone;  the  less  vertical  the  line  of  descent,  the  longer  is  the  danger 
19 


290  Contusions  and  Wounds 

zone.  The  higher  the  cuhninaling  j)oint  of  the  trajectory,  the  more  vertical 
is  the  line  of  descent;  hence,  the  shorter  is  the  danger  zone;  the  lower  the 
culminating  point,  the  flatter  is  the  trajectory,  and  the  less  vertical  the  line  of 
descent;  hence,  the  longer  the  danger  zone.  The  chief  object  of  improvements 
in  rifles  is  to  lower  the  trajectory  (that  is,  make  it  less  curved)  and  thus  lengthen 
the  danger  zone,  render  marksmanship  more  accurate,  and  insure  velocity. 


Fig.  118. — Trajectories  of  bullets  from  certain  rifles:  i,  Trajectory  of  Lee-Enfield  at  1500 
yards,  action-point,  81  feet  ;  2,  trajectory  of  Martini-Henrj'  at  1500  yards,  action-point,  17S 
feet ;  3,  trajectory  of  Lee-Enfield  at  2000  yards,  action-point,  194  feet ;  4,  trajectory  of  Mar- 
tini-Henry at  2000  yards,  action-point,  357  feet ;  5,  trajectory  of  Snider  at  2000  yards,  action- 
point,  866  feet ;  horizontal  scale, (i  inch=2ooo  feet)  ;  vertical  scale (i  inch=iooo 

24,000  I2,000 

feet).      Vertical    measurements   are    represented   on    twice    as    large    a  scale    as    horizontal 
measurements  (Spencer). 

Power  of  the  Bullet  to  Wound. — According  to  Spencer  (Ibid.) ,  this  depends 
upon  its  energy  and  the  ease  with  w^hich  its  energy  is  converted  into  work  on 
striking.  Energy  is  largely  a  matter  of  range.  At  short  range  energy  is 
enormous,  but  it  rapidly  diminishes  as  the  range  is  increased.  At  3000 
yards  energy  is  only  about  one-sixteenth  of  what  it  is  at  300  yards.  The 
ease  with  which  a  bullet  converts  energy  into  work  depends  upon  (see 
Spencer,  on  "  Gunshot- wounds  ") :  (i)  The  area  of  the  cross-secrion  of  the 
bullet.  The  larger  the  bullet,  the  worse  the  wound.  (2)  The  deforma- 
tion of  the  bullet.  Such  deformation  enlarges  the  area.  A  bullet  that 
expands  on  striking  is  said  to  ''mushroom.'''  The  modern  bullet  seldom 
deforms  much  unless  its  jacket  has  been  more  or  less  torn  off;  and  it  in- 
flicts, as  a  rule,  a  much  less  grave  injury  than  does  the  soft  bullet.  It 
has  been  found  that  this  very  humanity  of  the  bullet  is  at  times  regarded 
as  an  objection.  The  bullet  lacks  "stopping  power"  unless  it  strikes  a  vital 
part  or  a  large  bone,  and  a  wounded  man  may  continue  to  fight  and  charge. 
Civilized  men  ^^dll  usually  stop  w^hen  hit,  but  savages  very  often  will  not. 
Hence,  in  warfare  with  barbarous  people,  it  was  until  recently  the  custom  to 
modify  the  bullet.  A  portion  of  the  bullet  at  the  apex  of  the  projectile  was  left 
exposed,  and  such  a  bullet  was  said  to  be  uncovered  or  to  have  a  ''soft  nose.^' 
It  was  called  a  Dumdum  bullet,  because  such  missiles  were  first  made  at 
Dum.dum,  the  ordnance  factory  near  Calcutta.  When  a  Dumdum  bullet 
.strikes,  it  spreads  and  expands,  or  "mushrooms,"  and  inflicts  an  extensive 
and  dreadful  wound,  which  stops  the  most  ferocious  savage  or  the  most 
fanatical  tribesman.  These  expanding  bullets  are  often  wTongly  called  "ex- 
plosive bullets."  They  have  been  forbidden  by  The  Hague  Convention, 
although  Stevenson  and  some  other  surgeons  maintain  that  they  are  more 
humane  than  were  the  bullets  of  the  Snider  or  the  Martini-Henry  rifle. 

(3)   The  Resistance  Encountered. — If  energy  is  great  (as  at  close  range) 


Wounds  in  War  Intlicled  bv  Rifle-bullets 


291 


and  a  very  resistant  tissue  is  struclc  (bone),  dreadful  injury  may  be  inflicted, 
but  if  a  tissue  with  little  resistance  is  struck,  but  little  damage  may  be  done. 
At  a  long  range  the  energy  of  the  bullet  is  so  lessened  that  the  danger  to  re- 
sistant tissue  will  be  much  less;  whereas  injury  of  soft  parts  will  be  much  the 
same  as  at  close  range. 

The  Nature  of  the  Wounds  Inflicted  by  the  Small  Projectile. — The  effect  of 
lessening  the  size  of  the  bullet  is  to  decrease  its  wounding  power,  because, 
other  things  being  equal,  the  larger  the  bullet,  the  greater  its  wounding  power. 
In  many  instances  the  modern  bullet  \\\\\  make  a  clear  track,  without  lacera- 
tion or  comminution.  It  was  thought,  as  has  been  stated,  that  this  projectile 
would  prove  humane,  that  it  would  kill  comparatively  few,  and  that  the 
wounded  would  receive  injuries  which  would 
incapacitate  them,  but  from  which  most  of 
them  would  subsequently  recover.  Recent 
wars  have  indicated  that  at  a  range  of  over 
1500  yards  the  bullet,  as  a  rule,  penetrates 
cleanly,  making  a  wound  that  heals  by  first 
intention.  Sir  Frederick  Treves  expressed 
his  experience  by  saying,  "the  Mauser  bullet 
is  a  very  merciful  one." 

Very  many  studies  have  been  made  of  the 
action  of  the  modern  bullet,  and  numerous 
experiments  have  been  carried  out — firing 
through  boxes  filled  with  wet  sand,  firing 
into  thick  oak,  firing  at  cadavers  at  fixed 
distances  with  reduced  charges,  and  firing 
at  corpses  and  at  live  horses  with  service 
charges.  Xancrede,  some  years  ago,  wisely 
cautioned  us  to  remember  that  experiments 
upon  the  cadaver,  employing  reduced 
charges  and  standing  at  fixed  distances,  are 
uncertain  in  their  provings.  "The  dift'er- 
ence,"  he  said,  "between  the  velocity  of  rota- 
tion and  the  angle  of  incidence  with  reduced 
charges  at  fixed  distances  and  service  charges 
at  actual  distances  is  marked.  The  tension  of  living  muscle  and  fascia,  as 
compared  with  dead  tissues,  and  the  physical  change  of  the  semiliquid  fat  of 
adipose  tissue  and  medulla  to  a  more  solid  condition  by  the  loss  of  animal 
heat,  influence  the  results"  (Xancrede,  "Gunshot- wounds,"  Roswell  Park's, 
"Surgery  by  American  Authors"). 

All  the  theoretical  conclusions  derived  from  experiment  and  the  observa- 
tions made  on  the  otcasional  \actims  of  suicide  or  homicide  have  been  put  to  the 
test  of  war  in  recent  years;  and  we  now  draw  our  deductions  from  a  study  of  the 
wounds  in  the  Chitral  Expedition,  the  Greco-Turkish  War,  the  Spanish-Ameri- 
can War,  the  South  African  War,  the  taking  of  Pekin.  and  the  Russo-Japanese 
War.  Preconceived  opinions  have,  to  a  great  extent,  at  least  been  confirmed. 
It  has  been  found  that  the  wounds  are  usually  non-infected  and  are  apt  to  heal 
by  first  intention  unless  inflicted  by  ricochet,  which  deforms  the  bullet.  At  a 
range  of  1500  yards  or  more  the  wounds  are  commonly  clear  tracks,  \\athout 


Fig.  119. — Mauser  bullet-wound  of 
chest :  a.  Wound  of  entrance  ;  b,  point 
where  bullet  was  extracted  (Major 
Charles  F.  Kieffer,  U.  S.  A.). 


292 


Contusions  and  Wounds 


much  splintering  of  bone  or  laceration  of  tissues.  The  wound  of  entrance  is 
extremely  small  and  could  be  overlooked  by  a  careless  observer.  It  is  usually 
circular,  it  may  be  triangular.  The  bullet  is  far  less  liable  to  lodge  in  the  body 
than  was  the  older  bullet.     If  it  perforates,  the  wound  of  exit  is  usually  small, 


Fig.  120. — Deformation  of  leaden  bullets  (natural  size)  (Seydel). 

and  may  be  either  round  or  a  slit.  The  wound  of  exit  is  large  if  the  injury 
has  been  inflicted  at  close  range,  or  if  bone  has  been  splintered  and  driven 
along  with  the  bullet. 

Theoretically,  the  projectile  does  not  flatten,  but  it  has  been  found  that  in 
many  instances  it  does  flatten  a  Uttle.     Its  coat  is  apt  to  be  torn  ofl"  when  it 


Fig.  121. — Deformation  of  small-caliber  jacketed  bullets  (after  Bruns). 

strikes  hard  bone  at  a  distance  of  less  than  1800  yards.  Treves  has  pointed 
out  that  if  a  bullet  smashes  a  bone  and  lodges,  the  shell,  as  a  rule,  peels  off 
from  the  core.  Then  the  bullet  may  be  distorted  or  broken  into  fragments. 
At  long  range  the  bullet  may  lodge,  or  it  may  also  do  so  if  it  hits  a  man  after 
bounding  from  a  stone,  hard  ground,  or  a  piece  of  metal.     It  may  lodge  in 


Fig.  122. — I,  Empty  Krag  jacket  removed  from  thigh  after  penetrating  6  inches  at  340 
yards;  2,  3,  4,  5,  lodged  Krag  bullets  removed  from  wounds  after  deflection  from  frozen 
ground.     Ranges  from  50  to  300  yards. 

compact  bone.  In  Cuba,  lo  per  cent,  of  the  wounded  suffered  from  lodged 
bullets.  In  the  Russo-Japanese  War  less  than  4  per  cent,  of  the  wounded 
suffered  from  lodged  rifle  bullets. 

It  is  seldom  that  bits  of  clothing  are  carried  in  ^\^th  the  bullet,  but  some- 
times they  are,  and  some  fabrics  are  more  liable  to  be  carried  in  than  others. 


Wounds  in  War  Inflicted  by  Rifle-bullets  293 

Threads  are  not  unusually  carried  in  on  the  roughened  areas  cut  into  the  bullet 
by  the  grooves  of  the  rifling.  If  the  bullet  ricochets  from  stony  ground,  bits 
of  stone  may  enter  the  tissues. 

Blood-vessels  are  likely  to  be  cut  and  not  pushed  aside,  as  was  often  the 
case  with  the  old-time  bullets.  If  a  large  vessel  is  struck,  primary  hemor- 
rhage is  profuse  and  may  prove  rapidly  fatal.  The  modern  bullet  is  seldom 
deflected  in  the  tissues,  but,  as  a  rule,  it  passes  straight  ahead.  The  skin  is 
usually  split  by  it.  Fascia  and  muscle  are  likely  to  be  much  damaged,  but  in 
a  transverse  wound  of  muscle  the  fibers  may  be  separated  rather  than 
destroyed. 

Although  under  most  circumstances  this  bullet  is  humane,  it  has  been 
found  that  in  some  instances  it  pulpifies  structure  for  a  considerable  distance 
around  the  track  of  the  ball,  producing  what  is  known  as  an  explosive  effect. 
The  cause  of  this  condition  has  been  much  debated,  though  it  never  means  that 
the  bullet  has  exploded.  Some  think  that  it  is  always  due  to  comminution  of 
bone  and  the  blowing  of  bone-fragments  ahead  of  and  around  the  ball.  Most 
believe  that  the  sudden  impact  against  the  tissues  engenders  waves  of  force, 
which  cause  explosive  and  distant  damage.  Certain  it  is  that  an  explosive 
effect  causes  horrible  and  often  irreparable  injury. 

Explosive  effects  are  most  frequently  seen  at  close  range,  when  the  velocity 
of  translation  and  the  frequency  of  rotation  are  most  marked.  Such  injuries 
were  seen  in  the  marines  killed  at  Guantanamo,  in  persons  killed  during  the 
Milan  riots,  and  in  many  instances  in  South  Africa,  China,  and  Manchuria. 

A  pistol  bullet  has  no  explosive  action  at  all|  and  the  old-time  large^^  soft 
bullet  possessed  it  only  at  a  very  close  range.  The  modern  projectile  is  apt  to 
produce  explosive  effects  up  to  500  yards,  but  it  does  not  invariably  do  so.  Up 
to  1300  yards  it  is  Hable  to  produce  them  in  the  skull  and  brain;  and  at  this 
distance  a  single  bullet  may  entirely  destroy  the  cranium.  Explosive  effects 
may  at  times  occur  at  longer  distances  upon  the  Ijver,  spleen,  kidneys,  and  lungs, 
and  upon  hollow  viscera  containing  fluid.  At  a  distance  of  500  yards  or  less 
a  bone  will  usually  be  shattered  into  many  fragments;  whereas,  at  a  range  of 
1500  or  2000  yards,  the  bone  will,  as  a  rule,  be  cleanly  perforated,  usually 
without  comminution. 

It  is  often  extraordinary  how  little  trouble  follows  a  wound  with  a  modern 
projectile  and  how  quickly  heahng  occurs.  This  is  due  to  the  facts  that  the 
tissue  is  cleanly  perforated,  that  foreign  bodies  are  seldom  carried  in,  and  that 
the  wound  rarely  becomes  infected.  This  freedom  from  infection  is  not  due  to 
the  bullet  being  sterile.  It  is  not  sterile,  and  when  the  gun  is  fired  the  bul- 
let does  not  heat  sufificiently  to  certainly  destroy  bacteria.  The  bullet  is 
carried  in  a  dirty  belt  or  pouch,  is  handled  with  dirty  hands,  and  is  not 
clean  when  put  into  the  rifle,  but  its  sides  may  be  scraped  cleaner  by  the 
rifling  and  the  burning  powder  may  disinfect  it  in  part.  The  point,  however, 
contains  bacteria  on  its  surface.  They  are  few  in  number;  are  readily  scat- 
tered in  the  tissues;  and,  in  most  instances,  are  overcome  by  tissue  resistance. 
The  clean  track  of  the  bullet  which  is  usual  in  wounds  inflicted  at  ordinary 
fighting  ranges  impairs  tissue  resistance  much  less  than  a  badly  contused 
and  lacerated  wound.  In  some  observed  cases  there  have  been  almost  no 
symptoms  after  perforation  of  the  lung.  In  others,  none  after  perforation  of 
the  abdomen,  the  joints,  or  skull.     It  is  obvious  that  in  most  conflicts  the 


294  Contusions  and  Wounds 

modern  rifle  is  humane  and  that  its  humanity  is  largely  a  matter  of  range. 
At  a  range  of  1500  yards  or  over  it  is  a  humane  weapon. 

What  used  to  be  called  a  wind  contusion  is  a  severe  and  often  a  dreadful 
injury.  The  skin  being  unbroken,  bones  may  be  broken,  \dscera  ruptured, 
tissues  torn  asunder.  The  older  surgeons  beheved  that  such  an  injury  was 
produced  by  the  wind  pressure,  a  projecdle  passing  close  to,  but  not  touching 
the  surface.  We  now  know  that  they  result  from  a  projectile's  glancing  along 
the  surface,  the  elasticity  of  the  skin  saving  it  from  immediate  destruction, 
although  in  many  instances  it  sloughs  later. 

A  bullet,  in  striking,  never  gets  hot  enough  to  burn  a  part.  It  is  needless  to 
say  that  bullets  are  never  deliberately  poisoned. 

Symptoms. — Pain  is  seldom  severe  in  wounds  of  the  soft  parts,  but  violent, 
immediate  pain  is  felt  when  a  bone  or  a  nerve  is  injured;  the  pain  is  usually 
stinging  or  burning,  but  is  seldom  of  long  duration,  except  in  bone  injuries, 
spinal  cord  injuries,  and  nerve  injuries.  Sometimes  a  man  does  not  know 
he  has  been  struck.  It  is  common  to  have  anesthesia  or  numbness  and  loss  of 
muscle-function  about  the  wound  for  several  hours  or  days. 

Shock  is  very  variable.  In  some  cases  it  is  scarcely  noticeable,  in  others 
it  is  overwhelming.  It  is  most  marked  in  wounds  of  bone,  the  spine,  the  ab- 
domen, and  the  brain.  It  is  greatly  aggravated  by  hemorrhage.  Hemorrhage 
is  great  if  a  large  vessel  is  struck.  If  the  vessel  is  in  a  limb  it  is  seldom  that 
much  blood  escapes  externally,  but  a  large  hemorrhage  occurs  in  the  tissues. 
Such  cases  reach  the  hospital  for  treatment,  and  are  spoken  of  as  "traumatic 
aneurysm."  They  were  quite  common  in  South  Africa.  If  a  great  vessel  is 
divided  in  the  chest  or  abdomen,  the  patient' rapidly  bleeds  to  death  on  the  held, 
and  seldom  reaches  the  hospital  at  all. 

The  bullet  wound  tends  to  remain  uninfected  unless  bits  of  clothing  or 
other  foreign  bodies  have  been  carried  in,  unless  the  bullet  was  deformed,  or 
unless  the  wound  was  at  close  range.  If  suppuration  occurs,  it  is  apt  to  remain 
localized.  Pyemia  and  true  septicemia  are  rare.  In  the  Russo-Japanese  War, 
suppuration  seems  to'  have  been  common.  In  the  Japanese  hospitals  at 
least  60  per  cent,  of  wounds  of  the  soft  parts  by  undeformed  bullets  sup- 
purated. (Report  on  Russo-Japanese  War,  by  ]Maj.  Chas.  Lynch,  ^Medical 
Department,  General  Staff,  U.  S.  A.)  It  is  stated  that  among  the  Russians 
suppuration  occurred  in  30  per  cent,  of  the  cases.  More  wounds  suppurated 
in  winter  than  in  summer.  The  Russians  used  a  larger  bullet  than  the 
Japanese,  and  the  wound  inflicted  by  the  Russian  bullet  was  far  more  liable 
to  suppurate  than  was  that  produced  by  the  Japanese  projectile.  Practically 
all  wounds  of  bone  made  by  Russian  bullets  suppurated.  (Maj.  Lynch, 
Ibid.) 

Treatment. — The  mihtary  surgeon  is  a  speciahst,  and  he  must  know 
many  things  besides  the  treatment  of  the  sick  and  injured.  He  must  be  a 
master  of  hygiene;  he  must  possess  executive  capacity;  he  must  be  able  to 
disclipine  others  and  to  subject  himself  to  discipline;  he  must  be  forceful, 
self-reliant,  and  resourceful;  he  must  be  acquainted  with  the  laws  and  regula- 
tions of  the  military  estabhshment;  and  he  must  have  a  special  knowledge  of 
gunshot-wounds  as  received  in  battle.  Even  the  best  qualified  civil  surgeon 
is  unfit  to  pass  into  military  service  without  special  instruction.  It  is  for  this 
jeason  that  the  United  States  insists  that  every  man  appointed  to  the  Medical 


Treatment  of  Wounds  Inflicted  by  Rifle-bullets  295 

Corps  of  the  Army  or  Navy  shall  receive  special  instruction  in  the  Army  Medical 
School  or  the  Xaval  Medical  School  before  he  goes  to  a  regiment  or  a  ship. 
The  wounds  received  in  wai  are  peculiar,  and  treatment  appropriate  for  a 
wound  inflicted  by  a  revolver  bullet  is  often  inappropriate  or  impossible  for  a 
wound  intlicted  by  the  projectile  of  a  military  ritle. 

In  civil  life  the  patient  has  the  best  of  surroundings.  Every  care  can  be 
given  him.  Numerous  skilled  assistants  are  at  hand  if  needed.  The  problems 
of  the  case  are  entirely  surgical,  and  the  case  can  be  dealt  with  purely  accord- 
ing to  its  surgical  necessities.  In  war  there  are  problems  of  transportaticm 
which  are  not  presented  in  civil  life,  for  strategic  necessity  may  compel  hurried 
movement.  Accommodations,  also,  may  be  bad.  Shelter  may  be  imperfect, 
climate  and  meterological  conditions  may  be  most  trying.  Food  may  be 
scanty  and  inappropriate.  Medicines  may  be  scarce.  There  are  sure  to  be  too 
few  assistants.  After  some  engagements  in  South  Africa  the  British  sur- 
geons had  to  care  for  numbers  of  men  under  difficulties  that  were  appalling, 
among  which  were  fearful  clouds  of  dust  and  swarms  of  flies.  In  other  words, 
the  militan,'  surgeon,  after  a  battle,  is  seldom  able  to  treat  his  cases  purely  in 
accordance  with  surgical  necessities,  but  his  conduct  must  be  influenced  by 
other,  often  imperative,  needs.  If  there  are  numerous  wounded,  he  does  not 
have  time  to  do  immediate  laparotomies.  He  will  lose  some  cases  because  he 
has  not  done  laparotomy,  but  he  would  lose  many  more  other  cases  from  delay 
in  treating  dangerous  but  remedial  conditions  were  he  to  make  many  simpler 
cases  wait  until  his  laparotomies  had  been  performed.  He  is  forced  to  make 
the  abdominal  wounds  wait,  and  after  long  delay  there  is  seldom  any  use  in 
opening  the  abdomen  at  all. 

Again,  the  wound  inflicted  by  the  bullet  of  a  military  rifle  is  ver\-  different 
in  nature  and  in  danger  from  the  wound  inflicted  by  a  revolver  bullet.  In  the 
former,  if  a  large  vessel  is  struck,  it  is  perforated  or  dixided,  and  profuse  bleed- 
ing occurs,  either  into  a  ca\ity  or  in  the  tissues.  If  the  bleeding  occurs  in  a 
cavit}',  the  patient  usually  dies  on  the  field,  and  does  not  reach  the  first  dressing- 
station  at  all.  If  it  occurs  in  the  tissues,  a  "traumatic  aneurysm"  forms.  In 
revolver  bullet  wounds  primary  hemorrhage  is  seldom  severe.  Wounds  with 
revolver  bullets  almost  certainly  suppurate.  Wounds  with  the  undeformed 
hard-jacketed  projectile  that  has  not  richocheted  very  commonly  escape 
infection. 

Wounds  that  in  civil  life  might  require  only  a  resection,  may  in  military 
practice  require  amputation.  The  promise  of  aseptic  healing  leads  the 
military  surgeon  to  trust  many  wounds  without  operation  which  in  civil  life 
would  be  operated  upon  at  once,  and  both  surgeons  would  be  right  in  the 
different  courses  pursued  by  them. 

In  civil  Ufe  the  rule  is  absolute  to  open  the  abdomen  for  ever)'  case  of 
gunshot-wound  entering  that  ca\-ity.  The  experience  of  all  military  men  is 
that  more  cases  get  well  under  a  policy  of  non-interference  than  \\ith  laparot- 
omy. In  mih'tary  surgery  laparotomy  can  be  performed  only  when  there  is 
''time  to  do  it'^;  and,  even  then,  is  performed  only  when  there  is  hemorrhage 
or  else  certain  evidence  or  a  ver}'  strong  probability  that  an  organ  or  \-i5cu5  has 
been  struck  or  perforated.  On  account  of  the  difficulties  in  the  treatment  of 
the  wounded  in  militar}-  life,  as  compared  with  civil  life,  militar}-  surgery  is  a 
pure  specialty';  and  the  details  of  the  treatment  of  wounds  in  war  must  be  sought 


296  Contusions  and  Wounds 

for  in  treatises  by  military  surgeons.  The  watchwords  of  the  military  surgeon 
are  to  preserve  asepsis  and  to  avoid  meddlesome  interference. 

In  handling  patients  in  the  field  the  clothing  is  cut  away  (if  the  wound  is 
under  the  clothing).  If  sterile  water  can  be  obtained  the  wound  and  the  sur- 
face about  is  irrigated  with  it  before  dressings  are  applied.  If  sterile  water 
cannot  be  obtained  the  dressings  are  applied  at  once.  The  dressing  should 
be  absorbent  and,  if  possible,  antiseptic,  rather  than  aseptic  gauze.  Ab- 
sorbent cotton  should  be  placed  over  the  gauze,  and  a  bandage  of  linen 
should  be  applied  to  hold  the  dressing  in  place. 

In  warfare  at  the  present  day  an  attempt  is  made  to  limit  the  death-rate 
from  gunshot-wounds  by  protecting  them  from  infection  at  an  early  period  after 
the  accident.  Esmarch  offered  a  suggestion  which  has  been  adopted  in  the 
armies  of  all  civilized  countries.  Every  officer  and  private  soldier  carries  a 
package  which  contains  antiseptic  dressings,  and  at  the  first  opportunity  after 
the  infliction  of  a  wound,  if  possible  on  the  field,  these  dressings  are  applied  by 
the  soldier,  by  a  comrade  (for  even  the  privates  are  instructed  in  the  applica- 
tion), or  by  an  ambulance  man.  If  not  applied  on  the  field,  they  are  applied 
at  the  first  dressing-station  by  a  surgeon  or  a  hospital  steward.  The  dressing 
is  removed  only  when  there  are  indications  caUing  for  surgical  interference. 
Many  wounds  heal  under  this  primary  dressing.  In  the  United  States  army 
the  first-aid  package  is  carried  in  a  metal  case  to  prevent  contamination  and 
damage  by  moisture.  The  case  is  hermetically  sealed,  but  can  be  easily  opened. 
It  is  carried  hooked  to  the  cartridge  belt.  It  contains  two  bandages,  two  com- 
presses of  absorbent  corrosive  sublimate  gauze,  and  two  No.  3  safety-pins,  all 
wrapped  in  waxed  paper.  One  compress  is  stitched  to  the  center  of  each  band- 
age, and  the  bandage  is  so  folded  that  the  compresses  can  be  opened  without 
touching  its  inner  surface.  (In  the  foregoing  article  I  have  obtained  facts  from 
numerous  sources.  The  following  books  and  articles  I  found  particularly  ser- 
viceable: "Wounds  in  War,"  by  Surgeon-General  W.  F.  Stevenson,  of  the 
British  Army;  "Gunshot-wounds,"  by  Major  C.  G.  Spencer,  of  the  British 
Army;  "Military  Surgery,"  by  Surgeon-General  Robert  M.  O'Reilly,  U.  S.  A., 
in  Vol.  IV.  of  "  Keen's  Surgery  ";  "Naval  Surgery,"  by  Surgeon-General  P.  M. 
Rixey,  U.  S.  N.,  in  Vol.  IV.  of  "  Keen's  Surgery  ";  Treves,  in  the  "British  Medi- 
cal Journal,"  1900;  Senn,  in  "TheHispano-.American  War";  Makin,  "Surgical 
Experiences  in  South  Africa";  "Chirurgie  de  Guerre,"  Paris,  1897,  by  Con- 
stans;  "Surgical  Notes  from  the  Military  Hos[)itals  in  South  Africa,"  by 
Dent;  in  the  "British  Medical  Journal,"  1900;  "Gunshot-wounds,"  by  Maj. 
Wm.  C.  Borden,  U.  S.  A.,  in  the  "American  Practice  of  Surgery,"  by  Bryant 
and  Buck,  Vol.  II.;  "Delorme's  Traite  de  Chirurgie  de  Guerre";  "Recent 
Reports  of  the  Surgeon-General  of  the  U.  S.  A.";  the  "Chitral  Campaign," 
by  H.  C.  Thomson;  "Les  Projecdles  des  Armes  de  Guerre,"  by  Nimier  and 
Laval;  "Fifth  Volume  of  the  Proceedings  of  the  Associations  of  Military 
Surgeons,  U.  S.  A.";  Follenfant,  in  "Archives  de  Medicine  et  de  Pharmacie 
Militaire,"  July,  1906;  "Reports  of  Military  Observers  in  ^Manchuria  during 
the  Russo-Japanese  War,"  by  Maj.  Charles  Lynch,  ^ledical  Department, 
General  Staft",  U.  S.  A.,  1907.)  (For  gunshot- wounds  of  special  structures,  see 
Bones,  Joints,  Abdomen,  Brain,  etc.) 

Poisoned  wounds  are  those  into  which  some  injurious  substance,  chem- 
ical or  bacterial,  was  introduced.     This  poison  may  be  microbic  and  capable 


Malignant  Edema  or  Gangrenous  Emphysema  297 

of  self-multiplication,  or  it  may  be  chemical,  and  hence  incapable  of  multi- 
plication. There  are  three  classes  of  poisons:*  (1)  mixed  infection,  as  septic 
wounds,  dissection-wounds,  and  malignant  edema;  (2)  chemical  poison, 
such  as  snake-bites  and  insect-stings;  a;id  (3)  infection  with  such  diseases 
as  rabies,  glanders,  etc. 

Septic  or  infected  wounds  are  those  which  putrefy,  suppurate,  or 
slough.  Septic  wounds  should  be  opened  freely  to  secure  drainage,  and  hope- 
lessly damaged  tissue  should  be  curetted  or  cut  away.  The  wound  should  be 
washed  with  peroxid  of  hydrogen  and  then  with  corrosive  sublimate,  dusted 
with  iodoform  or  orthoform,  either  drained  with  a  tube  or  packed  with  iodo- 
form gauze,  and  dressed  with  hot  antiseptic  fomentations.  The  part  must  be 
kept  at  rest  and  internal  treatment  should  be  stimulating  and  supporting.  If 
lymphangitis  arises,  the  skin  over  the  inflamed  vessels  and  glands  is  to  be 
painted  \nth  iodin  and  smeared  ^^•ith  ichthyol,  and  quinin,  iron,  and  whisky 
are  given  internally.  The  temperature  is  watched  for  evidence  of  general 
infection  or  intoxication.  The  patient  must  be  stimulated  freely,  nourishing 
food  is  given  at  frequent  intervals,  pain  is  allayed  by  anodynes  if  necessary, 
and  sleep  is  secured.  In  infected  wounds  of  the  extremities  Bier's  treatment 
is  very  useful. 

Dissection=WOundS  are  simple  examples  of  infected  wounds,  and  they 
present  nothing  peculiar  except  virulence.  They  affect  butchers,  cooks, 
surgeons  who  cut  themselves  while  operating  on  infected  areas,  those  who 
make  post-mortems,  and  those  who  dissect.  A  dissection-wound  inflicted 
while  working  on  a  body  injected  with  chlorid  of  zinc  possesses  but  few 
elements  of  danger  unless  the  health  of  the  student  is  much  broken  down. 
If  a  wound  is  simply  poisoned  with  putrefactive  organisms,  there  is  rarely 
serious  trouble.  Post-mortems  are  pecuharly  dangerous  when  the  subject 
has  died  of  some  septic  process.  When  a  wound  is  inflicted  while  dissecting, 
wash  it  under  a  strong  stream  of  water,  squeeze,  and  suck  it  to  make  the  blood 
run,  lay  it  open  if  it  be  a  puncture,  paint  it  with  pure  carbolic  acid,  and  dress 
it  with  iodoform  and  hot  antiseptic  fomentations.  Trouble,  of  course,  may 
follow,  but  often  it  is  only  local,  and  a  small  abscess  forms.  It  should  be 
treated  by  hot  antiseptic  fomentations  and  early  incision.  Occasionally 
lymphangitis  arises,  adjacent  glands  inflame,  and  constitutional  symptoms 
arise.  It  is  rarely  that  true  septicemia  or  pyemia  arises  unless  the  wound 
was  inflicted  while  making  a  post-mortem  upon  a  person  dead  of  septicemia 
or  while  operating  on  a  septic  focus.  If  glands  enlarge  and  soften,  it  may  be 
necessary  to  remove  them  surgically. 

Malignant  edema  or  gangrenous  emphysema  arises  most  commonly 
after  a  puncture.  It  is  due  to  a  specific  bacillus  which  produces  great  edema. 
The  emphysema  which  soon  arises  is  due  to  mixed  infection  with  putrefactive 
organisms.  Pus  does  not  form,  but  gangrene  occurs.  The  disease  is  identical 
with  one  form  of  traumatic  spreading  gangrene  (page  185). 

Symptoms. — The  symptoms  are  identical  with  those  of  traumatic  spread- 
ing gangrene  with  emphysema. 

There  is  a  rapidly  spreading  edema,  followed  by  gaseous  distention  of  the 
tissues  and  by  gangrenous  cellulitis.     The  zone  of  edema  is  at  the  margin  of 
the  emphysema,  and  the  process  spreads  rapidly.     The  emphysematous  zone 
*  "American  Text-Book  of  Surgery." 


298  Contusions  and  Wounds 

crackles  when  pressed  upon.  The  area  of  edema  is  covered  with  blebs  which 
contain  thin,  putrid,  reddish  matter,  and  the  skin  becomes  mottled.  If  a 
wound  exists,  the  discharge  will  be  bloody  and  foul.  If  incisions  are  made, 
a  thin,  brown,  offensive  liquid  flows  out.  High  fever  rapidly  develops,  the 
patient  becomes  delirious,  and  often  coma  arises.  In  most  cases  death  ensues 
in  from  twenty-four  to  forty-eight  hours. 

Treatment. — If  malignant  edema  affects  a  limb  after  a  severe  injury 
amputate  at  once,  high  up.  If  it  affects  some  other  part  or  begins  in  a  limb 
after  a  trivial  injury,  make  free  incisions,  employ  hot,  continuous  antiseptic 
irrigations  or  the  hot  antiseptic  bath,  and  stimulate  freely  (page  iS6j. 

Stings  and  Bites  of  Insects  and  Reptiles:  Stings  of  Bees  and 
Wasps. — A  Ijee's  sting  consists  of  two  long  lances  within  a  sheath  M'ith  which 
a  poison-bag  is  connected.  The  wound  is  made  first  l)y  the  sheath,  the  poison 
then  passes  in,  and  the  two  barbed  or  twisted  lances,  moving  up  and  down, 
deepen  the  cut.  The  barbs  on  the  lances  make  it  difficult  to  rapidly  with- 
draw the  sting,  which  may  be  broken  off  and  remain  in  the  flesh.  Besides 
bees,  hornets,  yellow  jackets,  and  other  wasps  produce  painful  stings.  The 
sting  of  a  wasp  is  rarely  broken  off  in  the  tissues  because  the  beards  on  the 
darts  are  shorter  and  hence  the  sting  is  not  so  firmly  fixed  in  the  flesh,  and  also 
because  these  insects  are  more  rapid  and  nimble  in  their  actions.  Stings  of 
bees  and  wasps  rarely  cause  any  trouble  except  pain  and  swelling.  In  some 
unusual  cases  a  bee-sting  is  fatal;  persons  have  been  stung  to  death  by  a  great 
number  of  these  insects.  If  a  tick  bites  a  person  he  clings  to  his  victim.  If 
an  attempt  is  made  to  pull  it  off  his  barb  remains  in  the  tissues  and  an  abscess 
follows.  If  a  drop  of  ammonia  is  placed  upon  the  tick  he  will  at  once  withdraw 
his  barb.     A  tick  bite  never  causes  constitutional  disturbance. 

Symptoms. — If  general  symptoms  ensue,  they  appear  rapidly,  and  con- 
sist of  great  prostration,  vomiting,  purging,  and  delirium  or  unconsciousness. 
These  symptoms  may  disappear  in  a  short  time,  or  they  may  end  in  death 
from  heart-failure.     Stings  of  the  mouth  may  cause  edema  of  the  glottis. 

Treatment. — To  treat  a  bee-sting,  extract  the  sting  with  splinter  forceps 
if  it  has  been  broken  oft'  and  is  visible  in  the  wound.  If  it  is  not  visible, 
squeeze  the  part  lightly  in  order  to  expel  it,  or  at  least  expel  the  poison.  Pres- 
sure may  be  most  satisfactorily  made  by  means  of  the  barrel  of  a  key.  The 
poison  is  counteracted  by  touching  with  ammonia  or  washing  the  part  in 
ammonia-water,  touching  with  pure  carbolic  acid,  painting  with  tincture  of 
iodin,  or  soaking  in  a  strong  solution  of  common  salt  or  carbonate  of  sodium. 
The  part  may  be  dressed  with  lead- water  and  laudanum,  a  solution  of  washing- 
soda,  or  a  solution  of  common  salt.  If  constitutional  symptoms  appear, 
stimulate. 

Other  Insect=bites  and  Stings. — The  mandibles  of  a  poisonous  spider 
are  terminated  by  a  movable  hook  which  has  an  opening  for  the  emission  of 
poison.  The  bite  of  large  spiders  is  productive  of  inflammation,  swelUng, 
weakness,  and  even  death.  The  bite  of  the  poisonous  spider  of  New  Zealand 
produces  a  large  white  swelling  and  great  prostration;  death  may  ensue,  or 
the  victim  may  remain  in  a  depressed,  enfeebled  state  for  weeks  or  even  for 
months.  The  tarantula  is  a  much-dreaded  spider.  The  scorpion  has  in  its 
tail  a  sting.  The  sting  of  the  scorpion  produces  great  prostration,  dehrium, 
vomiting,  diaphoresis,  vertigo,  headache,  local  swelling,  and  burning  pain, 


Snake-bites  299 

followed  often  by  fever  and  suppuration,  and  occasionally  even  by  gangrene, 
but  it  is  rarely  fatal.  Centipedes  must  be  of  large  size  to  be  formidable  to 
man,  and  the  symptoms  arising  from  their  stings  are  usually  only  local. 

Treatment. — Tic  a  fillet  above  the  bitten  point;  make  a  crucial  incision, 
favor  bleeding,  and  paint  the  wound  with  pure  carbolic  acid  or  some  caustic 
or  antiseptic  (if  in  the  wilds,  burn  with  fire  or  gunpowder) ;  dress  antiseptically 
if  possible,  and  stimulate  as  constitutional  symptoms  appear.  Slowly  loosen 
the  ligature  after  symptoms  disappear.  Chloroform  stupes  and  ipecac  poul- 
tices are  recommended;  also  puncture  with  a  needle  and  rubbing  in  a  mix- 
ture of  3  parts  of  alcohol  and  i  part  of  camphor  (Bauer jie). 

Snake=bites. — The  poisonous  snakes  of  America  comprise  the  copper- 
heads (red  vipers  or  upland  moccasins) ,  water  moccasins  (rice  snakes  or  cotton- 
mouths),  and  rattlesnakes.  The  cobra  of  India  is  a  deadly  reptile.  In  some 
countries  great  numbers  of  people  and  the  lower  animals  are  killed  by  poison- 
ous serpents.  In  India  during  i8g8,  21,921  persons  and  at  least  80,000  cattle 
were  killed  by  snakes  ("Brit.  Med.  Jour.,''  Nov.  25,  1899).  It  used  to  be 
taught  that  there  is  no  essential  difference  in  the  action  of  venoms  of  different 
variedesof  snakes,  and  that  the  venom  of  an  Indian  cobra  is  practically  identical 
with  the  venom  of  an  American  rattler,  any  apparent  difference  in  action  depend- 
ing upon  difference  in  toxic  power  and  the  different  dose  of  poison  introduced. 
We  now  know  that  there  are  essendal  differences  in  venoms  (Leonard  Rogers 
in  "Lancet,"  Feb.  6,  1904).  The  natural  toxic  power  of  the  poison  varies  in 
different  species  and  also  in  different  members  of  the  same  species.  Poison 
injected  into  a  vein  may  prove  almost  instantly  fatal.  The  poison  is  not  ab- 
sorbed by  the  sound  mucous  membranes.  Poison  is  harmless  when  given  by 
the  mouth  and  swallowed,  but  if  direcdy  introduced  into  the  intestine  of  an 
animal  it  is  certainly  fatal.  The  pancreatic  ferment  destroys  the  toxic  power 
of  the  venom  (R.  H.  Elliot,  in  "Brit.  Med.  Jour.,"  May  12,  1900).  The  venom 
is  discharged  through  the  channeled  fangs  of  the  reptile,  ha\ing  been  forced  out 
by  contractions  of  the  muscles  of  the  poison-bag.  In  most  varieties  of  snakes 
the  teeth  lie  along  the  back  of  the  mouth  and  are  only  erected  when  the  reptile 
strikes.  The  maxillary  bones  of  the  rattlesnake  are  very  short  and  move 
with  great  freedom  at  the  prefrontal  articulation.  The  fangs  are  attached  to 
the  maxillar}'  bones  and  move  with  the  bones.  The  fangs,  when  depressed,  are 
carried  in  a  fold  of  mucous  membrane.  When  the  animal  is  ready  to  strike  the 
fangs  are  erected  into  a  vertical  position  and  carried  to  the  front  of  the  mouth. 
Cope  describes  the  movement  used  by  the  rattlesnake  in  biting.  The  body 
springs  forward,  but  never  more  than  two-thirds  of  the  reptile's  length,  the  jaws 
seize  the  tissues  and  then  the  fangs  penetrate  and  move  to  and  fro  as  the  poison 
emerges  from  them.  Snake-poison  is  a  thin,  greenish-yellow,  turbid,  sterile 
fluid,  of  acid  reaction  and  of  a  disrinctive  odor.  The  two  chief  poisonous 
principles  are  called  venom-peptone  and  venom-globulin  (Gustave  Langmann, 
"^Medical  Record,"  Sept.  15,  1900). 

Symptoms. — Rogers  ("Lancet,"  Feb.  6,  1904)  divides  poisonous  snakes 
into  two  classes:  the  cohihrines  (of  which  the  cobra  is  an  example)  and  the 
viperines,  which  are  not  so  poisonous  (this  class  includes  rattlesnakes  and  puff 
adders).  Colubrine  venom,  according  to  this  observer,  causes  paralysis  of 
the  respiratory  center  and  of  the  motor  end  organs  of  the  phrenic  nerves, 
destruction  of  red  blood-corpuscles,  lessened  coagulabihty  of  blood,  and  death 


300  Contusions  and  Wounds 

by  respiratory  paralysis.  Viperine  venom  causes  paralysis  of  the  vasomotor 
center,  great  destruction  of  red  corpuscles,  some  viperine  venoms  may  cause 
thrombosis,  and  death  from  any  one  of  them  is  due  to  vasomotor 
paralysis.  The  venom  of  some  snakes,  Rogers  says,  contains  a  mix- 
ture of  the  above-mentioned  venoms  (among  such  snakes  are  the  Aus- 
tralian colubrines  and  the  American  pit-adders).  The  mortality  from 
snake-bites  varies.  The  mortality  in  India  from  cobra  bites  is  about  25 
per  cent.  (Sir  Joseph  Fayrer).  The  mortality  in  America  from  rattlesnake 
bites  is  about  the  same.  The  local  symptoms  are:  pain,  soon  becoming 
intense;  mottled  sweUing  of  the  bitten  part,  which  swelling  may  be  enormous, 
and  which  is  due  to  edema  and  extravasation  of  blood,  and  assumes  a  pur- 
puric discoloration.  The  bite  0}  a  cobra  produces  inflammation  and  marked 
spreading  edema.  It  may  be  recovered  from  without  S}Tnptoms  or  with 
trivial  s}Tnptoms  it  may  induce  profound  systemic  involvement.  The  gen- 
eral symptoms  begin  in  a  comparatively  few  minutes.  The  coagulating 
power  of  the  blood  is  lost,  there  is  great  destruction  of  red  corpuscles.  The 
patient  is  terror-stricken  and  soon  becomes  unable  to  stand  because  of  weak- 
ness of  the  legs.  Glosso-laryngeal  paralysis  arises,  and  talking  and  swallowing 
become  impossible.  There  is  a  profuse  flow  of  saUva,  perhaps  nausea  and 
vomiting.  The  patient  may  be  dull  mentally  but  is  not  unconscious.  The 
paralysis  becomes  widespread,  and  finally  the  diaphragm  and  respiratory 
center  become  involved,  and  death  occurs  from  respiratory  paralysis.  Arti- 
ficial respiration  may  prolong  life  for  hours  (Sir  Joseph  Fayrer).  Bad  cases 
usually  die  in  three  or  four  hours,  but  life  may  last  for  many  hours.  A  rattle- 
snake  bite  produces  severe  pain  and  mottled  swelHng  from  blood  extravasation. 
In  some  cases  there  is  enormous  swelling  from  edema  and  blood;  the  discol- 
oration in  such  a  case  is  purpuric.  The  blood  of  the  victim  quickly  undergoes 
hemolysis  and  loses  the  power  of  coagulation.  It  was  previously  stated  that 
in  laboratory  experiments  it  has  been  shown  that  viperine  poison  may  produce 
thrombosis,  but  it  does  not  do  so  in  man,  as  it  contains  a  very  small  amount 
of  the  coagulating  element  (Rogers).  Extravasations  of  blood  occur  in  serous 
and  mucous  membranes  and  in  the  skin,  petechial  spots  frequently  arising 
upon  the  cutaneous  surface.  There  may  be  free  bleeding  from  mucous  sur- 
faces and  great  extravasation  beneath  the  conjunctivae.  These  blood  extrav- 
asations are  due,  according  to  Flexner,  to  destruction  of  vascular  endotheUum. 
General  symptoms  begin  in  from  a  few  minutes  to  several  hours.  The  symp- 
toms are  those  of  profound  shock,  possibly  with  delirium,  the  vaso-motor  center 
being  exhausted  and  finally  paralyzed.  There  is  usually  muscular  twitching, 
convulsions,  and  finally  paralyses  are  noted  in  most  cases  (pharyngeal  palsy, 
paraplegia,  and  ascending  paralysis).  There  maybe  complete  consciousness, 
or  there  may  be  lethargy,  stupor,  or  coma.  Death  may  occur  in  about  five 
hours,  but,  as  a  rule,  it  is  postponed  for  a  number  of  hours.  If  death  is  deferred 
for  a  day  or  more,  profound  sepsis  comes  upon  the  scene,  with  glandular 
enlargement,  suppuration,  and  sometimes  gangrene. 

Treatment. — Cases  of  snake-bite  must,  as  a  rule,  be  treated  without 
proper  appliances.  The  elder  Gross  was  accustomed  to  relate  in  his  lectures 
how  he  had  seen  an  army  officer  blow  off  his  finger  with  a  pistol  the  moment 
after  it  was  bitten  by  a  rattlesnake,  and  thus  escape  poisoning.  In  general, 
the  rules  are  to  twist  several  fillets  at  different  levels  above  the  bite,  to  excise 


Anthrax  301 

the  bitten  area,  to  suck  or  cup  it  if  possible,  and  to  cauterize  it  with  pure  acid 
or  by  heat.  An  expedient  among  hunters  is  to  cauterize  by  pouring  a  very  little 
gunpowder  on  the  excised  area  and  applying  a  spark,  or  by  laying  a  hot  ember 
on  the  wound.  When  a  hot  iron  is  available,  use  it.  The  fillets  are  not  to  be  re- 
moved suddenly,  and  they  had  best  be  kept  on  for  some  time.  Remove  the  high- 
est constricting  band  first;  if  no  symptoms  come  on  after  a  time,  remove  the 
next,  and  so  on ;  if  symptoms  appear,  reapply  the  fillet.  Some  surgeons  inject  in 
many  places  about  the  wound  a  few  drops  of  a  10  per  cent,  watery  solution  of 
chlorid  of  calcium.  It  is  taught  by  others  that  if  a  man  is  bitten  by  a  large 
and  deadly  snake,  the  surgeon,  if  one  is  at  hand,  should  at  once  amputate 
well  above  the  bite.*  Wjiiter  Blyth  pointed  out  that  permanganate  of  potas- 
sium mixed  with  an  equal  weight  of  cobra  venom  renders  the  venom  inert. 
A  number  of  surgeons  have  treated  snake  bites  by  injecting  in  and  about  the 
wound  a  i  per  cent,  solution  of  permanganate  of  potassium,  but  this  plan  is  in- 
efficient. Rogers  ("Lancet,"  Feb.  6,  1904)  says  we  should  tie  a  fillet  around 
the  hmb  above  the  bitten  part,  take  a  knife  and  enlarge  the  wound  and  rub 
in  crystals  of  permanganate.  WTiatever  local  treatment  is  employed  stimu- 
lants are  to  be  given  and  large  doses  of  alcohol  are  very  generally  rehed  upon. 
Some  give  strychnin  hypodermatically,  others  ether,  others  digitahs.  Hal- 
ford,  of  Australia,  advocated  the  intravenous  injection  of  ammonia  (10  n^ 
of  strong  ammonia  in  20  nx  of  water),  AdrenaHn  as  given  in  shock,  is  indi- 
cated if  the  vaso-motor  center  is  becoming  paralyzed,  and  auto-transfusion 
and  external  heat  are  also  indicated.  If  the  respiration  is  failing  artificial 
respiration  and  oxygen  inhalation  are  required.  Attempts  are  being  made 
to  obtain  a  curative  serum.  Animals  can  be  rendered  immune  by  giving 
them  at  first  small  doses  of  the  poison  and  gradually  increasing  the  amount 
administered.  It  is  asserted  that  the  serum  of  immune  animals  will  cure  a 
person  bitten  by  a  venomous  snake.  Cures  have  been  reported  after  the  use 
of  Calmette's  antivenene  serum.  Antivenene  is  obtained  by  immunizing  a 
horse  by  injecting  attenuated  venom.  The  mixture  to  be  attenuated  consists 
of  80  parts  of  cobra  venom  and  20  parts  of  viperine  venom.  It  takes  a  number 
of  months  to  obtain  strong  antivenene.  The  dose  is  from  10  to  20  cc. 
hypodermatically,  repeated  if  necessary  in  three  or  four  hours.  It  seems  cer- 
tain, however,  that  no  single  serum  can  antidote  the  venom  of  all  varieties  of 
serpents  (A.  T.  F.  Macdonald,  of  Australia),  and  it  has  been  shown  that, 
though  Calmette's  antivenene  is  antagonistic  to  colubrine  venom,  it  is  inert 
against  viperine  venom.  Again,  as  Rogers  says,  it  deteriorates  quickly  in 
hot  climates  and  is  seldom  on  hand  when  wanted.  The  horse  can  be  immun- 
ized against  rattlesnake  venom,  and  antivenene  obtained  from  the  horse  may  be 
used  against  rattlesnake  poison. 

The  poisonous  lizard   (Gila  monster)  can  kill  small  animals,  but  it 
is  not  believed  that  its  bite  is  ever  fatal  to  man. 

Anthrax  (Malignant  Pustule,  Charbon,  Wool-sorters'  Disease, 
MiLZBRAND,  or  Splenic  Fever)  is  a  term  used  by  some  as  synonymous  wnth 
ordinary  carbuncle,  but  it  is  not  here  so  employed.  It  is  a  specific  contagious 
disease  resulting  from  infection  with  the  bacillus  of  anthrax.  Animal  anthrax  is 
particularly  common  in  the  East  and  in  Russia,  and  is  frequently  met  with 
in  Germany,  Italy,  and  South  America.  In  some  regions  so  many  cases 
*  Charters  James  Symonds  in  "  Heath's  Dictionary  of  Practical  Surgery." 


302 


Contusions  and  Wounds 


arise  year  after  year  that  the  district  obtains  an  evil  notoriety.  It  is 
stated  that  in  Novgorod,  Russia,  in  four  years,  "56,000  horses,  cattle 
and  sheep,  and  528  men  perished  from  anthrax"  (Frank  S.  Billings,  in 
"Twendeth  Century  Pracdce").  It  is  a  rare  disease  in  the  United  States. 
In  Philadelphia  cases  occasionally  occur  in  workers  in  the  woolen  mills.  The 
author  has  seen  three  cases  of  human  anthrax,  two  of  which  occurred  in 
Philadelphia  and  one  in  New  Jersey.  Herbivora  are  most  liable,  next 
omnivora,  but  carnivora  seldom  suffer.  Anthrax,  as  met  with,  in  man,  is 
a  disease  contracted  in  some  manner  from  an  animal  with  splenic  fever. 

It  may  be  contracted  by  inocula- 
tion by  working  around  diseased 
animals,  by  handling  or  tanning 
their  hides,  or  by  sorting  their  hair 
or  wool;  Ijrush-makers,  spinners, 
workers  in  horn  and  combers,  rag 
sorters,  veterinary  surgeons,  clip- 
])ers,  stockmen,  farmers,  and 
butchers  may  become  inoculated. 
Infection  may  take  place  through 
the  hair  follicles  of  unbroken  skin. 
Alenschig  reported  two  such  cases 
("N.  Y.  Med.  Jour.,"  Nov.  18, 
1905).  Antlirax  may  be  conveyed 
by  eating  infected  meat  or  by 
drinking  infected  milk.  Flies  may 
( arry  the  poison.  Inhalarion  of 
poisoned  dust  may  infect  the  lungs. 
Catgut  ligatures  may  be  contami- 
nated and  carry  the  poison.  Many 
attempts,  not  altogether  Satisfac- 
tory, have  been  made  to  render 
animals  immune  (Pasteur,  Wool- 
bridge,  Hankin) .  Pasteur's  method 
has  been  used  in  France  with  de- 
cided success,  but  with  less  success  in  other  countries.  Certain  organisms 
are  antagonistic  to  anthrax  (the  streptococcus  of  erysipelas,  the  pneumo- 
coccus,  the  micrococcus  prodigiosus,  and  the  bacillus  pyocyaneus). 

Forms  of  Anthrax. — There  are  two  forms  of  the  disease — external  and 
internal.  Internal  anthrax  may  be  intestinal  from  eating  diseased  meat  or 
pulmonary  from  inhalation  of  poisoned  dust.  Intestinal  anthrax  arises  only 
when  the  bacilli  in  the  meat  contain  spores.  Koch  and  others  have  pointed 
out  that  the  non-sporulating  bacteria  are  destroyed  by  the^  gastric  juice. 
External  anthrax  may  be  anthrax  carbuncle  or  anthrax  edema.  Anthrax 
carbuncle  or  malignant  pustule  appears  on  an  exposed  portion  of  the  body, 
especially  the  hand  or  fingers,  in  over  80  per  cent,  of  cases  of  external  anthrax. 
I  saw  one  upon  the  temple.  It  appears  in  from  twenty-four  hours  to  six  days 
after  inoculation,  and  presents  an  itching,  burning  papule  with  a  purple  center 
and  a  red  base;  in  a  few  hours  the  papule  becomes  a  vesicle  which  contains 
bloody  serum  and  the  tissues  about  the  papule  become  swollen,  reddened,  and 


Fig.  123.— Anthrax.  Case  in  author's  wards 
in  Philadelphia  Hospital,  recovered.  Treated 
by  ipecac  both  externally  and  internally. 


Treatment  of  External  Anthrax  303 

indurated.  The  vesicle  bursts  and  dries,  the  base  of  it  swells  and  enlarges, 
other  vesicles  appear  in  circles  around  it,  and  there  is  developed  an  "  anthrax 
carbuncle,"  which  shows  a  black  or  purple  elevation  with  a  central  depression 
surrounded  by  one  or  more  rings  of  vesicles.  The  surrounding  tissues  become 
purple,  and  great  edema  may  spread  widely,  the  vesicles  grow  very  large  and 
new  vesicles  form,  and  gangrene  may  occur.  Pain  is  trivial  or  absent.  Lym- 
phatic enlargements  occur  but  pus  does  not  form.  Within  forty-eight  hours 
after  the  pustule  begins  micro-organisms  usually  appear  in  the  blood.  The 
constitutional  symptoms  may  rapidly  follow  the  local  lesion,  but  may  be  de- 
ferred for  a  week  or  more.  The  patient  feels  depressed,  has  obscure  aches  and 
pains,  and  is  feverish,  but  usually  keeps  about  for  a  short  period.  After  a 
time  he  is  apt  to  develop  rigors,  high  irregular  fevers,  sweats,  acute  fugitive 
pains,  diarrhea,  delirium,  typhoid  exhaustion,  dyspnea,  cough,  and  cyanosis. 
The  carbuncle  of  anthrax  is  distinguished  from  ordinary  carbuncle  by  the 
central  depression,  the  adherent  eschar,  the  absence  of  pain,  tenderness,  and 
suppuration  of  the  first,  as  contrasted  with  the  elevated  center,  the  multiple 
foci  of  suppuration  and  sloughing,  and  the  more  severe  pain  usual  in  the 
second.  If  anthrax  has  a  visible  lesion  and  the  constitutional  symptoms  are 
slight  or  absent  the  chance  of  cure  is  good.  In  cases  which  get  well  a  line 
of  demarcation  forms  about  the  pustule  and  the  gangrenous  area  is  rather 
rapidly  cast  off,  a  granulating  surface  remaining. 

Anthrax  Edema. — An  area  of  edema  surrounds  a  malignant  pustule  and 
often  spreads  widely,  but  in  cases  of  external  anthrax  without  a  pustule  there 
is  edema  alone.  This  lesion  occurs  in  connective  tissue,  especially  loose 
tissue.  It  is  a  spreading,  Hvid  edema,  with  an  ill-defined  margin.  There 
is  no  pain  and  usually  no  vesication  and  no  fever.  In  severe  cases,  however, 
there  is  fever,  vesicles  form,  and  gangrene  may  arise.  Anthrax  edema  differs 
from  cellulitis  in  the  absence  of  pus  formation,  and  from  mahgnant  edema 
by  the  less  disposition  to  result  in  gangrene.  Two  of  the  cases  I  have  seen 
were  anthrax  edema.  In  Horwitz's  case  in  the  Philadelphia  Hospital  the 
forearm,  arm,  and  shoulder  were  enormously  edematous.  In  Keen's  case 
in  the  Jefferson  College  Hospital  the  forearm  and  arm  were  edematous. 

Prognosis. — The  former  estimate  of  the  death-rate  from  external  anthrax 
was  from  25  to  30  per  cent.  If  upon  the  face  the  prognosis  is  much  worse  than 
if  upon  the  extremities,  and  if  upon  the  upper  extremity  worse  than  if  upon 
the  lower.  It  is  claimed  that  the  death-rate  has  been  notably  reduced  by 
modern  treatment,  and  under  serum  treatment  is  said  to  be  but  little  over  6  per 
cent.  In  a  series  of  15  cases  of  external  anthrax  reported  by  Royer  and  Holmes 
there  were  3  deaths  ("Therapeutic  Gazette,"  Jan.,  1908).  Eleven  of  these 
cases  received  serum  and  of  the  eleven  two  died. 

Pulmonary  anthrax  and  intestinal  anthrax  have  been  regarded  as  in- 
variably fatal,  but  vastly  better  results  may  be  looked  for  hereafter. 

Treatment  of  External  Anthrax. — If  a  person  is  wounded  by  an  object 
suspected  of  carrying  the  infection,  cauterize  the  wound  with  the  hot  iron.  A 
sufferer  from  anthrax  must  be  isolated  in  a  well- ventilated  room.  All  dress- 
ings are  to  be  burned,  all  discharges  asepticized,  and  after  the  removal  of  the 
patient  the  bed-clothes  are  burned  and  the  room  disinfected.  A  malignant 
pustule  should  be  entirely  excised,  and  the  wound  mopped  out  with  pure 
carbolic  acid  or  burned  with  the  hot  iron.     If  there  is  an  extensive  area  of 


304  Contusions  and  Wounds 

edema  it  should  be  freely  incised  at  several  point.-.  The  area  about  the  excised 
pustule  should  be  injected  w^ith  a  5  per  cent,  solution  of  carbolic  acid.  The 
wound  and  the  edematous  area  should  be  dressed  with  hot  antiseptic  fomen- 
tations, and,  if  dealing  with  an  extremity,  a  sphnt  is  applied.  Excision 
should  be  practiced  even  when  glands  are  enlarged,  but  it  will  prove 
ineffectual,  as  a  rule,  if  organisms  are  present  in  the  blood.  When  excision 
cannot  be  pjerformed  make  crucial  incisions  through  the  lesion,  mop  the 
wounds  with  pure  carbolic  acid,  and  inject  about  and  in  the  pustule  car- 
bolic acid  (i  :  20)  every  six  hours  until  the  disease  abates  or  toxic  symp- 
toms appear.  Dress  the  part  as  directed  above.  In  a  successful  case  the 
adherent  eschar  is  finally  separated  by  the  influence  of  the  fomentations. 
Davaine  advised  the  following  plan:  Inject  the  pustule  and  the  tissues  about 
it  at  many  points  every  eight  or  ten  hours  with  i  part  of  tincture  of  iodin 
diluted  with  2  parts  of  water  or  with  a  10  per  cent,  solution  of  carbolic  acid, 
or  with  a  0.1  per  cent,  solution  of  corrosive  sublimate.  Dress  with  wet  anti- 
septic gauze  and  apply  an  ice-bag.  Personally  I  would  not  use  an  ice-bag 
on  an  area  of  infection  but  would  prefer  heat.  In  anthrax  edema  inject  a 
5  per  cent,  solution  of  carbolic  acid  into  the  apparently  sound  skin  and  sub- 
cutaneous tissue  just  above  the  margin  of  the  edema  and  repeat  the  injections 
ever}'  six  hours.  Make  free  multiple  incisions  in  the  edematous  area  carry- 
ing each  incision  down  to  the  deep  fascia.  Dress  with  hot  antiseptic  fomen- 
tations and  if  dealing  with  a  limb  apply  a  splint.  In  Keen's  very  severe 
case  of  anthrax  edema,  this  treatment  was  carried  out  by  George  J. 
Schwartz  and  recovery  followed.  Constitutional  treatment  in  anthrax  edema 
or  malignant  pustule  must  be  sustaining  and  stimulating.  Maffucci  gives 
carbolic  acid  internally,  and  also  uses  it  externally.  Davies-Colley  uses  ipecac 
locally  and  gives  gr.  v  by  the  mouth  every  four  hoiu"s.  Statistics  indicate 
that  the  serum  treatment  is  of  the  greatest  value.  The  material  is  known 
as  Sclavo's  serum;  it  is  obtained  from  the  immunized  ass,  and  it  was  in- 
troduced into  practice  in  1897.  It  is  perfectly  harmless  and  may  be  given  in 
a  vein  or  subcutaneously.  Sclavo  injects  40  cc.  in  different  regions  of  the  wall 
of  the  abdomen.  If  improvement  is  not  obvious  in  twent}'-four  hours  the  dose 
is  repeated.  Intravenous  injection  is  reserved  for  severe  cases,  the  dose  being 
10  cc.  into  a  subcutaneous  vein  of  the  dorsal  surface  of  the  hand.  The  serum 
can  do  no  harm  and  should  always  be  given.  If  given  early,  all  cases  but  very 
severe  ones  \\ill  recover  (Legge's  Xilray  Lectures,  "Brit.  Med.  Jour.,"  March  18, 
1905).  The  persistence  of  anthrax  infection  in  a  room  was  well  shown  in  the 
record  of  Keen's  case.  The  infection  lingered  on  the  floor  of  the  room  in  which 
the  patient  had  been  operated  upon  for  a  long  time.  Three  disinfections  were 
necessarv'  before  it  became  impossible  to  obtain  anthrax  bacilli  from  the  con- 
taminated floor.  This  indicates  that  such  a  case  should  be  operated  upon  in  a 
room  not  regularly  used  for  operations. 

Hydrophobia,  Rabies  of  Lyssa. — Hydrophobia  is  a  spasmodic  and 
paralytic  disease  due  to  inoculation  \\ith  the  virus  from  a  rabid  animal.  In- 
oculation is  nearly  always  through  a  wound,  but  cases  occur  after  the  licking 
of  the  hand  by  a  diseased  dog.  The  disease  does  not  appear  to  arise  except 
as  the  result  of  inoculation.  It  is  most  common  in  dogs  and  wolves,  but  it 
may  develop  in  cats,  horses,  goats,  foxes,  cattle,  sheep,  and  pigs.  It  is  far 
more  common  in  the  camivora  than  the  herbivora.  It  is  said  that  poultry 
may  suffer  from  it.     Human  hydrophobia  in  most  instances  follows  dog  bites. 


Symptoms  of  Hydrophobia  305 

Roux  estimates  that  about  14  per  cent,  of  the  people  bitten  by  mad  animals 
develop  the  disease.  If  the  bite  is  on  an  exposed  part,  it  is  far  more  apt  to 
cause  rabies  than  if  the  ral^id  animal's  teeth  passed  through  clothing.  The 
saliva  is  the  usual  vehicle  of  contagion,  but  other  lluids  and  tissues  contain  the 
virus,  especially  the  brain  and  cord.  The  blood  and  urine  do  not  contain  it. 
Hydrophobia  has  been  known  for  centuries.  It  is  not  spoken  of  by  Hippoc- 
rates, but  is  described  by  Aristotle,  Pliny,  and  Celsus,  and  is  alluded  to  by 
Plutarch.  At  the  present  day  some  ardent  antivivisectionists  dispute  its 
existence.  The  fact  that  an  infant  bitten  by  a  rabid  animal  may  develop  rabies 
proves  that  the  disease  is  not  due  to  the  imagination.  Hydrophobia  is  almost 
invariably  fatal.  No  causative  micro-organism  has  been  demonstrated.  One 
must  exist,  but  it  probably  escapes  detection  because  of  its  very  small  size. 
Negri  has  discovered  in  the  central  nervous  system  bodies  which  are  probably 
protozoa  and  are  perhaps  the  cause  of  the  disease.  They  are  called  Negri 
bodies.  The  poison  cannot  gain  entrance  through  sound  mucous  membrane. 
It  used  to  be  thought  that  the  disease  was  particularly  apt  to  arise  in  hot  weather, 
but  it  is  now  known  that  it  may  occur  any  time  of  the  year.  There  was  a 
veritable  epidemic  of  it  among  the  animals  in  Greenland  in  i860  and  at  this 
time  the  temperature  averaged  25  degrees  below  zero  (F.  W.  Dudley,  in  "  Jour. 
Am.  Med.  Assoc,"  Dec.  19,  igo8).  It  is  common  in  Russia.  No  portion  of 
the  world  is  completely  exempt.  No  constant  post-mortem  lesions  have  been 
certainly  demonstrated  in  those  dead  of  rabies.  Gowers  believes  that  in  the 
spinal  cord  there  is  hyperemia,  but  no  infiltration  with  cells,  whereas  in  the 
medulla,  especially  about  the  respiratory  center,  there  are  hyperemia  and  cellu- 
lar infiltration  of  the  perivascular  spaces.  But  such  perivascular  infiltration 
can  occur  in  some  other  acute  conditions  and  hence  is  not  characteristic.  What 
is  known  as  the  rabic  tubercle  is  found  in  the  medulla  and  about  the  motor 
cells  of  the  upper  part  of  the  spinal  cord.  Each  tubercle  consists  of  an  aggre- 
gation of  embryonal  cells,  which  destroy  and  finally  replace  the  nen-e-ceUs 
which  they  surround.  Babes  thinks  the  tubercle  characteristic.  Infiltration  of 
the  ganglia  with  epithelioid  cells  and  round  cells  has  been  held  by  some  to  be 
characteristic,  but  both  the  rabic  tubercle  and  gangHon  infiltration  occur 
in  other  conditions.  The  disease  is  extremely  rare  in  the  United  States  and 
the  author  has  never  seen  a  single  case. 

If  a  dog  is  poisoned  with  barium  carbonate  the  symptoms  are  similar  to 
those  of  rabies  (see  Univ.  of  Penna.  Health  Bulletin,  Aug.,  1909). 

Symptoms. — The  period  of  incubation  of  human  hydrophobia  is  from  a 
few  weeks  to  several  months,  and  it  has  been  alleged  that  it  may  even  be  two 
years,  but  it  is  very  doubtful  if  there  is  ever  a  period  of  incubation  of  over 
six  or  seven  months.  The  average  incubation  period  in  man  is  forty  days 
(Ravenel).  The  initial  symptoms  are  mental  depression,  anxiety,  sleepless- 
ness, restlessness,  headache,  malaise,  and  often  pain  or  even  congestion  in 
the  cicatrix.  The  anxiety  which  is  usually  present  may  be  deepened  into 
actual  fear.  In  dogs  the  condition  of  fear  is  so  evident  that  Caelius  Aure- 
lianus  centuries  ago  called  the  disease  pantophobia  (fear  of  everything). 
The  previously-mentioned  symptoms  are  quickly  followed  by  dysphagia. 
It  is  not  only  water  that  is  difficult  to  swallow  but  everything  the  patient 
tries  to  drink  or  eat.  The  difficulty  in  swallowing  results  apparently  from 
apnea  produced  instantly  when  an  attempt  is  made  to  swallow.  Curtis 
points  out  that  the  difficulty  is  not  spasm  of  the  pharynx  and  larynx,  but 


3o6  Contusions  and  Wounds 

a  sense  of  immediate  suffocation  due  to  reflex  stimulation  of  respiratory 
inhibition.  If  spasms  occur — and  they  may  occur — they  are  secondary  to 
this  suffocative  state,  a  state  in  which  the  action  of  the  diaphragm  ceases  for 
a  time.  The  air-passages  become  congested  and  the  sufferer  makes  frequent 
and  painful  efforts  to  expel  thick  mucus,  and  the  efforts  produce  paroxysms 
of  suffocation.  Between  the  paroxysms  the  patient  is  evidently  somewhat 
breathless,  and  Warren  tells  us  that  his  speech  is  not  unlike  that  "  of  a  child 
who  has  recently  been  crying  and  is  endeavoring  to  control  itself"  ("Surgical 
Pathology  and  Therapeutics").  As  the  condition  grows  worse,  suffocative 
attacks,  which  were  at  first  induced  by  attempts  at  swallowing,  come  to  be 
caused  also  by  bright  lights,  sudden  or  loud  noises,  irritations  of  the  skin, 
or  even  thinking  of  swallowing.  At  length  suffocative  paroxysms  occur 
spontaneously  and  the  patient  jumps,  or  hurls  himself  about,  or  the  muscles 
of  the  entire  body  are  thrown  into  clonic  spasm.  Tonic  spasm  does  not  occur. 
A  condition  of  general  hyperesthesia  exists.  The  mind  is  usually  clear, 
although  during  the  periods  of  excitement  there  may  be  maniacal  furor 
with  hallucinations  which  pass  away  in  the  stage  of  relaxation.  The  tempera- 
ture is  moderately  elevated  (ioi°  to  103°  F.  or  higher).  The  spasmodic  stage 
lasts  from  one  to  three  days,  and  the  patient  may  die  during  this  stage  from 
exhaustion  or  from  asphyxia.  If  he  lives  through  this  period,  the  convulsions 
gradually  cease,  the  power  of  swallowing  returns,  and  the  patient  succumbs 
to  exhaustion  in  less  than  twenty-four  hours,  or  he  develops  ascending  par- 
alysis which  soon  causes  cardiac  and  respiratory  failure.  In  what  is  known 
as  paralytic  rabies,  a  very  rare  form  of  the  disease  in  human  beings,  the 
attack  comes  on  with  the  same  early  symptoms  met  with  in  the  commoner 
form,  but  paralysis  soon  begins  about  the  bitten  part  and  spreads  to  all  the 
limbs  and  to  the  trunk. 

In  hydrophobia  death  is  almost  inevitable.  Practically  all  cases  in  which 
it  is  alleged  that  recovery  ensued  were  not  true  hydrophobia,  but  hysteria. 
An  exception  must  be  made  of  Murri's  case.  Wood  says  that  in  hys- 
teria, especially  among  boys,  "beast-mimicry"  is  common,  the  suf- 
ferer snarling  like  a  dog;  and  in  the  form  known  as  "spurious  hydropho- 
bia,^^ in  which  there  may  or  may  not  be  convulsions,  there  are  a  dread  of 
water,  emotional  excitement,  snarling,  and  attempts  to  bite  the  bystanders 
(in  genuine  hydrophobia  no  attempts  are  made  to  bite,  and  no  sounds  are 
uttered  like  those  made  by  a  dog). 

Lyssa  is  separated  from  lockjaw  by  the  paroxysms  of  suffocation  and  the 
absence  of  tonic  spasms  in  the  former,  as  contrasted  with  the  fixation  of  the 
jaws  and  the  tonic  spasms  with  clonic  exacerbations  of  lockjaw. 

Treatment. — When  a  person  is  bitten  by  a  supposed  rabid  animal  and 
is  seen  soon  after  the  injury,  constriction  should  be  applied  if  possible  above 
the  wound,  the  wounded  area  should  be  excised,  cauterized  with  pure  nitric 
acid,  a  hot  iron  or  the  PaqueUn  cautery,  and  dressed  antiseptically.  If  the 
patient  is  not  seen  for  a  number  of  hours  or  a  day  or  two  after  the  injury, 
cauterization  is  useless;  it  is  not  only  useless,  but  it  may  delude  the  patient 
and  his  friends  into  a  feeling  of  security.  In  any  case,  send  the  patient  at  once 
to  a  Pasteur  institute.  If  the  animal  which  inflicted  the  injury  was  not  hy- 
drophobic, no  harm  will  result  from  inoculations;  if  it  was  hydrophobic, 
preventive  treatment  may  save  the  patient.     The  method  known  as  the  pre- 


Treatment  of  Hydrophobia  307 

ventive  treatment  was  devised  by  Pasteur,  who  discovered  the  following  re- 
markable facts:  If  the  virus  of  a  rabid  dog  (street  rabies)  be  placed  beneath 
the  dura  of  another  dog,  it  always  causes  hydrophobia  in  from  sixteen  to  twenty 
days,  and  invariably  causes  death.  If  the  virus  is  passed  through  a  series  of 
rabbits  it  gets  stronger  (laboratory  virus),  and  if  inserted  beneath  the  dura  of  a 
dog  it  causes  the  disease  in  from  five  to  six  days,  and  kills  in  four  or  five  days. 
The  virus  can  be  attenuated  by  passing  it  through  a  series  of  monkeys  or  by 
keeping  it  for  a  definite  time.  To  obtain  attenuated  preparations  in  a  con- 
venient form  Pasteur  made  emulsions  from  the  spinal  cords  of  hydrophobic 
rabbits,  the  animals  having  been  dead  two  or  three  weeks.  He  found  that  the 
emulsion  obtained  from  the  rabbit  longest  dead  is  the  weakest.  He  injected  a 
dog  with  emulsions  of  progressively  increasing  strength  and  made  it  immune  to 
hydrophobia.  The  patient  is  injected  with  an  emulsion  made  from  the  dried 
spinal  cords  of  hydrophobic  rabbits.  In  this  emulsion  the  virus  is  attenuated, 
and  day  by  day  the  strength  of  the  injected  virus  is  increased.  These  emul- 
sions cause  the  body-cells  to  form  antitoxin,  and  either  the  virus  of  street 
rabies  does  not  develop  at  all  or  by  the  time  it  begins  to  develop  a  quantity  of 
antitoxin  is  present  to  antagonize  it.  In  the  New  York  Pasteiu:  Institute 
patients  remain  under  treatment  for  fiiteendays,  two  inoculations  being  given 
daily.  In  cases  in  which  treatment  is  begun  late,. or  in  which  the  head  or 
face  was  bitten,  from  four  to  six  inoculations  are  given  each  day.  The  report 
of  the  Parisian  Pasteur  Institute  shows  that  since  its  foundation  there  has 
been  a  mortaUty  of  0.5  per  cent.  The  lowest  estimated  number  of  those 
attacked  by  hydrophobia  before  this  method  was  used  was  5  per  cent,  of  those 
bitten,  and  all  attacked  died;  hence,  the  Pasteiir  treatment  as  applied  in  the 
Parisian  Institute  shows  one-twenty-fifth  of  the  mortahty  which  attends  other 
preventive  methods.  Ravenel,  in  1901,  estimated  that  55,000  persons  have 
been  treated  by  the  Pasteur  method  and  that  less  than  i  per  cent,  have  died. 
The  value  of  this  plan  seems  definitely  estabhshed.  The  general  public  believes 
that  the  dog  which  did  the  biting  should  be  killed.  The  dog  should,  if  possi- 
ble, be  locked  up  and  watched  rather  than  killed.  It  may  be  proved  in  this 
way  that  it  did  not  have  hydrophobia.  If  it  were  necessary  to  kill  the  dog, 
or  if  the  dog  was  killed  at  once  or  soon  after,  the  physicians  of  the  Xew  York 
Pasteur  Institute  ad\ase  that  the  dog's  head  be  cut  from  the  body  with  an 
aseptic  knife  and  a  piece  of  the  medulla  oblongata  be  abstracted.  The  bit  of 
medulla  should  be  placed  in  a  mixture  of  equal  parts  of  glycerin  and  water 
which  was  previously  steriUzed  by  boiling.  The  bottle  should  be  sealed  and 
sent  to  the  institute,  in  order  that  inoculations  may  be  made  upon  animals  to 
prove  the  existence  or  absence  of  hydrophobia.  Babes  tubercles  and  Negri's 
bodies  are  at  once  sought  for  in  the  specimen,  and  if  they  are  found,  treatment 
should  be  started  at  once.  In  the  paroxysm  of  hydrophobia  the  treatment 
in  the  past  was  purely  paUiative.  If  we  employ  only  paUiative  methods,  keep 
the  patient  in  a  dark,  quiet  room,  reheve  thirst  by  enemata,  saturate  him  ^ith 
morphin,  empty  the  bowels  by  enemata,  attend  to  the  bladder  by  regular 
catheterization,  and  during  the  paroxysms  anesthetize.  Murri,  of  Bologna, 
cured  a  case  of  hydrophobia  by  injecting  emulsions  of  cords  of  rabibts  dead 
six,  five,  four,  and  three  days  respectively.  It  would  be  proper  to  try  this 
remedy  if  hydrophobia  develops.  A  serum  has  been  prepared  by  Tizzoni  and 
Centani  which  they  claim  is  successful  in  treating  the  disease  as  experimentally 


3o8  Contusions  and  Wounds 

induced  in  the  laboratory.  The  remarkable  suggestion  has  come  from  Tizzoni 
that  rabies  be  treated  with  rays  of  radium,  it  having  been  shown  that  rabic 
virus  can  be  destroyed  by  radium. 

Glanders,  Malleus,  Farcy,  or  Equinia.— Glanders  is  an  infectious 
eruptive  fever  occurring  in  horses,  asses,  goats,  hogs,  cats,  and  some  other 
animals,  and  communicable  to  man.  Cattle,  house  mice,  white  mice,  and 
white  rats  are  immune.  Human  glanders  is  by  no  means  as  uncommon  as  was 
once  thought.  Not  a  few  cases  die  undiagnosticated.  In  a  recent  study  156 
cases  were  discussed  (Robin,  "Studies  from  the  Royal  Victoria  Hospital  of 
Montreal,"  1906).  If  the  nodules  occur  in  the  nares,  the  disease  is  called 
"glanders";  if  beneath  the  skin,  it  is  termed  "farcy."  This  disease  is  due  to 
the  bacillus  mallei  and  is  communicated  to  man  through  an  abraded  surface  or 
a  mucous  membrane.  Bernstein  and  Carling  reported  6  cases  of  human 
glanders.  They  say:  "  In  none  of  our  cases  was  there  definite  evidence  of  the 
point  of  inoculation  or  path  of  infection,  and  the  general  evidence,  chnical  and 
experimental,  in  both  these  questions  is  so  conflicting  that  the  time  is  hardly 
ripe  for  the  expression  of  decided  opinions.  The  hypothetical  paths  are  by 
direct  inoculation  through  a  wound  or  by  the  hair  follicles,  by  inhalation  or  by 
ingestion  ("Brit.  Med.  Jour.,"  Feb.  6,  1909).  The  characteristic  lesions  are 
infective  granulomata  in  the  nares,  skin,  lungs,  and  subcutaneous  tissue.  In 
the  nares  granulomata  result  in  ulcers  and  under  the  skin  break  down  into  ab- 
scesses. From  the  site  of  inoculation  the  bacilli  are  disseminated  and  the 
cutaneous  and  muscular  structures  and  lungs  become  involved.  The  disease 
is  most  common  in  the  horse,  but  occurs  also  in  the  ass,  mule,  cat,  rabbit,  goat, 
and  other  animals.  Man  can  be  infected  from  a  diseased  animal,  and  as  the 
common  source  of  infection  is  the  horse,  the  usual  victims  are  those  who  use  or 
work  about  horses.    The  period  of  incubation  after  infection  is  four  or  five  days. 

Acute  and  Chronic  Glanders. — In  acute  glanders  there  is  septic  inflam- 
mation at  the  point  of  inoculation;  nodules  may  form  in  the  nose  and  ulcerate; 
there  is  profuse  nasal  discharge;  the  glands  of  the  neck  enlarge;  there  is 
weakness,  frontal  headache,  chilliness,  pain  in  the  back  and  limbs;  often  diar- 
rhea; after  a  time  the  muscles  become  painful;  there  is  fever,  the  evening  tem- 
perature being  100°  F.  or  higher,  and  the  morning  temperature  being  lower. 
Chills  may  occur.  There  may  be  chest  pains,  severe  muscular  pain,  bron- 
chitis, and  signs  of  pulmonary  congestion.  The  lungs  may  be  infected  by 
inspiration  of  the  bacilli  in  the  discharge  of  the  ulcers.  It  may  not  be  sus- 
pected that  the  patient  has  glanders  and  the  diagnosis  of  typhoid  may  per- 
haps be  made.  Twelve  to  fourteen  days  after  the  beginning  of  the  trouble  little 
hard  lumps  arise  in  the  muscles  and  just  beneath  the  skin.  In  a  few  days 
the  lumps  soften,  break  down,  and  discharge  a  bloody  fluid  which  contains 
the  bacilli  of  glanders.  In  a  number  of  cases  an  eruption  resembling  small- 
pox appears  on  the  face  and  about  the  joints,  and  this  exanthem  is  usually 
prophetic  of  approaching  death.  It  differs  from  smallpox  in  not  being  um- 
bilicated.  Leukocytosis  may  or  may  not  exist.  Acute  glanders  is  nearly 
always  fatal.  Chronic  glanders  lasts  for  months,  is  rarely  diagnosticated,  being 
mistaken  for  catarrh,  is  often  recovered  from,  but  if  uncured  will  sooner  or  later 
eventuate  in  a  fatal  acute  condition. 

Acute  and  Chronic  Farcy. — Acute  farcy  arises  at  the  site  of  a  skin- 
inoculation;  it  begins  as  an  intense  inflammadon,  from  which  emerge  inflamed 


Actinomycosis  309 

lymphatics  that  present  nodules  or  ^^ farcy-buds ^  Abscesses  f(jrm,  but  the  pus 
differs  in  appearance  from  ordinary  pus,  is  often  gelatinous,  and  may  be  red  in 
color.  There  are  joint-i)ains  and  the  constitutional  symptoms  of  sepsis,  but  no 
involvement  of  the  nares.  In  it  nodules  occur  upon  the  extremities,  which 
nodules  break  down  into  abscesses  and  eventuate  in  ulcers  resembling  those  of 
tuberculosis  or,  perhaps,  of  syphilis.     The  ulcers  form  rapidly  and  often  heal. 

Diagnosis  of  Glanders  and  Farcy. — Injecrion  of  mallein  may  produce 
a  significant  reaction  (fever,  malaise,  restlessness,  perhaps  a  distinct  rigor, 
sometimes  vomiting).  The  dose  used  is  10  to  15  minims  (Bernstein  and 
Carling,  in  "Brit.  Med.  Jour.,"  Feb.  6,  1909). 

Mallein  is  prepared  from  cultures  of  the  bacilli  of  glanders,  it  has  proved 
valuable  in  the  hands  of  veterinarians,  and  it  produces  a  reaction  when  injected 
into  an  animal  with  glanders  like  the  reaction  produced  by  tuberculin  on  a 
tuberculous  animal. 

Animal  injection  is  valuable  in  diagnosis.  The  highly  susceptible  guinea- 
pig  is  used  for  this  purpose.  The  doubtful  material  (nasal  mucus  or  pus  or  a 
tissue  fragment)  is  injected  into  the  peritoneal  sac  of  a  male  guinea-pig.  In 
three  to  four  days  the  testicles  enlarge  and  later  suppurate. 

The  pig  is  killed  and  the  pus  examined  for  the  bacillus  of  glanders.  Testic- 
ular enlargement  does  not  always  occur  even  when  the  inoculated  material  w'as 
from  a  lesion  of  glanders.  In  some  cases  it  does  not  occur  for  weeks.  As  a 
rule,  it  does  occur. 

In  the  lesions  of  glanders  the  bacilli  of  the  disease  are  scanty  and  in  many 
lesions  are  mingled  with  other  bacteria,  hence  the  bacteriological  diagnosis  is 
always  difficult  and  is  often  impossible  without  animal  inoculation.  The 
value  of  an  aggultination  test  is  as  yet  undetermined. 

Treatment. — In  treating  this  disease  the  point  of  infection  is  at  once  to 
be  incised  and  cauterized,  dusted  with  iodoform,  and  dressed  antiseptically. 
The  skin  over  enlarged  glands  and  swollen  lymphatics  is  to  be  painted  with 
iodin  and  smeared  with  ichthyol.  Bandages  are  applied  to  edematous  extrem- 
ities. Ulcers  are  curetted,  touched  with  pure  carbolic  acid,  dusted  with  iodo- 
form, and  dressed  antiseptically.  In  glanders  the  nostrils  should  be  sprayed  at 
frequent  inten^als  with  peroxid  of  hydrogen  and  syringed  with  a  solution  of 
sulphurous  acid.  The  mouth  must  be  rinsed  repeatedly  with  solutions  of 
chlorate  of  potassium.  Abscesses  are  to  be  opened,  mopped  with  pure  car- 
bolic acid,  and  dressed  antiseptically.  Stimulants  and  nourishing  diet  are 
imperatively  demanded.  Morphin  is  necessary  for  the  muscular  pain,  restless- 
ness, and  insomnia.  Digitalis  is  given  to  stimulate  the  circulation  and  kid- 
ney secretion.  Sulphur  iodid  and  arsenite  of  strychnin  have  been  used. 
Diseased  horses  ought  at  once  to  be  killed  and  their  stalls  should  be  torn  to 
pieces,  purified,  and  entirely  rebuilt.  A  man  with  chronic  glanders  should 
be  removed  to  the  seaside.  The  nasal  passages  must  be  kept  clean  and  the 
ulcers  must  be  cauterized  and  dressed  with  iodoform  gauze.  Nutritious  foods, 
tonics,  and  stimulants  are  necessary. 

Treatment  by  frequent  small  doses  of  mallein  finds  advocates.  It  has 
been  suggested  that  injection  of  the  serum  of  the  blood  of  an  immune  animal 
(the  ox.  for  instance)  might  be  serviceable. 

Actinomycosis  is  a  specific  infectious  disorder  characterized  by  chronic 
inflammation,  and  is  due  to  the  presence  in  the  tissues  of  the  adinomyces  or 


3IO  Contusions  and  Wounds 

ray-fungi.  As  stated  on  page  i8  the  ray-fungus  occuj)ies  a  position  between 
bacteria  and  moulds  and  more  than  one  variety  of  the  fungus  exists.  Some 
of  the  varieties  are  pathogenic,  others  do  not  seem  to  be.  It  is  anaerobic, 
but  when  dried  is  not  at  once  killed,  but  months  after  may  develop  if  placed 
under  favorable  condidons.  When  growing  in  the  tissues  it  usually  forms 
numerous  distinct  aggregations,  each  about  the  size  of  a  sand  grain,  and  called 
from  their  color  sulphur  grains.  Usually  the  growths  lie  in  purulent  matter. 
If  purulent  matter  containing  growths  is  rubbed  between  the  fingers  it  will 
give  a  gritty  sensation  like  sand  if  the  growth  is  not  very  recent.  The  growth 
of  the  fungi  causes  the  formation  of  an  infective  granuloma  and  great  masses 
of  granulation  dssue  may  form  with  collections  of  necrotic  or  purulent  matter 
here  and  there,  and  zones  of  fibrous  tissue.  The  fungi  are  easily  discovered 
in  the  sulphur  grains  with  the  microscope,  but  if  the  fungi  are  mycelial  and  are 
scattered  instead  of  being  gathered  into  granules  it  is  difficult  to  discover 
them.  This  disease  occurs  in  cattle  {lumpy  jaw)  and  in  pigs,  and  can  be  trans- 
mitted to  man,  usually  by  the  food.  At  the  point  of  inoculation  (which  is 
generally  about  the  mouth)  arises  an  infective  granuloma,  around  which  inflam- 
mation of  connective  tissue  occurs,  suppuration  eventually  taking  place.  In- 
oculation in  the  mouth  is  by  way  of  an  abrasion  of  mucous  membrane  or  through 
a  carious  tooth.  Chewing  straw  which  contains  the  fungi  is  the  mo.st  common 
method  of  infection.  The  ray-fungi  may  pass  into  the  lungs,  causing  pulmon- 
ary actinomycosis;  into  the  intestines,  causing  intestinal  actinomycosis;  into 
the  skin,  the  bones,  the  subcutaneous  tissues,  the  heart,  the  brain,  the  liver,  the 
urinary  organs,  etc.  Abdominal  anthrax  is  the  commonest  form  and  com- 
prises nearly  50  per  cent,  of  cases.  Cases  of  human  actinomycosis  until  very 
recently  were  looked  upon  as  sarcomata.  Many  sinuses  form,  ulcers  develop, 
but  large  abscesses  do  not  arise. 

The  pus  of  actinomycosis  contains  many  sulphur-yellow  bodies  visible 
to  the  naked  eye  and  composed  of  fungi.  These  bodies  usually  feel  gritty  when 
rubbed  between  the  fingers  because  of  the  presence  of  lime  salts. 

In  actinomycosis  the  adjacent  lymph-glands  are  very  seldom  involved 
unless  there  is  secondary  pyogenic  infection,  and  if  metastasis  occurs  it  takes 
place  by  the  veins.  The  condition  causes  but  slight  pain.  A  diagnosis  must 
be  made  from  syphilis,  sarcoma,  carcinoma,  and  tuberculosis.  The  formation 
of  a  tumor,  followed  by  sinuses  and  ulceration,  the  ulcer  having  thin,  non- 
indurated,  undermined  edges  and  edematous  granulation,  and  adjacent 
pus  cavities  joining  by  sinuses,  the  appearance  of  the  pus  and  the  micro- 
scopic study  of  the  discharge  are  significant.  An  actinomycotic  ulcer  may 
partially  heal  here  and  there.  It  is  well  to  remember  that  an  individual  with 
actinomycosis  may  react  to  tuberculin  like  a  person  with  tuberculosis.  The 
muscular  and  connective  tissues  become  infiltrated  and  hard,  as  though  a 
coagulating  material  had  been  injected  into  them  (Poncet  and  Berard,  in 
"Lyon  Medicale,"  March  27,  1904).  Edema  and  induration  extend  wide  of  the 
active  focus  of  disease.    Actinomycosis  may  last  for  years  or  it  may  prove  fatal. 

Cutaneous  actinomycosis  may  be  secondary  to  visceral  infection  vdth  the 
disease,  may  be  a  purely  local  condition,  or  may  be  associated  with  some 
adjacent  area  of  bone  infection.  The  gummatous  form  of  actinomycosis 
resembles  a  gummatous  syphilitic  area,  and  in  it  many  small  purulent  pockets 
open  by  fistulae  (Monestie). 


Treatment  of  Actinomycosis  311 

In  the  anthracoid  form  there  are  no  distinct  purulent  collections,  but  many 
fistute  discharge  pus  at  various  points  (Monestie). 

An  area  of  cutaneous  actinomycosis  is  characterized  by  the  existence  of 
violet,  blue,  gray,  or  black  maculae,  varying  in  size  from  that  of  a  pin's  head 
to  that  of  a  bean,  the  center  of  each  macule  being  white  and  containing  a 
minute  quantity  of  pus  (Derville). 

In  actinomycosis  of  bone  the  bone  enlarges  and  becomes  painful,  the  parts 
adjacent  swell  from  infiltration  and  soften,  pus  forms  and  reaches  the  surface 
through  fistula?,  and  the  skin  becomes  involved  secondarily. 

Abdominal  actinomycosis  takes  origin  from  the  gastro-intestinal  tract, 
an  actinomycotic  nodule  of  the  intestine  having  ulcerated,  adhesions  having 
formed,  and  an  actinomycotic  abscess  having  arisen,  or  actinomycotic  disease 
of  the  intestine  having  spread.  In  over  50  per  cent,  of  cases  of  abdominal 
actinomycosis  the  cecum  is  the  part  attacked.  A  fecal  fistula  may  form  and 
the  Uver  may  be  involved.  At  leat  150  cases  of  actinomycosis  of  the  appendix 
have  been  reported.  A  mass  containing  putrid  pus  develops.  If  not  evacuated, 
fistute  form.  It  is  a  very  chronic  condition  and  although  fistulae  may  heal, 
they  break  open  again  and  again  (Short,  in  "Lancet,"  Sept.  14,  1907).  The 
fungi  may  be  found  in  the  stools. 

The  mortality  of  actinomycosis  depends  upon  the  site  of  infection,  the 
question  of  secondary  infection,  and  the  plan  of  treatment.  If  pyogenic  in- 
fection occurs,  fatal  pyemia  may  arise.  The  prognosis  is  reasonably  good  in 
many  cases.  The  majority  of  cutaneous  cases  (nearly  90  per  cent.)  and  many 
osseous  cases  can  be  cured.  The  mortality  in  the  abdominal  cases  is  large. 
Grill  says  that  of  77  abdominal  cases  treated  surgically  45  died,  22  recovered, 
and  10  were  improved.  '  Frazier  ("Keen's  System  of  Surgery")  tells  us  that 
the  mortality  of  the  reported  cases  of  actinomycosis  in  the  United  States  was 
47  per  cent.,  and  quotes  Jiron  as  follows  regarding  the  mortality  of  the  various 
forms:  Face  and  neck,  11  per  cent.;  thorax,  83  per  cent.;  abdomen,  71  per 
cent.;  brain,  100  per  cent.  Actinomycosis  has  a  strong  tendency  to  redevelop 
even  after  apparently  thorough  excision.  A  case  of  cutaneous  actinomycosis 
of  the  arm,  seen  by  the  author,  was  operated  on  twenty  times.  Ulceration 
took  place  into  the  axillary  artery  and  death  was  narrowly  averted.  Recovery 
finally  ensued.  I  have  seen  three  cases  of  human  actinomycosis:  one  was  the 
patient  just  referred  to;  another  was  a  mattress  stuff er  (straw  being  used), 
his  lesions  were  on  the  chest  and  jaw  and  recovery  followed  operation; 
the  third  was  a  stable  hand,  who  died  from  lesions  of  the  face,  jaw,  and 
neck. 

Treatment. — Free  excision  if  possible;  otherwise  incision,  scraping,  cau- 
terization with  pure  carbolic  acid  or  silver  nitrate,  and  packing  with  iodoform 
gauze.  If  possible,  remove  the  entire  area;  if  not  possible,  remove  all  we  can. 
Sinuses  must  be  widely  opened,  each  collection  of  pus  must  be  drained,  and 
granulation  tissue  if  not  extirpated  must  be  scraped  away  with  a  sharp  spoon. 
Give  internally  large  doses  of  iodid  of  potassium.  This  drug  alone  has  cured 
many  cases.  It  is  given  for  a  week  or  two  and  is  then  discontinued  for  one 
week.  Von  Eiselsberg  advocates  the  use  of  tuberculin  injections.  In  a 
fistula  from  intestinal  or  appendical  actinomycosis  give  potassium  iodid  and 
sulphate  of  copper  (Bevan)  and  irrigate  the  sinuses  with  diluted  tincture  of 
iodin.     Cases  of  actinomycosis  should  be  placed  under  the  best  hygienic  con- 


312  Syphilis  or  Pox 

ditions,  should  live,  as  far  as  possible,  in  the  sunlight  and  open  air,  and  should 
be  given  nutritious  diets,  tonics,  and  often  stimulants. 

Blastomycosis. — The  very  existence  of  this  disease  has  been  denied,  but 
numerous  cases  have  been  reported  and  most  observers  regard  it  as  an  entity. 
It  may  be  a  local  infection  (cutaneous  blastomycosis),  but  in  some  cases  the 
disease  is  generalized  (systematic  blastomycosis).  The  disease  was  first 
described  by  Gilchrist  in  1894.  It  is  found  in  North  America,  South  America, 
Europe,  and  the  East. 

It  is  due  to  infection  with  a  variety  of  yeast  fungus.  In  the  skin  it  begins  as 
a  papule  or  an  indurated  pustule,  which  becomes  crusted  and  finally  warty, 
enlarges  at  the  periphery,  and  becomes  surrounded  by  more  recently  developed 
lesions.  The  area  becomes  studded  with  minute  abscesses,  crusted  foci,  and 
areas  of  bleeding  granulations.     Here  and  there  healing  may  occur. 

The  disease  may  arise  on  any  portion  of  the  body,  but  the  hands  and  face 
are  most  liable  to  it.  The  disease  is  slow  in  progress  and  lasts  for  many 
months.  If  it  progresses,  it  will  finally  produce  systemic  blastomycosis  or 
secondary  infection  will  produce  fatal  septicemia. 

Treatment. — In  some  cases  excision,  in  others  the  .v-rays.  Potassium 
iodid  is  useful. 


XVI.  SYPHILIS  OR  POX. 

Definition. — Syphilis  is  a  chronic  contagious,  and  sometimes  heredi- 
tary, constitutional  disease.  It  is  one  of  the  most  common  of  diseases  and 
comes  next  to  tuberculosis  as  a  cause  of  death.  Lesser  states  that  in  Berlin, 
of  men  over  twenty-five  years  of  age  who  come  to  autopsy,  9  per  cent,  are  syph- 
ilitic. In  the  United  States  it  is  twice  as  frequent  among  negroes  as  com- 
pared with  whites,  although  in  them  the  disease  is  apt  to  be  more  curable  and 
less  disastrous.  It  was  long  believed  that  only  members  of  the  human  family 
could  take  syphilis,  but  Metschnikoff  and  Roux  have  succeeded  in  inoculating 
chimpanzees  ("Annals  of  Pasteur  Institute,"  Dec,  1903) .  These  two  observers 
have  inoculated  many  animals  and  have  shown  that  the  nearer  the  animal  is 
to  man,  the  more  nearly  the  disease  resembles  human  syphilis.  Anthropoid 
apes  can  be  successfully  inoculated,  but  only  in  the  chimpanzee  are  human 
symptoms  accurately  produced.  Its  first  lesion  is  an  infecting  area  or  chancre, 
which  is  followed  by  lymphatic  enlargements,  eruptions  upon  the  skin  and 
mucous  membranes,  affections  of  the  appendages  of  the  skin  (hair  and  nails), 
"chronic  inflammation  and  infiltration  of  the  cellulovascular  tissue,  bones,  and 
periosteum"  (White),  and,  later,  often  by  gummata.  This  disease  is  probably 
due  to  a  microbe,  but  Lustgarten's  bacillus  has  not  been  proved  to  be  the  cause. 
One  fact  against  it  being  the  cause  is  its  presence  in  the  non-contagious  late 
gummata.  The  spirocha?ta  pallida  occurs  in  the  contagious  lesions  and  there 
seems  little  doubt  that  it  is  the  cause.  It  is  demonstrated  in  recent  scrapings 
from  specific  lesions.  The  more  contagious  the  lesion,  the  more  of  the  or- 
ganisms are  found.  The  later  the  lesion,  the  fewer  the  organisms  found. 
The  presence  of  a  great  number  means  a  malignant  case.  They  tend  to  dis- 
appear under  mercurial  treatment  (see  pp.  331  and  336).  Fenger  maintains 
that  syphilitic  fever  is  due  to  absorption  of  toxins;  that  the  eruptions  of  skin 


Transmission  of  Syphilis  313 

and  mucous  membranes  in  the  secondary  stage  arise  from  local  def)osit  and 
multiplication  of  the  virus;  that  many  secondary  symptoms  result  from  nutri- 
tive derangement  caused  by  tissue-products  passing  into  the  circulation,  that 
the  virus  exists  in  the  body  after  the  cessation  of  secondary  symptoms,  and 
that  it  may  die  out  or  may  awaken  into  activity,  producing  "reminders.'' 

During  the  primary  and  secondary  stages  fresh  poison  cannot  infect,  and 
this  is  true  for  a  long  time  after  the  disappearance  of  secondary  symptoms. 
As  a  matter  of  fact,  the  immunity  generally  lasts  for  life  and  reinfection  is  one  of 
the  rarest  of  occurrences.  Most  supposed  cases  of  reinfection  were  really 
instances  of  a  fresh  outbreak  of  an  old  disease.  Some  undoubted  cases  of 
reinfection  have  been  reported.  Immunity  in  the  primary  stage  is  due  to 
products  absorbed  from  the  infected  area.  Colle's  immunity  is  that  acquired 
by  mothers  who  have  borne  s}'philitic  children,  but  who  themselves  show  no 
sign  of  the  disease.  Prof  eta's  immunity  is  the  immunity  against  infection 
possessed  by  children  born  of  sjphilitic  parents.  Some  of  these  children  have 
never  shown  signs  of  disease,  but  nevertheless  they  are  immune.  It  is  claimed 
that  a  person  long  free  from  active  syphihs,  but  still  immune,  can  transmit  an 
immunity  to  his  children.  Tertiary  syphilitic  lesions  are  not  due  to  the  poison 
of  syphilis,  but  to  tissue-products  resulting  from  the  action  of  that  poison, 
or  to  nutritive  failure  as  a  consequence  of  the  disease.  Tertiary  sj^hilis  is 
not  transmissible,  but  it  secures  immunity. 

Transmission  of  Syphilis.— This  disease  can  be  transmitted— (i)  by 
contact  with  the  tissue-elements  or  virus — acquired  syphilis;  and  (2)  by 
hereditary  transmission — hereditary  syphilis.  The  poison  cannot  enter 
through  an  intact  epidermis  or  epithelial  layer,  and  abrasion  or  solution  of 
continuity  is  requisite  for  infection.  S}-philis  is  usually,  but  not  always,  a 
venereal  disease.  It  may  be  caught  by  infection  of  the  genitals  during  coition, 
by  infection  of  the  tongue  or  Hps  in  kissing,  by  smoking  poisoned  pipes,  by 
drinking  out  of  infected  vessels,  or  by  beastly  practices.  Syphihs  not  due  to 
sexual  relations  is  called  syphilis  of  the  innocent.  The  barber  is  a  danger, 
and  cases  are  reported  as  following  razor  cuts  and  particularly  the  applica- 
tion of  the  alum  stick  to  arrest  bleeding.  This  stick  is  used  over  and  over 
again  and  dried  blood  is  often  to  be  found  upon  it.  I  was  consulted  by  a 
man  who  had  been  thus  infected.  I  have  treated  two  young  girls  infected 
by  dentist's  instruments,  a  policeman  infected  by  a  pipe,  a  glassblower  infected 
from  the  blowpipe,  a  street  car  driver  who  got  the  disease  from  a  borrowed 
whistle,  a  police  officer  who  got  it  striking  a  prisoner  on  the  mouth  and  cutting 
his  own  knuckle  on  the  teeth,  a  hospital  orderly  who  infected  his  nose  by 
picking  it  with  a  contaminated  finger,  and  a  physician  who  caught  it  from  a 
patient.  Bulkley  ("Jour.  Am.  Med.  Assoc,"  March  4,  1905)  collected  1863 
cases  follo^^^ng  vaccination;  179  following  circumcision;  82  following  tattoo- 
ing, and  745  following  cupping  or  venesection.  The  initial  lesion  of  syph- 
ilis may  be  found  on  the  finger,  penis,  eyehd,  hp,  tongue,  cheek,  palate, 
labium,  vagina,  anus,  nipple,  etc.  Bulkley  found  that  in  1810  non-genital 
cases  the  chancre  was  on  the  lip,  in  1148  on  the  breast,  in  734  in  the  mouth, 
in  432  on  the  hand  or  one  of  the  fingers,  in  372  about  the  region  of  the  eye, 
and  in  307  on  the  tonsil.  \  person  may  be  a  host  for  syphihs,  carry  it,  give 
it  to  another,  and  yet  escape  it  himself  (a  surgeon  may  carry  it  under  his 
nails  and  a   woman   may  have  it  lodged  in  her  vagina).     S^'phihs  can  be 


314  Syphilis  or  Pox 

transmitted  by  vaccination  with  human  lymph  which  contains  the  pus  of  a 
syphiHtic  eruption  or  the  blood  of  a  syphiHtic  person.  Vaccine  lymph,  even 
after  passage  through  a  person  with  pox,  will  not  convey  syphilis  if  it  is  free 
from  blood  and  the  pus  of  specific  lesions;  it  is  not  the  lymph  that  poisons, 
but  some  other  substance  which  the  lymph  may  carry.  When  syphiHs  is 
caught  from  one  of  a  different  race  the  disease  is  apt  to  run  a  peculiarly 
severe  course.  The  apprehensions  of  the  sailor  regarding  "Chinese  pox"  are 
probably  well  founded. 

Effect  of  Syphilis  upon  Longevity. — This  is  a  difficult  matter  to 
determine.  Many  deaths  result  from  diseases  caused  by  syphilis  and  yet  they 
are  not  certified  as  due  to  syphilis.  My  own  belief  is  that  the  mortality  directly 
due  to  syphilis  is  very  small  indeed  (except  in  cases  of  congenital  syphilis), 
but  that  the  mortality  indirectly  due  to  it  is  very  large.  I  think  that  the  life 
insurance  companies  are  justified  in  requiring  those  who  have  had  syphilis  to 
pay  higher  premiums  than  those  who  have  never  had  the  disease. 

Syphilis  and  Tuberculosis. — SyphiHs  and  tuberculosis  may  e.xist. 
The  syphilis  may  be  severe  and  the  tuberculosis  mild  or  \ice  versa.  In  some 
cases  neither  is  severe  and  in  some  cases  both  are.  As  a  rule,  they  have  an 
unfavorable  influence  on  each  other.  Tuberculosis  is  not  very  unusual  in  the 
course  of  secondary  syphilis.  It  is  apt  to  run  a  rapid  course  because  of  the 
patient's  debility  and  worry  and  because  of  the  treatment  employed  for  the 
syphilis.  Old  syphilitics  may  develop  tuberculosis,  but  do  not  seem  particularly 
prone  to  do  so.  A  child  born  syphilitic  is  very  apt  to  become  tuberculous, 
more  apt  even  than  is  a  child  born  of  tuberculous  parents.  If  a  patient  who  is 
thought  to  be  well  of  syphilis  becomes  tuberculous  the  syphilis  may  crop  out 
again.  If  a  tuberculous  patient  becomes  syphiHtic  the  tuberculosis  gets  worse. 
It  is  well  known  that  syphilitic  ulcers  may  become  tuljerculous.  This  some- 
times occurs  in  the  larynx.  (See  chapter  on  SyphiHs  in  Bonney's  treatise  on 
"Pulmonary  Tuberculosis.") 

Syphilitic  Stages. — SyphiHs  was  divided  by  Ricord  into  three  stages: 
(i)  the  primary  stage — chancre  and  indolent  bubo;  (2)  the  secondary  stage 
— disease  of  the  upper  layer  of  the  skin  and  mucous  membranes;  and  (3)  the 
tertiary  stage — affections  of  connective  tissues,  bones,  fibrous  and  serous 
membranes,  and  parenchymatous  organs.  This  division,  which  is  useful 
cHnically,  is  still  largely  employed,  but  it  is  not  so  sharp  and  distinct  as  was 
believed  by  Ricord ;  it  is  only  artificial.  For  instance,  ozena  may  develop  dur- 
ing a  secondary  eruption,  and  bone  disease  may  appear  early  in  the  case. 

Syphilitic  Periods. — Wlfite  divides  the  pox  into  the  foUowing  periods: 
(i)  period  of  primary  incubation — the  time  between  exposure  and  the  appear- 
ance of  the  chancre;  from  ten  to  ninety  days,  the  average  being  twenty-five 
days;  (2)  period  of  primary  symptoms — chancre  and  bubo  of  adjacent 
Ivmph-glands ;  (3)  period  of  secondary  incubation — the  time  between  the  ap- 
pearance of  the  chancre  and  the  advent  of  secondary  symptoms:  about  six 
weeks  as  a  rule;  (4)  period  of  secondary  symptoms — lasting  from  one  to  three 
years;  (5)  intermediate  period — there  may  be  no  symptoms  or  there  may  be 
light  symptoms  which  are  less  symmetrical  and  more  general  than  those  of 
the  secondary  period:  it  lasts  from  two  to  four  years,  and  ends  in  recovery 
or  tertiary  syphilis;  (6)  period  of  tertiary  symptoms — indefinite  in  duration. 
The  fifth  and  sixth  periods  may  never  occur,  the  disease  having  been  cured 


Initial  Lesions  315 

Primary  Syphilis. — The  primary  stage  comprises  the  chancre  or  infect- 
ing sore  and  bubo.  A  chancre  or  initial  lesion  is  an  infective  granuloma 
resulting  from  the  poison  of  syphilis  and  is  most  usually  met  with  upon  the 
genital  organs.  A  chancre  may  be  derived  from  the  discharges  of  another 
chancre,  from  the  secretion  of  mucous  patches  and  moist  })apules,  from  syphi- 
litic blood,  or  from  the  pus  or  secretion  of  any  secondary  lesion.  Tertiary 
lesions  cannot  cause  chancre.  It  appears  at  the  point  of  inoculation  (page  3 13), 
and  is  the  first  lesion  of  the  disease.  During  the  three  weeks  or  more  requisite 
to  develop  a  chancre  the  poison  is  continuously  entering  the  system,  and  when 
the  chancre  develops  the  system  already  contains  a  large  amount  of  poison. 
A  chancre  is  not  a  local  lesion  from  which  syphilis  springs,  but  is  a  local 
manifestation  of  an  existing  constitutional  disease,  hence  excision  is  entirely 
useless.  If  we  take  the  discharge  of  a  chancre  and  insert  it  at  some  indifferent 
point,  into  the  person  from  whom  we  took  it,  a  new  indurated  chancre  will 
not  be  formed,  because  the  individual  already  has  syphilis,  but  auto-inocu- 
lation with  the  discharge  of  an  irritated  chancre  can  cause  a  non-indurated 
sore.  If  we  take  the  discharge  of  a  chancre  and  insert  it  into  a  healthy  per- 
son, an  indurated  chancre  follows.  Hence  we  say  that  primary  syphilis  is 
not  auto-inoculable,  but  is  hetero-inoculable.  A  soft  sore  can  be  produced 
in  the  lower  animals  by  inoculation  with  the  virus  of  a  chancre,  but  a  hard 
sore  cannot  except  in  chimpanzees.  Some  observers,  notably  Kaposi,  of 
Vienna,  advocate  the  unity  theory.  This  theory  maintains  that  both  hard 
and  soft  sores  are  due  to  the  same  virus,  the  infective  power  of  the  soft 
chancre  simply  being  less  than  that  of  the  hard  sore,  the  possibiHty  of  con- 
stitutional infection  depending,  not  upon  differences  in  the  poison,  but  rather 
upon  differences  in  the  soil  and  in  the  local  processes.  The  unicists  advocate 
excision  of  chancres,  soft  or  hard,  to  prevent,  if  possible,  constitutional  in- 
volvement. Most  syphilographers  believe  in  the  duality  theory,  which  we 
have  previously  set  forth.  This  theory  took  origin  from  the  classical  investi- 
gations of  Bassereau  and  Rollet.  The  duality  theory  maintains  that  the  soft 
sore  is  caused  by  a  poison  different  from  that  which  originates  the  hard  sore, 
and  that  a  true  soft  sore  never  infects  the  system.* 

Initial  Lesions. — An  initial  lesion,  hard  chancre,  or  infecting  sore 
never  appears  until  at  least  ten  days  after  exposure;  it  may  not  appear  for 
many  weeks,  but  it  usually  arises  in  about  twenty-five  days.  There  are  three 
chief  forms  of  initial  lesion:  (i)  a  purple  patch  exposed  by  peeling  epidermis, 
without  induration  and  ulceration — a  rare  form;  (2)  an  indurated  area  under 
the  epidermis,  without  ulceration — a  very  common  form;  and  (3)  a  round, 
indurated,  cartilaginous  area  with  an  elevated  edge,  which  ulcerates,  exposing 
a  velvety  surface  looking  like  raw  ham;  it  bleeds  easily,  rarely  suppurates, 
does  not  spread,  and  the  discharge  is  thin  and  watery.  This  is  the  " Htcnterian 
chancre,"  which  is  rarer  than  the  second  variety,  but  commoner  than  the  first, 
and  which  ulcerates  because  of  dirt,  caustic  appHcations,  or  friction. 

A  chancre  is  rarely  multiple;  but  if  it  is  so,  all  the  sores  appear  together  as 
a  result  of  the  primary  inoculation;  they  do  not  follow  one  another  because  of 
auto-infection.  A  hard  sore  does  not  suppurate  unfess  irritated  by  caustics, 
friction,  or  dirt,  or  unless  there  be  mixed  infection  with  chancroid;  its  nature 

*  For  a  full  discussion  of  these  points  see  the  writings  of  Fournier,  Alfred  Cooper, 
and  von  Zeissl,  and  especially  the  great  work  of  Taylor. 


3i6  Syphilis  or  Pox 

is  not  to  suppurate.  The  hardness  may  affect  only  the  base  and  margins  of 
an  ulcer  or  it  may  affect  considerable  areas,  but  it  has  well-defined  margins 
and  feels  hke  cartilage  encapsuled,  so  that  it  can  be  picked  up  between  the 
fingers.  This  hardness  or  sclerosis  is  due  to  gradual  inflammatory  exudation 
into  "the  tissue  at  the  base  of  the  ulcer  and  to  growth  of  the  nodule"  (von 
Zeissl).  It  feels  distinct  from  the  surrounding  tissues,  like  a  foreign  body 
lying  in  the  part.  A  chancre  untreated  may  last  many  months.  The  indu- 
ration usually  disappears  soon  after  the  appearance  of  secondary  symptoms. 
A  copper-colored  spot  remains,  and  does  not  disappear  until  the  disease  is 
cured.  Induration  may  again  appear  before  the  outbreak  of  some  distant 
lesion. 

Mixed  Infection  of  Chancre  and  Chancroid.— Von  Zeissl  says: 
"If  syphilitic  contagion  is  mixed  with  pus,  a  chancre  begins  as  a  circumscribed 
area  of  hj^oeremia  and  swelling,  which  undergoes  ulceration,  and  does  not 
develop  hardness  for  a  period  of  from  ten  days  to  several  weeks,  and  may 
develop  a  nodule  after  the  first  ulcer  has  entirely  healed."  This  condition  is 
seen  when  mixed  infection  occiirs,  the  chancroid  poison  being  quick,  and  the 
syphiUtic  poison  being  slow,  to  act.  If  chancroid  poison  is  deposited  some 
time  after  the  syphilitic  poison  has  been  absorbed,  the  induration  may  appear 
in  a  few  days  after  the  chancroid  begins.  A  soft  chancre  may  appear  upon  an 
existing  s}T3hilitic  nodule  and  may  eat  out  the  induration. 

Diagnosis  of  Chancre. — It  is  necessary  to  distinguish  a  chancre  from  a 
chancroid  and  from  ulcerated  herpes.  A  chancroid  appears  in  from  two  to 
five  days  after  contagion  (always  less  than  ten  days) ;  it  may  be  multiple  from 
the  start,  but,  even  if  beginning  as  one  sore,  other  sores  appear  by  auto-inocu- 
lation; it  begins  as  a  pustule,  which  bursts  and  exposes  an  ulcer;  the  ulcer 
is  circular,  has  thin,  sharp-cut,  or  undermined  edges,  a  sloughy,  non-granu- 
lating base,  and  gives  origin  to  a  thin,  purulent,  offensive  discharge  which  is 
both  auto-  and  hetero-inoculable.  These  soft  sores  have  no  true  sclerotic 
area,  do  not  bleed,  produce  no  constitutional  symptoms,  and  are  apt  to  be 
followed  by  acute  inflammatory'  buboes  which  tend  to  suppurate.  A  chan- 
croid causes  pain,  and  the  original  ulcer  enlarges  greatly.  A  chancre  appears 
in  about  twenty-five  days  after  inoculation  (never  before  ten  days) ;  it  is  gen- 
erally single,  but  if  multiple  sores  exist,  they  all  appear  together,  for  their  dis- 
charge is  not  auto-inoculable  if  the  sore  is  not  irritated;  an  auto-inoculation 
of  the  products  of  an  irritated  chancre  can  at  most  produce  only  a  soft  purulent 
ulcer.  A  chancre  begins  as  an  excoriation  or  as  a  nodule;  if  an  ulcer  forms, 
its  floor  is  covered  with  granulations  and  it  is  red  and  smooth;  the  discharge 
is  thin  and  scanty  and  not  offensive;  the  edges  are  thick  and  sloping;  it  is 
surrounded  by  an  area  of  induration,  and  bleeds  when  touched,  there  appear 
about  the  same  time  with  it  indolent  multiple  enlargements  of  the  adjacent 
glands,  which  rarely  suppurate,  and  it  is  followed  by  secondary  symptoms. 
A  chancre  causes  little  pain,  and  after  it  has  existed  for  a  few  days  rarely 
shows  any  tendency  to  spread.  A  urethral  chancre  appears  after  the  usual 
period  of  incubation;  it  is  situated  near  the  meatus,  one  hp  of  which  is  usually 
indurated;  the  discharge  is  slight,  often  bloody,  never  purulent;  indurated  mul- 
tiple buboes  arise;  the  sore  can  be  seen,  and  constitutional  symptoms  follow. 

Herpetic  ulceration  has  no  period  of  incubation;  it  may  follow  fever,  but 
usually  arises  from  friction  or  irritation  due  to  dirt  or  acrid  discharges.     It 


Syphilitic  Bu])o  317 

appears  as  a  group  of  vesicles,  all  of  which  may  dry  up,  or  some  may  dry  up 
and  ofhers  ulcerate,  or  they  may  run  together  and  ulcerate.  The  edges  of  an 
herpetic  ulcer  are  in  ''segments  of  small  circles"  (White);  the  ulcer  is  super- 
ficial, has  but  little  discharge,  and  does  not  have  much  tendency  to  spread; 
it  has  no  induration;  it  is  painful;  it  is  not  accompanied  by  bubo  unless  sup- 
puration is  extensive.     Herpes  is  not  followed  by  constitutional  involvement. 

A  chancre  may  be  mistaken  for  cancer  of  the  tongue.  "  A  chancre  of  this 
region  is  brownish-red,  a  cancer  being  bright  red.  A  chancre  is  soft  in  the 
center;  a  cancer  presents  uniformity  of  induration.  A  chancre  gives  origin 
to  a  thin,  purulent  discharge,  free  from  blood;  a  cancer  furnishes  a  non- 
purulent, bloody  discharge.  A  chancre  is  soon  followed  by  indolent  lymphatic 
enlargements  under  the  jaw;  a  cancer  is  followed  by  painful  enlargements." 
A  cancer  is  slower  in  evolution,  is  not  followed  by  constitutional  .symptoms, 
and  the  lymphatic  enlargements  are  much  later  in  appearing  than  in  chancre. 

Phagedena. — A  chancre  or  a  chancroid  may  be  attacked  by  phagedena,  a 
destructive  form  of  ulceration  which  was  once  common,  but  at  present  is  rare. 
The  ulceration  often  spreads  on  all  sides  and  also  deeply  into  the  tissues.  In 
some  cases  it  spreads  at  the  edge  in  one  direction  {serpiginous  ulceration),  in 
some  cases  sloughing  occurs.  Phagedena  occurs  only  in  the  debilitated  (anemic, 
drunkards,  strumous  subjects,  sufferers  from  diabetes,  Bright's  disease,  etc.; 
salivation  can  cause  it).  The  phagedenic  ulcer  is  irregular,  with  congested 
and  edematous  edges,  and  a  foul,  sloughy  floor. 

Chancre  Redux. — Some  observers  believe  that  reinfection  with  syphilis 
is  not  very  unusual.  Most  authorities  maintain  that  it  is  very  rare.  The  latter 
school  maintains  that  the  region  once  occupied  by  a  chancre  may,  after  many 
years,  become  indurated  anew.  Fournier  pointed  out  this  fact  thirty  years 
ago.     Such  a  reinduration  is  called  chancre  redux,  or  relapsing  chancre. 

If  syphilitic  manifestations  follow  such  an  induration,  we  must  conclude 
that  reinfection  has  truly  occurred.  If  they  do  not  follow,  and  this  is  the  rule, 
the  lesion  is  not  really  a  chancre,  but  is  probably  a  gumma  in  an  early  stage  of 
development.     Mauriac  pointed  out  this  last  fact.* 

Syphilitic  Bubo.— In  syphihtic  bubo  anatomically  related  lymphatic 
glands  enlarge  about  the  same  time  as  induration  of  the  initial  lesion  begins. 
In  the  very  beginning  these  glands  may  be  a  little  painful,  but  the  pain  is 
slight  and  of  temporary  duration.  These  enlargements  are  called  "indolent 
buboes";  they  may  be  as  small  as  peas  or  as  large  as  walnuts,  are  freely  mov- 
able, and  very  rarely  suppurate.  The  lesion  of  the  glands  is  hyperplasia  of  all 
the  gland-elements  and  of  their  capsules,  due  to  absorption  of  the  virus.  If 
the  patient  is  tuberculous,  the  bubo  is  apt  to  become  enormous,  lobulated,  and 
persistent.  If  the  chancre  appears  on  the  penis,  the  superficial  inguinal  and 
femoral  glands  enlarge,  usually  on  the  same  side  of  the  body  as  the  sore.  If 
the  sore  is  on  the  frenum,  both  groins  are  involved.  If  a  chancre  appears  on 
the  lip  or  tongue,  the  bubo  is  beneath  the  jaw.  These  buboes  may  remain 
for  many  months;  they  do  not  suppurate  unless  the  sore  suppurates  or  unless 
the  patient  is  of  the  tuberculous  type;  and  they  finally  disappear  by  absorption 
or  fatty  degeneration.     About  six  weeks  after  buboes   have  formed  in  the 

*  Mracek,  in  Wien.  klin.  Rundschau,  1896.  H.  G.  Antony,  in  Chicago  Medical  Re- 
corder, April,  1899. 


31 8  Syphilis  or  Pox 

glands  related  to  the  lesion  all  the  lymphatics  of  the  body  enlarge.  General 
lymphatic  involvement  arises  about  the  same  time  as  the  secondary  eruption. 
The  enlargement  of  the  post-cervical  and  epitrochlear  glands  is  diagnostically 
important.  Glandular  enlargements  persist  until  after  the  eruptions  have 
disappeared. 

Glandular  enlargement  always  occurs  in  syphilis,  but  the  bubo  exists  in 
only  one-third  of  the  chancroid  cases.     The  bubo  of  syphilis  is  multiple,  con- 
sisting of  a  chain  of  movable  glands  (the  glandulae  Pleiades  of  Ricord);  the 
bubo  of  chancroid  is  one  inflamed  and  immovable  mass.     The  bubo  of  syph- 
ilis is  indurated,  painless,  small,  and  slow  in  growth;  the  bubo  of  chancroid 
shows  inflammatory  hardness,  is  painful,  large,  and  rapid  in  growth;  the  first 
rarely  suppurates,  the  second  often  does.     The  skin  over  a  syphilitic  bubo  is 
normal;  that  over  a  chancroidal  bubo  may  become  red  and  adherent.     A  syph- 
ilitic bubo  is  not  cured  by  local  treatment,  but  is  cured  by  the  internal  use  of 
mercury  and  is  followed  by  secondary  symptoms.     A  chancroidal  bubo  re- 
quires local  treatment,  is  not  cured  by  mercury,  and  is  not  followed  by  secon- 
daries.    Herpes,  balanitis,  and  gonorrhea  rarely  cause  bubo,  but  when  they  do 
the  bubo  in  each  case  is  similar  to  that  caused  by  chancroid.     A  positive 
diagnosis  of  syphilis  can  be  made  when  an  indurated  sore  on  the  penis  is  followed 
by  multiple  indolent  buboes  in  the  groin  and  by  enlargement  of  distant  glands. 
General    Syphilis. — As  the  general  lymphatic  enlargement  becomes 
manifest  a  group  of  symptoms  known  as  ^^ syphilitic  fever"  may  appear.     In 
many  mild  cases,  however,  fever  is  absent  and  the  eruption  is  the  first  sign 
of  constitutional  involvement.     The  patient  usually  thinks  he  has  a  severe 
cold,  is  feverish  and  restless;  complains  of  headache,  lassitude,  sleeplessness, 
and  anorexia;  his  face  is  pale;   he  has  intermitting  rheumatoid  pains  in  the 
jo'.nts  and  muscles,  especially  of  the  shoulders,  arms,  chest,  and  back,  which 
pains  change  their  location  constantly  and  prevent  sleep;  night-sweats  occur, 
and  the  pulse  is  quite  frequent.     The  fever  usually  reaches  its  height  in  forty- 
eight  hours,  and  falls  as  the  eruption  develops.     The  eruption    develops 
usually  in  from  forty-eight  to  seventy-two  hours  after  the  onset  of  the  fever, 
but  may  not  do  so  for  one  week  or  even  more.     The  fever  and  the  discomfort 
are  worse  at  night.     In  type  the  fever  may  be  intermittent,  remittent,  or  con- 
tinued.    Prolonged  syphilitic  fever  with  delay  in  the  appearance  of  the  erup- 
tion gives  rise  sometimes  to  great  errors  in  diagnosis.     In  syphilitic  fever  there 
are  anemia,  trivial  leukocytosis,  and  a  marked  fall  in  hemoglobin.     Syphilitic 
fever  may  reappear  during  the  progress  of  the  disease. 

Secondary  Syphilis. — The  phenomena  of  secondary  syphilis  are  due 
to  poisoned  blood.  Fenger  states  that  the  poison  is  present  in  the  blood 
during  outbreaks,  but  not  during  the  quiescent  periods  between  outbreaks. 
Secondary  syphilis  is  characterized  by  plastic  inflammation,  by  the  forma- 
tion of  fibrous  tissue,  and  by  thickening  of  tissue.  Superficial  ulcerations 
may  occur.     Structural  overgrowths  appear  (for  instance,  warts). 

Syphilitic  Skin  Diseases. —  SyphUodermata  (syphilides)  are  due  to 
circumscribed  inflammation,  and  may  be  dry  or  purulent.  There  is  no  one 
eruption  characteristic  of  syphilis.  This  disease  may  counterfeit  any  skin 
disease,  but  it  is  an  imitation  which  is  not  perfect  and  is  never  a  counterpart. 
SyphiUtic  eruptions  are  often  circumscribed;  they  terminate  suddenly  at  their 
edges,  and  do  not  gradually  shade  into  the  sound  skin.     In  color  they  are  apt 


Erythema  319 

to  be  brownish-red,  hke  tarnished  copper;  especially  is  this  the  case  in  late 
syphihdes.  Hutchinson  cautions  us  to  remember  that  an  ordinary  non- 
specific eruption  may  be  copper-colored,  especially  in  people  with  dark  com- 
plexions and  when  it  occurs  on  the  legs.  Eruptions  are  apt  to  leave  a  brownish 
stain.  Early  syphihtic  eruptions  are  symmetrical.  SyphiHtic  eruptions  have 
an  affection  for  particular  regions,  such  as  the  forehead,  the  abdomen  and 
chest,  the  neck  and  scalp,  about  the  lips  and  the  alae  of  the  nose,  the  navel, 
anus,  groins,  between  the  toes,  and  upon  the  palms  and  soles.  Early  secon- 
dary eruptions  rarely  appear  on  the  face  or  hands.  Specific  eruptions  are  poly- 
morphous, various  forms  of  eruption  being  often  present  at  the  same  time,  so 
that  roseola  is  seen  here,  papules  there,  etc.  These  syphihdes  do  not  cause 
as  much  itching  as  do  non-specific  eruptions,  except  when  they  occur  upon  the 
scalp,  about  the  anus,  or  between  the  toes.  The  late  secondary  eruptions 
tend  to  an  arrangement  in  curved  hues. 

Forms  of  Eruption.— The  chief  forms  of  eruption  are:  (i)  erythema, 
(2)  papular  syphihdes,  (3)  pustular  syphihdes,  and  (4)  tubercular  syphihdes. 
Besides  these  eruptions  pigmentation  may  occur  (pigmentary  syphihde), 
and  blood  may  extra vasate  (purpuric  syphihde). 

Prince  A.  Morrow  does  not  beheve  in  erecting  the  vesicular  syphihdes  into 
a  special  group.  He  tells*  us  that  vesicles  sometimes  form  on  erythemato- 
papular  lesions,  but  their  presence  is  an  accident  and  not  a  regular  phenom- 
enon. So,  too,  the  bullous  syphihde  is  a  rare  accident  in  a  case,  and  even 
when  it  occurs  soon  becomes  pustular.  The  pemphigoid  syphihde  is  found 
almost  exclusively  in  hereditary  disease.* 

I.  Erythema  {macidcB,  roseola,  or  spots).  This  eruption  usually  comes  on 
gradually,  crop  after  crop  of  spots  appearing,  and  many  days  passing  before 
an  extensive  area  is  covered.  Occasionally,  however,  it  arises  suddenly 
(after  a  hot  bath,  after  taking  violent  exercise,  or  after  eating  an  indigestible 
meal).  This  eruption  consists  of  circumscribed,  irregularly  round,  h}^eremic 
spots,  about  one-eighth  of  an  inch  in  diameter,  whose  color  does  not  entirely 
disappear  on  pressure  in  an  old  eruption  but  does  in  a  recent  one.  The  color 
is  at  first  hght  pink,  but  it  becomes  red,  purple,  or  even  brown.  In  the  papular 
form  of  erythema  the  spots  are  shghtly  elevated.  Erythema  is  rare  upon 
the  face  and  the  dorsum  of  the  hands  and  feet.  It  attacks  especially  the  chest 
and  beUy,  but  appears  often  on  the  forehead,  the  bend  of  the  elbow,  and  the 
inner  portion  of  the  thigh,  the  neck,  and  the  flexor  surface  of  the  forearms 
and  arms.  It  appears  first  on  the  abdomen  and  last  on  the  legs.  Usually 
erythema  follows  syphihtic  fever,  about  six  weeks  after  the  chancre  appears, 
and  the  number  and  distinctness  of  the  spots  are  in  proportion  to  the  violence 
of  the  fever.  No  fever  or  shght  fever  means  there  will  be  but  few  spots  and 
they  will  soon  disappear.  In  rare  cases  the  eruption  is  very  transitory,  lasting 
but  a  few  hours,  but  it  usually  continues  for  several  weeks  if  untreated.  It 
may  pass  away  or  may  be  converted  into  a  papular  eruption.  Mercury  will 
cause  it  to  disappear  in  a  couple  of  weeks.  In  examining  for  this  form  of 
eruption  in  a  doubtful  case,  let  cold  air  blow  upon  the  chest  and  belly  (Hearn) ; 
this  blanches  the  sound  skin  and  makes  clear  any  discoloration.  No  desqua- 
mation attends  the  macular  eruption,  but  a  brownish  stain  remains  for  a  vari- 
able time  after  the  eruption  fades.  Erythema  means,  as  a  rule,  a  mild  and 
♦Morrow's  "System  of  Genito-urinary  Diseases,  Syphilology,  and  Dermatology." 


320 


Syphilis  or  Pox 


ciH-able  attack.     Macular  may  be  combined  with  the  next  form,  constituting 
a  maculopapular  eruption. 

The  maculopapular  syphihdes  are  evolved  from  the  macular  syphilides. 
They  are  sHghtly  elevated,  are  situated  upon  hyperemic  bases,  and  the  sum- 
mits of  some  of  them  may  undergo  slight  desquamation.  A  roseolar  area 
may  show  one  or  several  of  these  macular  papules.  They  are  apt  to  arrange 
themselves  in  segments  of  a  circle,  and  are  symmetrically  distributed.  This 
eruption  usually  appears  early,  but  may  appear  late.  It  may  fade  and  reap- 
pear several  times  in  the  same  patient.  The  eruption  lasts  a  few  weeks. 
[-  2.  Papular  syphilides,  which 

j  are  papules  or  elevations  covered 

with  dry  skin,  may  or  may  not  des- 
quamate.    If    they    do    desqua- 
mate, the  process  begins  over  the 
t     center.        They    usually    appear 
I     from  the  third  to  the  sixth  month 
!     of  the  disease.      They  may  be  pre- 
I     ceded  by  fever,  and   often   reap- 
I     pear  again  and  again.      They  are 
1     at  first  small  and  red,  but  become 
larger  and   brownish.     They  are 
firm  in  feel  and  vary  in  size  from 
the  head  of  a  pin  to  a  five-cent 
piece  or  larger.    Very  large  papules 
constitute    nummular    syphilides. 
They  all  tend  to  scale.     The  epi- 
derm  becomes  thin,  red,  and  glis- 
tening, splits  in  the  center  and  des- 
quamates, and  a  fringe  of  epidermis 
surrounds  the  desquamated  area. 
This  process  may  be  repeated  once 
or  oftener.     When  lenticular  pap- 
ules recur  in   the  late  secondary 
J     stage  they  are  apt  to  group  them- 
selves in  circles  Hmited  to  particu- 
lar regions   (annular   or  circinate 
syphiloderm).     They  may  be  present  as  miliary  papules,  lenticular  papules, 
moist  papules,  and  papules  with  marked  epidermic  proliferation  resembling 
psoriasis  (papulo-squamous  eruption).     Papules  on  fading  leave  very  persist- 
ent coppery-looking  stains.     Papules  upon  the  palms  and  soles  constitute  the 
so-called  "palmar  and  plantar  psoriasis,'^  which  appears  from  three  months  to 
one  year  after  the  appearance  of  the  chancre.     Papules  just  below  the  line  of 
the  hair  on  the  forehead  constitute  the  corona  veneris.     Papular  syphilides 
appear  especially  upon  the  forehead,  the  neck,  the  abdomen,  and  the  extremi- 
ties.    The  papular  or  squamous  syphihde  of  the  palms  and  soles  begins  as  a 
red  spot  which  becomes  elevated  and  brownish;  the  epidermis  thickens  and  is 
cast  off,  and  there  then  remains  a  central  red  spot  surrounded  by  undermined 
skin.     If  papules  are  in  regions  where  they  are  kept  moist  (as  about  the  anus), 
they  become  covered  with  a  sodden  gray  film  which  after  a  time  is  cast  off  and 


Fig.  124. — Condylomata  (Horwitz). 


Affections  of  ihc  Mucous  Membranes  321 

leaves  the  papule  without  epidermis.  The  sodden  papules  are  called  flat 
condylomata,  moist  or  humid  papules  or  plates  (Fig.  1 24) .  Papules  which  are  at 
first  small  may  become  large.  The  small  or  miliary  papules  constitute  syphil- 
itic lichen.  The  lenticular  ])apules  are  most  common,  and  strongly  tend  to 
scale  otY.  The  papular  syphilidcs  give  a  worse  prognosis  for  the  constitutional 
disease  than  do  spots.  The  syphilitic  negro  is  particularly  apt  to  develop  the 
annular  syphiloderm. 

3.  Pustular  syphilides  arise  from  papules.  The  condition  is  known 
as  acne  when  the  apex  of  the  papule  softens,  impetigo  when  the  whole  papule 
suppurates,  and  ecthyma  or  riipia  when  the  corium  is  also  deeply  involved. 
Vesicles  occasionally  precede  pustules.  The  pustular  eruption  appears  a 
number  of  months  after  infection  and  later  than  the  papular.  The  pustular 
eruption  gives  a  very  bad  prognosis  for  the  constitutional  disease.  Rupia  is 
formed  by  a  pustule  rupturing  or  a  papule  ulcerating,  the  secretion  drying 
and  forming  a  conical  crust  which  continually  increases  in  height  and  diam- 
eter, while  the  ulceration  extends  at  the  edges.  When  the  crust  is  pulled  off 
there  is  seen  a  foul  ulcer  with  congested,  jagged,  and  undermined  edges. 
Rupia  may  be  secondary  or  tertiary,  and  it  invariably  leaves  scars.  It  appears 
only  after  at  least  six  months  have  passed  since  the  chancre  began.  Secondary 
rupia  is  symmetrical.     Tertiary  rupia  is  asymmetrical. 

4.  Tubercular  syphilides  are  greatly  enlarged  papules  intermediate 
between  ordinary  papules  and  gummata. 

Diagnosis  between  Secondary  and  Tertiary  Syphilides. — A  secondary 
eruption  is  distinguished  from  a  tertiary  eruption  by  the  following:  the  first 
tends  to  disappear,  the  second  tends  to  persist  and  to  spread;  the  first  is  gen- 
eral and  symmetrical,  the  second  is  local  and  asymmetrical;  the  first  does  not 
spread  at  its  edge,  the  second  tends  to  spread  at  its  edge,  and  this  tendency, 
which  is  designated  ^^ serpiginous,^^  produces  an  ulcer  shaped  like  a  horseshoe 
(Jonathan  Hutchinson).  Secondary  lesions  appear  within  certain  limits  of 
time,  develop  regularly,  and  are  dispersed  by  mercurial  treatment.  Tertiary 
lesions  appear  at  no  fixed  time,  develop  irregularly,  and  are  not  cleared  up 
by  mercury. 

Affections  of  the  Mucous  Membranes. — The  chief  lesions  in  syph- 
ilitic affections  of  the  mucous  membranes  are  mucous  patches,  warts,  and 
condylomata.  The  first  phenomena  of  secondary  syphilis  are,  as  a  rule, 
symmetrical  ulcers  of  the  tonsils,  painless,  of  temporary  duration,  and  super- 
ficial (Hutchinson).  The  borders  of  the  ulcers  are  gray,  and  the  areas  are 
reniform  in  shape.  Catarrhal  inflammations  often  occur.  Eruptions  appear 
on  the  mucous  membranes  as  upon  the  skin.  Mucous  patches  are  papules 
deprived  of  epithelium;  they  are  gray  in  color,  are  moist,  and  give  off  an  offen- 
sive and  virulent  discharge.  They  usually  appear  as  areas  of  congestion,  swell- 
ing, and  abrasion  of  the  epidermis  upon  the  lips,  palate,  gums,  tongue,  cheeks, 
vagina,  labia,  vulva,  scrotum,  anus,  and  under  the  prepuce.  A  moist  papule 
of  the  skin  is  really  a  mucous  patch.  These  patches,  which  are  always  circular 
or  oval,  are  among  the  most  constant  lesions  of  the  secondary  stage,  appearing 
from  time  to  time  during  many  months.  If  a  patch  has  the  papillae  destroyed, 
it  is  called  a  "hald  patch."  If  the  papules  present  hypertrophied  papillae 
fused  together,  there  appear  enlargements  with  flat  tops,  termed  condylomata; 
if  the  papillae  of  the  papules  hypertrophy  and  do  not  fuse,  the  growths  are 


S22  Syphilis  or  Pox 

caMedwarts  (Fig.  124).  Mucous  lesions  of  the  mouth  are  commonest  in  smok- 
ers and  in  those  with  bad  or  neglected  teeth.  Hutchinson  says  that  persistence 
in  smoking  during  sv^Dhilis  may  cause  leukomata,  or  persistent  white  patches. 
The  vagina  and  lips  of  the  vulva  during  the  secondary  stage  are  often  covered 
with  mucous  patches.  The  uterus  may  contain  mucous  lesions  which  poison 
the  uterine  discharge.  The  lar^Tix  may  suffer  from  inflammation,  eruptions, 
and  ulceration  (hence  the  hoarse  voice  which  is  so  usual).  The  nasal  mucous 
membrane  may  also  suffer.  The  rectal  mucous  membrane  may  be  attacked 
with  patches,  and  so  may  the  glans  penis,  the  inner  surface  of  the  prepuce, 
and  the  urethra.  Early  in  the  secondary'  stage  in  some  cases  there  is  a  shght 
muco-purulent  urethral  discharge,  and  examination  with  an  endoscope  shows 
redness  of  the  mucous  membrane  of  the  anterior  urethra.  The  discharge  is 
contagious.  The  condition  may  be  followed  by  constriction  of  the  urethral 
cahber.     Distinct  ulceration  may  take  place. 

Affections  of  the  Hair. — In  s^-philis  the  hair  is  usually  shed  to  a  great 
extent.  This  loss  may  be  widespread  (beard,  mustache,  head,  eyebrows,  pubic 
hair,  etc.)  or  it  may  be  Hmited.  Complete  baldness  sometimes  ensues,  but 
it  is  rarely  permanent.  The  hairs  of  the  head  are  first  noticed  to  come  out 
on  the  comb;  on  pulling  them  they  are  found  loose  in  their  sheaths — so 
loose  that  Ricord  has  said  "a  man  would  drown  if  a  rescuer  could  pull  only 
upon  the  hair  of  the  head."  The  faUing  out  of  the  hair,  which  is  known  as 
alopecia,  usually  begins  soon  after  the  fever  or  about  the  time  of  the  erup- 
tion, but  it  may  be  postponed  until  much  later.  The  skin  of  a  syphilitic  bald 
spot  is  never  smooth,  but  is  scaly.  The  hair  may  thin  generally,  baldness 
may  appear  in  twisting  hues,  or  it  may  be  complete  only  in  limited  areas.  Alo- 
pecia results  from  shrinking  of  the  hair-pulp,  death  of  the  hair,  and  casting  off 
of  the  sheath. 

Affections  of  the  ^SlWs.— Paronychia  is  inflammation  and  ulceration  of 
the  skin  in  contact  with  a  nail  and  extending  to  the  matrix.  The  nail  is  cast 
off  partially  or  entirely.  Onychia  is  inflammaion  of  the  matrLx,  and  is  mani- 
fested by  white  spots,  brittleness  or  extended  opacity,  twisting,  and  breaking 
off  of  the  nail.  The  parts  around  are  not  affected.  The  damaged  nail  drops 
off  and  another  diseased  nail  appears. 

Affections  of  the  Ear. — Temporary  impairment  of  hearing  in  one  or 
both  ears  is  not  uncommon  in  s}'phihtic  affections  of  the  ear.  Rarely,  per- 
manent s}Tnmetrical  deafness  is  produced.  Meniere's  disease  is  sometimes 
caused  by  s^-philis. 

Affections  of  the  Bones  and  Joints. — In  syphiUs  there  may  be  slight 

and  temporary  periostitis.  Pain  and  tenderness  arise  in  various  bones,  the 
pain  being  worse  at  night  (osteocopic  pains).  Osteoperiostitis  usually  arises 
with  or  after  the  onset  of  the  secondary  eruption,  but  in  rare  instances  pre- 
cedes the  s\-phihdes.  The  bones  losually  involved  are  the  tibiae,  clavicles,  and 
skull.  Intense  headache  may  be  due  to  periostitis  of  the  inner  surface  of  a 
cranial  bone  (Mauriac).  Local  periostitis  may  form  a  soft  node  which  by 
ossification  becomes  a  hard  node.  Pain  like  that  of  rhetunatism  may  affect  the 
joints.  It  is  not  increased  by  motion  and  is  worse  at  night.  Such  pains 
are  by  no  means  uncommon  and  in  some  cases  are  very  severe.  The  joints 
are  not  stiff  except  perhaps  on  rising.  Paton  reminds  us  that  such  arthralgia 
is  an  early  sj-mptom  and  may  actually  antedate  the  secondary'  eruption  ("  Brit. 


Intermediate  Period  323 

Med.  Jour.,"  Nov.  28,  1903).  More  common  than  the  above  condition  is 
synovitis,  acute  or  chronic.  It  often  comes  on  rapidly  without  other  sjinptoms 
and  is  announced  by  swelling,  tenderness,  and  pain.  In  some  cases  the  pain 
is  severe,  and  the  patient  is  feverish  or  actually  ill.  Such  cases  constitute 
what  is  called  syphilitic  rheumatism,  hut  ihc  profuse  sweats  of  acute  rheu- 
matism are  absent,  the  heart  is  never  attacked,  the  skin  is  not  red,  the  fever 
is  not  high,  and  the  condition  is  not  migrating  (Piiton,  in  "Brit.  Med.  Jour.," 
Nov.  28,  1903).  Hydrarthrosis  may  arise  in  the  knee  as  a  sequence  of  either 
of  the  aliove  conditions,  or,  late  in  the  secondary  stage,  it  may  arise  without 
such  an  antecedent  trouble  (Paton).  Symmetrical  synovitis  has  been  noted. 
Secondary  syphilitic  disease  of  bone,  periosteum,  and  joints  lasts  only  a  short 
time  and  is  never  destructive. 

Affections  of  the  Eye. — Iritis  is  the  commonest  eye  trouble  which  may 
arise  during  secondary  syphilis.  It  appears  from  three  to  six  months  after  the 
chancre,  and  begins  in  one  eye,  the  other  eye  soon  becoming  affected.  The 
symptoms  are  a  pink  zone  in  the  sclerotic,  a  congested,  red  or  muddy  iris,  irreg- 
ularity of  the  pupil  accentuated  by  atropin,  the  existence  of  pain  and  photo- 
phobia, and  sometimes  hazy  or  even  clouded  pupil.  Rheumatic  iritis  causes 
much  pain  and  photophobia,  syphilitic  iritis  comparatively  little;  there  is  less 
swelling  in  the  first  than  in  the  second;  the  former  tends  to  recur,  the  latter 
does  not.  Iritis  is  usually  recovered  from,  good  vision  being  retained.  Diffuse 
retinitis  and  disseminated  choroiditis  never  occur  until  a  number  of  months 
have  passed  since  the  infection.  The  symptoms  are  failure  of  sight,  muscae 
volitantes,  and  very  little  photophobia.  The  diagnosis  of  retinitis  and  cho- 
roiditis is  made  by  the  ophthalmoscope. 

Affections  of  the  Testes. — Syphilitic  Sarcocele.— The  testicle  enlarges 
because  of  plastic  inflammation.  Both  glands  usually  suffer,  but  not  always. 
Fluid  distends  the  tunica  vaginalis.  The  epididymis  escapes.  The  testicle 
is  not  the  seat  of  pain,  is  troublesome  because  of  its  weight,  and  has  very 
little  of  the  proper  sensation  on  squeezing.  The  plastic  exudate  is  generally 
largely  absorbed,  but  it  may  organize  into  fibrous  tissue,  the  organ  passing 
into  atrophic  cirrhosis. 

The  Albuminuria  of  Secondary  Syphilis.— It  is  not  very  unusual 
for  nephritis  with  albuminuria  to  develop  early  in  the  secondary  stage.  There 
may  be  the  ordinary  symptoms  of  nephritis,  but  in  many  cases  there  is  albu- 
minuria and  nothing  more.  Large  amounts  of  albumin  run  away  from  the 
kidneys  and  the  high  percentage  of  albumin  in  the  urine  is  a  notable  feature. 
Many  of  these  cases  recover  completely,  some  become  chronic,  and  in  some  death 
occurs.  It  seems  probable  that  mercurial  treatment  is,  in  part  at  least,  respon- 
sible for  some  of  these  cases.  The  syphihtic  poison  causes  the  others.  Those 
in  which  there  is  albuminuria  and  nothing  more  are  due  to  syphiHs  rather  than 
to  mercury.  Those  in  which  there  is  dropsy  are  aggravated  and  perhaps  caused 
by  mercury  (Fleissinger,  in  "Journal  des  Practicens,"  August  3,  1907). 

Intermediate  Period. — Secondary  lesions  cease  to  appear  in  from 
eighteen  months  to  three  years.  In  the  intermediate  period  no  symptoms 
may  appear,  but  the  disease  is  still  for  some  time  latent  and  is  not  cured. 
Symptoms  may  arise  from  time  to  time.  These  symptoms,  which  are  called 
"reminders,"  are  not  so  severe  as  terdary  symptoms,  are  apt  to  be  symmet- 
rical, and  do  not  closely  resemble  secondary  lesions.     Among  the  reminders 


324 


Syphilis  or  Pox 


we  may  name  palmar  psoriasis  and  sarcocele.  Sarcocele  in  this  stage  is 
bilateral  and  rarely  painful.  Bilateral  indolent  epididymitis  occasionally 
occurs.  Sores  on  the  tongue,  a  papular  skin  eruption,  and  choroiditis  may 
arise.  Gummata  occasionally  occur  in  this  stage,  but  they  are  apt  to  be 
symmetrical  and  non-persistent  (symmetrical  superficial  dactyUtis) .  Arteritis 
may  occur,  beginning  in  the  intima  or  adventitia,  and  causing,  it  may  be,  aneur- 
ysm, thrombosis,  or  emboUsm.  Obliterative  endarteritis  may  cause  gangrene. 
Vascular  changes  are  notably  common  in  the  vessels  of  the  brain,  and  throm- 
bosis may  occur,  in  which  case  paralysis  comes  on  gradually,  preceded  by 
numbness,  although  sudden  paralysis  may  take  place.     These  paralyses  may 

be  Umited,  extensive,  transitory, 
or  permanent.  The  nervous  sys- 
tem often  suffers  in  this  stage 
(anesthetic  areas  and  retinitis). 
Tlie  viscera  are  often  congested 
and  infiltrated  (tonsils,  liver, 
spleen,  kidneys,  and  lungs). 

Tertiary  Syphilis. —  This 
stage  is  not  often  reached,  the 
disease  being  cured  before  it  has 
been  attained.  About  85  per  cent. 
of  syphiUtics  escape  it  entirely.  It 
is  not  so  much  a  stage  of  syphilis 
as  a  condition  of  impaired  nutri- 
tion which  results  from  the  dis- 
Fig.  125.— Syphilis  of  nose.  ease.     This  view  finds  confirma- 

tion in  the  fact  that  tertiary  lesions 
do  not  furnish  the  contagion.  The  primary  stage  disappears  without  treat- 
ment, the  secondary  stage  tends  ultimately  to  spontaneous  disappearance,  but 
tertiary  lesions  tend  to  persist  and  to  recur.  Tertiary  lesions  may  be  single 
or  may  be  widely  scattered;  when  multiple  they  are  not  symmetrical  except 
by  accident.  These  lesions  may  attack  any  tissue,  even  after  many  years  of 
apparent  cure;  they  all  tend  to  spread  locally,  they  all  leave  permanent  atrophy 
or  thickening,  they  all  tend  to  relapse,  and  a  local  influence  is  often  an  exciting 
cause.  Tertiary  syphilis  may  cause  marked  anemia  and  it  is  sometimes  the 
cause  of  pernicious  anemia  (Dumas  and  Pirrot,  in  "La  Presse  Medicale,"  xv., 
Nos,  39  and  40) . 

Tertiary  skin-eruptions  are  liable  to  ulcerate.  Various  eruptions  may 
occur:  papular  syphilides,  pustular  syphiHdes,  gummatous  syphihdes,  ser- 
piginous syphilides,  and  pigmentary  syphiHdes.  The  characteristic  syphilide 
is  rupia,  which  is  formed  by  a  pustule  rupturing  or  a  papule  ulcerating.  A 
brown  or  black  crust  forms  because  of  the  drying  of  the  discharge,  ulceration 
continues  under  the  crust,  new  crusts  form,  and,  as  the  ulcer  is  constantly 
increasing  peripherally,  the  new  crusts  are  larger  in  diameter  than  the  old 
ones  and  the  mass  assumes  the  form  of  a  cone.  An  ulcer  which  has  destroyed 
the  deeper  layers  of  the  skin  is  exposed  by  tearing  off  the  crust.  On  healing, 
a  rupial  ulcer  always  leaves  a  permanent  scar. 

Serpiginous  ulcers  are  common  in  tertiary  syphilis,  and  are  especially 
common  about  the  knees,  nostrils,  forehead,  and  lips.    Serpiginous  ulceration 


The  Gumma  325 

is  spoken  of  as  syphilitic  lupus.  It  is  preceded  by  a  widespread  brown- 
colored  nodular  cutaneous  infiltration.  The  nodules  suppurate,  run  together, 
crust,  and  produce  an  ulcer  which  spreads  rapidly  and  assumes  the  shape  of 
a  horseshoe. 

The  Gumma. — The  gumrha  is  the  typical  tertiary  lesion.  In  some  cases 
there  is  a  solitary  gumma;  in  others,  two  or  three  or  even  many  gummata. 
A  gumma  is  a  mass  of  granulation  tissue,  grayish-yellow  in  color,  containing 
many  cells  and  few  fibers.  Organization  of  the  gumma  fails  to  take  place 
because  of  a  want  of  sufficient  blood-supply,  the  cellular  mass  is  apt  to  undergo 
caseation,  and  when  this  occurs  an  ulcer  forms.  One  portion  of  the  mass 
may  caseate,  another  portion  may  become  fibrous.  In  some  cases  the  entire 
gvmima  becomes  fibrous.  \  gumma  varies  in  diameter  from  one-eighth 
of  an  inch  to  two  or  three  inches,  presents  a  center  of  gummy  degenera- 
tion, a  surrounding  area  of  immature  fibrous  tissue,  and  an  outer  zone  of 
embryonic  tissue  and  leukocytes.  A  gumma,  when  it  is  spontaneously  evac- 
uated,  exhibits  a  small  opening  or  many  openings  with  very  thin  red  and 


126. — Gumma  of  the  clavicle. 


undermined  edges;  the  ulcer  is  slow  to  heal,  and  forms  a  thin  scar,  white  in 
the  center,  but  pigmented  at  the  margins  and  usually  depressed  (Jonathan 
Hutchinson,  Jr.).  The  gummatous  ulcer  is  deep,  circular  in  outline,  \\\ih 
undermined  edges  and  an  uneven  floor  covered  with  a  thick,  white,  adherent 
slough.  Sometimes  there  is  no  slough,  but  an  extensive  area  is  infiltrated. 
A  gummatous  ulcer  may  coalesce  with  one  or  more  adjacent  ulcers.  The 
discharge  is  scanty  and  tenacious.  These  ulcers  are  often  seen  upon  the 
legs,  and  when  once  healed  rarely  recur.  A  gumma  in  the  internal  organs  may 
become  a  fibrous  mass.  Gummata  form  in  the  skin,  subcutaneous  tissues, 
submucous  structures,  muscles,  tongue,  joints,  bursae,  testes,  spinal  cord,  brain, 
and  internal  organs.  In  tertiary  syphiUs  an  inflammation  may  not  form  a  cir- 
cumscribed gumma,  but,  instead,  may  produce  a  diti'use  degenerating  mass. 
This  type  of  inflammation,  which  is  seen  in  bones,  is  called  "gummatous." 
In  the  nasal  cavity  a  gumma  is  rapidly  followed  by  an  ulcer  and  there  is  a 
strong  tendency  to  necrosis  of  the  vomer  and  sometimes  of  the  turbinated 
bones.  This  condition  produces  a  foul  discharge  and  is  known  as  syphilitic 
ozcena.     Advanced  necrosis  of  the  nasal  bones  causes  the  nose  to  ''fall  in," 


326 


Syphilis  or  Pox 


\'V-. 


which  is  a  hideous  deformity  (Fig.  127).  The  commonest  laryngeal  lesion  is 
multiple  ulceration  following  minute  gummata.  A  healing  gumma  in  a 
mucous  canal  such  as  the  rectum  or  larynx  causes  thickening  and  stricture. 
Tertiary  syphilis  is  a  common  cause  of  amyloid  degeneration  and  the  most 
frequent  cause  of  arterial  and  nervous  sclerosis. 

Various  Lesions. — Hutchinson  enumerates  the  lesions  of  tertiary  syphilis 
as  follows:     Periostitis,  forming  nodes  or  causing  sclerotic  hypertrophy,  or 

suppuration,  or  necrosis;  gummata  in 
various  parts;  disease  of  the.  skin  of 
the  type  of  rupia  or  lupus;  gumma  or 
inflammation  of  the  tongue,  causing 
sclerosis;  structural  changes  in  the 
nervous  system,  causing  ataxia,  oph- 
thalmoplegia externa  and  interna, 
general  paresis,  optic  atrophy,  and 
paralyses  of  cerebral  nerves;  amyloid 
degenerations;  and  chronic  inflamma- 
tion of  certain  mucous  membranes  (of 
the  mouth,  pharynx,  vagina,  rectum, 
etc.),  with  thickening  and  ulceration. 
Gummatous  infiltration  of  the  eyelid 
is  sometimes  observed.  Gummatous 
osteoperiostitis  of  the  vertebrae  may 
arise,  and  this  may  be  associated  with 
disease  of  the  membranes  or  cord. 
Syphilitic  inflammation  of  vertebra?  is 
called  syphilitic  spondylitis.  Unilat- 
eral enlargement  of  the  epididymis  is 
sometimes  noted,  the  mass  feeling 
heavy,  aching  a  little,  but  not  being 
very  tender.  Unilateral  sarcocele  may  be  met.  Gumma  may  arise  in  the 
iris,  the  larynx,  the  rectum,  and  the  nose. 

Tertiary  Syphilis  of  Bones. — The  bones  particularly  liable  to  disease 
are  the  skull,  sternum,  nasal  septum,  and  tibia.  The  usual  form  is  a  gumma 
resulting  in  caries  and  necrosis.  A  superficial  gumma  causes  syphilitic  peri- 
ostitis, a  deep  gumma,  syphilitic  osteomyelitis  (McFarland's  "Text-book  of 
Pathology").  Periostitis  affects  particularly  the  superficial  bones  (tibia, 
clavicle,  sternum,  ulna,  etc.).  It  begins  in  the  deeper  layer  of  the  periosteum, 
swelling  arises,  gummy  changes  occur,  and  the  bone  beneath  is  more  or  less 
destroyed.  In  the  skull  the  bone  may  be  completely  penetrated.  Not  un- 
usually syphilitic  periostitis  arises  at  the  seat  of  a  trivial  injury.  Sjphilitic 
osteomyelitis  occurs  particularly  in  the  phalanges  and  skull.  An  area  of 
syphilitic  bone  disease  may  undergo  repair,  osteosclerosis  usually  and  osteo- 
porosis sometimes  resulting.  Syphiliis  of  the  bones  of  the  nose  is  a  necrosis 
resulting  from  gummatous  ulceration. 

Tertiary  Dactylitis, — This  condition  is  a  gummatous  formation  in  a 
finger  or  toe.  There  is  a  superficial  form  in  which  the  deposit  begins  in  the 
subcutaneous  tissue  and  subsequently  involves  the  joint  Ugaments.  In  a  toe 
the  entire  digit  is  usually  involved,  in  a  finger  the  condition  is  usually  limited  to 


Fig.   12; 


-Destruction  of   the  nose  in  ter- 
tiary syphilis. 


Visceral  Syphilis  327 

the  proximal  phalanx.  Superficial  dactylitis  is  a  very  early  tertiary  phenome- 
non. A  painless  swelling  gradually  forms  and  it  is  most  distinct  on  the  dorsal 
surface.  The  sweUing  becomes  purphsh  or  reddish  blue  in  color  and  the  joint 
becomes  preternaturally  mobile.     The  swelling  may  ulcerate. 

Deep  dactylitis  is  a  very  late  tertiary  manifestation  and  is  osteomyelitis  and 
periostitis  of  the  fingers  or  perhaps  of  the  toes.  One  or  more  proximal  pha- 
langes are  apt  to  sutler.  The  skin  seldom  suffers.  Caries  and  necrosis  may 
occur  and  the  joint  may  be  destroyed,  or  the  bone  may  be  partially  absorbed 
and  shortened  from  dry  caries.     Ulceration  of  the  skin  is  rare. 

Tertiary  Syphilis  of  Joints. — (See  the  careful  study  of  E.  Percy  Pa  ton, 
in  ■"Brit.  Med.  Jour.,"  Nov.  28,  1903).  The  knee-joint  is  most  commonly 
affected.  Chronic  synontis  may  arise  with  considerable  or  even  great  swell- 
ing (hydrarthrosis),  tri\-ial  pain,  slight  functional  impairment,  some  thicken- 
ing of  s}'no\-ial  membrane,  and  some  harshness  or  grating  on  movement. 
Gummatous  s^-no^^tis  may  arise,  a  condition  which  sometimes  follows  the 
ordinary  synovitis,  but  more  often  exhibits  ver}-  Uttle  swelhng.  The  S}-no\-ial 
membrane  exhibits  irregular  areas  of  thickening  and  the  s}'mptoms  resemble 
those  of  a  tuberculous  joint  (Paton). 

In  some  s_\-phihtic  joints  the  disease  begins  in  the  bone  and  cartilage. 
In  such  a  condition  there  is  rigidit}',  marked  hmitation  of  movement,  pains 
not  often  severe,  and  some  deformit}'  (Paton) .  Again,  as  Paton  points  out,  a 
joint  may  be  involved  by  an  adjacent  s}'phihtic  area,  s}'no\itis  arising,  or,  if 
a  gumma  breaks  into  a  joint,  secondary  pyogenic  infection  may  follow.  Anky- 
losis may  foUow  joint  s\'phiUs. 

Visceral  Syphilis. — Amyloid  changes  may  occur  in  any  of  the  \iscera  of 
an  indi\idual  with  tertiar}-  syphilis,  and  such  changes  may  be  found  in  people 
in  whom  suppuration  never  occurred.  The  lungs  may  undergo  fibroid 
induration  (sx-phiUtic  phthisis).  Syphihtic  phthisis  is  often  a  non-febrile 
malady.  The  sputum  does  not  contain  the  bacilli  of  tuberculosis,  night- 
sweats  and  diarrhea  are  unusual,  and  emaciation  and  exhaustion  are  less 
decided  than  in  tuberculosis.  Gummata  may  form  in  the  heart,  liver,  spleen, 
or  kidneys.  The  capsule  and  fibrous  septa  of  the  liver  may  thicken,  the  organ 
being  puckered  by  contraction.  Albuminuria  may  occur  in  tertiarv'  s)-pliilis. 
It  may  be  caused  by  fibroid  changes  in  the  kidneys,  by  the  formation  of  gum- 
mata, or  by  amyloid  degeneration.  Its  occurrence  should  be  watched  for. 
Mercury  and  iodid  of  potassium  have  been  regarded  as  causative  of  albumin- 
uria in  some  cases.  When  albuminuria  is  associated  with  arterial  disease  and 
elevated  tension  the  condition  is  to  be  regarded  as  parasyphilitic  rather  than 
syphihtic.  When  albuminuria  results  from  a  true  s}-phihtic  lesion  of  the  kid- 
ney, there  is  enlargement  of  the  Uver,  that  organ  is  often  painful,  there  is 
ascites,  and  sometimes  jaundice  (Fiessinger). 

Sj'phihs  may  cause  disease  of  the  stomach,  and  probably  does  so  more 
frequendy  than  was  formerly  supposed,  because  it  is  diflicult  to  distinguish 
from  more  common  diseases.  The  condition  may  be  gummatous  infiltration 
of  the  walls  of  the  stomach,  multiple  and  minute  gummata,  ulcerations  result- 
ing from  breaking  down  of  gummata,  or  s}'philitic  endarteritis  of  the  gas- 
tric vessels.  When  ulcers  heal,  cicatricial  contraction  results.  Sometimes  a 
large  mass  can  be  palpated.  The  symptoms  last  for  years.  There  is  pain 
after  eating,  but  hemorrhage  does  not  occur  unless  ulcer  forms.     Sj'philitic 


328  Syphilis  or  Pox 

ulcers  and  gummata  of  the  stomach  may  be  cured  by  efficient  antisyphilitic 
treatment.  Like  lesions  may  form  in  the  intestines.  Flexner,  Frankel, 
Fournier,  and  others  have  discussed  -this  subject.* 

Nervous  syphilis  may  be  manifested  by  disorders  of  the  brain,  cord,  or 
nen^es.  It  is  rare  after  severe  secondaries,  and  is  most  common  when  sec- 
ondaries were  Hght  or  so  trivial  as  to  have  escaped  observation.  Severe 
secondaries  seem  to  cast  oflf,  mitigate,  or  exhaust  the  poison.  Nervous  syph- 
ihs  may  result  directly  from  the  specific  disease,  and  such  lesions  are  trvdy 
syphilitic.  It  may  result  indirectly  from  the  specific  disease,  and  such  lesions 
are  called  parasyphilitic.  For  instance,  a  gumma  of  the  brain  is  a  true  s}-ph- 
Uitic  lesion,  but  locomotor  ataxia  following  s}-philis  is  a  parasyphilitic  lesion. 
Syphilitic  lesions  are  improved  or  ciu-ed  by  antisyphilitic  treatment,  para- 
syphilitic conditions  are  not.  Brain  syphiHs  is  usually  a  late  phenomenon 
(from  one  to  thirty  years  after  infection).  The  lesion  may  be  gumma  of  the 
membranes  (tumor),  gummatous  meningitis,  arterial  atheroma,  or  obliterative 
endarteritis.  A  gumma  may  eventuate  in  a  scar,  a  cyst,  or  a  calcareous  mass. 
The  symptoms  of  brain  syphiHs  depend  on  the  nature,  seat,  and  rate  of  devel- 
opment of  the  lesions.  It  is  to  be  noted  that  s}TDhilitic  palsy  is  apt  to  be  limited, 
progressive,  and  incomplete.  Epilepsy  appearing  after  the  thirtieth  year  is 
very  probably  specific  if  alcohol  as  a  cause  can  be  ruled  out.  Persistent  head- 
ache, tremor,  insomnia  or  somnolence,  transitory,  hmited,  and  erratic  palsies, 
unnatural  slowness  of  utterance,  amnesia,  vertigo,  and  epilepsy  are  very 
suggestive  of  syphilis.  Sudden  ptosis  is  very  significant;  so  is  sudden  palsy 
of  one  or  more  of  the  extrinsic  eye-muscles.  In  syphihtic  insomnia  the  patient 
cannot  get  to  sleep  at  night  for  a  long  while,  but  when  he  once  gets  to  sleep  he 
reposes  well.  The  type  of  insanity  which  is  most  apt  to  arise  is  a  Ukeness  or 
counterpart  of  general  paralysis,  and,  like  ordinary  paresis,  it  is  not  curable. 
Spinal  syphilis  may  cause  sclerosis,  a  condition  like  Landry's  paralysis, 
softening,  and  tumor.  Neuritis  is  not  uncommon  in  syphilis.  Many  of  the 
diseases  which  follow  syphilis  are  due  to  it  only  indirectly,  and  are  not  bene- 
fited by  specific  treatment.     Among  them  are  paresis  and  locomotor  ataxia. 

Justus's  Test  for  Syphilis. — The  test  described  by  Justus,  in  1894, 
consists  in  first  estimating  the  amount  of  hemoglobin  present,  then  making  a 
single  mercurial  inunction,  and  again  estimating  the  hemoglobin.  It  is 
claimed  that  the  corpuscles  of  an  untreated  sj-philitic  are  unduly  sensitive,  and 
if  the  disease  is  present  a  mercurial  inunction  will  cause  a  loss  of  10  to  20  per 
cent,  of  hemoglobin  within  twenty-four  hours,  which  fall  persists  a  few  hours 
and  is  then  followed  by  a  ri>e  to  a  level  above  that  which  existed  when  the  test 
was  applied.  It  is  often  demonstrable  in  secondary,  tertiary,  or  congenital 
syphilis.  It  usually  fails  in  latent  cases,  when  an  initial  lesion  is  recent,  and 
in  early  secondary  syphilis,  and  in  some  diseases  other  than  S}T)hilis  the  reac- 
tion can  be  obtained.-  I  regard  the  test  as  unreliable.  Justus  claims  that  the 
test  is  positive  in  from  70  to  80  per  cent,  of  all  cases  of  florid  syphiUs  ("  Deutsch. 
Arch.  f.  klin.  Med.,"  1903,  vol.  Ixxv.,  p.  i). 

The  Serum   Diagnosis  of  Syphilis  (W'assermann's  Test).— This 

test  can  only  be  employed  in  institutions  possessed  of  the  best  laboratory 

facilities.     It  is  technical  in  the  extreme.     In  order  to  understand  it  certain 

facts  must  be  knowTi. 

*  See  editorial  in  Jour.  Amer.  Med.  .\ssoc.,  March  24,  1900,  and  Roudnitzky,  quoted 
in  Progressive  Medicine,  June,  1908,  from  Prakt.  Vratch,  August  and  September,  1907. 


Wassermann's  Test  for  Serum  Diagnosis  of  Syphilis  329 

Every  serum  contains  material  known  as  complement,  and  complement  is 
destroyed  by  heat.  When  bacteria  or  alien  corpuscles  are  injected  into  a  living 
animal,  the  tissues  of  that  animal  react  and  amboceptor  is  formed.  Ambocep- 
tor includes  all  antibodies.  Amboce])tor  is  not  destroyed  by  heat.  If  we 
inject  the  corpuscles  of  sheep's  blood  into  a  rabbit,  amboceptor  forms  and  ap- 
pears in  the  rabbit's  serum.  Amboceptor  unites  with  complement  and  with 
alien  corpuscles  and  the  sheep's  corpuscles  are  dissolved.  The  blood  of  the 
rabbit  now  contains  a  distinct  excess  of  amboceptor.  If  some  of  this  blood  is 
drawn  and  the  serum  is  placed  in  a  test-tube,  it  will  dissolve  in  the  tube  cor- 
puscles of  sheep's  blood  if  they  are  added  to  it.  If,  however,  the  rabbit  serum 
is  heated  for  one-half  hour  to  50°  C.  before  being  placed  in  a  test-tube,  the  heat 
destroys  the  complement,  and  then  the  rabbit  serum  will  be  unable  to  dis- 
solve the  corpuscles  of  sheep's  blood  because  amboceptor  without  complement 
is  incapable  of  effecting  solution. 

If,  however,  after  destroying  the  complement  by  heat,  any  other  serum 
is  added,  the  added  serum  furnishes  the  necessary  complement  and  the  mixture 
is  now  able  to  dissolve  sheep's  corpuscles. 

On  these  facts  the  serum  diagnosis  of  syphilis  depends. 

Wassermann  proved  that  if  an  extract  made  of  a  syphilitic  organ  is  placed 
in  the  serum  of  a  syphilitic  individual,  the  amboceptor  or  antibody  will  unite 
with  the  complement  and  with  the  organ  extract,  although  the  union  cannot 
be  recognized  by  inspection.  In  order  to  be  able  to  identify  the  occurrence  of 
such  a  union  a  process  must  be  gone  through. 

The  serum  of  the  patient  thought  to  be  sjrphilitic  is  heated  and  comple- 
ment is  thus  destroyed.  It  is  then  mixed  with  the  organ  extract,  which  unites 
with  the  amboceptor  of  the  serum,  one  arm  of  the  amboceptor  being  still 
unsaturated  and  open  for  union.  Guinea-pig  serum  is  now  added  to  furnish 
complement.  If  the  patient  is  syphilitic  the  serum  complement  just  added 
will  unite  with  the  unsaturated  arm  of  the  antibody  or  amboceptor.  To  find 
out  if  this  has  taken  place  we  add  the  heated  serum  of  a  rabbit,  which  will 
destroy  sheep's  corpuscles  if  fresh  serum  is  added  to  it. 

"Sheep's  corpuscles  are  also  added.  If  the  complement  contained  in  the 
guinea-pig  serum  that  was  added  was  taken  up  or  united  with  by  the  syphilitic 
antibody,  there  will  be  none  left  over,  and  consequently  the  added  sheep's 
corpuscles  will  not  be  dissolved.  If,  however,  the  serum  was  not  syphihtic, 
the  complement  will  not  have  been  taken  up,  but  will  be  left  over  for  union 
with  the  hemolytic  amboceptor  of  the  inactivated  rabbit  serum,  which  latter 
unites  with  the  blood-corpuscles,  and  the  combination  causes  the  solution  of  the 
latter"  (Wm.  J.  Butler,  "N.  Y.  Med.  Journal,"  Jan.  30,  1909). 

Butler  made  a  study  of  150  cases  and  found  reaction  positive  in  123.  Ten 
cases  of  primary  syphilis  were  examined  and  all  showed  the  reaction. 

Of  36  cases  in  the  secondary  stage,  34,  or  95  per  cent.,  showed  it.  Of  31 
cases  in  the  tertiary  stage,  29,  or  94  per  cent.,  showed  it.  Of  16  latent  cases, 
9,  or  56  per  cent.,  gave  a  positive  reaction.  Of  55  cases  of  parasyphilis  and 
visceral  syphilis,  41,  or  76  per  cent.,  gave  a  positive  reaction. 

Two  cases  which  gave  positive  reactions  failed  to  give  any  after  active 
mercurial  treatment  (Wm.  J.  Butler,  Ibid.) . 

It  is  interesting  and  perhaps  important  that  the  test  can  be  made  with 
milk  taken  from  the  breast  of  a  nursing  mother  as  well  as  with  her  serum. 


330  Syphilis  or  Pox 

It  seems  certain  that  the  serum  test  has  high  diagnostic  value.  A  positive 
reaction  indicates  that  the  poison  is  active  and  calls  upon  the  physician  to 
apply  active  treatment.  This  should  be  the  rule,  no  matter  how  long  it  has 
been  since  there  were  any  external  manifestations  of  the  disease.  Wet  nurses 
should  be  tested  by  this  method  before  being  allowed  to  assume  charge  of  an 
infant.  Positive  reactions  have  been  obtained  in  noma  and  scarlet  fever,  but 
neither  of  these  diseases  would  be  confused  with  syphilis  (Wm.  J.  Butler, 
Ibid.j. 

The  test  seems  to  prove  that  s\philis  is  the  cause  of  paresis  and  locomotor 
ataxia.     It  v\ill  probably  be  much  simplified  in  technic  in  the  near  future. 

Diagnosis  by  Finding  the  Spirochaeta  Pallida. — This  method  is 
of  the  greatest  value.  The  organism,  if  carefully  searched  for,  is  found  in 
chancre,  in  all  the  lesions  of  early  secondar}-  s\-phili5,  and  in  congenital  5}'phili5. 
It  is  not  found,  it  is  true,  in  the  gumma,  but  the  gumma  is  not  a  contagious 
lesion.     It  is  not  found  in  lesions  other  than  syphilis. 

Treatment  of  the  Primary  Stage. — It  has  long  been  taught  that  a 
chancre  should  not  be  excised  because  the  disease  is  constitutional  when  the 
chancre  appears,  and  excision  and  cauterization  inflict  needless  pain  and  do  no 
good.  Several  observers  during  recent  years  have  claimed  that  ablation  of  the 
chancre  will  in  some  instances  prevent  the  disease.  In  the  reported  cases  there 
is  some  doubt  as  to  the  diagnosis  and  they  do  not  prove  the  contention.  It  is 
very  doubtful  if  ablation  is  of  service.  It  may  be  tried  if  the  lesion  is  on  the 
prepuce  and  there  is  no  glandular  involvement.  It  should  not  be  tried  if 
ablation  requires  mutilation.  It  was  shown  by  Metschnikoff  that  constitu- 
tional s\-philis  can  be  prevented  by  rubbing  calomel  ointment  into  the  seat  of 
infection  within  eighteen  hours  of  the  intercourse,  but  prevention  of  develop- 
ment is  not  prevention  after  a  chancre  forms.  This  preventive  measure  is 
now  in  use  in  the  U.  S.  'Sa.vy.  The  ointment  used  contains  33  parts 
of  calomel,  10  of  vaselin,  and  67  of  lanolin.  The  initial  lesion  should 
never  be  cauterized  unless  it  is  phagedenic  or  becoming  so.  Order  the  patient 
to  soak  the  penis  for  five  minutes  twice  daily  in  warm  salt  water  (a  teaspoonful 
of  salt  to  a  cupful  of  water),  and  then  to  spray  the  sore  with  pero.xid  of  hydro- 
gen diluted  with  an  equal  bulk  of  water.  The  ulcer  is  then  dried  with  absor- 
bent cotton  and  on  it  is  dusted  a  powder  composed  of  equal  parts  of  bis- 
muth and  calomel.  The  buboes  in  the  groin  require  no  local  treatment 
unless  they  tend  to  suppurate.  If  they  persist  or  become  large,  paint  them 
with  iodin  or  rub  ichthyol  ointment  or  merciirial  ointment  into  them,  and 
apply  a  spica  bandage  to  the  groin.  Some  authorities  give  mercur}-  in  this 
stage  in  order  to  prevent  secondaries.  The  younger  Gross  opposed  this 
strongly,  and  aflSrmed  a  wish  to  see  the  secondan,'  eruption — first,  because 
it  proves  the  diagnosis;  and,  second,  because  it  affords  valuable  prognostic 
indications  (an  er}thematous  eruption  means  a  hght  case,  an  early  pustular 
eruption  means  a  grave  case  with  serious  compUcations) ;  I  have  always 
followed  the  plan  of  Gross,  and  do  not  order  mercury  until  constitutional 
SMnptoms  develop.  If  phagedena  arises,  place  the  patient  at  once  upon 
stimulants  and  nutritious  diet,  secure  sleep,  and  destroy  the  ulcer  by  the  use 
of  nitric  acid  or  the  cauter\'  while  the  patient  is  anesthetized.  After  cau- 
terization dust  the  sore  with  iodoform  and  dress  with  wet  antiseptic  gauze. 
Several  times  a  day  change  the  dressings,  and  at  each  change  spray  the  sore 


Medical  Treatment  331 

with  peruxid  of  hydrogen,  irrigate  with  bichlorid  of  mercury  solution,  and 
dust  with  iodoform.  It  may  be  necessary  to  cauterize  several  times.  In 
some  cases  it  will  be  necessary  to  employ  continuous  irrigation  with  an  anti- 
septic fluid.  These  cases  are  sometimes  fatal  and  usually  produce  great 
destruction  of  tissue.  In  chancre  redux  watch  carefully  for  the  symptoms  in 
order  to  determine  if  the  condition  is  really  one  of  reinfection  or  if  we  are 
dealing  with  a  gumma  which  resembles  a  chancre  in  appearance. 

Treatment  of  the  Secondary  Stage. — The  chance  of  cure  in  most  cases 
is  excellent  if  the  patient  follows  advice.  The  prognosis  is  much  worse  if  the 
patient  is  a  hard  drinker  or  is  the  victim  of  Bright's  disease,  diabetes,  tuber- 
culosis, or  other  chronic  exhausting  malady.  In  the  secondary  stage  the  aim  is 
to  cure  the  disease.  That  it  can  be  cured  is  known  because  reinfection  occur- 
in  some  persons.     The  old  axiom,  "Syphilis  once,  syphilis  ever, "is  not  true. 

Diet  and  General  Care. — In  the  beginning  of  treatment  the  patient  must 
see  his  physician  every  day  or  two  until  the  proper  dose  of  mercury  has  been 
ascertained.  For  the  following  six  months  he  should  see  his  physician  once 
a  week,  and  during  the  next  six  months  once  every  other  week.  During  the 
second  year  he  needs  to  see  him  once  every  month.  Of  course,  if  complica- 
tions arise  at  any  period  the  visits  must  be  more  frequent.  At  the  beginning 
of  the  attack  he  must  have  his  teeth  put  in  perfect  order.  Tobacco  is  abso- 
lutely forbidden  because  its  use  favors  the  development  of  mucous  patches  in 
the  mouth.  Alcohol  as  a  beverage  is  prohibited.  It  is  used  only  as  a  medi- 
cine. The  teeth  should  be  gently  scrubbed  with  a  soft  brush  in  the  morning, 
in  the  evening,  and  after  each  meal,  and  a  mild  astringent  or  antiseptic  mouth- 
wash and  gargle  is  to  be  used  several  times  a  day.  If  the  gums  become  red 
and  tender,  chlorate  of  potash  is  used  as  a  gargle  and  mouth-wash  (i  ounce  of 
the  drug  to  i  pint  of  water).  The  patient  should  wear  .flannel  in  winter. 
The  author  beheves  Guiteras's  rules  are  sound,  and  in  accordance  with  them 
directs  the  patient  to  refrain  from  kissing  any  one  on  the  lips  and  from  using 
a  common  towel,  wash-rag,  cup,  glass,  pipe,  or  razor.  He  is  told  to  sleep 
alone  in  bed,  to  wash  his  hands  often,  to  wear  gloves,  and  to  keep  his  fingers 
out  of  his  mouth.  Every  morning  he  should  take  a  warm  bath,  being  espe- 
cially careful  to  cleanse  the  anus,  perineum,  axillae,  groins,  and  between 
the  toes ;  and  after  the  bath  these  parts  should  be  dusted  with  borated  talc 
powder.  A  Turkish  bath  once  a  week  is  ordered  by  Guiteras  when  no  skin- 
eruption  exists.  The  patient  must  avoid  drafts,  cold  and  wet;  must  take  a 
moderate  amount  of  gentle  outdoor  exercise,  and  must  sleep  eight  hours  out  of 
the  twenty-four.  The  diet  is  of  importance,  and  in  this,  too,  the  author  fol- 
lows Guiteras  and  orders  the  patient  to  avoid  eating  anything  fried,  or  any 
meat  or  fish  which  has  been  canned,  salted,  or  preserved.  Fruits,  pickles, 
tea,  condiments,  alcoholic  beverages,  clams,  pork,  veal,  and  pastry  are  not  to 
be  taken.  (See  article  by  Luke  Begg  in  "  Phila.  Med.  Jour.,"  June  7, 
1901.) 

Medical  Treatment. — Mercury  must  be  used,  the  form  being  a  matter 
of  choice.  Fournier  advocated  intermittent  treatment.  In  this  plan  give 
gr.  J  of  protiodid  of  mercury  daily  for  six  months,  then  stop  for  a  month ; 
then  give  mercury  for  three  months,  then  stop  two  months.  During  the  first 
year  the  patient  is  under  treatment  nine  months,  and  during  the  second  year 
eight  months.     Some  prefer  the  intermittent  and  others  the  continuous  plan 


332  Syphilis  or  Pox 

of  treatment.  The  author  prefers  the  continuous  plan.  In  following  the 
continuous  plan  find  the  patient's  tolerance  to  mercury,  and  keep  him  for  two 
years  on  daily  doses  below  the  amount  he  will  tolerate.  Gross's  rule  for  con- 
tinuous treatment  is  to  order  pills  of  green  iodid  of  mercury,  each  pill  con- 
taining gr.  i.  The  patient  is  ordered  one  pill  after  each  meal  to  begin  with; 
the  next  day  the  after-breakfast  dose  is  increased  to  two  pills;  the  following 
day  the  after-dinner  dose  is  two  pills,  and  so  on,  one  pill  being  added 
every  day.  This  advance  is  continued  until  there  is  slight  diarrhea,  griping, 
a  metallic  taste,  or  tenderness  on  snapping  the  teeth  together,  whereupon  one 
pill  is  taken  ofif  each  day  until  all  unfavorable  symptoms  disappear.  Then 
the  dose  is  reduced  one-half  and  this  amount  is  called  the  tonic  dose.  This 
experimentation  finds  a  dose  on  which  the  patient  can  be  kept  with  entire 
safety  for  a  long  time;  but  if  it  is  found  that  colic  or  diarrhea  is  apt  to  recur, 
there  must  be  added  to  each  pill  gr.  Y2"  of  opium.  The  patient  is  given  mer- 
cury in  this  way  for  two  years.  Every  time  new  symptoms  appear  the  dose 
is  raised,  and  as  soon  as  they  disappear  it  is  lowered  to  the  standard.  If  the 
protiodid  is  not  tolerated,  give  the  bichlorid: 

R      Hydrarg.  chlor.  corros. ,  gr.  j; 

Syr.  sarsaparilla;  comp.,  f^iij- — M. 

Sig. — £3  ,  in  water,  after  meals. 

Mercury  with  chalk  in  i-  or  2 -grain  doses  four  times  a  day,  with  or  without 
Dover's  powder  in  i -grain  doses,  may  be  used.  Mercurial  inunctions  pro- 
duce a  rapid  effect,  but  irritate  the  skin.  The  drug  should  be  rubbed  in  with 
a  gloved  hand.  There  can  be  used  once  a  day  ^  dram  of  oleate  of  mercury 
(10  per  cent.)  or  i  dram  of  mercurial  ointment,  rubbed  into  the  skin.  The 
first  day  it  is  rubbed  into  the  inside  of  one  thigh,  the  second  day  into  the  inside 
of  the  other  thigh;  the  third  day  into  the  inside  of  one  arm;  the  fourth  day 
into  the  other  arm;  next,  into  one  groin  and  then  into  the  other  groin,  and  then 
inunction  is  again  made  at  the  point  of  original  application,  and  so  on.  After 
the  rubbing  the  patient  puts  on  underclothes  and  goes  to  bed,  and  in  the 
morning  takes  a  bath.  The  ointment  may  be  smeared  on  a  rag,  which  is  then 
worn  between  the  stocking  and  sole  of  the  foot  during  the  day. 

Fumigation  is  performed  by  volatilizing  each  night  3j  of  calomel.  The 
patient  sits  naked  on  a  cane-seat  chair,  and  is  wrapped  up  to  the  neck  in  a 
blanket  which  drops  tent-like  to  the  floor;  the  calomel  is  put  upon  an  iron 
plate  under  the  chair,  and  is  heated  by  an  alcohol  lamp  beneath  the  plate. 
The  skin  becomes  coated  with  calomel,  and  the  subject,  after  putting  on  woolen 
drawers  and  an  undershirt,  gets  into  bed.  Hypodermatic  injections  of  mer- 
cury are  used  by  some  physicians.  They  cause  an  eruption  to  disappear 
rapidly,  but  may  produce  abscesses,  and  relapses  are  prone  to  occur.  I 
agree  with  Dr.  Orville  Horwitz  that  the  hypodermatic  method  will  not  abort 
the  disease;  should  never  be  a  routine  treatment;  in  suitable  cases  it  is  very 
valuable  for  symptomatic  use,  as  when  lesions  on  the  face  or  in  important 
structures  make  a  rapid  impression  desirable  or  necessary;  in  cases  which  ob- 
stinately relapse  under  other  treatment,  and  in  syphilis  of  the  nervous  system. 
J.  William  White,  after  a  large  experience  with  this  method,  says  that  hypo- 
dermatic injections  of  corrosive  sublimate  are  painful  and  are  strongly  objected 
to  by  many  patients;  that  this  method  of  treatment  is  occasionally  dangerous 
and  even  fatal;  that  it  is  liable  to  be  followed  by  local  complications  (erythema, 


Medical  Treatment  ;^;^^ 

nodosities,  cellulitis,  abscess,  sloughing) ;  that  it  cannot  be  carried  out  by  the 
patient,  but  requires  the  surgeon's  constant  intervention.  This  syphilographer 
concludes  that  hypodermatic  medication  does  not  offer  advantages  justifying 
its  use  as  a  systematic  method  of  treatment,  and  that  it  encourages  insufficient 
treatment — those  ''short  heroic  courses"  which  Hutchinson  shows  are  fol- 
lowed by  the  gravest  tertiary  lesions.  "The  claim  that  by  a  few  injections 
the  time  of  treatment  can  be  measured  by  months  or  even  by  weeks,  instead 
of  by  years,  would  seem,  as  Mauriac  has  said,  to  involve  the  idea  that  mercury 
given  hypodermatically  acquires  some  new  and  powerful  curative  property 
which,  given  in  other  ways,  it  does  not  possess."  *  The  usual  plan  is  to  give 
daily  a  hypodermatic  injection  of  corrosive  sublimate  deep  into  the  back  or 
buttock,  the  dose  being  gr.  j  of  the  drug.  Thirty  such  injections  are  used 
unless  some  contraindication  demands  their  discontinuance  sooner.  The 
treatment  is  then  stopped.  If  the  symptoms  recur,  however,  the  patient  is 
given  another  course,  the  daily  dosage  being  gr.  ^,  the  treatment  being  again 
stopped  after  thirty  injections,  but  being  continued  anew  in  ^-grain  doses  if 
the  symptoms  recur.  The  following  preparation  is  used  by  some  syphilo- 
graphers:  0.5  of  a  part  of  corrosive  sublimate,  3  parts  of  guaiacol,  and  97  parts 
of  sterile  olive  oil.  Thirty  minims  contains  gr.  -^  of  corrosive  sublimate.  This 
mixture  should  be  thrown  deeply  into  the  buttock  and  it  causes  no  pain.  The 
use  of  gray  oil  hypodermatically  has  warm  advocates.  It  is  claimed  that  it 
provokes  but  little  pain  and  irritation,  and  that  it  is  a  very  efficfent  remedy. 
The  oil  should  not  be  thick  like  an  ointment,  because  such  a  preparation  could 
not  be  used  without  warming,  and  heat  causes  the  mercury  to  aggregate  in 
lumps.  Olive  oil  should  not  be  used,  as  it  becomes  rancid.  Dumesnil's 
formula  is  the  best  ("Brit.  Med.  Jour.,"  Jan.  18,  1908,  p.  177) : 

"The  ingredients  must  be  sterilized  before  they  are  incorporated,  as  it  is 
impossible  to  sterilize  the  product.  If  the  directions  given  below  are  carefully 
followed  no  risk  of  septic  poisoning  is  to  be  apprehended.  The  formula  pro- 
posed by  M.  Dumesnil  has  been  accepted  by  a  committee  especially  appointed 
by  the  Societe  de  Pharmacie  of  Paris,  to  investigate  the  methods  of  preparing 
gray  oil.  Twenty-six  gm.  of  anhydrous  wool-fat  and  60  gm.  of  pure  Hquid 
paraffin  {hiiile  de  vaseline  medicinale)  are  sterilized  separately  in  glass  flasks 
at  120°  C.  for  twenty  minutes.  A  pestle  and  mortar  are  steriHzed  by  means  of 
burning  alcohol  and  placed  therein  are  40  gm.  of  mercur\-  and  then  the  wool- 
fat.  The  metallic  particles  are  triturated  until  they  are  sufficiently  minute  when 
examined  under  a  magnification  of  480  diameters,  and  then  the  liquid  paraffin 
is  added  in  small  portions.  The  product  should  weigh  126  gm.  and  measure  100 
cc.  and  should  be  transferred  immediately  to  phials  of  2-,  5-,  and  lo-cc.  capacit}', 
pre\iously  sterilized  at  180°  C." 

An  injection  is  given  twice  during  the  first  week,  once  during  the  second 
week,  and  after  this  once  a  week  or  once  every  other  week  for  an  indefinite 
period  of  time.     It  may  be  given  oftener  if  symptoms  arise  or  persist. 

Taylor  believes  that  gray  oil  may  give  rise  to  unpleasant  and  sometimes 
even  dangerous  symptoms,  and  that  it  should  be  used  with  extreme  care  and 
only  in  selected  cases  in  which  other  remedies  are  contraindicated.  He  says 
that  in  reading  about  the  h\-podermatic  method  he  has  been  struck  with  the 

*  J.  William  White,  in  Morrow's  "  System  of  Genito-urinary  Diseases,  Syphilology, 
and  Dermatology.'* 


334  Syphilis  or  Pox 

fact  that  "the  most  serious  resuks  have  almost  invariably  followed  injections 
in  which  fatty  matters  have  been  the  vehicle  of  suspension."  * 

Some  surgeons  employ  intravenous  injections  of  mercury.  Lane  injects, 
at  first  every  other  day  and  later  daily,  20  rT\^  of  a  i  per  cent,  solution  of  cyanid 
of  mercury.  The  skin  in  front  of  the  elbow  is  rendered  aseptic,  a  fillet  is  tied 
around  the  arm,  the  needle  is  inserted  into  a  vein,  the  fillet  is  loosened,  the 
fluid  is  injected,  and  the  needle  is  withdrawn.  This  method  of  using  mercury 
is  painless  and  produces  a  rapid  effect.  It  may  be  used  in  nervous  svphilis, 
but  should  not  be  used  as  a  routine.  In  whatever  way  mercury  is  given,  do 
not  allow  it  to  produce  salivation  (hydrargyrism  or  ptyalism).  Always  re- 
member that  mercury  may  cause  albuminuria  and  examine  the  urine  at  regular 
intervals  during  a  course  of  the  drug.  If  albumin  appears  in  the  urine,  cut 
down  the  dose  of  mercury  or  stop  the  drug  for  a  time.  In  the  beginning  of  a 
case  of  syphilis,  if  the  kidneys  are  found  to  be  diseased,  give  the  mercury 
cautiously,  and  never  fail  to  examine  the  urine  at  regular  intervals.  An 
individual  can  take  more  mercury  in  summer  than  in  winter  because  during 
the  warm  weather  perspiration  favors  elimination. 

In  order  to  cure  syphilis  mercury  should  be  given  for  two  years,  and  the 
mercurial  course  must  be  followed  by  at  least  a  six  months'  course  of  iodid  of 
potash.  Reminders  require  both  iodid  of  potash  and  mercury  (mixed  treat- 
ment) .  Throughout  the  mercurial  course  the  patient  should  be  weighed  once  a 
week,  and  if  it  is  at  any  time  found  that  the  weight  is  decreasing,  tonics,  con- 
centrated food,  and  cod-hver  oil  are  ordered.  If  the  weight  continues  to 
grow  less  and  the  health  begins  obviously  to  fail,  stop  the  mercury  for  a  time, 
continue  the  cod-liver  oil,  tonics,  and  nourishing  food,  and  order  hot  baths, 
fresh  air,  iron,  and  chlorid  of  gold  and  sodium.  If  during  the  mercurial  course 
albumin  appears  in  the  urine  and  some  edema  is  noted,  the  mercury  should  be 
stopped  for  several  or  a  number  of  weeks  and  the  patient  should  be  given  a 
milk  diet.  If  marked  albuminuria  is  noted,  but  no  other  symptoms  exist, 
mercury  need  not  be  discontinued,  but  the  patient  is  watched  most  carefully 
for  the  advent  of  any  other  symptom  (Fiessinger,  in  "Journal  des  Practiciens," 
August  3,  1907). 

Acute  Ptyalism,  or  Salivation.— In  acute  ptyalism  the  saliva  be- 
comes thick  and  excessive  in  amount;  the  gums  become  spongy  and  tender  and 
liable  to  bleed.  Tenderness  is  detected  early  by  snapping  the  teeth.  A 
metallic  taste  is  complained  of;  the  breath  becomes  fetid;  the  oral  structures 
swell;  the  teeth  loosen;  the  saliva  is  produced  in  great  quantity;  and  there  are 
purging,  cohc,  and  exhaustion.  Sometimes  there  are  fever  and  a  diffuse 
scarlatiniform  eruption  upon  the  skin.  A  chronic  hydrargyrism  may  be 
shown  by  salivation,  gastro-intestinal  disorder,  emaciation,  mental  depression, 
weakness,  albuminuria,  and  tremor.  To  avoid  salivation,  advance  the  dose 
with  great  caution  and  instruct  the  patient  as  to  the  first  signs  of  the  trouble. 
He  should  use  a  soft  toothbrush  and  an  astringent  mouth-v/ash  (gr.  xlviij  of 
boric  acid  to  oiv  each  of  Listerine  and  water).  When  ptyalism  is  noted,  dis- 
continue the  administration  of  the  drug.  Employ  the  above  mouth-wash  or 
one  composed  of  a  saturated  solution  of  chlorate  of  potassium.  Order  gr. 
YYo  of  atropin  twice  a  day,  and  in  bad  cases  spray  the  mouth  with  peroxid  of 
hydrogen  and  use  silver  nitrate  locally  (gr.  xx  to  oj).  Give  stimulants  (iron, 
*  "  Venereal  Diseases,"  by  Robert  W.  Taylor. 


Tertiary  Sta<2;e  335 

quinin,  and  strychnin)  and  nutritious  food.  A  weel^ly  Turkish  bath  is  of 
great  service.  In  chronic  hydrargyrism  stop  the  administration  of  the  drug, 
use  tonics,  stimulants,  open-air  exercise,  Turkish  baths,  and  nutritious  food. 
The  chlorid  of  gold  and  sodium  forms  a  substitute  for  mercury.  The  use  of 
iodid  of  potassium  is  of  questionable  value  in  ptyalism. 

Treatment  of  CompUcations  in  the  Secondary  Stage.— The  compli- 
cations of  the  secondary  stage  usually  require  local  applications  in  addition 
to  general  remedies.  Mucous  patches  in  the  mouth  should  be  touched  with 
bluestone  every  day,  an  astringent  mouth-wash  being  employed  several  times 
daily.  If  the  patches  ulcerate,  they  should  be  touched  once  a  day  with  lunar 
caustic;  if  these  areas  proliferate,  they  should  be  excised  and  cauterized. 
Vegetations  or  growing  papules  on  the  skin  must,  if  calomel  powder  fails  to 
remove  them,  be  cut  away  with  scissors  and  be  cauterized  with  chromic  acid 
or  with  the  Paquelin  cautery.  Condylomata  demand  washing  with  ethereal 
soap  several  times  daily,  thorough  drying,  dusting  with  equal  parts  of  calomel 
and  subnitrate  of  bismuth  or  with  borated  talcum,  and  covering  with  dry 
biphlorid  gauze.     If  these  simple  procedures  fail,  excise  and  cauterize. 

For  psoriasis  of  the  palms  and  soles  diachylon  ointment,  mercurial  plaster, 
or  painting  with  tincture  of  iodin  should  be  employed.  Ulcers  of  paronychia 
are  dressed  with  iodoform  and  corrosive  sublimate  gauze.  Deep  cutaneous 
ulcers  are  cleaned  once  a  day  with  ethereal  soap,  sprayed  with  peroxid  of 
hydrogen,  dressed  with  iodoform  and  corrosive  sublimate  gauze  and  bandaged. 
When  the  process  of  granulation  is  well  established  dress  with  i  part  of  un- 
guent, hydrarg.  nitratis  to  7  parts  of  cosmolin.  In  sarcocele  mercurial  oint- 
ment should  be  rubbed  into  the  skin  of  the  scrotum  or  the  testicle  be  strapped. 
In  alopecia  the  hair  should  be  kept  short,  and  every  night  the  scalp  should  be 
cleaned  with  equal  parts  of  green  soap  and  alcohol  rubbed  into  a  lather  with 
water.  After  the  soap  has  been  washed  out  some  hair  tonic  should  be  rubbed 
into  the  scalp  with  a  sponge.  A  favorite  preparation  of  Erasmus  Wilson's 
consisted  of  the  following  ingredients: 

R.      01.  amygd.  dil., 

Liq.  ammonia;,  ad  f^j; 

Sp.  rosemaiini, 

Aquse  mellis,  ad  fgiij. — M. 

Ft.  lotio. 

One  part  of  tincture  of  cantharides  to  8  parts  of  castor  oil  may  be  rubbed  into 
the  scalp.  Solutions  of  quinin  are  esteemed  by  some.  A  useful  wash  for  the 
scalp  is  the  following:  3j  of  borate  of  sodium,  3j  of  spirits  of  camphor,  oij 
of  glycerin,  and  sufficient  orange-flower  water  to  make  fsiv. 

In  treating  persistent  skin-lesions,  inunctions,  injections,  fumigations,  or 
mercurial  baths  may  be  used.  Baths  are  suited  to  patients  with  delicate  skins, 
to  those  whose  digestion  fails  when  mercury  is  given  by  the  mouth,  and  to 
those  whose  lungs  will  not  tolerate  fumigations.  Half  an  ounce  of  corrosive 
sublimate  with  4  scruples  of  sal  ammoniac  are  mixed  in  about  4  ounces  of 
water;  this  is  added  to  a  bath  at  a  temperature  of  95°  F.  The  patient  gets 
into  this  bath,  covers  the  tub  with  a  blanket,  leaving  only  his  head  exposed, 
and  remains  in  the  bath  an  hour  or  so.  Mercurial  baths  may  rapidly  cause 
salivation. 

Tertiary  Stage. — If  at  any  time  during  the  case  there  appear  tertiary 


336  Syphilis  or  Pox 

symptoms,  the  patient  should  be  put  on  mixed  treatment.  In  any  case,  after 
two  years  of  mercury  add  iodid  of  potassium  to  the  treatment.  White's  rule 
is  to  use  mixed  treatment  for  at  least  six  months  (if  any  symptoms  appear), 
the  six  months'  course  dating  from  their  disappearance.  This  emphasizes 
the  fact  that  the  iodids  alone  will  not  cure  tertiary  syphilis.  In  obstinate 
tertiary  lesions  and  in  nervous  syphilis  the  iodids  should  be  run  up  to  an 
enormous  amount  (from  30  to  250  grains  per  day).  Sometimes  people  can 
take  large  doses  of  iodid  when  small  doses  produce  iodism.  Cyon  explains 
this  curious  fact  as  follows:  small  doses  combine  with  some  products  of  the 
thyroid  gland  and  form  toxic  iodo-thyrin.  Large  doses  are  diuretic,  form 
soluble  salts,  and  are  rapidly  eliminated.  An  easy  way  to  give  iodid  is  to  order 
a  saturated  solution  each  drop  of  which  equals  about  one  grain  of  the  drug. 
Each  dose  of  the  iodid  is  given  one  hour  after  meals  and  in  at  least  half  a  glass 
of  water.  If  the  iodid  disagrees,  it  may  be  given  in  water  containing  one  dram 
of  aromatic  spirit  of  ammonia,  or  5  drops  of  fluidextract  of  ergot,  or  it  may  be 
given  in  milk.  The  iodid  of  sodium  may  be  tolerated  better  than  the  potas- 
sium salt,  as  it  is  less  depressing  to  the  circulation,  or  the  iodids  of  sodium,  potas- 
sium, and  ammonium  may  be  combined.  Gotheil  sometimes  gives  tincture  of 
iodin  in  lo-drop  doses,  well  diluted.  In  giving  the  iodids,  begin  with  a  small 
dose.  During  a  course  of  the  iodid  always  give  tonics  and  insist  on  plenty  of 
fresh  air.  Arsenic  given  daily  tends  ta  prevent  skin  eruptions.  The  iodids 
may  disagree  for  a  time,  but  tolerance  may  be  estabhshed  as  the  administration 
is  continued.  Iodid  can  be  given  as  an  enema  in  milk.  The  value  of  the  newer 
organic  iodin  preparations  is  as  yet  uncertain.  Some  of  them  are  given 
hypodermatically.  The  iodids  when  they  radically  disagree  produce  iodism — 
a  condition  which  is  made  manifest  by  a  flow  of  mucus  from  the  nose,  con- 
junctival irritation,  a  bad  taste  in  the  mouth,  exhaustion,  anorexia,  nausea,  and 
tremor.  In  some  subjects  there  are  outbreaks  of  acne,  vesicular  eruptions,  or 
even  bullae  or  hemorrhages.  Iodism  calls  for  the  abandonment  of  the  drug, 
and  the  administration  of  increasing  doses  of  Fowler's  solution,  of  arsenic,  of 
laxatives,  of  diuretic  waters,  or,  if  there  is  great  exhaustion,  of  stimulants.  In 
some  cases  belladonna  is  of  service.  Some  patients  who  cannot  take  the  al- 
kaline iodids  may  take  syrup  of  hydriodic  acid.  After  the  patient  has  been 
for  six  months  under  mixed  treatment  without  a  symptom,  stop  all  treatment 
and  await  developments.  If  during  one  year  no  symptoms  recur,  the  patient  is 
probably  cured;  if  symptoms  do  recur,  there  must  be  six  months  more  of  treat- 
ment and  another  year  of  watching.  It  would  be  wise  were  every  person  who 
has  had  syphilis  to  take  a  six  weeks'  course  of  mercury  and  iodid  twice  a  year 
for  the  balance  of  life.  It  is  probable  that  such  a  plan  would  save  many  from 
visceral  syphilis  and  late  nervous  syphilis.  Syphilitic  ulcers  are  treated  locally 
.by  cleanliness,  antiseptic  apphcations,  and,  if  the  situation  admits  of  it,  by  the 
daily  use  of  the  hot-air  apparatus  or  by  the  induction  of  hyperemia  by  means  of 
the  rubber  bandage  or  the  cupping-glass.  If  albuminuria  arises  during  the 
tertiary  stage  and  there  is  arterial  disease  with  high  tension,  mercury  will  do 
harm.     In  albuminuria  without  high  tension,  it  may  be  given  (p.  323). 

The  Question  of  Marriage. — Fournier  has  insisted  that  it  is  a  great  wrong 
to  tell  a  syphihtic  that  he  can  never  marry.  He  must  not  marry  until  he  is 
cured,  and  he  is  not  cured  until,  after  the  cessation  of  the  use  of  iodid,  he  goes 
one  year  without  treatment  and  without  symptoms. 


Hereditary  Syphilis  337 

Hereditary  Syphilis. — Transmitted  congenital  syphilis  is  heredi- 
tary syphilis  manifest  at  birth.  Acquired  syphihs  (except  in  the  case  of  a 
woman  who  obtains  the  disease  from  a  fetus)  always  presents  the  chancre  as 
an  initial  lesion;  hereditary  syphilis  never  does.  Hereditary  syphilis  may 
present  itself  at  birth,  and  usually  shows  itself  within,  at  most,  the  first  six 
months  of  extra-uterine  life.  In  rare  cases  (tardy  hereditary  syphilis)  the 
disease  does  not  become  manifest  until  puberty. 

Rules  oj  Inheritance.— According  to  von  Zeissl,*  the  rules  of  inheritance  are 
as  follows: 

1.  If  one  parent  is  syphilitic  at  the  time  of  procreation,  the  child  may  be 
syphilitic. 

2.  Syphilitic  parents  may  bring  forth  healthy  children. 

3.  If  a  mother,  healthy  at  procreation,  bears  a  child  syphilitic  from  the 
father,  the  mother  must  have  latent  pox  or  must  be  immune,  having  become 
infected  through  the  placental  circulation.  She  often  shows  no  symptoms, 
having  received  the  poison  gradually  in  the  blood,  and  having  thus  received, 
it  may  be  said,  preventive  inoculations.  Certain  it  is  that  mothers  are  almost 
never  infected  by  suckling  their  syphilitic  children  (CoUes's  law). 

4.  If  both  parents  were  healthy  at  the  time  of  procreation,  and  the  mother 
afterward  contracts  syphilis,  the  chijd  may  become  syphilitic,  and  the  earlier 
in  the  pregnancy  the  mother  is  diseased,  the  more  certain  is  the  child  to  be 
tainted.     This  is  known  as  "infection  in  utero." 

5.  The  more  recent  the  parental  syphilis,  the  more  certain  is  infection  of 
the  offspring.     The  children  are  often  stillborn. 

6.  When  the  disease  is  latent  in  the  parents  it  is  apt  to  be  tardy  in  the 
children. 

7.  The  longer  the  time  which  has  passed  since  the  disappearance  of 
parental  symptoms,  the  more  improbable  is  infection  of  the  children. 

8.  In  most  instances  parental  syphilis  grows  weaker,  and  after  the  parents 
beget  some  tainted  children  they  bring  forth  healthy  ones. 

Syphilis  in  the  mother  is  more  dangerous  to  the  offspring  than  syphilis  in 
the  father.  The  frequent  immunity  of  the  mother  is  due  to  the  fact  that  her 
tissues  produce  antitoxins  under  the  influence  of  the  slowly  absorbed  virus. 
The  milk  of  a  syphihtic  mother  contains  quandties  of  antibodies  ("Bab.  Zeit- 
schrift  f.  Geb.  und  Gynakologie,"  vol.  Ix.,  No.  2). 

Many  women  affected  with  hereditary  syphilis  are  sterile.  Many  syph- 
ihtic women  abort  before  the  eighth  month,  most  commonly  in  the  fifth 
month.  The  fetus  very  often  dies  at  an  early  period  of  gestation.  This  may 
be  due  to  a  gummatous  placenta  or  to  a  degeneration  of  placental  follicles. 
Bab  (Ibid.)  reports  that  out  of  33  infants,  victims  of  congenital  syphihs,  16  were 
born  aHve  and  7  of  these  died  within  a  few  days.  Hyde  says  that  about  90 
per  cent,  of  those  born  living  subsequently  die  of  the  disease. 

Evidences  oj  Hereditary  Syphilis  (manifest  at,  or  oftener  soon  after,  birth). 
— Hutchinson  says  that  at  birth  the  skin  is  almost  invariably  clear.  In  from 
six  to  eight  weeks  "  snufSes  "  begin,  which  are  soon  followed  by  a  skin-eruption, 
by  body-wasting,  and  by  a  chain  of  secondary  symptoms  (iritis,  mucous 
patches,  pains,  condylomata,  etc.).  The  child  looks  like  a  withered-up  old 
man.     Eruptions  are  met  with  on  the  palms  and  soles.     Intertrigo  is  usual. 

*  '•  Pathology  and  Treatment  of  Syphilis." 


33^  Syphilis  or  Pox 

Cracks  occur  at  the  angles  of  the  mouth,  and  leave  permanent  radiating  scars. 
The  abdomen  is  tumid,  and  there  is  apt  to  be  exhausting  diarrhea.  The 
secreting  and  absorbing  glands  of  the  intestinal  tract  atrophy.*  It  is  doubtful 
if  distinct  gummatous  tumors  form  in  hereditary  syphilis.  The  t)pe  of  dis- 
ease induced  is  a  diffuse  interstitial  cellular  change 'in  the  viscera,  and  the 
viscera  are  much  more  apt  to  suffer  than  in  acquired  syphilis.  The  liver, 
spleen,  and  pancreas  often  enlarge  from  interstitial  changes,  and  the  lungs 
sometimes  are  attacked  in  the  same  manner.  Sometimes  synovitis  or  arthritis 
arises,  the  condition  being  similar  to  that  met  with  in  acquired  syphilis. 
A  form  encountered  between  the  thu-d  month  and  end  of  the  second  year, 
according  to  Paton,  is  characterized  by  growth  into  the  joint  of  f ungating 
granulation  tissue,  the  joint  is  useless,  and  the  parts  about  are  swollen  and 
edematous.  Atrophic  lesions  may  appear  in  the  bones.  In  the  skull  the  bone 
may  be  softened  by  removal  of  its  salts  or  be  thinned  by  the  pressure  of  the 
brain.  In  the  long  bones  the  epiphyseal  lines  suffer,  the  attachment  of  the 
epiphyses  to  the  shafts  is  weak,  and  separation  is  easily  induced.  Epiphy- 
sitis is  common,  rarely  causes  pain,  and  rarely  leads  to  suppuration,  except  in 
children  who  are  old  enough  to  walk  (Coutts).  Osteophytic  lesions  of  the 
skull  are  shown  by  symmetrical  spots  of  thickening  upon  the  parietal  and 
frontal  bones  (natijorm  skulls).  In  the  long  bones  osteophytes  are  frequently 
formed.  In  some  cases  osteophytes  grow  from  the  epiphysis,  and  in  con- 
sequence deformity  and  impaired  function  are  noted  and  a  certain  amount 
of  ankylosis  may  occur.  This  condition  of  osteophytic  growth  from  an  epi- 
physis was  called  by  Fournier  arthropathie  dejormant.  A  child  with  preco- 
cious hereditary  syphilis  is  apt  to  die,  but  if  it  Uves  from  six  months  to  one 

year  the  symptoms  for  a  time  disappear, 
and  for  years  the  disease  may  be  latent. 
Diagnosis  is  difficult  after  the  third  or  fourth 
year,  especially  if  the  disease  be  associated 
with  rickets  or  tuberculosis.  When  later 
Fig.  128. — Hutchinson  teeth.  Symptoms  arise  they  may  be  various,  namely: 

noises  in  the  ears,  often  followed  by  deaf- 
ness; interstitial  keratitis;  synovitis  in  any  joint,  particularly  painless  but 
marked  symmetric  effusion  in  the  knee-joints,  with  trivial  functional  dis- 
turbance; ossifying  nodes;  developmental  osseous  defects;  suppurative  peri- 
ostitis; ulcerations;  death  of  bone;  faUing  in  of  the  nose;  nervous  maladies; 
occasionally  sarcocele,  dactylitis,  etc. 

Dactylitis  is  common  in  hereditary  syphiHs.  There  is  a  superficial  and 
a  deep  form  (p.  326).  Commonly,  a  swelling  gradually  forms.  It  is  fusiform 
in  shape  and  becomes  purple  in  color.  It  lasts  for  months.  One  or  more 
fingers  may  be  involved  and  the  fingers  are  more  apt  to  suffer  than  the  toes. 
The  proximal  phalanx  is  most  liable  to  the  lesion.  The  superficial  form  is  apt 
to  soften  and  ulcerate;  the  deep  form  not  infrequently  causes  tissue  destruction 
and  shortening  of  the  digit  from  rarefying  osteitis.  Some  cases  of  superficial 
dactylitis  are  symmetric  and  of  short  duration  and  are  to  be  regarded  as  late 
secondary  lesions. 

In  hereditary  syphiHs  the  eye  symptoms  are  of  great  diagnostic  import- 
ance.    In  212  cases  of  congenital  syphiUs  Fournier  found  eye  trouble  in  loi. 
*  Coutts,  in  Brit.  Med.  Jour.,  1894,  1643. 


Treatment  of  Hereditary  Syphilis  339 

Keratitis  and  choroiditis  are  the  most  usual  forms.  Bone  trouble  occurs 
in  ahnost  half  of  the  cases,  but  is  not  often  severe  enough  to  cause  symptoms. 
The  tongue  often  shows  a  smooth  base  (Virchow's  sign).  Hirschberg believed 
choroiditis  to  be  pathognomonic.  The  descendants  of  syphilitic  parents 
may  exhibit  certain  pathologic  conditions  which  are  not  directiy  syphilitic. 
Fournier  calls  such  phenomena  parasyphilitic.  Among  these  phenomena  are 
arrest  of  development  of  the  body  at  large  or  of  special  structures,  weakness 
of  constitution,  and  stigmata  of  degeneration. 

Diagnosis. — In  the  diagnosis  of  hereditary  syphilis  the  condition  of  the 
teeth  is  of  considerable  importance:  the  temporary  teeth  decay  soon,  but 
present  no  characteristic  defect.  If  the  upper  permanent  central  incisors  are 
examined,  they  are  often,  but 
by  no  means  always,  found 
defective.  Other  teeth  may 
show  defects,  but  in  these 
alone  are  characteristic  defects 
hkely  to  appear.  In  hereditary 
syphilis  they  may  present  an 
appearance  of  marked  devia- 
tion from  health,  and  are  then 
called  "  Hutchinson  teeth " 
(Fig.  128).  If  they  are 
dwarfed,  too  short  and  too 
narrow,  and  if  they  display  a 
single    central    cleft    in    their 

free  edge,  then   the   diagnosis  ^.^  i^g.-Dactylitis. 

of  syphilis  is  probable.    If  the 

cleft  is  present  and  the  dwarfing  absent,  or  if  the  peculiar  form  of  dwarf- 
ing be  present  without  any  conspicuous  cleft,  the  diagnosis  may  still  be  made. 
The  view  that  teeth  of  this  nature  prove  the  existence  of  hereditary  syphilis 
and  that  they  occur  only  in  syphihs  has  been  abandoned  by  Hutchinson  him- 
self. In  fact,  only  one-fifth  of  congenital  syphiHtics  have  these  teeth,  and 
one-third  of  the  cases  of  Hutchinson  teeth  are  in  individuals  free  from  syphilis. 
In  early  infancy  the  diagnosis  of  syphihs  is  made  by  the  snuffles,  the  broad 
nose,  the  skin-eruptions,  the  wasted  appearance,  the  sores  at  the  mouth- 
angles,  the  tenderness  over  bones,  condylomata,  and  the  history  of  the  parents. 
The  diagnosis  at  a  later  period  is  made  by  the  existence  of  symmetrical  inter- 
stitial keratitis,  choroiditis,  the  smooth  base  of  the  tongue,  deafness  which 
comes  on  without  pain  or  running  from  the  ear,  ossifying  nodes,  white  radiat- 
ing scars  about  the  mouth-angles,  sunken  nose,  natiform  skull,  deformity  of 
long  bones,  painless  inflammation  of  epiphyses,  and  Hutchinson  teeth.  It 
must  be  remembered  that  a  child  born  apparently  healthy  and  presenting 
no  secondary  s}Tnptoms  may  show  bone-disease,  keratitis,  or  syphilitic  deaf- 
ness at  puberty.  Finding  the  spirochseta  is  of  immense  importance  in  arri\ing 
at  a  diagnosis.  It  is  always  found  unless  the  organ  examined  is  decomposed 
or  the  fetus  is  macerated.  (See  article  by  Wm.  S.  Gottheil,  "Progressive 
Medicine,"  Sept.,  1908.) 

Treatment. — In  infants  mercurial  inunctions  are  to  be  used  until  the 
symptoms  disappear,  but  mercury  must  not  be  forced  or  be  continued  too  long 


34©  Tumors  or  Morbid  Growths 

after  the  symptoms  are  gone.  There  must  be  rubbed  into  the  sole  of  each 
foot  or  the  palm  of  each  hand  5  grains  of  mercurial  ointment  every  morning 
and  night.  Brodie  advised  spreading  the  ointment  (in  the  strength  of  3j  to 
the  ounce)  upon  flannel  and  fastening  it  around  the  child's  belly.  If  the  skin 
is  so  tender  that  mercury  must  be  administered  by  the  mouth,  order  that  gr. 
y  2"  to  i  of  mercury  with  chalk,  with  i  grain  of  sugar,  be  taken  three  times  a 
day  after  nursing.  If  tertiary  symptoms  appear,  and  in  any  case  when  the 
secondaries  have  passed  away,  give  gr.  ss  to  j  or  more  of  iodid  of  potassium 
several  times  a  day  in  syrup.  The  mixed  treatment  should  be  continued 
intermittently  until  puberty.  Local  lesions  require  local  treatment,  as  in 
the  adult.  A  syphilitic  child  should,  if  possible,  be  nursed  by  its  mother,  as 
it  will  poison  a  healthy  nurse,  and  also  because  the  mother's  milk  contains 
antibodies.  If  the  baby  has  a  sore  mouth,  it  must  be  fed  from  a  bottle,  and  if 
the  mother  cannot  nurse  the  child,  it  must  be  brought  up  on  the  bottle.  For 
the  cachexia  use  cod-liver  oil,  iodid  of  iron,  arsenic,  and  the  phosphates. 


XVII.  TUMORS  OR  MORBID  GROWTHS. 

Division. — Morbid  growths   are  divided   into   (i)    neoplasms   and  (2) 

cysts. 

Neoplasms. — A  neoplasm  is  a  pathological  new  growth  which  tends  to 
persist  independently  of  the  structures  in  which  it  Hes,  and  which  performs 
no  physiological  function.  We  say  that  a  tumor  performs  no  physiological 
function  in  order  to  make  clear  that  it  is  never  a  useful  addition  to  the  economy, 
but  we  must  not  imagine  that  the  cells  of  a  tumor  are  devoid  of  physiological 
activity.  As  Fiitterer  ("Medicine,"  March,  1902)  has  shown,  the  cells  of  a 
carcinoma  of  the  liver  may  secrete  bile,  and  even  the  cells  of  a  secondary  focus 
developing  in  the  course  of  hepatic  carcinoma  may  also  secrete  bile.  The 
cells  of  a  tumor  may  be  active,  but  this  activity  is  not  useful  and  does  not  con- 
stitute physiological  function.  A  hypertrophy  is  diiJerentiated  from  a  tumor 
by  the  facts  that  it  is  a  result  of  increased  physiological  demands  or  of  local 
nutritive  changes,  and  that  it  tends  to  subside  after  the  withdrawal  of  the 
exciting  stimulus.  Further,  a  hypertrophy  does  not  destroy  the  natural  con- 
tour of  a  part,  while  a  tumor  does.  Inflammation  has  marked  symptoms :  its 
swelling  does  not  tend  to  persist,  it  terminates  in  resolution,  organization  or 
suppuration,  and  examination  of  a  section  of  tissue  under  the  microscope  dif- 
ferentiates it  from  tumor.  Inflammation,  too,  has  an  assignable  exciting 
cause.  A  new  growth  is  a  mass  of  newly  formed  tissue;  hence  it  is  improper 
to  designate  as  tumors  those  swelHngs  due  to  extravasation  of  blood  (as  in 
hematocele),  or  of  urine  (as  in  ruptured  urethra),  to  displacement  of  parts 
(as  in  hernia,  floating  kidney,  or  dislocation  of  the  liver),  or  to  fluid  disten- 
tion of  a  natural  cavity  (as  in  hydrocele  or  bvirsitis). 

Classes  of  Tumors. — There  are  two  classes  of  tumors;  the  first  class 
includes  those  derived  from  or  composed  of  ordinary  connective  tissue  or  of 
higher  structures.  These  all  originate  from  cells  which  are  developed  from 
the  mesoblast.  There  are  two  groups  of  connective-tissue  tumors:  (o)  the 
t}^ical,  innocent  or  benign,  which  mimic  or  imitate  some  connective  tissue 
of  the  healthy  adult  human  body;  and  {b)  the  atypical  or  malignant,  which 


Causes  of  Tumors  341 

find  no  counteri^art  in  the  healthy  adult  human  body,  but  rather  in  the  im- 
mature connective  tissues  of  the  embryo. 

The  second  class  of  tumors  includes  those  which  are  derived  from  or  com- 
posed of  epithelium:  (a)  the  typical,  or  innocent,  composed  of  adult  epithe- 
lium; and  (/))  the  atypical,  or  malignant,  composed  of  embryonic  epithelium. 

Miiller's  Law. — Miiller's  law  is  that  the  constituent  elements  of  neoplasms 
always  have  their  types,  counterparts,  or  close  imitations  in  the  tissues,  either 
embryonic  or  mature,  of  the  human  body. 

Virchow's  Law. — Virchow's  law  is  that  the  cells  of  a  tumor  spring  from 
pre-existing  cells.     There  is  no  special  tumor-cell  or  cancer-cell. 

The  starting-point  of  a  tumor  is  a  focus  of  embryonal  cells,  which  focus 
may  have  originated  before  the  person  was  born  or  may  have  resulted  after 
birth  from  some  disease  or  injury.  The  nature  of  the  tumor  depends  first 
upon  the  embryonal  layer  from  which  it  took  origin.  Connective-tissue  tumors 
spring  from  the  mesoblast;  epithehal  tumors  spring  from  the  epiblast  or  the 
hypoblast.  The  nature  of  the  tumor  depends  also  upon  the  stage  in  which  the 
growth  of  its  cells  is  arrested.  If  the  cells  remain  embryonal,  the  growth  is  re- 
garded as  maHgnant;  if  they  become  fully  developed,  it  is  regarded  as  innocent. 

The  term  "heterologous"  is  no  longer  used  to  signify  that  the  cellular 
elements  of  a.  tumor  have  no  counterpart  in  the  healthy  organism,  but  is 
employed  to  signify  that  a  tumor  deviates  from  the  type  of  the  structure  from 
which  it  takes  its  origin  (as  a  chondroma  arising  from  the  parotid  gland). 
Tumors  when  once  formed  almost  invariably  increase  and  persist,  though 
occasionally  warts,  exostoses,  and  fatty  tumors  disappear  spontaneously. 
Tumors  may  ulcerate,  inflame,  slough,  be  infiltrated  with  blood,  or  undergo 
mucoid,  calcareous,  or  fatty  degeneration. 

Causes. — The  causes  of  tumors  are  not  positively  recognized,  those 
alleged  being  but  theories  varying  in  probability  and  ingenuity. 

The  inclusion  theory  0}  Cohnheim  supposes  that  more  embryonic  cells  exist 
than  are  needful  to  construct  the  fetal  tissues,  that  masses  of  them  remain  in 
the  tissues,  and  that  these  embryonic  cells  may,  later  in  life,  be  stimulated 
into  active  growth  perhaps  by  injury  or  irritations  or  hereditary  tendency. 
In  other  words,  Cohnheim  believes  that  all  tumors  arise  from  embryonal 
cells  which  were  included  or  imprisoned  by  adult  cells  during  fetal  Hfe  and 
were  not  used  during  development;  or  from  cells  which  were  "displaced 
from  their  proper  relations  during  the  process  of  cell  differentiation  in  the 
embryo"  (Henry  Morris,  "Lancet,"  Dec.  12,1903).  The  embryonic  hypo- 
thesis seems  to  receive  a  certain  force  from  the  facts  that  exostoses  do  some- 
times develop  from  portions  of  unossified  epiphyseal  cartilage,  and  that 
tumors  often  arise  in  regions  where  there  was  a  suppression  of  a  fetal  part, 
closure  of  a  cleft,  or  an  involution  of  epithelium  (epitheUoma  is  usual  at  muco- 
cutaneous junctions).  This  theory  does  not  explain  the  origin  of  malignant 
tumors  in  scars  or  recent  callus  in  parts  subjected  to  injury  or  operation,  etc. 
(Henry  Morris). 

Durante's  addition  to  Cohnheim's  theory  does  explain  them.  Cohn- 
heim taught  that  the  matrix  from  which  a  tumor  springs  is  always  an  ante- 
natal embryonic  area.  Dvirante  says  a  tumor  may  also  spring  from  a  post- 
natal embryonic  area  resulting  from  injury  of  the  mature  tissues,  lessening 
their  activities  chemical  and  physiological  (Morris)  and  causing  them  to  revert 
to  an  embryonic  condition. 


342  Tumors  or  Morbid  Growths 

Objection  has  been  made  to  the  Cohnheim  theory  on  the  ground  that 
an  embryonal  matrix  could  not  remain  quiescent,  but,  as  Henry  Morris  says, 
certain  teeth,  the  female  mammary  gland,  the  larynx,  and  certain  appendages 
of  the  skin  may  not  develop  until  puberty  ("Bradshaw  Lecture,"  in  "Lancet," 
Dec.  12,  1903).  Branchial  cysts  which  are  known  to  have  such  an  origin 
are  seldom  seen  until  after  puberty,  and  the  same  is  true  of  many  dermoids. 

Morris  shows  that  congenital  matrices  have  been  shown  to  exist  in  the  brain, 
tongue,  eye,  testicle,  ovary,  broad  ligament,  hne  of  coalescence  in  the  trunk 
and  other  places,  and  such  matrices  constitute  fetal  rests  or  vestiges.  The 
same  author  shows  that  post-natal  matrices  may  arise  in  the  healing  of  a 
wound  or  ulcer,  fistula,  burns,  etc.  Portions  of  epithelium  are  separated, 
get  placed  deeply  in  the  newly-forming  tissue,  become  surrounded  by  connec- 
tive tissue,  and  may  later  take  on  active  growth.  As  Ribbert  points  out  any 
fragment  of  isolated  and  imprisoned  tissue  may  become  a  tumor. 

Heredity  is  an  extremely  uncertain  influence,  though  not  an  influence  to 
be  denied.  I  believe  that  there  is  such  a  thing  as  a  more  or  less  complete 
immunity  to  cancer  and  that  there  is  such  a  thing  as  a  predisposition  to  cancer, 
and  the  predisposition  as  well  as  the  immunity  may  be  hereditary  or  acquired. 
Youth  constitutes  an  almost  though  not  quite  certain  immunity.  Cancer  is 
very  rare  in  youth,  and  when  it  does  occur  in  a  young  person  it  is  always 
very  malignant.  Its  occurrence  means  unnatural  lack  of  tissue  resistance  or 
unusual  vigor  of  cancer  cells.  The  retrogressive  changes  of  age  are  predis- 
posing causes.  S.  W.  Gross  found  hereditary  influence  by  no  means  frequent 
in  cancer  of  the  breast.  It  is  affirmed  by  some,  denied  by  others,  and 
doubted  by  a  number.  At  most,  hereditary  influence  may  only  predispose. 
Nevertheless,  cases  have  occurred  which  cannot  be  explained  by  the  term 
coincidence.  In  the  celebrated  "Middlesex  Hospital  case,"  a  woman  and 
five  daughters  had  cancer  of  the  left  breast.  A.  Pearce  Gould  had  charge 
of  a  woman  for  cancer  of  the  left  breast.  The  mother  of  this  patient,  the 
mother's  two  sisters,  and  two  of  the  mother's  cousins  had  died  of  cancer. 
Power  reports  a  remarkable  instance  of  family  predisposition  to  cancer.  A 
patient  had  his  right  breast  removed  for  cancer  in  1896.  In  1897  cancerous 
glands  were  removed  from  the  axilla.  In  1898  he  was  seen  again  vnih.  an 
irremovable  recurrent  growth.  His  father  died  of  cancer  of  the  breast.  He 
had  two  brothers,  one  of  whom  died  of  cancer  of  the  throat  when  sixty-five 
years  of  age,  the  other  having  died  of  cancer  of  the  axilla  when  he  was  only 
twenty-four  years  old.  Of  his  eight  sisters,  four  died  of  cancer  of  the  breast, 
and  the  two  who  are  living  both  suffer  from  cancer  of  the  breast.  One 
sister  died  when  an  infant  and  one  died  after  giving  birth  to  a  child.*  The 
Emperor  Napoleon,  his  father,  his  brother  Lucien,  and  his  sisters  Pauhne 
and  Caroline  died  of  gastric  cancer.  That  there  is  such  a  thing  as  pre- 
disposition is  rendered  probable  by  the  fact  that  out  of  many  exposed  under 
like  conditions  a  single  one  may  develop  cancer.  I  believe,  \A'ith  Murphy,  that 
there  may  be  such  a  thing  as  absence  of  resistance  to  the  cause  of  cancer  on 
the  part  of  certain  tissues  and  that  such  impairment  of  resistance  may  be 
hereditary. 

Injury   and  inflammation   may   undoubtedly   prove   exciting  causes.     A 
blow  is  not  infrequentiy  followed  by  sarcoma;  the  irritation  of  a  hot  pipe-stem 
*  Brit.  Med.  Jour.,  July  16,  1898. 


Causes  of  Tumors  343 

may  excite  cancer  of  the  lip;  the  scratching  of  a  jagged  tooth  may  cause  cancer 
of  the  tongue;  chimney-sweeps'  cancer  (which  used  to  be  seen  in  the  old 
days  when  '"the  sweep"  was  an  institution),  arose  from  the  irritation  of 
dirt  in  the  scrotal  creases;  and  warts  often  arise  from  constant  contact  with 
acrid  materials. 

Physiologic  activity  favors  the  development  of  sarcoma,  and  physiologic 
decline  favors  the  development  of  carcin<jma. 

Parasitic  Influences. — Many  beheve  that  parasites  cause  cancer.  This 
theor}-  does  not  maintain  that  the  tumor  is  the  parasite,  but  that  it  contains 
the  parasite,  although  Pfeiffer  and  Adamciewicz  did  at  one  time  assert  that 
a  cancer-cell  is  not  a  body-cell,  but  a  parasite  resembling  an  epithelial  cell. 
Butlin.  in  1905,  asserted  his  belief  that  the  cancer-cells  are  parasites  and  act 
independently  like  protozoa.  Most  observers  deny  this  contention  because, 
were  it  true,  there  w^ould  be  only  one  variety  of  cancer,  because  cases  could  only 
arise  by  direct  contact,  and  because  it  would  leave  unanswered  how  the  original 
growth  arose,  as  it  could  not  have  come  from  a  pre-existing  cancer-cell  (Brand, 
in  "Lancet,"  Jan.  11,  1908).  Some  facts  render  a  parasitic  origin  of  malig- 
nant growths  not  improbable;  as,  for  instance,  the  likeness  of  some  tumors  to 
infective  granulomata,  the  tendency  to  secondar\-  development  in  distant  parts 
of  the  body,  the  resemblance  of  the  secondary  to  the  primar>'  growths,  and  the 
tenacit)-  of  their  persistence.  A  parasitic  origin  of  cancer  is  possibly  suggested 
by  its  geographic  distribution,  the  disease  being  ven,-  common  in  low  and 
■  marshy  districts,  and  Ha%iland  ("Lancet,"  April  27,  1894)  and  others  main- 
tain that  certain  houses  become  infected,  the  disease  appearing  in  these 
houses  among  successive  families  inhabiting  them.  They  speak  of  such 
abodes  as  "■cancer-houses''  (p.  384). 

Some  surgeons  believe  that  cancer  is  contagious,  but  most  obsen-ers  deny 
it.  Hanau  found  a  rat  suffering  with  cancer  and  inoculated  other  rats  from 
it.  Moreau  in  1894  inoculated  mice  from  a  movise  with  cancer.  Guelliott, 
of  Rheims,  believes  that  cancer  is  primarily  a  local  infection.  He  believes 
this  because  Moreau  and  Hanau  have  inoculated  it  from  one  animal  to  another 
of  the  same  species,  and  if  this  can  be  brought  about  experimentally  he  sees 
no  reason  whv  it  cannot  happen  accidentally.  This  surgeon  says  that  can- 
cer is  very  unequally  distributed,  that  genuine  cancer-centers  and  "cancer- 
houses  "  exist,  and  that  numerous  cases  of  accidental  infection  have  occurred* 
Hahn  apparentlv  succeeded  in  grafting  cancer  from  one  part  to  another  on 
the  same  individual.  Jensen  and  BorreU  have  inoculated  the  disease  in  white 
mice.  :Mavet,  of  Lvons,  holds  that  cancer  can  be  reproduced  by  grafting  or 
by  injection  of  cancer-fluid.  Graf  could  not  find  "cancer-houses"  after  a 
careful  search,  f  Geissler  claims  to  have  produced  the  disease  in  a  dog  by 
planting  fragments  of  cancer  in  the  subcutaneous  tissue  and  vaginal  tissue, 
but  Czernv,  Rosenbach,  and  others  dispute  the  claim.  PUmmer  tells  us 
that  an  epidemic  of  cancer  arose  among  the  captive  white  rats  in  the  Frei- 
burg Pathological  Institute,  and  in  each  case  the  growth  was  on  the  rear  part 
of  the  bodv.  RosweU  Park  beUeves  that  Gaylord  has  really  produced  adeno- 
carcinoma'in  the  lower  animals.  Hauser  disputes  the  assertion  that  cancer 
must  be  an  infectious  disease  because  it  is  foUowed  by  secondary  growths. 

*  Amer.  Jour,  of  Med.  Sciences,  June,  1895. 
t  Archiv.  f.  klin.  Chir.,  1995,  1.,  p.  i44- 


344  Tumors  or  Morbid  Growths 

Secondary  growths  in  an  infectious  disease  are  caused  by  the  bacterium; 
secondary  growths  in  cancer  are  caused  by  the  transference  of  cells  of  pii- 
mary  growth.*  Hauser  says  with  truth  that  the  close  connection  between 
innocent  and  malignant  growths  renders  the  parasite  view  untenable,  because 
to  hold  it  we  would  be  forced  to  believe  that  every  tumor  has  a  special  para- 
site or  that  one  parasite  may  cause  many  kinds  of  tumors. 

There  seems  to  be  no  doubt  that  autotransference  of  cancer  can  occur, 
although  it  rarely  does  so.  Sippel  has  reported  a  case  in  which  vaginal 
carcinoma  developed  at  the  point  where  the  vagina  was  in  contact  with  a  pre- 
existing cancer  of  the  portio.f  Cornil  has  seen  cancer  transferred  from  one 
of  the  labia  majora  to  the  other,  and  from  one  lip  to  the  other.  Geissler  was 
unable  to  transplant  cancer,  and  Gratia  also  failed  in  his  attempts.  Duplay 
and  Bazin  say  that  transmissibihty  is  possible,  but  only  under  conditions  which 
are  not  practically  realized.  The  facts  that  transplantation  can  be  sometimes 
carried  out,  and  that  contagion  is  a  possible  occurrence  under  exceptional 
circumstances,  do  not  prove  that  cancer  is  a  parasitic  disease,  but  simply 
prove  that  it  can  be  transplanted.  It  is  not  that  the  cancer  carries  a  parasite 
which  will  cause  the  disease  in  sound  tissues,  but  rather  that  the  cells  of  the 
cancer  may  themselves  take  root  and  grow  in  sound  tissues.  The  para- 
sitic theory  arose  from  observation  of  the  metastasis  which  occurs  during  the 
progress  of  the  disease,  and  received  support  from  the  fact  that  inoculation 
of  another  part  of  an  individual  suffering  from  cancer  may  be  followed  by 
the  development  of  a  tumor  hke  the  original  growth.  For  instance,  if  a  can- 
cer is  growing  upon  the  lower  lip,  the  upper  lip  may  be  inoculated  {contact 
cancer).  The  same  it  true  of  the  labia.  Mr.  Harrison  Cripps  reported  the 
occurrence  of  cancer  of  the  skin  of  the  arm  from  contact  with  an  ulcer- 
ating scirrhus  of  the  breast.  It  has  also  been  pointed  out  that  carcinoma  is 
especially  common  in  regions  predisposed  by  their  situation  to  injury  and 
infection,  and  that,  "among  the  lower  animals  at  least,  tumors  resembling 
carcinomas  have  been  transplanted  from  one  to  another"  ("Recent  Studies 
upon  the  Etiology  of  Carcinoma,"  by  Joseph  Sailer,  "Phila.  Med.  Jour.," 
June  7,  1902).  But  there  is  great  doubt  as  to  the  cancerous  nature  of  some 
of  the  tumors  which  have  been  successfully  transplanted  from  one  animal  to 
another. 

A  transplanted  mouse  cancer  may  grow  for  a  time  and  then  completely 
disappear,  and  some  observers  (among  them  Gaylord)  hold  that  when  this 
occurs  the  mouse  has   become  immune. 

In  1908  the  German  Pathological  Society  met  in  Kiel  and  discussed  various 
problems  of  cancer.  In  this  meeting  Sticker  maintained  that  there  is  such  a 
thing  as  natural  immunity  to  tumors.  He  showed  that  a  tumor  arising 
spontaneously  in  an  animal  can  never  be  transplanted  into  an  animal  of  another 
species,  and  very  seldom  can  a  malignant  tumor  be  transplanted  into  an  animal 
of  the  same  species.  He  quotes  Metschnikoff's  utter  failure  to  transplant 
human  tumors  into  anthropoid  apes  and  reports  his  own  failure  to  transplant 
human  tumors  into  various  domestic  animals.  He  made  over  400  trials  and 
failed  every  time  ("Jour.  Am.  Med.  Assoc,"  from  Sticker.  "Zeitschr.  f. 
Krebsforschung,"  1908,  vii.). 

*  Hauses,  in  Biolog.  Centralbl.,  Oct.  2,  1895. 
t  Centralbl.  f.  Gynak.,  No.  4,  1894. 


Causes  of  Tumors  345 

In  successful  transplantations  there  is  as  yet  no  proof  that  epithelial  cells 
were  not  transferred  with  the  supposed  parasites,  and  if  they  were  transferred 
the  success  of  the  experiment  does  not  prove  that  cancer  is  due  to  parasites, 
but  simply  proves  again  what  we  knew  before — that  epithelial  cells  can  be 
transplanted.  Many  parasites  have  been  regarded  as  causative  by  different 
observers.  Bacteria,  yeast-cells,  and  protozoa  have  been  found  by  different 
experimenters.  It  is  not  thought  that  bacteria  are  causative.  Yeasts  are 
regarded  as  causative  by  some.  It  is  certain  that  they  may  exist  in  cancer, 
but  it  is  by  no  means  certain  that  they  cause  the  disease.  They  may  be  only 
a  contamination.  Gaylord  and  others  regard  the  protozoa  as  causative,  but 
this  statement  does  not  seem  to  be  proved.  ]Many  of  the  supposed  parasites 
of  cancer  have  been  shown  to  be  cell-degenerations  or  contaminations.  We 
are  justified  in  concluding  that  the  parasitic  origin  is  not  as  yet  proved,  and  we 
agree  with  the  elder  Senn  that  it  is  improbable. 

Tillmanns  elaborately  discussed  the  subject  of  cancer  in  the  Congress  of 
1895.  His  conclusions  seem  most  sound  and  scientific.  He  says  there  is 
no  evidence  of  a  bacterial  origin  of  cancer.  The  parasitic  origin  has  not  been 
proved,  and  protozoa  have  not  certainly  been  found.  Cancer  can  be  trans- 
ferred from  one  part  to  another  of  the  same  individual,  or  from  one  indi- 
vidual to  another  of  the  same  species,  but  never  to  one  of  a  different  species. 
It  is  possible  that  cancer  can  spread  by  contagion;  this  is  ver}^  rare,  but  can 
happen  (as  when  penile  cancer  is  followed  by  cen^ix  cancer  in  a  wife).  Be- 
cause it  is  sometimes  possible  to  transfer  cancer,  this  does  not  prove  that  the 
disease  is  parasitic  or  infectious;  it  simply  shows  that  tissue  has  been  success- 
fully transplanted. 

Cancer  a  deux  is  cancer  developing  in  people  who  live  together.  Such 
cases  suggest  but  do  not  prove  contagion.  Behla  collected  19  cases  and 
Guelliot  103  cases.  Conjugal  cancer  is  classified  as  cancer  a  deux.  A  wife, 
for  instance,  may  have  cancer  of  the  womb  and  a  husband  may  develop  can- 
cer of  the  penis,  supposedly  from  contact.  Conjugal  cancer  is  probably  due 
to  irritation  or  implantation  and  not  to  microbic  inoculation. 

Actinomycosis,  long  thought  to  be  a  true  tumor,  is  now  known  to  arise 
from  the  ray-fungus.  Some  think  that  psorosperms  cause  cancer.  There 
can  be  no  doubt  that  changes  in  the  Hver  which  practically  constitute  a  new 
growth  can  arise  from  the  growth  of  a  cell  called  by  Darier  the  "  psorosperm. " 
A  disease  due  to  psorosperms  is  called  a  "psorospermosis."  It  is  afl&rmed 
by  some  that  molluscum  contagiosum,  follicular  keratosis,  cancer,  and  Paget's 
disease  are  due  to  psorosperms.  Some  claim  to  find  the  parasite  in  all  cases 
of  cancer,  while  others  can  find  it  in  only  4  or  5  per  cent,  of  the  cases. 

Heneage  Gibbes  afiirms*  that  dilatation  of  the  bile-ducts  of  a  rabbit's 
liver  is  caused  by  the  chronic  irritation  arising  from  multiplication  of  the  coc- 
cidium  oviforme  in  them,  and  not  in  the  columnar  cells  of  the  bile-ducts,  as  has 
been  stated;  and,  further,  that  the  large  majority  of  glandular  cancers  show 
nothing  that  can  be  considered  parasitic,  the  suspicious  appearances  noted 
in  some  few  cases  being  due  to  endogenous  cell-formation.  The  coccidium 
oviforme  is  a  genus  of  the  sporozoa,  class  protozoa,  the  lowest  division  of  the 
animal  kingdom.  To  this  case  belong  the  monera  and  infusoria.  (For  a 
further  discussion  of  this  subject  see  page  54). 

*  Amer.  Jour,  of  Med.  Sciences,  July,  1893. 


346  Tumors  or  Morbid  Growths 

Malignant  and  Innocent  Tumors. — Malignant  growths  infiltrate 
the  tissues  as  they  grow;  benign  tumors  only  push  the  tissues  away;  hence 
malignant  tumors  are  not  thoroughly  encapsuled,  while  innocent  tumors  are 
encapsuled.  ISIalignant  tumors  grow  rapidly;  innocent  tumors  grow  slowly. 
Malignant  tumors  become  adherent  to  the  skin  and  cause  ulceration ;  innocent 
tumors  rarely  adhere  and  rarely  cause  ulceration.  Many  malignant  tumors 
give  rise  to  secondary  growths  in  adjacent  lymphatic  glands  (cancer,  except 
in  the  esophagus  and  antrum  of  Highmore,  always  does  so;  sarcoma  rarely 
causes  them,  unless  the  growth  be  melanotic  or  unless  it  arises  from  the  testicle 
or  tonsil).  Innocent  tumors  never  cause  secondar}'  lymphatic  involvement; 
although  the  glands  near  the  tumor  may  enlarge  from  accidental  inflammatory 
complications.  The  malignant  tumors,  especially  certain  sarcomata  and 
soft  cancers,  may  be  followed  by  secondary  growths  in  distant  parts  and 
various  structures  (bones,  viscera,  brain,  muscles,  etc.);  innocent  tumors  are 
not  followed  by  these  secondary  reproductions,  although  multiple  fatty  tumors 
or  multiple  lymphomata  may  exist.  Malignant  tumors  destroy  the  general 
health,  inducing  anemia  and  cachexia;  innocent  tumors  do  not,  unless  by  the 
accident  of  position,  ^lalignant  tumors  tend  to  recur  after  removal;  innocent 
tumors  do  not  if  operation  was  thorough.  The  special  histologic  feature  of  a 
malignant  growth  is  the  possession  by  its  cells  of  a  power  of  reproducdon  which 
knows  no  limit,  the  cells  of  the  tumor  living  among  the  body-cells  like  a  parasite 
and  invading  and  destroying  the  body-cells. 

The  Cachexia  of  Malignant  Disease. — This  condidon  arises  sooner  or 
later  in  every  uncured  case  of  sarcoma  and  carcinoma. 

In  sarcoma  there  is  advancing  anemia  and  often  episodes  of  elevated  tem- 
perature due  to  the  absorption  of  toxic  materials  from  the  tumor.  The  blood 
examination  gives  results  similar  to  those  found  in  cancer,  but  leukocytosis  is 
more  frequent.  Pain  is  far  less  prominent  than  in  cancer  unless  a  nerve  is 
involved  or  squeezed.  Ulceration  occurs  much  later  in  sarcoma  than  in 
carcinoma. 

In  carcinoma  (p.  379)  the  emaciation  is  rapid  and  decided,  the  loss  of 
strength  is  significant  and  notable,  and  the  anemia  is  marked  and  progressive. 
It  is  due  to  pain,  sleeplessness,  ulceration,  impaired  appetite  and  digestion, 
repeated  hemorrhages,  and  the  absorption  from  the  tumor  of  toxic  products 
(especially  isohemolysins) .  Loss  of  hemoglobin  is  early  and  is  followed  by 
decrease  in  the  number  of  red  cells.  In  many  cases  considerable  amounts  of 
sugar  exist  in  the  blood.  In  both  sarcoma  and  carcinoma  the  development  of 
secondary  growths  aggravates  the  anemia. 

Classification. — Tumors  may  be  classified  as  follows: 

I.  Connective-tissue  tumors  (those  derived  from  the  mesoblast). 
I.  Innocent  tumors,  or  those  composed  of  mature  connective  tissue: 
Lipomata,  or  fatty  tumors;  fibromata,  or  fibrous  tiunors;  chondro- 
mata,  or  cartilaginous  tumors;  osieomata,  or  bony  tumors;  odonto- 
mata,  or  tooth-tumors;  myxomata,  or  mucous  tumors;  myomata,  or 
muscle-tumors;  neuromata,  or  tumors  upon  nerves;  gliomata,  or  tu- 
rners composed  of  neurogha;  angiomata,  or  tumors  formed  of  blood- 
vessels; lymphangiomata,  or  tumors  formed  of  lymphatic  vessels. 
The  term  lymphoma,  meaning  a  tumor  of  a  lymphatic  gland,  was 
formerly  appUed  to  hypertrophy  and  hyperplasia  of  a  lymphatic 


Lipomata  347 

gland,  no  matter  whether  caused  by  syphilis,  tubercle,  Hodgkin's 
disease,  or  any  other  morbid  impression.  The  term  has  been 
largely  abandoned  except  as  expressing  enlargement  of  a  gland, 
and  does  not  convey  any  suggestion  as  to  the  cause.  It  is  doubtful 
if  there  is  such  a  thing  as  a  true  lymphoma,  understanding  by  the 
term  a  neoplasm  arising  from  and  composed  of  lymphoid  cells  and 
resembling  lymphatic  structure.  In  the  described  cases  the  possi- 
bility of  infection  as  a  cause  has  not  been  eliminated. 
2.  Malignant  tumors,  or  those  composed  of  embryonic  connective  tissue: 

Sarcomata  and  adrenal  tumors. 

Endotheliomata  are  regarded  by  some  as  constituting  an  independent 
group  and  by  others  as  a  variety  of  sarcomata. 

II.  Epithelial  tumors  (those  derived  from  the  epiblast  or  hypoblast). 

1.  Innocent  tumors,  or  those  composed  of  mature  epithelial  tissue: 
Adenomata,  or  tumors  whose  type  is  a  secreting  gland;   and  papillo- 

niata,  or  tumors  whose  type  is  found  in  the  papillae  of  skin  and 
mucous  membranes. 

2.  Malignant  tumors,  or  those  composed  of  embryonic  epithelial  tissue: 

Carcinomata,  or  cancers. 

III.  Cystomata  are  cystic  tumors,  the  cyst-walls  of  which  are  new  growths 
and  the  contents  of  which  are  produced  by  the  cells  of  the  newly 
formed  cyst- walls. 

IV.  Teratomata   (tumors  containing  epiblastic,  hypoblastic,  and  meso- 

blastic  elements). 

Innocent  Connective=tissue  Tumor.— These  growths  mimic  or  imi- 
tate some  connective  tissue  or  higher  tissue  of  the  mature  and  heaUhy  organism. 

Lipomata  are  congenital  or  acquired  tumors  composed  of  fat  contained 
in  the  cells  of  connective  tissue,  which  cells  are  bound  together  by  fibers.  If 
the  fibers  are  excessively  abundant,  the  growth  is  spoken  of  as  a  fibrofatty 
tumor.  A  fatty  tumor  has  a  distinct  capsule,  tightly  adherent  to  surrounding 
parts,  but  loosely  attached  to  the  tumor;  hence  enucleation  is  easy.  Fibrous 
trabeculse  run  from  the  capsule  of  a  subcutaneous  Hpoma  to  the  skin;  hence 
movement  of  the  integument  over  the  tumor  or  of  the  tumor  itself  causes 
dimpling  of  the  skin.  An  ordinary  circumscribed  Hpoma  is  of  doughy  soft- 
ness, is  lobulated,  of  uniform  consistence,  and  on  being  tapped  imparts  to  the 
finger  a  tremor  known  as  pseudofluctuation.  A  fatty  tumor  is  mobile,  although 
it  may  be  attached  to  the  skin  at  points  by  trabeculae.  Lipomata  are  most 
frequent  in  middle  life,  and  their  commonest  situations  are  in  the  subcutaneous 
tissues,  especially  of  the  back  or  of  the  dorsal  surfaces  of  the  limbs;  they 
usually  occur  singly,  but  may  be  multiple  and  sometimes  symmetrical.  Senn 
described  the  case  of  a  woman  who  had  a  fatty  tumor  in  each  axilla.  A 
lipoma  may  grow  to  an  enormous  size  (in  Rhodius's  case  the  tumor  weighed 
sixty  pounds),  and  the  growth  may  be  progressive  or  may  be  at  times  sta- 
tionary and  at  other  dmes  active.  The  skin  over  a  fatty  tumor  somedmes 
atrophies  or  even  ulcerates;  the  tumor  itself  may  inflame  or  pardy  calcify. 
When  a  Hpoma  has  once  inflamed,  it  becomes  immovable.  Subcutaneous 
lipoma  of  the  palm  of  the  hand  or  sole  of  the  foot  bears  some  resemblance 
cHnically  to  a  compound  ganglion;  it  is  apt  to  be  congenital.  Lipomata  of 
the  head  and  face  are  rare.     In  the  subcutaneous  tissues  of  the  groms,  neck, 


348 


Tumors  or  Morbid  Growths 


pubes,  axillae,  or  scrotum  a  mass  of  fat  may  form,  unlimited  by  a  capsule  and 
known  as  a  "  diffuse  lipoma"  (Fig.  131).     A  diffuse  lipoma  may  dip  down 


Fig.  130. — Lipoma.      Wandered  from  a.xilla. 


Fig.  131. — Diffuse  lipoma. 


J' 


among  the   muscles.     Such   masses  attain  large  size.     The  typical  diffuse 
lipoma  is  occasionally  seen  on  the   neck.     It  begins  back   of  the  mastoid 

process  on  one  side  or  on  both 
sides.  When  large,  it  completely 
surrounds  the  neck,  a  huge  double 
chin  forming  in  front,  a  great  mass 
hanging  on  each  side,  and  the  pos- 
terior portion  being  divided  into 
two  halves  by  a  median  depression. 
A  nevolipoma  is  a  nevus  with  much 
fibrofatty  tissue.  A  very  vascular 
fatty  tumor  is  called  lipoma  telan- 
giectodes. If  the  tumor  stroma 
contains  large  veins,  the  growth 
is  called  a  cavernous  lipoma.  A 
tumor  containing  much  blood  can 
be  diminished  in  size  by  pressure. 
Fatty  tumors  may  arise  in  the  sub- 
serous tissue,  and  when  such  a 
growth  arises  in  either  the  femoral 
or  inguinal  canal  or  the  linea 
alba  it  resembles  an  omental  her- 
nia and  is  spoken  of  a.s  a.  fat-hernia. 
In  the  retroperitoneal  tissues  enor- 
mous fibrofatty  tumors  occasion- 
ally grow,  and  these  neoplasms  tend  to  become  sarcomatous.  Lipomata 
may  arise  from  beneath  synovial  membranes  and  will  project  into  the  joints, 


Fig.  132. — Lipoma  of  submaxillary  region. 


Fibromata 


349 


being  still  covered  by  synovial  membrane.  Fatty  tumors  occasionally  arise 
in  submucous  tissues,  between  or  in  muscles,  from  periosteum,  and  from  the 
meninges  of  the  spinal  cord  (J.  Bland  Sutton).  A  fatty  tumor  may  undergo 
metamorphosis.  The  stroma  may  be  attacked  by  a  myxomatous  process  or  a 
calcareous  degeneration.  The  fat-cells  themselves  may  become  calcareous. 
Oil-cysts  sometimes  form.  A  xanthoma  is  a  growth  composed  of  fatty  tissue  in 
and  about  which  there  is  marked  infiltration  with  small  cells.  Such  a  tumor 
is  flattened  and  slightly  elevated.  Several  or  many  of  these  growths  occur 
in  the  same  person.  The  eyelids  are  4he  most  common  seat  of  xanthoma. 
The  tumor  may  undergo  involution  or  may  become  sarcomatous. 

Diabetics  are  liable  to  develop  xanthomata. 

Treatment. — A  single  subcutaneous  lipoma  should  be  extirpated.  The 
capsule  must  be  incised,  when  the  tumor  can  be  torn  out  forcibly  or  can  be 


Fig-  133 — Fatty  tumor. 


enucleated  by  dissection;  drainage  is  always  employed  for  twenty-four  hours, 
as  but>Tic  fermentation  will  be  apt  to  occur,  and  necrosis  of  small  particles 
of  fat  predisposes  to  infection.  Multiple  subcutaneous  lipomata,  if  very 
numerous,  should  not  be  interfered  with  unless  troublesome  because  of  their 
size  or  situation,  when  the  growth  or  growths  causing  trouble  should  be 
removed.  It  is  difficult  to  extirpate  entire  a  diffuse  Hpoma,  and  several  opera- 
tions may  be  needed  to  effect  complete  removal.  Liquor  potassae,  once  recom- 
mended as  possessing  power,  when  taken  internally,  to  limit  the  growth  of 
multiple  lipomata  or  diffuse  lipoma,  seems  to  be  useless.  Subperitoneal 
lipomata  are  rarely  diagnosticated  until  the  belly  has  been  opened  or  the 
growth  has  been  removed. 

Fibromata  are  tumors  composed  of  bundles  of  fibrous  tissue.  There 
are  two  forms,  the  hard  and  the  soft.  A  hard  fibroma  consists  of  wavy  fibrous 
bundles  lying  in  close  contact.    Here  and  there  connective-tissue  corpuscles 


350 


Tumors  or  Morbid  Growths 


exist  between  the  fibers.  A  fibroma  has  no  distinct  capsule,  though  surround- 
ing tissues  are  so  compressed  as  to  simulate  a  capsule.  Fibromata  are  occa- 
sionally congenital,  are  most  usual  in  young  adults,  but  they  may  occur  at  any 
period  of  Hfe,  and  in  any  part  of  the  body  containing  connective  tissue.  Pure 
fibromata,  which  are  rare,  are  generally  sohtary,  grow  slowly,  are  of  uniform 
consistence,  have  not  much  circulation,  and  are  hard  and  movable.  Fibro- 
mata may  form  upon  nerves,  they  may  arise  in  the  mammar>-  gland,  they  may 
develop  in  the  lobe  of  the  ear,  and  they  may  spring  from  various  fibrous  mem- 
branes, from  the  periosteum  of  the  base  of  the  skull  {nasopharyngeal  fibro- 
mata), and  from  the  gums  (pbrous  epiilides).  A  soft  fibroma  contains  much 
areolar  tissue,  the  spaces  of  which  are  filled  with  fluid,  so  that  the  tissue  seems 
edematous.  Soft  fibromata  grow  from  the  skin,  mucous  membranes,  sub- 
cutaneous tissue,  intermuscular  planes,  and  periosteum.  Soft  fibromata  are 
especially  apt  to  arise  from  the  skin  of  the  scrotum,  labia,  inner  surface  of 
arm  and  thigh,  and  of  the  belly  wall  of  a  pregnant  woman.  They  are  not  un- 
usually multiple,  grow  slowly,  but  more 
rapidly  than  the  hard  fibromata,  and 
may  become  quite  large  and  jxjssess 
distinct  pedicles.  Fibromata  may  be- 
come cystic,  calcareous,  osseous,  col- 
loidal, or  sarcomatous,  and  may  inflame, 
ulcerate,  or  even  become  gangrenous. 

A  painjid  subcutaneous  tubercle, 
which  is  a  form  of  fibroma  commonest 
in  females,  arises  in  the  subcutaneous 
cellular  tissue,  usually  of  the  extremities. 
It  is  firm,  very  tender,  movable,  rarely 
larger  than  a  pea,  and  the  skin  over  it 
seems  healthy.  Violent  pain  occurs  in 
paroxysms  and  radiates  over  a  con- 
siderable area,  of  which  the  tubercle 
is  the  center.  These  paroxysms  may 
occur  only  once  in  many  days  or  many 
times  in  one  day.  Pain  is  always  developed  by  pressure,  and  may  be  linked 
with  spasm.  Nerve-fibrilke  are  now  known  to  exist  in  these  tubercles,  a  fact 
which  was  long  denied. 

A  mole  is  a  fibroma  of  the  skin  which  is  congenital  or  appears  in  the  early 
weeks  of  life.  It  is  rounded  or  flat,  is  usually  pigmented  and  of  a  bro\\Ti  color, 
is  shghtly  elevated  above  the  cutaneous  level,  and  has  a  few  hairs  or  an  abun- 
dant crop  of  hair  growing  from  it,  and  varies  in  size  from  a  pin's  head  to 
several  inches  in  diameter,  or  may  even  occupy  an  extensive  area  of  a  Hmb  or 
of  the  trunk.  The  tumor  rarely  grows  after  the  thirteenth  or  fourteenth  year. 
A  mole  may  become  malignant,  melanotic  carcinoma  may  arise  from  its 
epithelial  structures,  or  melanotic  sarcoma  from  its  connective-tissue  ele- 
ments. A  mole  is  an  extremely  vascular  structure;  it  bleeds  freely  when  cut 
or  scratched,  and  it  sometimes  ulcerates.  Occasionally  several  or  many  moles 
exist  in  the  same  individual.  If  a  mole  begins  to  increase  rapidly  in  size, 
operation  is  imperative,  as  rapid  growth  probably  indicates  malignant  change. 
Fibrous  epulis  is  a  fibroma  arising  from  the  gums  or  periodontal  membrane 


Fig.  134. — Keloid  following  a  bum. 


Morphea  351 

(J.  Bland  Sutton)  in  connection  with  a  carious  tooth  or  retained  snag;  it  is 
covered  by  mucous  membrane,  grows  slowly,  may  attain  a  large  size,  and 
sometimes  has  a  stem,  but  is  more  often  sessile.  It  may  undergo  myxo- 
matous change  or  may  become  sarcomatous. 

Fibrous  tumors  may  arise  from  the  ovary,  the  intestine,  and  the  larynx. 
Pure  fibromata  of  the  uterus  are  very  rare,  but  fibromyomata  are  very  com- 
mon (see  Myomata,  page  357);  hence  the  term  "uterine  fibroid"  should  be 
abandoned. 

Desmoid  tumors  of  the  abdominal  wall  are  cellular  fibromata.  A  desmoid 
tumor  has  a  strong  disposition  to  become  sarcoma.  It  has  no  real  capsule. 
It  takes  origin  from  one  of  the  abdominal  muscles  or  muscular  insertions 
or  from  fascia,  particularly  from  the  rectus  muscle  or  its  sheath.  In  most 
cases  the  growth  is  slow;  in  some  it  is  rapid  and  the  tumor  may  attain  a  great 
size.  It  may  project  either  anteriorly  or  toward  the  abdomen.  This  form  of 
tumor  is  vastly  more  common  in  women  than  in  men  and  is  especially  com- 
mon in  women  who  have  born  children.  It  may  occur  at  any  age,  but  is 
most  frequent  in  those  between  twenty-five  and  thirty-five.  It  is  a  very  rare 
tumor.     (See  Harvey  B.  Stone,  "Annals  of  Surgery,"  August,  1908.) 

MoUiiscum  fhrosnm  is  an  overgrowth  of  the  fibrous  tissue  of  both  the  skin 
and  the  subcutaneous  structure.  Senn  excludes  this  form  of  growth  from 
consideration  with  fibromata  because  of  its  supposed  infective  origin.  It  may 
be  limited  or  widely  extended;  it  may  appear  as  an  infinite  number  of  nodules 
scattered  over  the  entire  body  or  as  hanging  folds  of  fibrous  tissue  in  certain 
areas.  Keloid  (Fig.  135)  is  a  fibroma  of  the  true  skin.  It  is  a  hard,  fibrous, 
vascular  growth,  with  a  broad  base,  arising  in  scar-tissue;  it  is  crossed  by 
pink,  white,  or  discolored  ridges,  and  is  named  from  a  fancied  likeness  to  the 
crab.  It  has  rarely  attacked  mucous  membrane.  It  is  more  common  in 
negroes  than  in  whites,  and  is  most  frequent  in  the  cicatrices  of  burns,  though 
it  may  arise  in  the  scar  of  any  injury,  as  the  scar  from  piercing  the  ears,  and 
in  the  scars  of  syphilitic  lesions,  tuberculous  processes,  smallpox,  or  vaccina- 
tion. I  believe  that  the  scars  of  tuberculous  lesions  and  the  scars  even  of 
ordinary  wounds  in  tuberculous  individuals  are  particularly  apt  to  become 
keloidal.  It  is  very  common  in  a  person  with  keloid  to  be  able  to  find  some 
near  or  distant  tuberculous  lesion,  or  a  history  of  former  tuberculosis,  or  the 
record  of  the  individual  ha\ing  tuberculous  tendencies.  This  would  explain 
the  frequency  of  keloid  in  negroes.  The  \'ictim  of  keloid  usually  reacts  to 
tuberculin.  It  is  not  bacteria  in  the  scar,  but  rather  the  toxins  which  I  regard 
as  probably  responsible.  The  growth  seldom  begins  in  early  childhood  or 
in  old  age.  It  grows  slowly,  lasts  for  many  years,  and  may  eventually  undergo 
involution  and  disappear.  It  is  usually  believed  that  it  is  almost  useless  to 
remove  keloid  by  operation,  as  it  will  almost  certainly  return,  yet  a  study  of 
the  growth  removed  shows  no  reason  for  the  inevitable  return.  Charles  A. 
Porter  has  reported  a  case  of  massive  keloid  of  the  face  and  hands  notably 
benefited  by  many  operations  and  skin-grafting.  In  this  case.  Porter  says, 
"there  has  been  a  gradual  but  distinct  abatement  of  the  tendency  to  form 
keloid  tissue"  (Annals  of  Surgery,  July,  1909).  The  fibrous  tissue  of  keloid 
springs  from  the  outer  walls  of  the  blood-vessels.  The  papillae  of  the  skin 
above  the  tumor  are  destroyed  or  replaced  by  fibrous  tissue. 

Morphea,  spontaneous  or  true  keloid,  is  a  name  used  to  designate  a  growth 


352 


Tumors  or  Morbid  Growths 


of  this  description  which  does  not  arise  from  a  scar;  but  it  seems  certain  that 
scar-tissue  was  present,  though  possibly  in  small  amount  from  trivial  injury. 
The  fact  that  keloid  is  especially  common  in  the  negro  race  (a  race  predis- 
posed to  tuberculosis)  and  that  it  is  so  frequently  met  with  in  the  scars  of 
known  tuberculous  processes,  suggests  the  possibility  of  a  tuberculous  cause 
for  the  condition.  The  rapid  return  of  keloid  after  operation  suggests  a 
near  or  distant  infection  which  furnishes  material  to  a  point  of  least  resist- 
ance which  causes  keloid  to  redevelop.  Some  cases  of  keloid  have  active  tuber- 
culous lesions,  others  have  had  them,  in  still  others  latent  or  distant  lesions 
may  be  found  by  careful  search.     In  many  cases  there  is  a  family  history 


Fig.  135. — Keloid  (case  of  Dr.  L.  L.  Hill,  Montgomen-,  Ala.). 

of  tuberculosis.  I  am  at  present  investigating  this  important  matter.  It 
is  certain  that  the  keloid  itself  does  not  contain  bacteria.  Repeated  exami- 
nations have  failed  to  find  them.  It  is  quite  possible  that  the  growth  con- 
tains toxins  of  tubercle  bacilli,  the  toxins  being  the  irritant  cause.  I  am  now 
seeking  to  determine  if  material  from  keloid  introduced  into  tuberculous 
animals  will  cause  a  reaction,  and  if  a  reaction  follows  the  injection  of  tuber- 
culin into  the  victims  of  keloid. 

Fibrous  and  papillomatous  growths  covered  with  endotheHum  may  spring 
from  any  serous  membrane.  Such  a  growth  of  the  choroid  plexus  calcifies 
early  and  constitutes  a  psammoma  or  brain-sand  tumor.  Such  tumors  are 
met  with  not  only  in  the  choroid  plexus,  but  also  in  the  conarium  and  the  dura. 
All  psammomata  are  not  fibrous;  some  are  gliomatous  and  some  are  endo- 
theliomatous.  A  cholesteatoma  is  a  fibrous  growth  covered  with  endothelium 
and  containing  layers  of  crystalline  fat.  It  occurs  especially  in  the  pia  mater, 
but  mav  arise  in  either  of  the  other  membranes  or  even  in  the  brain  substance, 
and  is  called  a  pearl  tumor. 


Chondromata  353 

Treatment. — When  in  accessible  regions  fibromata  should  be  enucleated. 
Fibromata  should  not  be  let  alone,  because  any  fibrous  tumor  may  become  a 
sarcoma.  If  a  hard  fibroma  of  the  skin  exists  the  skin  is  incised  and  the  tumor 
is  "shelled  out."  A  soft  fibroma  is  removed  by  an  incision  carried  round  the 
base  of  its  pedicle.  A  painful  subcutaneous  tubercle  should  be  excised.  If 
a  mole  shows  the  slightest  disposition  to  enlarge,  or  if  it  is  subjected  to  pressure 
or  irritation,  it  should  be  removed,  because  if  allowed  to  remain  it  might 
develop  into  a  malignant  growth.  It  is  often  desirable  to  remove  a  hair}-  or 
pigmented  mole,  not  only  because  it  may  become  malignant,  but  also  because 
it  is  unsightly.  Fibrous  epulis  requires  the  cutting  away  of  the  entire  mass, 
the  removal  of  the  related  snag  or  carious  tooth,  and  sometimes  the  biting 
away  of  a  portion  of  the  alveolus  with  rongeur  forceps.  A  naso-phar}'ngeal 
fibrous  polyp  usually  contains  sarcomatous  elements  or  becomes  a  spindle- 
ceU  sarcoma.  If  it  has  a  pedicle,  it  may  be  removed  by  the  cauter\-  loop.  In 
a  severe  case  a  part  of  the  superior  maxillary  bone  is  removed  by  osteoplastic 
resection  to  permit  of  extirpation.  Keloid  should  rarely  be  operated  upon: 
it  will  only  return,  and  wall  also  recur  in  the  stitch  holes.  Trust  to  time  for 
involution,  or  use  pressure  with  flexible  collodion,  by  which  method  J.  M. 
Da  Costa  cured  a  case  following  smallpox.  It  may  be  necessar}-  to  operate 
because  of  ulceration.  If  it  is  necessary  to  operate,  remove  the  keloid  and 
considerable  adjacent  tissue  and  fill  the  gap  with  Thiersch  grafts.  The 
administration  of  thyroid  extract  may  be  of  benefit  (a  gr.  v  tablet  three  or  four 
times  a  day).  This  drug  must  be  given  cautiously,  as  it  may  cause  attacks 
characterized  by  fever,  dyspnea,  and  rapid  pulse.  Thiosinamin  h^-poder- 
matically  has  been  used,  it  is  claimed,  with  benefit.  A  10  per  cent,  solution 
is  made,  and  from  10  to  15  minims  can  be  injected  into  the  gluteal  muscles 
even,-  third  day.     I  have  seen  two  keloids  cured  by  the  use  of  the  x-rays. 

Chondromata  (enchondromata)  are  tumors  formed  either  of  hyaline 
cartilage,  of  fibrocartilage,  or  of  both.  Chondromata  are  apt  to  arise  from 
certain  glands,  the  long  bones,  the  pelvis,  the  rib  cartilages,  and  the  bones  of 
the  hands  or  feet,  and  often  spring  from  unossified  portions  of  epiphyseal 
cartilage.  They  may  be  single  or  multiple,  and  are  most  commonly  met  with 
in  the  young.  They  have  distinct  adherent  capsules;  they  grow  slowly,  and 
if  of  osseous  origin  progressively  hoUow  out  the  bones  by  pressure ;  they  cause 
no  pain;  they  impart  a  sensation  of  firmness  to  the  touch,  unless  mucoid 
degeneration  forms  zones  of  softness  or  fluctuation ;  they  are  inelastic,  smooth 
or  nodular,  immovable,  and  often  ossify.  A  chondroma  may  grow  to  an 
enormous  size.  A  chondroma  of  the  parotid  gland  or  testicle  practically 
always  contains  sarcomatous  elements,  and  any  chondroma  may  become 
a  sarcoma.  Chondromata  are  notably  frequent  in  persons  who  had  rickets 
in  early  hfe.  EccJiondroses.  which  are  '•small  local  overgrowths  of  car- 
tilage" (J.  Bland  Sutton),  arise  from  articular  cartilages,  especially  of 
the  knee-joint,  and  from  the  cartilages  of  the  larynx  and  nose.  Loose  or 
floating  cartilages  in  the  joints  may  be  broken-off  ecchondroses  or  portions 
of  hyaline  cartilage  which  are  entirely  loose  or  are  held  by  a  narrow  stalk,  and 
which  arise  by  chondrification  of  villous  processes  of  the  s}-no\-ial  membrane; 
only  one  or  vast  numbers  may  exist;  one  joint  may  be  involved,  or  several; 
they  may  produce  no  symptoms,  but  usually  produce  from  time  to  time  violent 
pain  and  immobihty  by  acting  as  a  joint-wedge.     An  ecchondroma  may  arise 


354 


Tumors  of  Morbid  Growths 


within  the  medullary  canal  of  a  long  bone,  from  foci  of  dormant  cartilage,  and 
may  lead  to  the  dcvelojjment  cf  a  solitary  cyst  of  large  size  by  softening  of  the 
tumor.  The  femur  is  the  most  usual  site  of  disease.  It  begins  very  insidiously 
and  progresses  gradually.  There  are  slight  lameness,  trivial  pain,  tenderness 
below  the  level  of  the  trochanter,  apparent  shortening  and  some  bulging  of 
bone.     The  bone  may  bend  or  at  some  .'^pot  may  thin  sn  that  the  cyst  can  be 


Fig.  136. — Multiple  osteomata. 

felt.  Such  a  bone  fractures  from  slight  force, 
and  after  a  fracture,  when  the  effused  blood 
and  inflammatory  exudate  have  been  absorbed, 
a  tumor  can  be  distinctly  detected.  A  solitary 
cyst  of  a  long  bone  is  apt  to  be  regarded  clin- 
ically as  a  sarcoma  (Bergmann-Virchow). 

Treatment. — Remove  chondromata  when- 
ever possible,  for,  if  allowed  to  remain  undis- 
turbed, they  are  apt  to  resent  this  hospitality 
by  becoming  sarcomatous.  Incise  the  capsule 
and  take  away  the  grovv^th,  using  chisels  and 
gouges  if  necessary.  Incomplete  removal 
means  inevitable  recurrence.  Amputation  is 
very  rarely  demanded.  Loose  bodies  in  the 
joints,  if  productive  of  much  annoyance,  are 
to  be  removed,  the  joint  being  opened  with 
the  strictest  antiseptic  care.  Amputation  is 
sometimes  performed  for  a  solitary  cyst  of  a 
long  bone,  the  surgeon  having  looked  upon 
the  growth  as  sarcomatous.  If  a  correct  diagnosis  is  arrived  at,  an  attempt 
should  be  made  to  remove  the  cyst  without  amputation.  Bergmann  suc- 
ceeded in  extirpating  such  a  mass  from  the  femur. 

Osteomata. — Osteomata  are  tumors  which  are  composed  of  osseous 
tissue.  J.  Bland  Sutton  says  that  osteomata  are  ossifying  chondromata. 
Osteomata  take  origin   from   bone,    cartilage,   connective   tissue,   especially 


Fig.  137. — Multiple  osteomata. 
Hundreds  of  them  throughout  the 
body. 


Odontomata  355 

tissue  near  the  bone,  serous  membrane,  and  certain  glands  and  organs.  Com- 
pact osteomata,  which  are  identical  in  structure  with  the  compact  tissue  of 
bone,  arise  from  the  frontal  sinus,  mastoid  process,  external  auditory  meatus, 
and  other  regions  in  those  beyond  middle  life;  they  are  small,  smooth,  round, 
densely  hard,  with  small  and  occasionally  cartilaginous  bases. 

Cancellous  osteomata,  which  comprise  the  great  majority  of  bone-tumors, 
are  similar  in  structure  to  cancellous  bone.  They  spring  from,  and  are  crusted 
with,  cartilage;  they  may  have  fibrous  capsules,  and  are  often  movable  when 
recent,  but  soon  become  fixed;  they  have  broad  bases,  are  angled,  nodular, 
firm  (but  not  so  hard  as  are  the  compact  osteomata),  painless  except  when 
pressed,  occur  particularly  at  the  ends  of  long  bones,  may  grow  to  large  size, 
and  are  commonest  in  youth.  Osteomata  near  joints  become  overlaid  by 
bursK,  which  in  rare  instances  communicate  with  an  adjacent  joint. 

The  term  exostosis  has  been  used  as  being  synonymous  with  osteoma,  but 
^ATongly  so,  as  an  exostosis  is  an  irregular,  local,  bony  growth  which  does  not 
tend  to  progress  without  Hmit,  and  which  is,  hence,  not  a  tumor.  A  true  exos- 
tosis is  seen  in  the  ossification  of  a  tendon-insertion,  in  a  limited  growth  from 
one  of  the  maxillary  bones,  and  in  a  local  growth  from  the  last  phalanx  of  the 
big  toe,  which  latter  form  of  growth  is  known  as  a  subungual  exostosis.  Ex- 
ostoses of  the  retrocalcaneal  bursa  occasionally  arise  when  this  bursa  is  inflamed. 
Inflammation  of  this  bursa  is  known  as  Achillodynia  or  Albert's  disease.  The 
bony  masses  sometimes  found  in  the  brain,  lungs,  testicle,  various  glands, 
and  tumors  are  not  true  osteomata.  Osteomata  do  not  tend  to  become 
malignant  and  do  not  recur  after  removal. 

Treatment. — Osteomata  which  are  non-productive  of  pain  or  trouble 
do  not  demand  removal.  If  they  produce  pain  by  pressure,  if  they  press  upon 
important  structures,  if  they  cause  annoving  deformities,  or  if  they  grow 
rapidly,  then  remove  them  by  means  of  chisels,  gouges,  or  the  surgical  engine. 
Subungual  exostosis  should  always  be  removed.  The  nail  should  be  split 
and  part  of  it  taken  away,  and  the  bony  mass  be  gouged  away  or  be  cut  off 
with  forceps. 

Odontomata  *  are  tumors  composed  of  tooth-tissue.  They  spring  from 
the  germs  of  teeth  or  from  developing  teeth.  J.  Bland  Sutton  divides  them 
into  (i)  those  springing  from  the  follicle;  (2)  those  springing  from  the  papilla; 
and  (3)  those  springing  from  the  whole  germ. 

Epithelial  odontomes,  or  multilocular  cystic  tumors,  arise  from  the 
foUicle,  occur  oftenest  in  the  lower  jaw,  dilate  the  bone,  have  capsules,  and 
are  made  up  of  masses  of  cysts  which  are  filled  with  brown  fluid.  These 
cysts  are  met  with  most  frequently  before  the  age  of  twenty.  Follicular  odon- 
tomes, or  dentigerous  cysts,  oftenest  spring  from  the  follicles  of  the  permanent 
molars.  In  a  dentigerous  cyst  there  exists  an  expanded  follicle  which  dis- 
tends the  bone,  the  follicle  being  filled  with  thick  fluid  and  containing  a  portion 
of  a  tooth.  A  fibrous  odontome  is  due  to  thickening  of  the  tooth-sac,  which 
prevents  eruption  of  the  tooth;  fibrous  odontomes  are  usually  multiple,  and 
are  apt  to  occur  in  rickety  children.  A  cementome  is  due  to  enlargement, 
thickening,  and  ossification  of  the  capsule,  the  developing  tooth  being  encased 
in  cement.     A  compound  jollicular  odontome  is  due  to  ossification  of  portions 

*  This  section  is  abridged  from  J.  Bland  Sutton's  striking  chapter  upon  odontomes  in 
his  recent  work  on  "  Tumors.'' 


356  Tumors  or  Morbid  Growths 

only  of  an  enlarged  and  thickened  capsule,  and  the  tumor  contains  bits  of 
cementum,  portions  of  dentine,  or  small  misshapen  teeth.  A  radicular 
odontome  springs  from  the  papilla  and  arises  after  the  crown  of  the  tooth  is 
formed  and  while  the  roots  are  forming;  hence  it  contains  dentine  and  cement, 
but  no  enamel.  Composite  odontomes  are  formed  of  irregular,  shapeless 
masses  of  dentine,  cement,  and  enamel.  All  the  above  forms  occur  in  man. 
They  present  themselves  as  hard  tumors  associated  with  teeth  or  in  an  area 
where  teeth  have  not  erupted.  Occasionally  an  odontome  simulates  necrosis; 
it  is  surrounded  by  pus,  and  a  sinus  forms. 

Treatment. — The  diagnosis  is  scarcely  ever  made  until  after  an  incision; 
hence,  be  in  no  haste  to  excise  large  portions  of  bone  for  a  doubtful  growth; 
incise  first  and  see  if  it  be  an  odontome,  which  requires  only  the  removal  of 
an  implicated  tooth,  curetting  with  a  sharp  spoon  and  packing  w^ith  iodo- 
form gauze. 

Myxomata  are  tumors  composed  of  mucous  tissue.  They  are  rare  as 
independent  growths,  although  myxomatous  change  is  frequent  in  the  stroma 
of  other  tumors.  The  tissue  type  of  these  tumors  is  found  in  the  vitreous 
humor  of  the  eye  and  in  the  perivascular  tissues  of  the  umbilical  cord  (Whar- 
ton's jelly).  Bowlby  states  that  myxomata  are  in  reahty  soft  fibromata  whose 
intercellular  substance  has  been  replaced  by  mucin.  The  myxomatous  state 
may  be  a  stage  in  the  formation  of  a  fibroma,  a  stroma  not  having  developed. 
Myxomata  may  result  from  myxomatous  degeneration  of  cartilage,  of  muscle, 
or  of  fibrous  tissue.  These  tumors  are  soft,  elastic,  usually  pedunculated, 
tremulous,  and  vibratory.  The  stroma  is  very  delicate  and  carries  minute 
blood-vessels.  Cutting  into  a  myxoma  causes  a  straw-colored,  clear  jelly 
to  exude.  Myxomata  grow  slowly,  are  encapsuled,  have  but  little  circulation, 
and  the  diagnosis  may  be  impossible  before  removal  of  the  growth.  Some 
pathologists  place  myxomata  among  the  malignant  tumors,  but  most  consider 
them  as  benign  tumors,  though  they  tend  strongly  to  become  sarcomatous 
{myxosarcomata) .     A  sarcoma  may  undergo  myxomatous  degeneration. 

Myxomata  may  arise  from  the  skin;  from  the  mucous  membrane  of  the 
nose,  the  frontal  sinus,  the  antrum,  the  womb,  the  auditory  meatus,  and  the 
tympanum  (gelatinous  polyps);  from  the  parotid  and  mammary  glands; 
from  the  subcutaneous  tissue,  the  nerve-sheaths,  the  intermuscular  septa, 
the  rectum,  and  the  bladder  (polyps).  They  may  be  congenital,  but  occur 
most  often  in  young  adults,  as  a  result  of  inflammation.  A  sudden  increase 
of  growth  indicates  beginning  malignancy  (sarcomatous  change).  When 
a  tumor  begins  to  undergo  myxomatous  transformation  we  give  to  it  a  com- 
pound name;  for  instance,  a  chondroma  undergoing  myxomatous  change  is 
a  chondromyxoma,  a  fibroma  undergoing  a  like  change  is  a  fibromyxoma,  etc. 
Mucous  polypi  grow  from  the  mucous  membrane  of  the  nose,  particularly 
from  the  outer  wall  near  the  middle  turbinated  bone,  and  often  from  the  roof 
of  the  nares.  Mucous  polypi  are  soft  and  jelly-like,  of  a  grayish  color,  and 
have  stems  or  pedicles;  they  may  be  seen  through  the  anterior  nares,  may 
project  behind  the  veil  of  the  palate,  and  may  bulge  out  from  the  passages  of 
the  nose ;  they  may  be,  and  usually  are,  multiple ;  they  may  be  present  in  one 
nasal  fossa  or  in  both;  and  they  occur  most  commonly  in  youths  and  adults 
between  the  ages  of  fifteen  and  thirty-five  years. 

Hydatid  moles  of  pregnancy  are  due  to  myxomatous  changes  in  the  chorion. 


Myomata  357 

Treatment. — In  treating  myxomata,  remove  them  promptly  and  thor- 
oughly, because  of  the  danger  of  sarcomatous  change.  Polyps  of  the  bladder 
are  removed  by  means  of  cutting  forceps  after  suprapubic  cystotomy  has  been 
performed.  Nasal  polyps  may  usually  be  twisted  off  or  be  removed  by  the 
wire  snare  or  galvanocautery.  Occasionally  when  the  growths  are  numerous 
and  recur  rapidly  after  removal,  the  inferior  turbinated  bones  should  be  re- 
moved with  a  saw  (Rouge's  operation).  This  operation  secures  ready  access 
to  the  area  of  disease,  which  can  be  attacked  radically.  A  very  soft  myxoma 
breaks  up  when  removal  is  attempted,  and  the  base  must  be  cauterized. 

Myomata  are  tumors  composed  of  unstriped  muscle-fiber  mixed  often 
with  fibrous  tissue.  They  are  called  liojnyomata.  Tumors  composed  of 
striated  muscle-fiber  and  spindle-cells  are  known  as  rhabdomyomata .  They 
are  very  rare  and  are  always  sarcomatous.  Liomyomata  are  found  in  the 
womb,  in  the  prostate  gland,  in  the  walls  of  the  gullet,  vagina,  stomach, 
bladder,  and  bowel,  in  the  broad  ligament,  ovary,  and  round  ligament,  in  the 
scrotum,  and  in  the  skin.  Myomata  usually  begin  during  or  after  middle 
age;  they  are  encapsuled,  they  grow  slowly,  they  are  firm  and  hard,  and 
produce  annoyance  by  their  size  and  weight  or  by  obstructing  a  viscus  or 
channel.  A  liomyoma  of  the  posterior  portion  of  the  middle  of  the  prostate 
gland  is  known  as  a  "  middle  lobe." 

The  so-called  uterine  fibroid  is  a  myoma  or  fibromyoma.  Uterine  myo- 
mata may  originate  within  the  walls  of  the  womb  (intramural  myomata), 
from  the  muscular  structure  of  the  mucous  lining  (submucous  myomata),  or 
from  the  muscular  tissue  of  the  serous  covering  (subserous  myomata).  Intra- 
mural uterine  myomata  may  be  single  or  multiple  and  may  grow  to  an  enor- 
mous size.  Submucous  myomata  project  into  the  cavity  of  the  womb  (fleshy 
polyps),  and  may  project  into  the  vagina.  They  distend  the  uterus  and  are 
often  accompanied  by  menorrhagia  or  metrorrhagia.  In  some  rare  cases  the 
projecting  tumor  is  detached  by  Nature  and  the  patient  is  cured ;  in  some  cases 
the  myoma  becomes  gangrenous.  A  fleshy  polyp  may  produce  inversion  of 
the  fundus  of  the  womb.  Subserous  uterine  myomata  cause  trouble  only  by 
the  inconvenience  of  weight  or  the  discomfort  of  pressure.  Uterine  myomata 
are  commonest  in  single  women,  and  arise  most  frequently  between  the  ages 
of  twenty-five  and  forty-five.  Negro  women  are  especially  prone  to  develop 
such  tumors.  They  may  never  produce  any  symptoms.  Some  of  these 
growths,  by  enlarging  until  they  ascend  above  the  pelvic  brim,  produce 
abdominal  distention;  some  become  jammed  or  impacted  in  the  pelvis,  and 
produce  by  pressure  retention  of  urine,  obstruction  to  the  passage  of  feces 
or  hydronephrosis.  Impaction  may  occur  temporarily  at  each  menstrual 
period.  Many  myomata  produce  uterine  hemorrhage;  some  cause  retro- 
version of  the  womb ;  some  protrude  from  the  cervical  canal ;  some  are  so  large 
that  they  cause  disastrous  pressure  upon  the  colon  (obstruction),  upon  the 
iliac  veins  (great  edema),  or  upon  the  ureters  (hydronephrosis).  Uterine 
myomata  usually  shrink  after  the  menopause.  Pregnancy  in  a  myomatous 
womb  usually  ends  in  abortion.  Uterine  myomata  may  undergo  fatty, 
calcareous,  or  myxomatous  change,  and  may  be  infected  by  septic  organisms 
as  a  result  of  the  use  of  a  uterine  sound  or  of  infection  of  the  pedicle  after 
oophorectomy.  Infection  of  a  uterine  myoma  causes  great  enlargement, 
elevated  temperature,  sweats,  and  exhaustion. 


35^  Tumors  or  Morbid  Growths 

The  symptoms  of  myomata  of  the  alimentary  canal  are  similar  to  or 
identical  with  the  symptoms  of  malignant  growths.  Myomata  of  the  skin 
are  rare  growths;  they  are  encapsuled,  firm  or  elastic,  and  painless. 

Treatment. — Cutaneous  myomata  are  removed  in  the  same  manner  as 
fibrous  tumors.  Uterine  myomata  are  treated  by  rest  and  the  administration 
of  ergot,  barium  chlorid,  and  dilute  sulphuric  acid.  If  this  treatment  fails 
to  arrest  serious  bleeding  due  to  a  flesh  polyp,  dilate  the  cervical  canal  and 
remove  the  growth.  If  there  be  dangerous  bleeding  in  a  woman  who  has 
some  years  to  wait  for  the  menopause  and  who  has  not  a  removable  polyp  as 
the  cause,  perform  oophorectomy  in  order  to  bring  on  an  artificial  menopause. 
When  a  myoma  becomes  impacted  at  each  menstrual  period,  remove  the  ovaries 
and  Fallopian  tubes.  Subserous  myomata  may  be  removed  from  the  uterus 
after  abdominal  section,  the  resulting  wound  in  the  uterus  being  sutured. 
Hysterectomy  is  indicated  for  some  very  large  tumors,  for  tumors  that  grow 
after  the  menopause,  and  for  infected  myomata.  If  the  abdomen  be  opened 
to  perform  oophorectomy,  and  the  tubes  and  ovaries  are  found  so  implicated 
in  the  growth  that  they  cannot  be  removed  completely,  or  the  broad  ligament 
is  found  so  drawn  out  that  a  safe  pedicle  cannot  be  secured,  perform  a  hyster- 
ectomy.* A  recent  suggestion  for  the  shrinkage  of  uterine  myomata  is  to 
ligate  both  the  uterine  and  ovarian  arteries.  If  a  m\'oma  of  the  prostate  causes 
severe  obstruction,  perform  a  suprapubic  cystotomy  and  remove  the  major 
portion  of  the  enlarged  gland;  or  make  both  a  suprapubic  and  a  perineal 
opening,  push  the  gland  into  the  perineum  and  shell  it  out  with  the  finger,  or 
make  permanent  suprapubic  drainage. 

Neuromata. — A  true  neuroma  springs  from  nerve-tissue  (brain,  cord,  or 
nerve-trunks) ;  it  is  composed  of  medullated  or  non-medullated  nerve-fibers 
which  form  a  plexus  or  network,  and  which  are  not  continuous  with  the  fibers 
of  the  nerve-trunk  or  other  area  from  which  the  tumor  grows.  True  neuro- 
mata, which  are  rare  growths,  arise  during  middle  life;  they  are  small  in  size; 
are  due  to  injury  or  hereditary  tendency,  and  they  may  be  single  or  multiple. 
There  is  usually  around  the  tumor,  rather  than  in  it,  severe  neuralgic  pain, 
which  is  greatly  intensified  by  dampness,  by  blows,  or  by  rough  handling. 
The  parts  below  a  neuroma  are  cold,  swollen,  often  anesthetic,  and  frequently 
present  motor  paralysis  or  trophic  disorder.  A  jalse  neuroma  or  neurofibroma 
is  a  fibrous  tumor  growing  from  a  nerve-sheath,  and  is  identical  in  structure 
with  the  sheath.  False  neuromata  may  be  single,  but  they  are  often  multiple; 
they  may  be  as  small  as  peas  or  as  large  as  oranges;  they  are  smooth  and 
movable,  and  may  cause  great  pain  or  may  be  painful  only  when  pressed  or 
struck;  they  may  spring  from  roots,  trunks,  or  branches,  and  they  may  be 
linked  with  the  disease  known  as  "  moUuscum  frbrosmn.''  In  plexijorm 
neuro7na  some  branches  of  a  nerve  enlarge  and  lengthen  like  an  artery  in  a 
cirsoid  aneurysm ;  the  mass  feels  like  beads  or  like  a  bag  of  worms ;  it  is  mobile, 
and  no  pain  is  felt  on  moving  it;  and  it  is  generally  congenital.  In  plexiform 
neuroma  the  nerve-sheath  undergoes  myxomatous  change.  Malignant 
neuroma  is  a  primary  sarcoma  of  a  nerve-sheath,  though  any  neuroma  may 
become  sarcomatous. 

Traumatic  neuromata  are  false  neuromata  and  are  occasional!}'  well  ex- 

*  See  J.  Bland  Sutton's  admirable  article  on  "Uterine  Myomata"  in  his  work  on 
"Tumors." 


Angiomata  or  Hemangioma ta  i  359 

hibitcd  after  nerve-scclion  or  amputation.  On  nerve-section  the  distal  end 
shrinks  and  atrojihies,  the  j)roximal  end  enhirges  and  becomes  bulbous.  A 
traumatic  neuroma  is  composed  of  fibrous  tissue  which  contains  nerve-fibers. 
Such  a  growth  is  usually,  but  not  always,  painful  on  pressure  or  during  damp- 
ness, and  is  most  commonly  seen  in  a  stump  which  did  not  heal  by  first  inten- 
tion. In  performing  an  amputation  cut  the  nerves  high  up,  and  thus  keep 
them  out  of  the  scar,  permit  them  to  remain  mobile  in  their  sheaths,  and  so 
prevent  a  tender  stump.  A  tender  stump  may  be  due  to  anchoring  of  a  nerve 
in  a  scar,  the  nerve  ceasing  to  glide  when  the  individual  moves  the  extremity. 
The  condition  known  as  painful  subcutaneous  tubercle  was  discussed  on  page 

35°- 

Treatment. — A  false  neuroma  is  to  be  removed,  if  possible,  without  de- 
stroying the  nerve-trunk.  If,  in  removing  a  neuroma,  it  is  necessary  to  exsect 
a  portion  of  a  nerve-trunk,  always  endeavor  to  suture  the  ends  of  the  divided 
nerve  so  as  to  facilitate  restoration  of  function.  For  multiple  neuromata — at 
least  should  the  number  be  large  or  should  moUuscum  fibrosum  exist — surgery- 
can  do  nothing.  Plexiform  neuromata  may  often  be  removed,  but  amputation 
may  be  required.     Painful  neuromata  in  stumps  should  be  excised. 

Qltomata. — These  tumors  develop  from  neuroglia  and  more  often  from 
the  white  substance  than  from  the  gray.  They  are  usually  single,  and  arise 
in  the  brain,  rarely  in  the  cord,  and  very  rarely  in  the  cranial  nerves.  They 
may  take  origin  in  one  of  the  cerebral  hemispheres,  in  the  cerebellum,  in  the 
pons,  or  in  the  medulla.  Some  gliomata  are  soft  and  bear  a  close  relationship 
to  sarcoma ;  others  are  hard  and  resemble  fibroma. 

A  glioma  is  a  circumscribed  growth  in  contrast  to  a  gliosis,  which  is  a 
widespread  and  unlimited  hyperplasia  of  the  neuroglia.  Syringomyelia  is 
due  to  gliosis  of  the  spinal  cord. 

"A  glioma  consists  of  cells  containing  rounded  or  oval  nuclei  with  very 
little  protoplasm  and  fine  protoplasmic  extensions  which  interlace  and  form 
an  intercellular  reticulum"  (Stengel). 

A  glioma  passes  almost  insensibly  into  surrounding  tissue,  and  there  is  no 
distinct  edge;  hence,  because  of  the  slight  differentiation  from  brain  sub- 
stance, it  may  be  overlooked  during  exploration.  It  is  harder  than  the  sur- 
rounding tissue;  is  vascular  and  of  a  pink  or  red  color;  and  the  normal 
shape  of  the  part  is  often  very  little  altered,  although  the  tumor  may  reach 
the  size  of  a  lemon. 

Hemorrhage  may  take  place  into  a  glioma,  softening  may  occur,  cavities 
may  form,  or  the  growth  may  become  sarcomatous  or  psammomatous.  The 
symptoms  of  a  glioma  of  the  brain  depend  on  the  situation. 

Treatment. — When  the  growth  can  be  localized  it  is  justifiable  in  some 
cases  to  attempt  its  removal.     Even  a  partial  removal  may  be  of  benefit. 

Angiomata  or  Hemangiomata. — An  angioma  is  a  tumor  composed 
largely  of  dilated  blood-vessels.  The  older  surgeons  called  such  growths 
erectile  tumors.  Some  of  the  so-called  angiomata  are  not  genuine  new  growths, 
but  are  due  to  dilatation  and  elongation  of  blood-vessels. 

Simple  or  capillary  angiomata,  nevi,  or  "  mother's  marks,"  which 
afifect  the  skin  or  subcutaneous  tissue,  are  composed  of  enlarged  and  twisted 
capillaries  and  of  anastomosing  vessels  surrounded  by  fat.  These  growths 
are  congenital  or  appear  in  the  first  few  weeks  of  life;  they  are  flat  and  slightly 


36o 


Tumors  or  Morbid  Growths 


raised,  and  are  of  a  bright-pink  color  if  composed  cliietly  of  arterioles,  and 
are  bluish  if  composed  mainly  of  venules;  they  are  but  little  elevated ;  they  can 
be  almost  completely  emptied  by  pressure;  they  occasionally  pass  away  spon- 
taneously, but  usually  grow  constantly  and  may  become  cavernous;  they  may 
ulcerate  and  occasion  violent  or  fatal  hemorrhage.  One  or  several  large 
vessels  connect  a  nevus  to  adjacent  blood-vessels.  Port-wine  or  claret 
stains  are  pink  or  blue  discolorations  due  to  superficial  nevi  of  the  skin ;  they 
may  be  small  in  extent  or  they  may  involve  a  very  large  area,  are  not  elevated, 
and  do  not  usually  spread.  Telangiectasis  is  a  form  of  nevus  involving  the 
skin  and  subcutaneous  tissue  in  which  many  arterioles  and  venules  exist. 
Simple  angiomata  are  common  on  the  forehead,  the  scalp,  the  face,  the  neck, 
the  back,  and  the  extremities.  They  may  appear  on  the  labia,  the  tongue, 
or  the  lips. 

Cavernous  angiomata,  or  venous  nevi  (Fig.  138),  resemble  in  structure 
corpora  cavernosa  of  the  penis;  there  are  large  endothelial  lined  spaces  with 
thin  walls  carrying  blood,  and  there  may  be  distinct  vessels  as  well.  Arteries 
send  blood  into  the  spaces,  and  veins  receive  it  from  the  spaces.  These 
channels    and    sinuses    are    enormously    distended    capillaries.     Cavernous 


Fig.  138. — Dr.  Hansen's  case  of  cavernous  angioma 
of  the  eyelids. 


Fig.  139. — Cavernous  angioma  of  face. 


angiomata  arise  in  the  shin  and  subcutaneous  tissues;  they  are  usually  con- 
genital, but  may  develop  from  simple  angiomata;  they  are  purple  or  blue  in 
color;  are  more  distinctly  elevated  than  the  capillary  nevi;  may  be  either 
cutaneous  or  subcutaneous;  swell  when  the  child  cries,  and  are  apt  to  pulsate; 
they  may  be  emptied  by  pressure,  and  often  look  like  cysts  with  very  thin 
walls.  Cavernous  angiomata  may  arise  in  the  breast,  the  tongue,  the  lip,  the 
cheek,  the  gums,  the  subcutaneous  tissues,  or  the  muscles.  If  an  angioma 
contains  an  excess  of  fat,  the  growth  is  called  a  "  nevoid  Hpoma." 

Plexiform  angiomata  are  known  as  "  cirsoid  aneurysms"  or  aneurysms 
by  anastomosis  (page  432). 

Angiomata  noticed  soon  after  birth  may  disappear  completely  or  may 
enlarge  progressively. 


Treatment  of  Angiomata  or  Hemangiomata 


361 


Treatment. — These  growths  if  large  or  growing  must  be  treated.  A 
capillary  nevus  can  often  be  quickly  cured  by  touching  it  with  fuming  nitric 
acid.  A  second  application  of  acid  may  be  required.  The  growth  may  be 
destroyed  by  heat — ''  a  knitting-needle  at  a  dull-red  heat  or  the  galvano- 
cautery"  (Wharton).  The  application  of  ethylate  of  sodium  or  the  employ- 
ment of  electrolysis  will  destroy  the  growth.  Astringent  injections  are  dan- 
gerous unless  the  base  of  the  nevus  is  ligated,  because  they  may  lead  to  the 
formation  of  emboli. 

Small  port-wine  stains  may  be  removed  by  electrolysis  or  multiple  incisions, 
but  extensive  stains  are  inelfaceable.     Small  nevi  may  be  Ugated  under  harelip 

pins,  larger  nevi  may  be  strangu- 
lated in  sections  by  the  Erichsen 
suture  (Fig.  141),  or  may  be  com- 
pletely excised.  Excision  is  usually 
the  best  plan  for  the  cure  of  angio- 
mata. It  is  rapid,  thorough,  and 
leaves  but  a  trivial  scar.  Excision 
should  always  be  employed  if  we 
feel  sure  that  the  edges  of  the  wound 
can  be  subsequently  approximated 
and  that  there  will  not  be  a  dan- 
gerous loss  of  blood.  It  is  some- 
times justifiable  to  excise  an  angi- 
oma even  when  approximation  of 


Fig.  140. — Cavernous  angioma  :  Subcutaneous 
tissue  of  leg. 


Fig.  141. 


-Method  of  applying  Erichsen 's 
ligature. 


In  such  a  case  the  raw  surface 


the  wound  will  obviously  be  impossible, 
should  be  covered  with  Thiersch  grafts. 

Most  superficial  nevi  and  many  cavernous  angiomata  can  be  treated  by 
excision.  The  incisions  must  be  beyond  the  dilated  vessels.  In  large  angio- 
mata involving  the  skin  and  also  deeper  parts,  or  involving  a  structure,  like 
the  Up,  which  it  is  undesirable  to  remove,  electrolysis  should  be  employed. 
The  operation  should  be  carried  out  with  aseptic  care  and,  if  the  tumor  is 
large,  an  anesthetic  should  be  given. 


362 


Tumors  or  Morbid  Growths 


The  positive  pole  produces  a  firm  and  hard  clot.  One  or  more  needles 
connected  with  the  ix)sitive  pole  are  inserted  into  the  tumor,  the  needles 
being  insulated  to  within  about  a  quarter  of  an  inch  of  their  points.  A  flat 
moist  pad  is  placed  upon  the  skin  near  the  tumor  and  is  attached  to  the  nega- 
tive pole,  and  the  pad  is  moved  from  time  to  time  during  the  operation. 

From  twentv-five  to  seventy-five  milliamperes  is  the  proper  strength,  and 
the  current  is  passed  for  ten  minutes.    The  current  is  increased  for  a  moment 

„^^  before  withdrawing  the  needles,  other- 
IF^  wise  they  will  stick  to  the  tissue  and 
cause  bleeding  when  torn  loose.  After 
the  withdrawal  of  the  needles  the  nevus 
will  be  found  to  be  hard,  but  the 
hardness  will  gradually  disappear.  It 
may  be  necessary  to  repeat  the  opera- 
tion a  number  of  times  at  intervals  of 
ten  days.* 


Fig.  142. 


-Cavernous  angioma  and  lymph- 
angioma. 


Fig.  143. — Cavernous  angioma,  lymphangioma, 
and  lymphangiectasis,  also  beginning  cancer. 


Lymphangiomata  are  tumors  composed  of  dilated  lymph-vessels  and 
are  often,  though  not  invariably,  congenital  (Fig.  143).  A  lymphatic  nevus 
is  a  colorless  or  faintly  pink  elevation;  if  it  is  punctured  with  a  needle,  lymph 
flows  from  the  puncture.  One  or  several  nevi  may  be  present  in  the  same 
individual.  The  dilatation  is  due  to  blocking  of  the  lymph-channels.  Local 
lymphangioma  of  the  tongue  is  manifested  by  a  cluster  of  papillary  projec- 
tions containing  lymph.  Macroglossia  is  a  congenital  enlargement  of  the  an- 
terior portion  of  the  tongue,  which  enlargement  grows  more  and  more  marked, 
until  finally  the  tongue  is  forced  far  out  of  the  mouth.  This  condition  of  tongue 
enlargement  is  due  to  lymphangioma  of  the  mucous  membrane.  Lymph 
scrotum  is  due  to  a  similar  growth.  A  collection  of  these  warty-looking  dila- 
tations is  called  lymphangiectasis.     Just  as  cavernous  angiomata  constitute 

*  Cheyne  and  Burghard's  "Manual  of  Surgical  Treatment." 


Malignant  Connective-tissue  Tumors,  or  Sarcomata  363 

a  variety  of  blood-vessel  tumors,  so  cavernous  lymphangiomata  constitute  a 
variety  of  lymph- vessel  tumors,  and  the  spaces  of  the  latter  are  filled  with 
lymph  instead  of  with  blood.  Areas  affected  with  lymphangiectasis  are  liable 
to  repeated  attacks  of  erysipelas-like  inflammation.  Whether  this  inflam- 
mation is  causative  or  secondary  is  not  known.  In  tropical  countries  blocking 
of  lymph-channels  may  be  brought  about  by  the  filaria  sanguinis  hominis,  a 
parasite  which  lurks  in  the  lymph-vessels  during  the  day  and  is  found  in  the 
blood  only  at  night.  Lymphangiectasis  is  often  the  first  stage  of  elephan- 
tiasis. 

Treatment. — A  lymphatic  nevus  requires  excision.  In  macroglossia  the 
bulk  of  the  mass  should  be  removed  by  a  V-shaped  cut,  the  mucous  mem- 
brane being  sutured  so  as  to  cover  the  stump.  In  conditions  due  to  the  filaria, 
anilin-blue  has  been  given  internally. 

Malignant  Connective=tissue  Tumors,  or  Sarcomata. — The  sarco- 
mata are  composed  of  embryonic  tissue-cells,  the  intercellular  substance  being 
very  scanty  and  they  resemble  a  process  of  chronic  inflammation.  They  de- 
velop from  connective  tissue,  rarely  have  a  definite  stroma,  and  the  constituent 
cells,  as  a  rule,  proliferate  with  great  rapidity.  If  a  sarcoma  has  a  stroma  of 
connective  tissue,  this  stroma  contains  lymphatics  and  such  a  sarcoma  in- 
fects adjacent  glands.  In  most  cases  there  is  no  connective- tissue  stroma  and 
no  lymphatics.  In  a  sarcoma  without  a  definite  stroma  the  blood-vessels  are 
not  surrounded  by  lymph-spaces  and  are  quickly  invaded  by  cells  (B.  H. 
Buxton).  The  rapidly  growing  forms  are  very  vascular,  the  blood  flowing  in 
vessels  whose  walls  are  very  thin  or  running  in  canals  lined  by  endothelium 
and  bounded  by  sarcomatous  cells.  Such  a  tumor  may  pulsate  and  have  a 
bruit,  and  hemorrhage  often  takes  place  into  its  substance.  A  rapidly-growing 
soft  sarcoma  with  dusky  skin  above  it  (Fig.  145;  maybe  mistaken  for  an  abscess. 
A  slow-growing  sarcoma  has  but  few  vessels.  Sarcoma  tends  strongly  to  infil- 
trate adjacent  parts.  The  growth  disseminates  by  means  of  the  blood  and  the 
vessel- walls,  particles  of  the  tumor  being  carried  by  the  venous  blood  to  the 
heart  and  from  this  organ  to  the 
lungs,  where  they  lodge  and  form 
secondary  growths.  Emboli  from 
these  secondary  foci  are  sent  out  by 
the  arterial  blood  to  various  portions 
of  the  body,  as  the  bones,  kidneys, 
brain,  liver,  etc.  This  process  is 
known  as  "metastasis.'"  In  some 
cases  sarcoma  is  disseminated  widely 
throughout  the  body,  almost  all  the 
tissues  showing  minute  white  spots 
of  secondary  sarcoma  which  resem- 
ble tubercles.  Such  widespread  dis- 
semination is  called  sarcomaiosis. 
Sarcoma  follows  the  vein-walls  for 
considerable  distances  and  builds 
elongated  masses  of  tumor-substance 

inside   the    veins.       The    tumor    may  F.g.  i44.-Sarcoma  of  the  antrum. 

possess  a  capsule  when  it  is  in  an  early  stage,  but  soon  loses  this  except  in  very 
slow-growing  varieties  or  in  mixed  forms  growing  by  central  proliferation. 


364 


Tumors  or  ]\Iorbid  Growths 


Fig.  145 — Small  round-celled  fungating  sarcoma  of  neck. 


V 


Fie.  146. — Small  round-celled  sarcoma  of  neck.     Skin  has  given  way  and  a  bleeding  mass  is  exposea. 


\'arieties  of  Sarcomata 


365 


but  secondan-  sarcomata  are  t)ften  encapsuled.  Sarcomata  may  arise  at  any 
age  from  birth  to  extreme  senility,  but  they  are  commonest  during  youth  and 
early  middle  age.  They  are  not  hereditar>',  and  often  follow  traumatism 
and  inflammation.  A  number  of  obserA'ers  maintain  that  they  are  due  to 
parasites  (the  question  of  the  parasitic  origin  of  malignant  disease  is  discussed 
on  page  343).  A  sarcoma  may  be  primary  or  may  arise  from  malignant 
change  in  an  innocent  connective-tissue  growth  (chondrosarcoma,  fibrosar- 
coma, etc.).  A  sarcoma  rarely  affects  adjacent  lymphatic  glands  unless  it 
contains  lymphatics,  and  the  great  majority  of  sarcomata  do  not  contain 
them.  Occasionally  sarcoma-cells  are  carried  to  adjacent  glands  by  the 
vein-walls  rather  than  by  the  lymph-stream.  Sarcoma  of  the  tonsil,  sarcoma 
of  the  testicle,  melanotic  sarcoma,  and  lymphosarcoma  do  affect  the  glands. 
The  skin  over  the  tumor  may  give  way,  a  bleeding  fungus-mass  protruding 
fungus  hsematodes)  (Figs.  145. 146,  and  147),  and  suppuration  may  cause  septic 
enlargement  of  adjacent  glands 
After  removal  of  a  sarcoma  the 
growth  tends  to  recur,  and  the 
recurrent  tumor  may  be  either 
more  or  less  malignant  than  its 
predecessor,  the  degree  of  malig- 
nancy being  in  direct  ratio  to  the 
number  and  smallness  of  the  cells. 
A  sarcoma  is  malignant  by  local 
tissue-infection  and  by  dissemina- 
tion. Sarcomata  rarely  cause 
pain  when  they  are  not  ulcerated. 
They  are  commonest  in  the  skin 
and  connective  tissue  of  the 
extremities,  but  they  arise  also 
from  bone,  neuroglia,  periosteum, 
the  hmphatic  glands,  the  breast, 
the  testicle,  the  eyeball,  the  paro- 
tid, and  other  parts.  Xot  unusually 
a  pigmented  mole  becomes  sarcomatous.  Hemorrhages  into  a  sarcoma  often 
occur,  with  the  result  of  suddenly  increasing  the  size  of  the  mass  and  forma- 
tion of  blood-cysts.  Sarcomata  are  subject  to  partial  fatty  degeneration,  to 
myomatous  changes  which  produce  cavities  filled  with  fluid,  to  calcification, 
and  occasionally  to  necrosis  of  large  masses. 

Varieties  of  Sarcomata. — The  following  species  of  sarcomata  are  recog- 
nized: 

I.  Round-celled  sarcoina  is  a  tumor  composed  of  round  or  spherical  cells 
and  resembling  a  chronic  inflammatory  area.  The  intercellular  substance 
is  scanty,  the  mass  is  soft  and  vascular,  and  grows  with  great  rapidity.  It 
often  softens,  and  may  become  cystic.  The  cells  may  be  small  or  large.  The 
smaller  the  cells  the  more  malignant  the  growth.  A  growth  composed  of 
small  round  cells  is  the  most  malignant  form  of  sarcoma  (Fig.  150).  Lym- 
phosarcoma is  a  form  of  round-celled  sarcoma  which  arises  from  l\Tnphatic 
glands,  IjTnphoid  tissues,  the  thymus  gland,  the  spleen,  and  some  other 
structures.     The  structure  01  a  lymphosarcoma  resembles  the  structure  of 


Fig.  147- — Sarcoma  of  neck  (Honvitz'). 


366 


Tumors  or  ^vlorbid  Growths 


Fig.  148.— Dr.  W.  R.  Bishop's  case  of  small-celled  sarcoma  of  the  antrnm. 


Fig.  149 — Osteosarcoma  of  eighteen  months'  standing;  of  right  side  of  superior  maxilla.    Note  bonj 

lump  on  left  side  of  lower  jaw. 


Varieties  of  Sarcomata 


367 


a  lymph-gland  in  the  fact  that  it  has  a  reticulum  which  looks  like  lymph- 
adenoid  structure.  Chloroma  is  a  form  of  lymphosarcoma  arising  particularly 
from  the  periosteum  of  the  bones  of  the  cranium  and  face.     The  cells  contain 


Fig.  150. — Small  round-celled  sarcoma  of  the  neck. 

greenish  pigment,  hence  the  name.  What  is  known  as  glioma  of  the  eyeball 
is  not  a  true  glioma,  but  is  really  a  sarcoma  compo.sed  of  small  round  cells. 

2.  Spindle-celled  sarcoma  is  a  tumor  composed  of  large  or  small  spindle- 
shaped  cells  lying  in  a  matrix,  which  may  be  homogeneous,  but  which  may 
show  some  attempt  at  fiber  formation.  Angular  cells  and  stellate  cells  are 
often  present.  The  cells  may 
be  placed  in  columns,  which 
are  at  some  places  nearly 
parallel,  and  which  at  others 
diverge  or  interlace.  Often 
there  is  no  orderly  arrange- 
ment. Spindle-celled  sarco- 
mata are  usually  harder  than 
round-celled  growths,  but  are 
sometimes  quite  soft.  Cystic 
changes  may  occur.  If  there- 
is  a  large  amount  of  inter- 
cellular substance  the  growth 
is  known  as  a  fibrosarcoma. 
A  rhabdomyoma  is  really  a 
spindle-cell  sarcoma  contain- 
ing striated  muscle-cells.   The 

spindle-cell  sarcomata  often  contain  cartilage.  Spindle-cell  growths  are  by 
no  means  as  malignant  as  round-cell  tumors.  Often  they  do  not  show  any 
tendency  to  metastasis.  The  greater  the  amount  of  intercellular  substance 
and  the  fewer  the  cells,   the  less  the   malignancy.      Bloodgood  points  out 


Fig.    151.- 


-Spindle- celled   sarcoma  of  sheath  of  flexor 
tendon  of  finger. 


368  Tumors  or  Morbid  Growths 

that  in  one  group  of  cases  (the  least  malignant)  the  spindle  cells  exhibit  a  dis- 
position to  form  fibroblasts  {fibro spindle-cell  sarcoma).  In  another  group  (the 
most  malignant)  there  are  no  fibroblasts  and  round  cells  are  distributed 
among  the  spindle  cells  {mixed  spindle-cell  and  round-cell  sarcoma) .  Spindle- 
cell  growths  constitute  the  majority  of  sarcomata  met  with  in  practice. 

3.  Giant-cell,  myeloid,  or  medullary  sarcoma  is  characterized  by  the 
presence  of  numerous  very  large  cells,  with  many  nuclei  looking  exactly  like 
the  myeloplaques  of  bone-marrow.  Such  a  growth  is  maroon  colored  on 
section.  It  arises  usually  from  bone,  especially  from  the  interior  of  a  long 
bone,  hence  is  often  called  osteosarcoma.  It  is  almost  invariably  single,  but 
Rehn  reported  a  case  of  multiple  giant-cell  sarcoma  of  bone,  and  Crile  and 
Hill  reported  another.  It  may,  however,  arise  from  other  structures  than  bone. 
It  is  the  least  malignant  form  of  sarcoma.     Metastases  do  not  occur  and  the 


■•*^, 


Fig.  152. — Melanotic  sarcoma. 

growth  often  admits  of  complete  extirpation  and  cure.  Some  surgeons  do  not 
class  these  growths  with  sarcomata.  Bloodgood  regards  their  malignancy  as 
very  sHght.  Friedlander  looks  upon  them  as  benign  angeiomata  in  which  giant 
cells  have  been  formed  by  endothelial  cells  budding  into  spaces  lined  with 
endothehum. 

4.  Alveolar  Sarcoma. — Alveolar  sarcoma  is  a  tumor  containing  both 
round-cells  and  spindle-cells,  and  characterized  by  the  formation  of  acini, 
filled  with  round-cells  of  large  size  resembling  epithelioid  cells.  The  walls 
of  the  acini  are  formed  of  spindle-cells  and  fibrous  tissue,  and  in  these  tra- 
beculi  are  the  blood-vessels.  The  collection  of  the  cells  in  the  alveoli 
makes  the  structure  resemble  that  of  a  cancer.  Such  growths  are  often  pig- 
mented. Alveolar  sarcomata  arise  particularly  from  moles  of  the  skin,  but 
may  arise  from  lymphatic  glands,  serous  membranes,  the  testicle,  and  other 
parts.     Such  growths  are  very  malignant. 


Varieties  of  Sarcomata 


369 


5.  Melanotic  or  Black  Sarcoma  (Fig.  152). — The  color  of  such  a  tumor  is 
due  to  pigment  in  the  cells  or  matrix.  These  growths  are  usually  camposed  of 
round  cells,  but  may  consist  of  spindle  cells,  and  they  are  sometimes  alveolar. 
Melanotic  sarcomata  spring  from  parts  which  contain  pigment  (for  instance, 
the  skin  and  the  choroid  coat  of  the  eye) ;  they  are  very  malignant;  they  impli- 
cate related  lymphatic  glands,  undergo  early  metastasis,  and  during  their 
existence  the  urine  contains  pigment. 

Malignant  growth  from  a  congenital  pigmented  mole  used  to  be  regarded  as 
melanotic  sarcoma,  but  Bloodgood  would  place  these  growths  in  a  group  by 
themselves.     He  says  that  the  weight  of  opinion  is  on  the  side  of  those  who 


Fig.  153. — Dr.  Hansen's  case  of  cystic  myxosarcoma  of  the  orbit. 

maintain  that  the  cells  are  of  epithelial  origin  misplaced  early  in  embryonic 
life,  and  that  the  tumor  is  a  cancer.  Many  surgeons  still  regard  such  a  tumor 
as  sarcoma. 

6.  Hemorrhagic  sarcoma  is  a  sarcoma  containing  blood-cysts  which  result 
from  parenchymatous  hemorrhages. 

7.  Angeiosarcoma  or  hemangeiosarcoma  takes  origin  from  the  outer  coat  of  a 
blood-vessel.  The  growth  is  often  very  vascular,  and  when  the  blood-vessels 
are  notably  dilated  the  tumor  is  called  a  telangiectatic  sarcoma.  The  ordinary 
forms  of  angeiosarcoma  are  only  moderately  malignant,  but  alveolar  and 
melanodc  forms  occur  which  are  highly  malignant.  Angeiosarcoma  may  arise 
in  the  skin,  in  a  serous  membrane,  in  intermuscular  structure,  in  bone,  or  in  a 
salivary  gland.     It  most  frequently  takes  origin  from  a  nevus. 

24 


370 


Tumors  or  Morbid  Growths 


8.  Cylindroma,  or  Plexijorm  Sarcoma. — In  this  variety  the  ceUs  adjacent 
to  vessels  have  undergone  hyahne  or  myxomatous  degeneration;  the  ceUs 
distant  from  vessels  are  unchanged.  Section  shows  the  normal  cells  appar- 
ently contained  in  spaces  with  hyaline  walls.  These  degenerative  changes 
occur  most  often  in  the  angiosarcomata.  Cylindromata  arise  from  the  brain, 
salivary  glands,  lachrymal  glands,  and  rarely  from  the  subcutaneous  tissue. 
The  growths  are  only  moderately  malignant.* 

9.  Mixed  tumors  consist  partly  of  mature  and  partly  of  embryonic  tissue, 
the  cellular  elements  exceeding  the  adult  elements  in  amount.  Among  these 
mixed  tumors  are  fibrosarcoma  or  the  recurrent  fibroid  tumor,  myxosarcoma 
(Fig.  153),  chondrosarcoma,  gJiosarcoma,  and  osteosarcoma. 

10.  Endotheliomata  are  tumors  springing  from  endothehum,  and  the  name 
is  retained  no  matter  what  change  the  growth  ultimately  undergoes.  Many 
writers  include  under  the  term  endothelioma  psammoma,  myxosarcoma, 
angiosarcoma,  and  plexiform  sarcoma.  Others  consider  endothelioma  a 
special  and  characteristic  form  of  sarcoma.  Some  would  not  consider  it  with 
the  sarcomata  at  all.  The  growth  may  take  origin  from  the  "endothe- 
lium of  the  blood-vessels  and  of  the  perivascular  lymph-spaces,  of  the  lymph- 
vessels,  and  of  the  great  serous  cavities  (peritoneum,  pleura,  meninges)."! 
The  characteristic  cell  is  the  endothelial  cell,  usually  known  as  the  epithe- 
lioid cell.  The  structure  of  these  tumors  is  very  variable  and  depends  upon 
the  origin.  Some  tumors  "recalling  the  original  vascular  network"  ("Amer- 
ican Text-Book  of  Pathology"),  others  being  distinctly  alveolar.  Many 
pathologists  consider  a  psammoma  of  the  dura  to  be  an  endothelioma  with  a 
fibrous  stroma.  A  psammoma  contains  calcareous  particles.  In  appear- 
ance an  endothelioma  strongly 

*f''^  y^'V^^^H^HI      resembles  cancer,  and   such   a 

growth  is  often  spoken  of 
as  endothelial  cancer.  Such 
growths  can  arise  in  many  dif- 
ferent situations,  but  are  par- 
ticularly common  in  the  peri- 
toneum, pleural  membrane, 
membranes  of  the  brain,  ovary, 
and  testicle.  I  have  removed 
an  endothelioma  of  the  tonsil, 
one  of  the  mammary  gland,  one 
of  the  nasopharynx,  and  one 
of  the  carotid  gland.  The  pro- 
liferating endothelial  cells  lie  in 
lymph-spaces.  Many  endothe- 
liomata grow  rapidly,  second- 
ary growths  form,  and  metas- 
tases are  apt  to  pass  to  the  serous  membranes.  Certain  endotheliomata  grow 
slowly,  do  not  infiltrate  adjacent  structure,  and  do  not  produce  secondary 
growths.  In  the  l)rain  and  cord  endothelioma  may  produce  no  symptoms  for 
a  long  time.  It  is  not  as  yet  possible,  clinically,  to  distinctly  recognize  endo- 
theliomata from  ordinary  sarcomata. 

*  Stengel,  "Text-Book  of  Pathology." 

I  "An  American  Text-Book  of  Pathology,"  edited  by  Hektoen  and  Riesman. 


Fig.  154. — Recurrent  sarcoma  of  the  sternum. 


Treatment  of  Sarcomata 


371 


II.  Mycosis  fiingoidcs  is  a  disease  which  resembles  sarcoma  in  many 
particulars  and  may  perhaps  be  a  form  of  sarcoma.  It  attacks  the  skin  and 
subcutaneous  tissues.  The  skin  at  tirst  becomes  red  and  swollen;  numerous 
nodules  form;  the  nodules  become  distinct  tumors,  soften  at  their  centers, 
and  fungation  occurs.  Microscopically  the  tumor  resembles  a  lymphaden- 
oma.  Mycosis  fungoides  is  considered  by  some  pathologists  to  be  multiple 
cutaneous  sarcoma. 

Treatment  of  Sarcomata. — Remove  a  sarcoma  at  once  if  it  is  in  an 
accessible  spot.     Never  delay  removal.     Cut  well  clear  of  it.     If  affecting  a 


Fig.  155. — Central  sarcoma  of  the  fibula. 


part  where  amputation  is  impossible,  the  rapidly  growing  sarcomata  will 
almost  inevitably  return,  and  the  very  malignant  variety,  if  uninterfered  with, 
may  terminate  life  in  six  months:  but  even  in  such  case  operation  postpones 
the  evil  day  and  renders  it  possible  that  death  will  occur  from  metastatic 
growth  in  an  organ,  and  that  the  patient  will  escape  the  horrors  of  ulceration 
and  hemorrhage  from  the  original  tumor.  Slow'ly  growing  and  hard  tumors 
offer  some  prospects  of  cure.  The  mixed  tumor  (as  a  recurrent  fibroid)  may 
repeatedly  recur,  and  yet  the  patient  may  be  cured  at  last  by  a  sixth,  an 
eighth,  or  a  tenth  operation.  In  a  case  of  spindle-cell  sarcoma  of  the  breast 
the  younger  Gross  performed  22  operations  in  the  course  of  four  years,  and 
eleven  years  later  the  woman    was  well.     In  a  case  of  recurrent  fibroid  of 


372 


Tumors  or  ]\Iorbid  Growths 


the  neck,  the  younger  Gross  operated  five  times.  Three  years  after  Prof. 
Gross's  death  I  operated  upon  the  same  patient,  and  again  two  years  later. 
Nine  years  after  the  last  operation  she  was  alive  and  well.  In  sarcoma  of  a  long 
bone  (though  not  in  giant-cell  sarcoma)  amputation  should,  as  a  rule,  be  per- 
formed, although  Bloodgood  proves  that  in  many  of  these  cases  extensive 
excision  is  just  as  useful.  In  giant-cell  sarcoma  incision  and  curetting  may 
be  employed  or,  if  this  is  insufficient,  subperiosteal  excision.  Bloodgood  has 
reported  the  cases  of  giant-cell  sarcoma  from  Halsted's  clinic.  The  reports 
show  that  excellent  results  follow  this  plan  of  treatment.  If  the  soft  parts  are 
involved,  they  must  be  removed  wide  of  the  growth.  Amputation  is  necessary 
only  when  the  removal  of  soft  parts  must  be  so  extensive  as  to  hopelessly  muti- 
late the  limb.     In  sarcoma  of  either  jaw-bone,  excision;  of  the  eye,  enucleation; 


Fig.  156. 


-Inoperable  sarcoma  of  the  L^ 


of  the  testicle,  castration  is  demanded.  Sarcoma  of  the  ovary  in  adults  de- 
mands removal,  but  in  children  the  operation  is  generally  useless.  Sarcoma 
of  the  kidney  in  adults  calls  for  nephrectomy,  but  in  children  the  operation  is 
usually  of  htde  avail.  In  my  experience,  in  the  cases  of  sarcoma  of  the  kidney 
which  survived  operation,  the  growth  always  appeared  in  the  other  kidney. 
In  melanotic  sarcoma  extirpate  the  growth  widely  and  remove  anatomically 
related  lymph-nodes,  or  in  some  cases  amputate  far  away  from  the  tumor 
and  remove  lymph-nodes.  In  ver}-  malignant  sarcoma  even  amputation  does 
not  often  cure.  Removal  of  a  sarcoma  when  there  is  no  hope  of  a  cure  is  often 
justifiable  to  prolong  Hfe,  to  relieve  the  patient  of  a  foul,  offensive,  bleeding 
mass,  and  to  permit  of  an  easier  road  to  death  by  means  of  metastasis  to  an 
internal  organ.  In  an  inoperable  case  the  ligation  of  the  vessel  of  supply  may 
do  good.  In  sarcoma  of  the  tonsil  Dawbarn  ad\nses  the  extirpation  of  the 
external  carotid  artery  and  the  ligation  of  its  branches.     The  operation  is  per- 


Treatment  of  Sarcomata  373 

formed  first  on  one  side  of  the  tumor  and  in  a  week  or  so  on  the  other  side. 
I  employed  it  in  5  cases  with  distinct  but  temporary  benefit.  Occasionally, 
though  very  rarely,  suppuration  cures  a  sarcoma.  Wyeth,  of  New  York, 
reported  a  case  of  sarcoma  of  the  abdominal  wall.  It  was  found  possible  to 
remove  only  part  of  the  growth;  suppuration  followed  and  the  tumor  disap- 
peared, and  ten  years  later  had  not  returned.  A  study  of  statistics  seems  to 
indicate  that  more  cases  of  sarcoma  are  cured  after  operation  if  the  wound 
suppurates  than  if  it  remains  aseptic,  and  it  has  been  proposed  to  dehberately 
infect  the  wound  with  pus  germs  to  lessen  the  danger  of  recurrence.  If  the 
wound  is  large,  it  should  not  be  infected  until  it  is  nearly  healed.  If  it  is 
small,  it  may  be  infected  at  the  time  of  operation  or  soon  after.  After  am- 
putating for  sarcoma,  Wyeth  waits  until  the  wound  is  nearly  healed  and  then 
infects  it  by  inserting  a  gauze  drain  saturated  with  cultures  of  pure  streptococ- 
cus pyogenes  (Wyeth's  ''  Surgery  ").  After  removing  a  sarcoma  in  any  region, 
the  patient  should  be  given  courses  of  injections  of  Coley's  fluid  (see  below). 
It  has  been  observed  that  an  attack  of  erysipelas  occasionally  greatly 
benefits  a  sarcoma,  causing  large  masses  of  the  growth  to  soften  or  to  slough 
and  exposing  a  granulating  surface.  Busch  noticed  this  in  1S66,  but  the  fact 
had  been  observed  in  the  seventeenth  century.  Interest  was  decidedly 
awakened  by  Billroth's  case  of  sarcoma  of  the  pharynx  which  was  cured  by 
an  attack  of  facial  erysipelas.  It  was  suggested  that  in  inoperable  cases  of 
sarcoma  erysipelas  might  be  established  artificially.  Fehleisen  inoculated 
tumors  with  cultures  of  erysipelas.  Lassar,  in  1891,  employed  the  toxins 
(cultures  rendered  sterile  by  heat  and  filtration).  In  1892  Coley  began  his 
observations.  The  first  plan  was  as  follows:  a  bouillon  culture  was  made  of 
the  streptococci;  this  culture  was  filtered  through  porcelain  and  an  injection 
was  given  once  a  day  into  and  about  the  sarcoma.  The  first  dose  was  rr^x, 
and  it  was  progressively  increased.  The  effect  was  to  cause  a  febrile  reaction, 
and  sometimes  the  injections  lead  to  softening  or  suppuration.  Coley's 
present  method  is  as  follows:  make  cultures  of  erysipelas  cocci  in  cacao  broth; 
after  three  weeks  inoculate  them  with  the  bacillus  prodigiosus,  and  cultivate 
the  mixed  growth  for  four  weeks.  The  mixed  cultures  are  maintained  at  a 
temperature  of  136°  F.  until  they  become  sterile.  This  sterile  fluid  contains  the 
toxins.  The  dose  is  from  i  to  8  minims.  If  the  fluid  is  injected  remote  from 
the  tumor  the  initial  dose  should  be  i  minim.  If  the  fluid  is  injected  into 
the  tumor  the  initial  dose  is  ^  to  |^  a  minim  (Wm.  B.  Coley,  in  "Am.  Jour.  Med. 
Sciences,"  March,  1906).  The  dose  should  be  gradually  increased  until  a 
chill  occurs  in  from  one-half  an  hour  to  two  hours  after  the  injection,  followed  by 
a  temperature  of  ioi°-io4°  F.  In  some  cases  there  is  so  much  depression  after 
reaction  that  injections  are  given  every  other  day,  but  if  safely  possible,  they 
should  be  given  every  day  (Coley).  The  object  is  to  obtain  a  reaction  with 
each  injection.  The  more  vascular  the  tumor  the  more  severe  the  reaction 
(Coley).  If  an  area  softens  during  treatment  Coley  advises  us  to  open  and 
drain  the  softened  area.  If  improvement  is  going  to  occur  it  usually  begins 
in  from  one  to  four  weeks.  If  there  is  no  improvement  within  four  weeks 
there  vdW  not  probably  be  any.  It  seems  definitely  proved  that  cases  are 
occasionally  cured  by  Coley's  fluid.  Spindle-celled  sarcomata  are  influ- 
enced most  favorably.  Round-celled  sarcomata  are  very  refractor}-  and  so 
are  cancers.     The  method  is  not  entirely  free  from  danger.     It  seems  of 


374 


Tumors  or  Morbid  Growths 


value  in  post-operative  cases  to  prevent  recurrence.  For  this  purpose  it  is 
used  twice  a  week  for  several  months  and  at  greater  intervals  for  a  long 
period  of  time.  Last  autumn  1  brought  before  the  class  in  the  Jeflferson 
Hospital  a  colored  woman  (Fig.  157)  with  an  inoj>erable  spindle-cell  sarcoma 
of  the  thigh  and  groin.  A  pordon  of  it  was  removed  and  the  remainder  com- 
pletely disappeared  from  injections  of  Coley's  fluid.  She  remains  well  at  present, 
over  nine  months  after  treatment  was  suspended.  This  patient  had  a  violent 
reaction  every  day  for  weeks.  She  was  given  as  much  as  7  minims  at  a  dose. 
Emmerich  and  Scholl  claim  good  results  in  inoperable  sarcoma  from  the 
injection  of  erysipelas  serum.  A  sheep  is  injected  with  cultures  of  erysipelas, 
the  blood  is  drawn,  the  serum  separated,  filtered  to  remove  cocci,  and  injected 
about  the  sarcoma.  Results  are  not  definite.  Among  other  agents  which 
have  been  used  to  inject  inoperable  sarcomata  we  may  mention  alcohol, 
chlorid  of  zinc,  arsenic,  corrosive  sublimate,  thiosinamin,  pepsin,  alkahes,  etc. 
The  injection  of  anilin  products  into  the  sarcoma,  which  once  received 
qualified  commendation  from  some  observers,  has  been  abandoned  by  most 


Fig.  157. — Huge  sarcoma  of  buttock  cured  by  partial  extirpation  and  Coley's  fluid. 


surgeons.  The  :x'-rays  are  sometimes  of  benefit,  but  are  not  so  serviceable  as 
in  carcinoma  and  possess  a  certain  danger,  for  occasionally  after  using  them 
disseminadon  rapidly  occurs.  Abbe  and  others  have  obtained  some  remark- 
able results  with  radium,  but  such  results  are  the  exception,  not  the  rule. 

Hypernephromata,  or  Adrenal  Tumors. — Some  of  these  tumors  bear 
a  strong  resemblance  to  adenomata  and  carcinomata.  Some  adrenal  tumors 
are  benign,  and  among  such  tumors  we  note  fatty  and  fibrous  growths  and 
growths  reseml>ling  glioma.  Another  benign  growth  imitates  the  structure  of 
the  cortex  of  the  adrenal.  Malignant  tumors  occur,  and  many  of  them  are 
identical  or  almost  identical  with  sarcoma.  One  form  is  composed  of  epi- 
thelioid cells  and  resembles  endothelioma.  An  adrenal  tumor  may  arise  from 
the  adrenal  body  proper  or  from  "rests"  in  ectopic  portions  of  adrenal  within 
the  kidney,  ovary,  testicle,  solar  plexus,  renal  plexus,  Tver,  mesentery,  or  some 
other  part.  Some  of  these  tumors  attain  a  large  size.  Metastases  are  late, 
but  tend  to  occur  eventually  even  in  hypernephromata  which  seem  benign, 
and  may  occur  even  when  the  primary  growth  has  given  rise  to  no  symptoms. 
The  metastases  are  lodged  particularly  in  the  bones,  the  lungs,  and  the  liver. 
In  a  case  from  which  I  removed  a  goiter  and  death  resulted  from  reactionary^ 


Pa])illomata,  or  Warts 


375 


hemorrhage,  the  tumor  (which  1  had  considered  to  be  adenoma)  was  found  to 
be  composed  of  adrenal  tissue.     Unfortunately  an  autopsy  was  not  permitted. 

Accessory  adrenals  are  common.  They  are  known  as  adrenal  rests. 
"They  are  found  oftenest  in  the  connective  tissue  about  the  main  adrenals, 
but  also  in  the  kidneys,  the  right  lobe  of  the  liver,  along  the  renal  vessels  and 
spermatic  veins,  in  the  inguinal  canals,  and  in  the  broad  ligaments"  ("Amer- 
ican Text-Book  of  Pathology").     Tumors  may  take  origin  from  adrenal  rests. 

Innocent  Epithelial  Tumors.— These  growths  imitate  an  epithe- 
lial tissue  of  the  mature  and  healthy  organism. 


■5^ 


jf' 


Pig    158. — Keen's  case  of  papilloma  with  angioma. 

Papillomata,  or  Warts  (Fig.  158).— PapiUomata  are  formed  upon  the 
type  of  cutaneous  and  mucous  papilla.  A  papilloma  consists  of  a  fibrous 
stroma  which  contains  blood-vessels  and  lymphatics  and  is  covered  with  epithe- 
lium of  the  variety  appertaining  to  the  diseased  part.  Papillomata  grow  from 
the  skin  and  from  mucous  membranes;  they  may  be  single  or  multiple;  many 
may  form  in  one  region  or  various  distant  parts  may  be  affected;  they  may  be 
painless  or  may  be  ulcerated  or  bleeding;  they  vary  in  color  from  light  pink 
to  deep  brown  or  black.  Papillomata  of  the  skin  are  usually  hard;  papillo- 
mata of  mucous  membranes  are  soft.  A  skin-wart  may  be  smooth  and 
rounded,  or  may  look  like  a  cauliflower,  the  epidermis  upon  it  being  very 


376  Tumors  or  Morbid  Growths 

rough.  A  papilloma  of  a  mucous  membrane  looks  like  a  cauliflower.  Papil- 
lomatous masses  may  gather  around  the  anus,  the  vagina,  or  the  penis  during 
the  existence  of  a  filthy  discharge  {venereal  warts,  Fig.  159),  and  crops  of  warts 
may  appear  on  the  hands  of  those  who  work  in  irritant  material  (as  petroleum). 
Papillomata  are  apt  to  arise  in  mucous  membranes  about  carcinomata  or 
chronic  ulcerations.  A  large  crop  of  warts  may  disappear  in  a  single  night; 
hence  the  popular  belief  in  the  efficacy  of  charms.  Warts  are  particularly 
common  on  the  skin  of  the  back  of  the  hands  and  fingers,  the  skin  of  the  back, 
and  the  skin  of  the  neck  and  scalp.  A  single  skin-wart  may  reach  the  size 
of  a  walnut  and  become  pigmented.  The  squamous  epithelium  covering 
a  skin- wart  may  become  horny  (a  wart-horn).  Other  cutaneous  horns  arise 
from  the  nails,  from  the  scars  of  burns,  or  from  ruptured  sebaceous  cysts. 

Villous  papillomata  grow  chiefly  from  the  bladder,  but  they  may  also  grov,- 
from  the  stomach  and  intestine.     A  papilloma  of  mucous  membrane  covered 


Fig.  159. — \'enereal  warts. 

with  squamous  epithelium  looks  like  a  wart  of  the  skin.  Papillomata  of  the 
larynx  are  formed  of  squamous  epithelium.  Villous  papillomata  form  tufts 
like  the  villous  processes  of  the  chorion;  they  may  be  single  or  multiple,  and 
may  be  sessile  or  pedunculated;  they  are  very  vascular,  and  are  apt  to  bleed 
freely.  Papillomata  may  arise  in  cysts  of  the  paroophoron,  in  cysts  of  the 
mammary  gland,  from  the  choroid  plexuses  of  the  ventricles  of  the  brain, 
and  from  the  spinal  membranes.  Papillomata  may  give  rise  to  hemorrhage 
or  may  impair  the  function  of  a  part.  Any  papilloma  may  become  a  cancer. 
Treatment.— Venereal  warts  are  treated  by  repeatedly  washing  with 
peroxid  of  hydrogen,  drying  with  cotton,  and  dusting  with  a  powder  composed 
of  borated  talcum  or  of  equal  parts  of  calomel  and  subnitrateof  bismuth,  or 
of  oxid  of  zinc  and  iodoform.  If  they  do  not  soon  dry  up,  cut  them  off  with 
scissors  and  burn  with  the  Paquelin  cautery.  Ordinary  warts  may  usually 
be  destroyed  in  a  short  time  by  daily  applications  of  lactic  or  chromic  acid. 
In  multiple  warts  of  the  face  Kaposi  appHes  daily  for  several  days  a  portion 


Adenomata  377 

of  the  following  combination:  sublimed  sulphur,  5v;  glycerin,  3iss;  acetic 
acid,  oiiss.  Keeping  a  wart  constantly  moist  with  castor  oil  will  usually  cause 
it  to  drop  off.  Warts,  and  even  extensive  callosities,  ma\-  be  removed  by 
painting  once  a  day  for  five  days  with  pure  carbolic  acid  and  covering  with 
lint  kept  wet  with  boric  acid.  A  convenient  plan  is  to  paint  a  wart  daily 
with  a  solution  containing  i  part  of  corrosive  sublimate  to  30  parts  of  collo- 
dion (hydrarg.  chlor.  corros.,  5ss;  collodion,  5x^0-  Large  warts  should  be 
excised.  Mllous  papillomata  of  the  bladder  demand  the  performance  of  a 
suprapubic  cystotomy  in  order  to  remove  them.  A  papilloma  of  the  larynx 
may  be  removed  with  the  cautery  loop  or  may  be  destroyed  with  the  cautery. 

Adenomata. — Adenomata  are  tumors  corresponding  in  structure  to 
normal  epithelial  glands.  They  have  a  framework  of  vascular  connective 
tissue,  and  they  may  contain  acini  and  ducts  like  racemose  glands  or  tubes 
hke  tubular  glands.  The  acini  or  tubules  contain  epithelium  of  either  the 
cyhndrical  or  polyhedral  variety.  Adenomata  grow  from  secreting  glands, 
but  cannot  produce  the  secretion  of  the  glands  from  which  they  spring;  or, 
if  they  do  secrete,  the  fluid  is  retained,  and  not  discharged  bv  the  gland-ducts. 
Adenomata  occur  in  the  mammary  gland,  the  parotid,  the  ovary,  the  thyroid 
gland,  the  Hver,  the  sweat-glands,  the  sebaceous  glands,  the  kidney,  the 
pylorus,  and  the  prostate;  and  they  may  spring  as  pedunculated  growths 
from  the  mucous  lining  of  the  intestine  and  uterus.  They  are  en  capsuled, 
are  usually  single,  but  may  be  multiple,  are  of  slow  growth,  but  mav  attain  a 
great  size;  they  do  not  tend  to  recur  after  thorough  removal,  do  not  involve 
adjacent  glands,  and  do  not  disseminate;  they  are  firm  to  the  touch;  they 
tend  to  become  cystic  (especially  in  the  th}Toid  gland),  the  fluid  which  dis- 
tends the  ducts  being  formed  by  mucoid  liquefaction  of  the  prohferating 
epithelium.  If  cysts  form,  the  growth  is  spoken  of  as  a  cystic  adenoma.  If 
the  framework  of  an  adenoma  contains  considerable  fibrous  tissue,  the 
tumor  is  named  a  pbro-adenoma.  Adenomata  are  particularly  Uable  to 
become  carcinomatous. 

In  the  breast  a  fibro-adenoma  has  a  distinct  capsule;  it  is  elastic  and 
movable,  is  usually  superficial,  and  one  occasionally  exists  in  each  gland. 
They  are  most  common  before  the  age  of  thirty,  and  are  often  painful,  espe- 
cially during  menstruation.  Cystic  adenomata  of  the  breast  attain  a  large 
size;  they  are  encapsuled  and  grow  slowly,  are  most  common  after  the  thirtieth 
year,  and  are  rarely  painful.  Both  fibro-adenoma  and  cystic  adenoma  may 
arise  in  the  male  breast.  Young  unmarried  women  not  unusually  develop 
in  the  breast  small,  very  tender,  and  painful  bodies,  most  usually  around 
the  edge  of  the  areola,  which  bodies  increase  in  size  and  become  more  tender 
during  menstruation;   they  are  only  cysts  of  the  mammary  tissue. 

Adenomata  of  the  th}Toid  gland  usually  begin  before  the  fifteenth  year. 
Adenomata  may  arise  in  the  prostate  if  that  gland  be  already  the  seat  of  senile 
h}-pertrophy.  Adenomata  of  mucous  glands  may  arise  in  the  young  or 
middle-aged.  Adenomata  of  mucous  membranes  often  cause  hemorrhage 
and  interfere  with  function. 

Treatment. — Adenomata  should  be  extirpated.  To  let  them  alone 
exposes  the  patient  to  the  danger  of  cancerous  change.  By  confusing  adeno- 
mata of  the  mammar}'  gland  with  small  cysts  of  that  structure  an  erroneous 
belief  has  arisen  that  the  former,  as  well  as  the  latter,  may  sometimes  be 


378 


Tumors  or  Morbid  Growths 


cured  by  the  local  use  of  iodin,  mercury,  ichthyol,  and  the  internal  use  of  iodid 
of  potassium.     The  treatment  in  the  breast,  as  elsewhere,  is  excision. 
Malignant    Epithelial    Tumors,  Carcinomata,   or    Cancers.— 

Cancers  are  tumors  taking  origin  from  epithelial  structures  and  composed  of 
embryonic  epithelial  cells  which  are  clustered  in  spaces,  nests,  or  alveoli  of 
fibrous  tissue,  and  which  proliferate  enormously,  extending  beyond  normal 
anatomical  boundaries  and  as  an  invading  host  entering  into  connective  tissue 
by  way  of  the  lymph-spaces.  This  unrestrained  and  unlimited  reproduction 
of  epithelial  cells  is  the  characteristic  of  cancer.  The  heakhy  epithelium 
has  a  strictly  hmited  power  of  reproduction,  as  is  illustrated  by  a  skin-graft. 
Cancerous  epithelium  has  an  unlimited  power  of  reproduction.  The  alveoli 
of  cancer  are  distended  lymph-spaces  filled  with  proliferating  cells.  The 
cells  of  a  cluster  are  not  separated  by  any  stroma,  and  the  walls  of  the  alveoli 
carry  blood-vessels  and  lymphatics.  The  growth  may  be  cancerous  from 
the  start,  or  may  have  begun,  many  think,  as  an  innocent  epithelial  tumor. 
Cancers  are  always  derived  from  epithelium  (of  glands,  of  skin,  of  mucous 
membrane,  etc.),  and  if  found  in  a  non-epithelial  tissue  must  be  secondary, 
or  must  have  arisen  from  a  depot  of  embryonal  epithelial  cells  of  prenatal 
origin  or  from  a  dermoid  cyst  lying  in  the  midst  of  a  non-epithehal  tissue,  or  epi- 
thelial cells  must  have  been  displaced  so  as  to  be  among  mesoblastic  elements,  by 
inflammation  or  injury.  For  instance,  the  bone  does  not  normally  contain  epi- 
thelial cells.  If  osteomyelitis  arises  operation  is  performed  and  a  lot  of  skin 
may  be  buried  in  the  bone  cavity  or  an  epithelial  graft  may  adhere.  Such  an 
epithelial  area  may  become  cancerous.  Carcinomata  have  no  capsules, 
rapidly  infiltrate  surrounding  tissues,  and  are  firmly  anchored  and  immovable. 
In  the  beginning  a  cancer  is  a  local  lesion ;  but  it  soon  attacks  adjacent  tissue 

and  related  lymph-glands  and  by  nieans 
of  the  lymph  is  carried  to  other  struc- 
tures, producing  secondary  tumors  and 
diseases  and  enlargement  of  more  dis- 
tant lymph-glands.  Finally  lymph 
containing  cancer-cells  reaches  the 
blood  by  the  lymph-vessels  and  reaches 
distant  parts  and  secondary  tumors  or 
metastatic  deposits  form.  AVhen  lym- 
phatic vessels  are  obstructed,  lymph 
filled  with  cancer-cells  may  flow  in  a 
direction  the  reverse  of  that  pursued 
in  health.  Widespread  or  general 
dissemination  is  due  to  carcinomatous 
thrombosis  of  a  vein,  or  perforation  of 
the  wall  of  a  vein,  multiple  emboli  form- 
ing. Strange  to  say,  emboli  composed 
of  cancer-cells  may  be  surrounded 
with  blood-corpuscles  and  move  against 
the  blood-current.  A  secondary  growth 
(Fig.  1 60)  consists  of  cells  identical  in 
character  with  and  similar  in  arrangement  to  those  of  the  parent  growth.  The 
cells  of  the  secondary  growth  were  transported  from  the  primary  growth  and 


Fig.  160.— Secondary  carcinoma  of  the  sub 
mental  and  submaxillary  lymphatic  glands  fol 
lowing  carcinoma  of  the  lip  (Senn). 


Malignant  Epithelial  Tumors,  Carcinomata,  or  Cancers        379 

multiply  in  their  new  situation.  For  instance,  the  cells  of  a  primary  carcinoma 
of  the  hver  may  secrete  bile,  and  the  cells  of  a  metatastic  area  may  do  the  same. 
Fiitterer  has  reported  a  case  of  carcinoma  of  the  thyroid  the  pulmonary  met- 
astases of  which  secreted  colloid.  Stewart  reported  a  case  of  cancer  of  the 
lungs  and  liver  secondary  to  cancer  of  the  pancreas.  The  secondary  growths 
were  of  a  structure  similar  to  the  pancreas  and  contained  trypsin.  Metas- 
tases from  a  columnar-celled  rectal  cancer  are  composed  of  columnar  cells. 
Metastases  from  a  squamous-celled  epithehoma  are  composed  of  squamous 
cells.  In  rare  cases  metastasis  of  carcinoma  of  the  stomach  has  occurred  in 
the  rectum.  Schnitzler  reported  11  such  cases  ("Mitth.  a.  d.  Grenzgeb.  der 
Med.  u.  Chir.,"  1908,  xix..  No.  2).  Such  a  condition  is  probably  due  to 
implantation.  Contact  cancer  has  already  been  referred  to  (page  344). 
We  often  speak  of  lymph-nodes  enlarging  when  affected  with  cancer.  The 
enlargement  certainly  occurs,  but  is  not  due  to  growth  of  the  cells  of  the 
lymph-node.  It  results  from  multipHcation  of  the  carcinoma  cells  deposited 
in  the  gland.  As  Henry  Morris  says  ("The  Bradshaw  Lecture,"  "Lancet," 
Dec.  12,  1903) ,  the  parenchyma  of  the  involved  part  does  not  undergo  transition 
into  cancer.  After  the  growth  of  epitheUum  has  lasted  for  a  length  of  time  the 
patient  becomes  poisoned  by  materials  absorbed  from  the  seat  of  disease,  and 
finally  dies  from  cachexia  and  exhaustion  or  some  complication.  Cancer  is  rare 
before  the  age  of  forty,  although  occasionally  it  is  met  with  in  younger  persons. 
Cancer  of  the  rectum  is  sometimes  met  with  as  early  as  the  twenty-fourth  year. 
I  have  operated  on  a  woman  of  twenty-six  for  cancer  of  the  breast  and  on  a  man 
of  twenty  for  epithelioma  arising  in  the  old  scar  of  a  burn  (Fig.  82).  When 
xeroderma  pigmentosum  exists  in  children,  cancer  may  arise  in  areas  of  the  dis- 
ease. If  cancer  appears  in  a  young  person,  growth  is  sure  to  be  extremely 
rapid.  A  carcinoma  is  often  the  seat  of  pricking  pain;  the  growth  tends 
strongly  to  recur  after  removal ;  is  prone  to  ulcerate,  causing  pain,  hemorrhage, 
and  cachexia;  makes  rapid  progress,  and  is  often  fatal  in  from  one  to  two 
and  a  half  years.  It  is  more  common  in  women  than  in  men,  and  rarely 
exists  in  association  with  tubercle.  After  a  cancer  has  existed  for  a  time  in 
an  important  structure,  or  after  a  superficial  cancer  has  ulcerated  and  become 
hemorrhagic,  there  are  noted  in  the  individual  evidences  of  illness  and  exhaus- 
tion. We  speak  of  this  condition  as  the  cancerous  cachexia,  and  in  it  the 
muscles  are  wasted,  the  body-weight  is  constantly  diminishing,  the  complex- 
ion is  sallow,  the  face  is  sunken,  pearly  white  conjunctivae  contrast  strongly 
with  the  yellow  skin,  the  pulse  is  weak  and  rapid,  and  night-sweats  occur. 
The  above  condition  is  due  to  the  absorption  of  toxic  products  from  the 
diseased  tissues,  which  products  damage  the  blood-corpuscles,  and  also  to 
pain,  loss  of  sleep,  deprivation  of  exercise,  malassimilation  of  food,  and  per- 
haps bleeding.  Mental  depression  is  not  believed  by  many  surgeons  a  cause 
of  recurrence.  As  J.  D.  Bryant  says,  it  is  simply  expressive  of  a  condition 
of  nutritive  failure  which  may  favor  recurrence.  We  must  remember,  how- 
ever, that  the  great  name  of  Paget  is  associated  with  the  belief  that  not  un- 
common antecedents  of  the  disease  are  "deep  anxiety,  deferred  hope,  or 
disappointment"  ("Lectures  on  Surgical  Pathology,"  1863).  Recurrence 
after  operation  is  due  to  the  growth  of  cells  which  were  not  removed  at  the 
operation.  Cancer  may  kill  by  obstructing  a  canal,  by  destroying  the  func- 
tions of  a  viscus  organ,  by  hemorrhage,  by  anemia,  by  sepsis,  or  by  exhaustion. 


380  Tumors  or  Morbid  Growths 

Serum  Reaction  in  Cancer. — Kelling,  in  1906,  pointed  out  that  the  blood- 
serum  of  a  cancer  patient  has  a  hemolytic  action  on  the  red  corpuscles  of  the 
lower  animals.  It  has  been  known  for  some  time  that  the  serum  of  persons 
affected  with  certain  diseases  is  able  to  destroy  the  red  blood-corpuscles  of 
normal  individuals;  in  other  words,  such  sera  are  hemolytic  to  the  red  blood- 
corpuscles  of  healthy  human  beings.  The  agents  in  a  serum  which  hemolize 
the  red  corpuscles  in  other  sera  are  called  isohemolysins.  Isohemolysins  are 
contained  in  the  sera  of  syphiUs,  tuberculosis,  and  cancer.  Weil  pointed  out 
that  the  serum  of  a  dog  suffering  from  advanced  lymphosarcoma  destroys  the  red 
corpuscles  of  normal  dogs,  but  is  resisted  by  the  red  corpuscles  of  animals  that 
are  victims  of  the  same  disease.  Attempts  are  being  made  to  utilize  the  serum 
reaction  for  diagnostic  purposes.  Different  observers  employ  difl'erent  technic 
and  differ  widely  in  their  conclusions.  Crile  ("  Jour.  Am.  Med.  Assoc,"  Dec. 
12,  1908)  is  disposed  to  think  highly  of  the  diagnostic  value  of  the  serum  reac- 
tion. Janeway  ("Annals  of  Surgery,"  May,  1909)  obtained  positive  results  in 
48.5  per  cent,  of  the  35  cancer  cases  examined.  Janeway 's  conclusions  are 
wisely  cautious.  He  states  that  a  negative  reaction  is  not  proof  positive  that 
cancer  is  absent.  A  positive  reaction  makes  the  existence  of  malignant  dis- 
ease probable,  especially  if  advanced  tuberculosis  and  syphilis  are  absent. 

The  fact  that  the  serum  of  a  cancer  patient  contains  agents  destructive  to 
red  corpuscles  explains  the  anemia  and  cachexia  of  cancer.  Janeway  points 
out  that  the  serum  of  sufl'erers  from  benign  tumors  never  exhibits  the  reaction. 

Cause  of  Carcinoma. — Heredity  is  discussed  on  page  342. 

I .  Irritation. — As  Dennis  says,  cUnical  evidence  points  strongly  to  the  view 
that  inflammatory  changes  following  irritation  are  responsible  for  cancer. 
Individuals  v^ith  phimosis  are  particularly  prone  to  cancer  of  the  penis.  Those 
who  smoke  a  short-stemmed  clay  pipe,  which  grows  hot  when  in  use,  are  most 
liable  to  cancer  of  the  lower  lip.  In  the  old  days  chimney-sweeps  often 
developed  cancer  of  the  scrotum,  which  was  always  irritated  by  soot  in  the 
cutaneous  folds.  Cancer  of  the  gall-bladder  may  arise  if  gall-stones  exist. 
Cancer  of  the  skin  of  the  hands  may  arise  in  .r-ray  workers.  Cancer  of  the 
skin  may  be  induced  by  the  influence  of  hght  (James  Nevins  Hyde,  in  "Am. 
Jour.  Med.  Sciences,"  Jan.,  1906).  An  ulcer  may  be  the  irritating  focus 
which  leads  to  the  development  of  cancer  at  its  edge  (see  MarjoHn's  ulcer, 
page  175).  So  may  a  scar.  As  is  well  knowTi,  certain  innocent  tumors  may 
become  cancerous.  The  believers  in  the  parasitic  theory  maintain  that  irri- 
tation and  inflammation  simply  open  the  gates  to  the  real  cause,  which  they 
assert  is  a  parasite. 

In  certain  regions  of  the  body,  notably  the  tongue  and  Hp,  we  regard  pro- 
longed chronic  inflammation  as  very  apt  to  eventuate  in  cancer,  and  if  it  is 
not  cured  by  ordinary  means  we  advise  operation.  A  condition  persisting  in 
spite  of  ordinary  treatment,  prone  to  eventuate  in  cancer,  but  not  as  yet  demon- 
strably cancerous,  is  called  the  pre-cancerous  stage  of  cancer.  It  probably  is 
aheady  cancer,  although  so  early  as  to  lack  the  positive  signs. 

A  wart  is  the  result  of  an  inflammation  and  a  wart  may  become  a  cancer. 
The  edge  of  a  gastric  ulcer  may  become  cancerous.  Cancer  may  arise  from  a 
scar  or  the  edge  of  an  old  ulcer  of  the  skin,  the  lip,  the  cheek,  or  the  tongue. 

Certain  benign  tumors  tend  to  become  cancerous,  especially  if  irritated 
by  injuries,  caustic  applications,  or  inefficient  attempts  to  remove  them  surgi- 


Causes  of  Carcinoma 


381 


cally.  Any  papilloma  and  any  adenoma  may  become  cancerous.  A  benign 
epithelial  tumor  is  always  a  menace  and  is  to  be  regarded  as  a  possible  or 
potential  carcinoma. 

Whereas  chronic  inflammation  or  irritation  of  epithelial  structures  is  not 
infrequently  followed  by  carcinoma,  a  single  traumatism,  as  a  blow,  very 
seldom  is.  .\  woman  with  cancer  of  the  breast  is  apt  to  lay  the  blame  upon  a 
blow,  but  very  seldom  can  the  surgeon  regard  the  blow  as  causal.  In  many  cases 
cancer  was  present  when  the  injury  was  received,  and  the  injur)-  drew  attention 
to  the  tumor.  Tissues  degenerated  by  advancing  age  are  particularly  prone  to 
develop  cancer  from  irritation.  In  De  la  Camp's  collection  of  9906  cases,  only 
19  were  under  twenty  years 
of  age.  \'ictims  of  rheuma- 
toid arthritis  seem  particularly 
liable  to  cancer. 

Cancer  is  most  common 
beyond  the  age  of  forty,  and 
the  liabilit)-  increases  as  years 
increase.  Although  old  peo- 
ple are  most  liable  to  cancer, 
the  growth  is  not  nearly  so 
malignant  in  them  as  when  it 
occurs  in  young  persons. 

2.  The  Inclusion  Theory 
of  Cohnheim.  —  This  theory 
was  set  forth  on  page  341. 

3.  The  Thiersch  Hypothe- 
sis.— This  maintains  that  nor- 
mal, healthy  connective  tissue 
has  a  restraining  intluence 
on  the  growth  of  adjacent 
epithelium;  when  connective 
tissue  degenerates  (as  in  ad- 
vancing years  or  after  pro- 
longed irritation)  its  control 
over  epithelium   is  weakened 

and  the  epithelium  grows  more  rapidly  than  it  does  normally,  and  from  the 
moment  it  invades  the  connective  tissue  cancer  exists.  This  theor}-  assumes 
that  the  connective  tissue  is  a  police  force  and  the  epithelial  cells  the  criminal 
class.  When  the  first  is  weakened  or  corrupted  the  second  becomes  active 
and  uncontrolled. 

4.  The  Parasitic  Theory. — \'arious  agents  have  been  described  as  causes, 
viz.,  bacteria,  protozoa,  and  yeast  fungi. 

This  theor}'  was  discussed  on  page  343.  We  do  not  regard  it  as  proved, 
and  even  Plimmer,  warm  advocate  as  he  is  of  the  theory  of  contagion,  admits 
that  as  yet  there  is  no  clearly  demonstrated  case  of  the  transference  of  cancer 
from  one  man  to  another.  I  can  find  no  authenticated  case  on  record  of  a 
surgeon  ha\ing  been  infected  by  cancer  during  an  operation.  Transplanta- 
tion has  been  carried  out  from  one  animal  to  another  of  the  same  species, 
although  attempts  to  do  so  usually  fail.     Tyzzer,  of  Han-ard,  succeeded  in 


Fig.  161. — Epithelioma  of  right  temporal  region. 
Paralysis  of  right  side  of  face.  Papule  noticed  by 
patient  two  years  prior  to  admission. 


382  Tumors  or  Morbid  Growths 

nearly  46  per  cent,  of  his  inoculation  experiments  with  the  Jensen  tumor  and 
he  has  kept  up  the  tumor  formation  for  ten  generations.  (See  Fourth  Report 
from  the  Harvard  Medical  School  of  the  Caroline  Brewer  Croft  Fund  Cancer 
Commission.)  It  is  a  serious  question,  however,  if  mouse  cancer  is  really 
cancer  at  all.  Mouse  cancer  is  far  more  strongly  hereditary  than  human 
cancer;  spontaneous  cure  is  by  no  means  uncommon;  metastasis  is  rare; 
the  disease  may  occur  as  an  epidemic  in  a  laboratory.  It  has  been  asserted 
that  it  may  revert  to  sarcoma  (Apolant,  in  "Miinch.  med.  Wochenschr.,"  1907, 
liv.),  and  it  may  revert  to  adenoma  (Apolant,  Ibid.).  These  tendencies 
separate  mouse  cancer  very  positively  from  human  cancer.  It  has  not  been 
transplanted  from  an  animal  of  one  species  to  an  animal  of  another  species. 
In  any  case  even  a  successful  transplantation  of  cells  is  a  very  different  thing 

from  contagion.     The  late  Prof. 
^1^"  '  Nicholas    Senn    deliberately   im- 

'^^  planted  a  piece  of  cancer  in  the 

tissues  of  his  own  forearm  with- 
out result  ("Jour.  Am.  Med. 
Assoc,"  .\pril  28,  1906).  Re- 
cently advocates  of  the  contagion 
theor}^  claim  that  mouse  cancer 
can  be  reproduced  after  trans- 
plantarion  even  when  the  cells  in 
the  inoculated  matter  have  been 
killed  by  exposure  to  the  intense 
cold  induced  by  liquid  air  (Salim, 
'^^^^  l^^H  Moore,  and  Walker,  in  "Lancet," 
Fig.  162. — Carcinomatous  horn.  Jan.  25,  1908).     If  these  observa- 

dons  should  be  sustained,  they 
would  indicate  that  the  element  responsible  for  growth  of  a  graft  is  not  cellular 
and  might  be  microbic.  AHbert  carried  out  similar  experiments  with  like  results. 
5.  The  Biological  Theory. — In  a  unicellular  organism  the  function  of 
reproduction  is,  of  course,  possessed  by  the  cell.  In  a  muldcellular  organism 
certain  cells  are  set  apart  for  the  performance  of  the  function  of  reproduction, 
but  all  the  cells  possess  the  potentiality  for  reproduction,  but  fail  to  exercise 
it.  If  cells  undergo  atavistic  reversion  they  may  again  assume  the  repro- 
ductive function.  If  they  do,  unrestrained  growth  will  result,  and  such 
unrestrained  growth  is  cancer. 

N.  F.  MacHardy  ("Lancet,"  Oct.  24,  1903)  states  that  if  a  unicellu- 
lar organism  has  not  sufficient  reproductive  energy  it  fuses  with  another  cell 
and  is  thus  stimulated  to  produce  numerous  daughter-cells.  In  multicellu- 
lar organisms  cells  may  also  fuse,  take  on  active  reproductive  power,  and 
produce  hosts  of  new  cells.  When  cells  are  persistently  irritated,  MacHardy 
affirms  that  they  become  worn  out  by  making  repeated  attempts  at  repair, 
undergo  atavistic  reversion,  and  actively  assume  the  power  of  reproduction. 
According  to  this  theory  cancer  is  expressive  of  atavistic  reversion  of  epithe- 
lial cells.  • 

The  Prevalence  and  the  Alleged  Increase  of  Carcinoma.— Crile 
estimates  that  at  the  present  time  there  are  probably  80,000  cases  of  cancer 
in  the  United  States,  and  states  that  in  hospital  autopsies  cancer  is  found 


Distribution  of  Cancer  383 

in  I  case  out  of  12  ("Med.  Record,"  June  6,  1908).  Is  cancer  increasing? 
Of  course  the  number  of  cases  increases  with  the  increase  of  population.  The 
apparent  death-rate  from  cancer  increases  year  Ijy  year.  It  is  pointed  out 
by  W.  Roger  Williams  that  in  England  and  Wales  the  mortality  from  cancer 
has  increased  from  i  to  5646  in  1840,  to  1  to  1306  in  1896,  and  the  proportion 
to  deaths  from  other  causes  has  risen  from  i  to  129  in  1840,  to  i  to  22  in  1896.* 
Roswell  Park  comments  on  the  increasing  number  of  deaths  from  cancer  in 
New  York  State,  and  says  if  it  continues  for  the  next  ten  years  the  disease 
will  kill  more  persons  annually  than  phthisis,  smallpox,  and  typhoid  com- 
bined. It  has  been  stated  that  of  persons  living  above  the  age  of  thirty-five, 
that  I  woman  in  8,  and  i  man  in  12,  will  die  of  cancer  (Copeman,  quoted  by 
Brand,  in  "Lancet,"  Jan.  11,  1908).  Such  statements  are  truly  alarming,  and 
yet  the  reality  of  all  of  this  apparent  increase  is  doubtful.  A  part  of  the 
apparent  increase  is  due  to  the  greater  frequency  of  exploratory  operations  for 
diagnostic  purposes,  to  the  greater  frequency  of  post-mortem  examinations,  to 
more  correct  diagnoses  of  obscure  internal  conditions,  and  to  greater  accuracy 
than  was  once  either  usual  or  expected  in  filling  up  death  certificates. 
Neusholme  says  that  just  as  deaths  certified  as  due  to  old  age  grow  apparently 
fewer  every  year,  so  other  non-specific  certifications  grow  fewer,  and  cancer 
gains  as  they  lose.  The  diminution  in  infant  mortality  also  causes  a  relative 
rise  in  the  apparent  cancer  mortality.  The  above  facts  certainly  account  for 
a  portion  of  the  alleged  increase,  but  we  must  also  remember  that  we  are  cur- 
ing many  more  cases  by  operation  than  we  used  to  be  able  to,  and  hence  that 
the  death-rate  from  cancer  is  not  the  real  and  final  measure  of  the  incidence 
of  cancer.  The  experience  of  most  practical  surgeons  is  that  there  is  a  real 
increase  in  cancer,  but  the  extent  of  the  increase  cannot  be  ascertained  with 
any  accuracy. 

Hereditary  Influence. — This  was  referred  to  on  page  342.  It  can  be  at 
most  only  tissue  predisposidon  or  a  diminution  of  tissue  resistance  to  the  real 
cause  of  cancer,  whatever  that  may  be.  Some  previously  quoted  cases  are  too 
impressive  to  be  regarded  as  coincidences.  Williams  ("Brit.  Med.  Jour.," 
May  9,  1908)  points  out  that  24.2  per  cent,  of  women  with  cancer  of  the  breast 
have  or  had  relatives  with  a  history  of  cancer.  Williams  states  that  Butlin's 
estimate  is  37  per  cent.;  Leaf's,  23  per  cent.;  and  Nunn's,  29.3  per  cent. 

Immunity. — This  was  referred  to  on  page  342. 

It  is  known  that  mouse  tumors  which  follow  transplantation  in  some  cases 
retrogress  and  undergo  spontaneous  cure,  and  that  animals  in  which  this  has 
occurred  are  found  to  have  become  immune  to  a  reinoculation  of  a  like  tumor. 
Crile  and  Beebe  present  some  studies  on  this  interesting  subject  in  the  "  Journal 
of  Medical  Research,"  June,  1908.  Gaylord  and  Clowes  found  that  the 
serum  of  an  animal  thus  rendered  immune  tends  to  destroy  tumor  cells,  and 
experimented  with  the  transfusion  of  the  blood  of  immune  animals  into  ani- 
mals with  active  tumors;  7  animals  out  of  10  were  cured  The  blood  of  an 
animal  naturally  immune  to  tumor  inoculation  is  said  to  act  similarly  to  that 
of  an  animal  which  has  acquired  immunity,  as  shown  by  retrogression  of  a 
tumor. 

Distribution  of  Cancer. — It  occurs  in  all  climates,  and  all  races  except 
Eskimo  are  liable  to  it.  It  is  more  common,  however,  among  the  civilized 
*  "Lancet,"  Aug.  20,  1898. 


384  Tumors  or  Morbid  Growths 

than  the  barbarous.  It  is  rarer  among  the  black  and  yellow  races  than  the 
white  race.  The  .American  Indian  seldom  suffers  from  it.  It  occurs  in  the 
lower  animals  far  less  often  than  in  man,  is  more  common  in  domestic  than  in 
wild  animals,  and  in  capdve  wild  animals  than  in  those  free  and  at  large. 
It  can  even  occur  in  cold-blooded  animals.  Cancer  is  most  common  in  the 
temperate  zone.  It  is  usually  asserted  that  the  disease  is  rare  in  the  tropics, 
but  Dudley  denies  that  this  statement  is  true  of  the  Philippine  Islands 
("Jour.  Am.  Med.  Assoc,"  May  23,  1908).  Cancer  is  certainly  less  common 
in  India  than  in  England,  and  it  is  very  rare  in  Greenland.  It  is  almost  un- 
known among  the  natives  of  Algeria.  It  is  usually  believed  that  cancer  is 
most  prevalent  in  low  and  marshy  districts.  It  is  less  common  at  high  alti- 
tudes and  among  the  dwellers  on  soils  of  chalk  and  lime. 

Cancer  Regions  and  "Cancer  Houses." — Some  regions  show  a  remark- 
able frequency  of  cancer.  In  Bookfield,  New  York,  during  five  years  nearly 
10  per  cent,  of  the  deaths  were  due  to  cancer. 

Tynes  ("Jour.  Am.  Med.  Assoc,"  March  21,  igoS)  reports  that  in  Fisher- 
ville,  Pennsylvania,  in  265  families  there  were  105  deaths,  and  18  of  them  were 
due  to  cancer.  It  is  maintained  by  Ha\dland  and  others  that  certain  houses 
become  infected  and  that  cancer  appears  in  such  houses  again  and  again  among 
successive  families  inhabiting  them.  Such  houses  are  called  "cancer  houses," 
and  many  remarkable  facts  have  been  collected  relating  to  them,  facts  which  to 
some  observers  seem  to  prove  contagion,  but  which  to  others  merely  serve  as 
interesting  examples  of  coincidence. 

Leeson  ("Practitioner,"  Feb.,  1909)  is  of  the  latter  opinion  and  shows  that 
there  was  not  a  cancer  house  in  his  district.  He  studied  248  cases  of  cancer  and 
all  but  4  of  them  were  in  dift'erent  houses.  As  this  author  says:  "If  we  are 
to  accept  such  evidence  as  that  on  which  the  belief  in  cancer  houses  is  founded, 
we  must  beheve  in  'apoplexy  houses,'  'liver  houses,'  etc." 

Influence  of  Diet. — Some  blame  meat,  some  tomatoes,  etc.,  for  the  de- 
velopment of  cancer.  Vernueil  and  Reclus,  commenting  on  the  fact  that 
carnivora  are  much  more  prone  to  cancer  than  herbivora,  suggested  that  the 
increase  of  cancer  during  recent  years  might  be  due  to  the  increased  consump- 
tion of  meat  by  the  poorer  classes.  There  is  no  proof  of  the  truth  of  this 
suggesdon.  In  fact.  Prof.  Senn  points  out  that  the  Eskimos  seem  immune  to 
tumor  formation,  yet  they  live  on  an  exclusive  animal  diet  and,  furthermore, 
are  the  healthiest  people  in  the  world. 

Recurrence  After  Operative  Removal. — This  is  usually  due  to  the  fact 
that  all  of  the  cells  were  not  removed.  Such  recurrence  may  be  due  to  cutting 
across  lymph  tracts  and  flooding  the  wound  with  carcinoma  cells,  which  lodge 
and  grow.  The  growth  of  cancerous  nodules  in  the  abdominal  scar  resulting 
from  an  exploratory  operation  for  cancer  of  the  stomach  is  obser\'ed  every  now 
and  then.  It  is  probably  due  to  contact  invasion  of  the  scar  area,  which  area 
has  lessened  vital  resistance  to  cancer  cells. 

Murphy  thinks  that  the  same  explanation  holds  when  the  stitch  cicatrices 
become  cancerous  ("General  Surgery,"  by  John  B.  Murphy,  in  "Practical 
Medicine  Series  for  1909"). 

Extension  of  Cancer. — It  spreads  by  the  lymphatics  and  rapidly  involves 
the  anatomically  associated  lymph-nodes.  In  the  nodes  the  migrating  cancer 
cells  are  imprisoned  for  a  time,  and  in  this  incarceration  Hes  the  hope  of  sur- 


Spontaneous  Disappearance  of  Cancer  385 

gery.  The  adjacent  glands  are  involved  much  more  rajjidly  than  we  used  to 
think.  They  are  usually  involved  within  a  few  weeks  of  the  start  of  the  growth, 
except  in  superficial  epithelioma,  in  which  cases  they  are  not  involved  at  all. 

In  a  structure  devoid  of  capsule  (as  the  tongue,  the  mammary  gland,  etc.), 
Lockwood  points  out  that  involvement  of  related  lymph-nodes  is  practically 
immediate. 

Lymphatic  involvement  may  result  in  the  formation  of  a  mass  much  larger 
than  the  parent  growth.  The  ducts  between  the  primary  cancer  and  the  in- 
volved glands  are  filled  with  carcinoma  cells  and  their  walls  become  infiltrated. 
Hence  in  an  operation  the  ducts  should  not  be  cut  across  or  the  wound  will  be 
flooded  with  fluid  rich  in  cancer  cells  and  the  ducts  should  be  extirpated  as  well 
as  the  glands.  To  Qood  the  wound  with  fluid  containing  embryonic  cells  is 
very  dangerous,  for  some  of  them  may  adhere,  multiply,  and  reproduce  the 
disease.  After  a  time  the  capsules  of  cancerous  nodes  rupture  and  peri- 
glandular tissue  becomes  involved.  The  cells  are  held  in  the  first  glandular 
stopping  place  (the  anatomically  related  glands)  for  a  time,  but  sooner  or  later 
other  and  more  distant  glands  become  involved.  In  certain  abdominal 
cancers  (stomach,  rectum,  and  uterus)  the  thoracic  duct  may  become  obstructed 
by  cancer  cells.  Large  glands  may  cause  much  trouble  from  pressure.  When 
they  soften  and  break  down  the  skin  becomes  involved  and  dreadful  sores 
form,  oozing  foul  matter  and  blood.  Death  may  be  due  to  hemorrhage  from 
a  large  vessel  which  has  become  infiltrated. 

Several  times  I  have  been  consulted  by  patients  on  account  of  glandular 
enlargements  of  the  neck,  the  patients  never  having  noticed  a  small  primary 
lesion  in  the  mouth,  and  yet  the  entire  glandular  disease  was  secondary  to  the 
limited  oral  trouble. 

Dissemination  or  Metastasis. — These  terms  mean  the  formation  of 
secondary  growths.  These  growths  are  formed  by  small  fragments  of  cancer 
being  broken  off  and  carried  to  lodgement  in  distant  structures.  Such  small 
fragments  are  called  cancer  emboli.  Cancer  emboli  may  be  carried  by  lymph  or 
blood.  When  cancer  emboli  lodge  in  a  region  favorable  to  their  growth 
their  constituent  cells  multiply  and  produce  secondary  growths.  A  secondary 
growth  is  the  histological  counterpart  of  the  parent  growth,  and  an  examination 
of  a  secondary  growth  gives  us  accurate  information  as  to  the  nature  of  the 
primary  growth.  In  cancer  of  the  rectum  there  may  be  secondar}^  deposits 
in  the  liver  or  in  bone  containing  structure-like  rectal  glands.  In  cancer  of 
the  stomach  secondary  nodules  in  the  skin  may  contain  structure  resembling 
the  gastric  glands.  Secondary  deposits  are  by  no  means  as  common  in  cases 
of  squamous-celled  cancer  as  in  glandular  cancer. 

Another  method  of  dissemination  is  observed  in  the  abdomen.  When 
cancer  of  a  viscus  breaks  through  the  peritoneal  coat,  the  cells  are  spread  widely 
by  peristaltic  movements  and  peritoneal  fluid,  and  the  peritoneum  becomes 
extensively  involved.  This  involvement  is  a  form  of  contact  cancer.  Any 
structure  may  be  the  seat  of  a  secondary  growth.  The  lung  is  frequently 
aft'ected,  so  is  the  Hver,  so  are  the  bones.  Any  organ  or  tissue  may  become 
the  host  for  secondary  deposits  of  carcinoma. 

Spontaneous  Disappearance  of  Cancer. — This  is  an  excessively  rare 
event  in  human  beings,  but  it  does  occasionally  occur.    Gaylord  has  collected  1 1 
cases  which  he  considers  authentic,  viz.,  2  epitheliomata  (i  of  the  tongue  and 
25 


386 


Tumors  or  Morbid  Growths 


1  ig.  163. — Carcinoma  of  the  auricle. 


I  of  the  lip),  I  scirrhous  cancer  of  the  breast,  i  malignant  adenoma  of  the 
rectum,  and  7  cases  of  chorion  carcinoma  ("Seventh  Annual  Report  of  the 
Cancer  Laboratory  of  New  York  State  Department  of  Health").  The  same 
author  also  notes  the  spontaneous  disappearance  of  two  sarcomata.  Spon- 
taneous disappearance  of  Jensen  tumors  successfully  inoculated  in  mice  is 
quite  common.  It  occurred  in  23  percent,  of  Gaylord's  animals.  Spontane- 
ous disappearance  is  not  due  to  the  fatty  degeneration  and  necrosis  so  often 
found  about  the  center  of  a  carcinoma,  but  to  deprivation  of  the  epithehal  cell 

5^    of  some  or  all  of  its  vitaht}'  by 

an  utterly  unknown  process. 
Some  observers  think  sponta- 
neous cure  is  brought  about  by 
the  stimulation  of  an  immu- 
nizing force.  When  spontane- 
ous cure  occurs  cancer  cells  are 
gradually  replaced  by  scar  tis- 
sue, and  the  resulting  scar  may 
contain  cancer  cells  immeshed 
in  it.  Hence,  after  apparent 
retrogression,  growth  may  begin 
anew. 

Besides  the  apparently  posi- 
tively authenticated  cases  re- 
ported by  Gaylord,  there  are 
numerous  cases  on  record  in 
which  it  is  highly  probable  cancer  disappeared  spontaneously.  These  cases 
are  collected  in  the  appendix  to  the  previously  cited  report  of  Gaylord. 

Blood  Changes  in  Cancer  Cases.— In  early  cases  there  is  no  notable 
change  in  either  erythrocytes  or  hemoglobin.  In  more  advanced  cases  as 
cachexia  begins  a  secondary  anemia  develops,  fall  of  hemoglobin  antedating 
diminution  in  leukocytes. 

The  anemia  may  become  so  profound  that  it  resembles  pernicious  anemia; 
in  fact,  some  observers  have  asserted  that  pernicious  anemia  may  arise.  The 
anemia  of  cancer  is  not  benefited  by  medical  treatment. 

In  gastric  cancer,  because  of  vomiting  and  diarrhea,  blood  concentration 
may  occur,  the  red  corpuscles  being  6,000,000  or  even  7,000,000  per  cmm. 

The  leukocytes  may  be  normal,  but  are  often  increased.  It  has  recently 
been  claimed  by  Macalister  and  Ross  ("The  Lancet,"  Jan.  16,  1909)  that  the 
blood  of  a  patient  with  cancer  contains  a  material  in  its  plasma  which  is  an 
excitant  for  the  leukocytes  of  healthy  persons.  As  pre\-iously  stated  (page  380) 
the  serum  of  the  blood  of  a  person  \nth  cancer  contains  agents  destructive  to 
the  red  corpuscles  of  healthy  blood. 

Classification  of  Carcinomata. — Carcinomata  are  classified  as  follows: 
(i)  Epithelioma;  (2)  rodent  ulcer,  or  Jacob's  ulcer;  (3)  spheroidal-celled 
cancer;  (a)  schirrous;  (b)  encephaloid;  (c)  colloid;  and  (4)  cylindrical-celled 
cancer.  Clinically  we  speak  of  cidrass  cancer,  a  condition  sometimes  arising 
when  the  mammar\'  gland  is  cancerous  and  due  to  the  infiltration  of  the 
cutaneous  h-mphatics  with  cancer-cells;  chimney-sweeps^  cancer  and  paraffin 
workers'  cancer,  if  either  of  these  occupations  seems  to  have  been  causative; 


Classification  of  Carcinomata  387 

cancer  a  deux,  a  phrase  used  in  France  to  signify  that  carcinoma  has  occurred 
in  two  persons  of  a  household  who  are  not  blood  relations,  but  have  been  in 
close  contact;  contact  cancer,  when  cancer  appears  in  an  area  which  was  in  close 
contact  with  a  cancerous  area  in  the  same  individual — for  instance,  when 
a  cancer  of  the  upper  lip  follows  a  malignant  growth  of  the  lower  Hp;  when 
a  carcinoma  of  the  face  follows  a  like  growth  of  the  hand;  when  a  cancer 
appears  on  the  penis  of  a  husband  whose  wife  has  cancer  of  cervix  uteri  or 
vagina.  A  melanotic  carcinoma  is  a  form  of  encephaloid  in  which  the  cells 
contain  melanin.  Scirrhous  cancer  contains  much  fibrous  tissue  and  is 
densely  hard.  An  encephaloid  is  very  soft  or  brain-hke.  Marjolin's  nicer 
is  an  epithelioma  which  arises  from  the  epithelial  edge  of  a  chronic  ulcer,  a 
scar  or  a  sinus  (page  175).  Fig.  82  shows  a  Marjolin  ulcer  arising  in  the  scar 
of  a  burn. 

Epitheliomata. — An  epithelioma  arises  from  surface  epithelium,  and  may 
arise  from  squamous  cells  or  cylindrical  cells,  according  to  the  location. 

Squanwus-celled  epithelioma  (Fig.  161)  takes  origin  from  the  skin  or  from 
a  mucous  membrane  covered  with  pavement  epithelium.  It  is  especially  apt 
to  appear  at  the  junctions  of  skin  and  mucous  membrane  (as  the  lips)  or  the 
point  of  juxtaposition  of  different  kinds  of  epithelium.  Such  a  growth  may 
arise  in  the  anus  or  vagina;  on  the  penis,  scrotum,  lips  or  tongue;  in  the 
mouth  or  nose;  on  the  skin,  and  other  situations.  There  is  an  ingrowth 
of  surface  epithelium  into  the  subepithelial  connective  tissue,  colonies 
of  cells  growing  inward  and  forming  epithehal  nests.  It  may  arise  with- 
out discoverable  cause,  it  may  follow  prolonged  irritation,  or  it  may  arise 
in  a  wart  or  fissure.  In  the  nipple  it  is  not  very  unusually,  and  in  the 
scrotum  and  nose  it  is  occasionally,  preceded  by  a  persistent  dermatitis 
due  possibly  to  psorosperms,  and  known  as  Pagefs  disease.  Paget's  disease 
is  not  true  eczema,  but  is  rather  maHgnant  dermatitis.  A  crust  gathers  on 
the  part,  and  beneath  this  crust  is  a  raw,  red,  and  moist  surface,  the  edge  of 
which  is  slightly  elevated  and  somewhat  indurated.  In  the  beginning  there 
is  a  strong  resemblance  to  eczema.  The  nipple  is  apt  to  retract.  The  parts 
are  the  seat  of  a  constant  itching  and  scalding  sensation.  The  area  may 
become  cancerous  in  a  few  weeks,  but  may  not  for  years.  I  have  recently  seen 
a  case  of  Paget's  disease  of  the  glans  penis.  Scjuamous  epithelioma  generally 
begins  as  a  warty  protuberance  which  soon  ulcerates.  A  malignant  or  true 
cancerous  ulcer  (Fig.  161)"  has  a  hard,  irregular  base,  uneven  edges,  a  foul, 
fungus-like  bottom,  and  gives  off  a  sanious  or  ichorous  discharge.  This  ulcer 
is  the  seat  of  sharp,  pricking  pain,  sometimes  bleeds,  and  extends  over  a  con- 
siderable area,  embracing  and  destroying  every  structure.  Epithehoma 
usually  affects  lymphatic  glands  early,  but  such  infection  may  be  delayed  for 
eight  or  ten  months.  EpitheHomatous  glands  break  down  in  ulceration, 
making  frightful  gaps  and  often  causing  fatal  hemorrhage.  Dissemination 
is  not  nearly  so  common  as  in  other  forms  of  cancer,  but  it  does  sometimes 
occur. 

Cylindrical-celled  Epithelioma. — This  form  of  growth  takes  origin  from 
structures  covered  with  or  containing  cyHndrical  epithelium,  and  it  contains 
cyHndrical  or  columnar  cells.  It  is  composed  of  a  stroma  of  fibers  between 
which  lie  tubular  glands  lined  with  columnar  epithelium  and  containing 
masses  of  epithelial  cells.     Such  tumors  are  found  in  the  uterus  and  gastro- 


388 


Tumors  or  Morbid  Growths 


intestinal  tract,  and  may  begin  from  the  surface  epithehum  or  from  the  cells 
of  tubular  glands.  In  these  tumors  there  is  an  acinusdike  structure  and  the 
spaces  are  filled  with  proliferating  epithelium.  Cylindrical-celled  cancers 
also  arise  from  the  mammary  gland,  liver,  and  kidney.  One  of  the  most 
common  seats  of  cyhndrical  cancer  is  the  rectum.  Cancer  of  the  rectum 
may  occur  at  an  earlier  age  than  cancer  elsewhere,  being  not  uncommon 
between  the  ages  of  twenty-eight  and  forty.  Cyhndrical-celled  epitheliomata 
are  at  first  covered  with  mucous  membrane,  but  they  soon  ulcerate  and  involve 
the  submucous  and  muscular  coats  in  the  growth.  They  grow  rather  slowly, 
usually,  but  not  always,  cause  lymphatic  involvement,  and  finally  dissemi- 
nate widely.  They  require  in 
some  regions  from  five  to  six 
years  to  cause  death.  In  the 
rectum,  however,  growth  is  much 
more  rapid  and  few  victims  of 
cylindrical-celled  carcinoma  of 
the  rectum,  if  unoperated  upon, 
live  beyond  2  years  and  many  of 
them  die  long  before  this  period. 
A  rodent  or  JacoVs  tilcer,  epi- 
thelioma exedens  or  cancroid  (Fig. 
164;,  was  called  by  the  older  sur- 
geons "noli  me  tangere,"  because 
they  found  that  surgical  interfer- 
ence (incomplete  removal  as  we 
now  know)  was  sometimes  fol- 
lowed by  very  active  growth.  A 
rodent  ulcer  is  scarcely  ever  met 
with  except  upon  the  face  though 
Jonathan  Hutchinson  saw  one 
upon  the  forearm,  and  James 
Berry  met  with  one  upon  the 
nose   and    forehead.     It  begins 


Fig.    164. — Rodent   ulcer.     Case   in    the   author's 
wards  in  Philadelphia  Hospital. 


arm.  It  is  especially  common  upon  the 
after  the  age  of  forty  as  a  Uttle  warty  prominence  which  ulcerates  in  the 
center,  the  ulceration  progressing  at  a  rate  equal  to  the  new  growth.  The 
ulcer  becomes  deep;  it  is  not  crusted;  its  edges  are  irregular,  hard,  and  everted; 
the  floor  is  smooth  and  of  a  grayish  color;  the  discharge  is  thin  and  acrid; 
and  the  parts  about  the  sore  contain  numbers  of  visible  vessels.  Jacob's  ulcer 
grows  slowly,  may  last  for  years,  does  not  involve  the  lymphatics,  produces 
no  constitutional  cachexia,  and  is  rarely  fatal.  In  some  cases,  although 
growth  is  ven,'  slow,  destruction  eventually  becomes  ver>'  great  because  of 
ulceration,  there  is  great  loss  of  tissue  and  horrible  deformity.  A  rodent 
ulcer  is  usually  considered  to  be  a  malignant  epithelial  growth  which  springs 
from  a  sweat-gland,  a  sebaceous  gland,  or  a  hair-foUicle,  but  Kanthack 
asserts  that  before  ulceration  the  rete  and  the  sweat-glands  are  normal,  but 
the  sebaceous  glands  are  destroyed.  The  base  and  edges  of  the  ulcer  are 
hard,  which  differentiates  it  from  lupus;  and,  further,  the  baciUi  of  tubercle 
may  sometimes  be  cultivated  from  the  discharge  of  an  area  of  lupus  (page 
250).     Rodent  ulcer  begins  below  the  skin,  ordinary  epithelioma  begins  in 


Classification  of  Carcinomata  389 

the  skin,  and  a  rodent  ulcer  contains  no  cell-nests.  A  rodent  ulcer  very 
rarely  undergoes  cicatrization,  a  fact  which  differentiates  it  from  lupus. 
Occasionally,  but  very  rarely,  a  small  portion  of  the  gro\\i:h  sloughs  out  and 
a  temporary  scar  forms  at  this  point. 

Adenocarcinoma  or  Glandular  Carcinoma. — Glandular  carcinomata  in 
structure  resemble  racemose  glands.  They  consist  of  a  stroma  of  connective 
tissue  and  alveoli  filled  with  proliferating  epithelial  cells.  If  the  proportion 
between  the  fibrous  stroma  and  the  cellular  elements  is  about  the  same  as  in  a 
normal  gland,  the  growth  is  called  simple.  When  the  cellular  element  is  in 
e.xcess  the  growth  is  soft  (medullary),  and  when  the  fibrous  stroma  is  in  excess 
the  growth  is  hard  (scirrhous) . 

1.  Scirrhous  carcinoma  is  a  white  and  fibrous  mass  which  has  no  capsule, 
which  infiltrates  tissues,  and  which  draws  in  toward  it,  by  the  contraction  of 
its  outlying  fibrous  processes,  adjacent  soft  parts,  thus  producing  dimpling, 
or,  as  in  the  breast,  retraction  of  the  nipple.  It  is  composed  of  spheroidal 
cells  in  alveoli  formed  of  connective-tissue  bands.  The  commonest  seat  of 
scirrhus  is  the  female  breast.  It  occurs  also  in  the  skin,  vagina,  rectum, 
prostate,  uterus,  stomach,  and  esophagus.  It  is  most  frequent  in  women 
after  forty.  It  begins  as  a  hard  lump  which  is  at  first  painless,  but  which 
after  a  time  becomes  the  seat  of  an  acute,  localized,  pricking  pain.  This 
lump  grows  and  becomes  irregular  and  adherent,  causing  puckering  of  the 
soft  parts.  After  the  skin  or  mucous  membrane  above  it  has  become  infil- 
trated ulceration  takes  place  and  a  fungous  mass  protrudes  which  bleeds 
and  suppurates.  The  adjacent  lymphatic  glands  usually  become  cancerous, 
the  time  occupied  being  from  six  to  ten  weeks,  and  constitutional  involvement 
is  rapid  and  certain. 

2.  Medullary  or  encephaloid  carcinoma  is  a  soft  gray  or  brain-like  mass. 
It  is  a  rare  growth,  it  has  no  capsule,  and  it  may  appear  in  the  kidney,  liver, 
ovary,  testicle,  mammary  gland,  stomach,  bladder,  and  maxillary  antrum. 
An  encephaloid  cancer  often  contains  cavities  filled  with  blood,  and  this 
variety  is  known  as  a  "hematoid"  or  a  ''telangiectatic"  carcinoma.  These 
growths  are  soft  and  semi-fluctuating,  they  infiltrate  rapidly  and  soon  fungate, 
and  they  terminate  life  in  from  a  year  to  a  year  and  a  half.  If  the  cells  of 
encephaloid  become  filled  with  melanin,  the  condition  is  called  "melanosis" 
or  "melanotic  cancer." 

3.  Colloid  cancer  is  extremely  rare.  It  arises  from  either  a  scirrhus  or  an 
encephaloid,  when  the  cells  or  the  stroma  of  such  a  growth  undergo  colloidal 
degeneration.  On  section  there  will  be  seen  in  the  center  of  the  growth  a 
series  of  cavities  filled  with  a  material  resembling  honey  or  jelly ;  the  periphery 
is  frequently  an  ordinary  scirrhus  or  encephaloid  cancer.  Colloid  degenera- 
tion is  most  prone  to  attack  carcinomata  of  the  stomach,  mammary  gland, 
and  intestine.  The  name  colloid  cancer  is  often  given  to  glistening,  gelatinous, 
malignant  growths  springing  from  the  ovary,  testicle,  mamman,-  gland,  or 
gastro-intestinal  tract.  The  condition  is  due  to  mucous  degeneration  of  the 
connective  tissue  or  of  the  epithelial  tissue  of  a  carcinoma.  Only  a  portion 
of  the  tumor  may  degenerate  or  the  entire  mass  may  become  gelatinous. 

Syncytioma  Malignum* — By  this  name  is  meant  a  maUgnant  epithelial 
growth  arising  from  the  site  of  the  placenta  during  pregnancy  or  the  puerperal 
state.  It  resembles  placenta  in  appearance  and  rapidly  causes  metastases 
by  way  of  the  blood-vessels.     It  is  quickly  fatal. 


390  Tumors  or  Morbid  Growths 

Treatment. — Cancer  is  so  prevalent,  is  so  dreadful  in  its  nature  and  in- 
exorable in  its  progress,  tends  so  strongly  to  cause  death  in  from  two  to  five 
years,  people  are  so  afraid  of  it,  and  so  many  physicians  are  hopeless  of  curing  it 
that  multitudes  seek  relief  from  the  obsessed  Christian  scientists  or  from  the 
vulgar  criminal  cjuacks.  It  cannot  be  too  strongly  insisted  that  in  the  begin- 
ning cancer  is  a  local  disease  curable  by  early  and  radical  operation,  that  early 
diagnosis  should  be  made,  and  that  prompt  operation  is  imperative.  Delay  is 
not  only  disastrous,  it  is  usually  fatal.  Certainly  at  least  50  per  cent,  of  the 
cases  of  cancer  I  see  are  beyond  operation  when  they  are  first  brought  to 
the  hospital,  they  having  sacrificed  the  golden  moments  during  which  cure 
was  possible.  Carcinomata  demand  early  and  wide  excision,  with  removal 
of  implicated  glands.  Anatomically  related  lymph-nodes  must  be  removed 
even  if  they  show  no  evidence  of  involvement.  If  operation  is  earlv  and  thor- 
ough, and  if  certain  regions  are  involved,  a  considerable  proportion  of  cases. 
can  be  cured.  Carcinomata  of  the  lip,  the  skin,  and  the  mammary  gland 
can  often  be  cured.  A  recurrent  growth  may  be  removed  as  a  palliative 
measure,  to  lessen  pain  and  to  relieve  the  patient  from  ulceration  and  hemor- 
rhage, but  such  an  operation  is  rarely  curative.  If  a  growth  does  not  recur 
within  five  years  after  removal,  a  cure  has  probably  been  attained;  in  fact, 
if  there  is  no  recurrence  within  three  years,  the  case  is  probably  cured.  The 
three-year  limit  has  been  usually  accepted  since  Volkmann's  paper  on  the 
subject.  A  rodent  ulcer  should  be  excised  or  else  be  curetted  and  cauterized 
with  the  hot  iron  or  the  Paquelin  cautery.  In  cancer  of  the  lower  lip,  remove 
the  grow^th  by  Grant's  operation  {q.  v.),  or  by  a  V-shaped  incision,  or 
cut  away  the  entire  lip.  In  every  case  remove  the  glands  beneath  the  jaw. 
In  cancer  of  the  tongue,  excise  this  organ  and  also  the  lymph-nodes  from 
beneath  the  jaw  and  in  the  anterior  carotid  triangles.  In  cancer  of  the. 
breast,  remove  the  breast,  the  pectoral  fascia,  and  the  great  pectoral  muscle, 
and  take  away  the  fat  and  glands  of  the  axilla.  In  cancer  of  the  rectum,  if 
near  the  surface,  excise  the  rectum  from  below;  if  above  five  inches  from  the 
anus,  do  the  sacral  resection  of  Kraske  and  then  remove  the  growth.  In 
cancer  of  the  esophagus,  perform  gastrostomy;  in  cancer  of  the  pylorus,  per- 
form pylorectomy  or  gastro-enterostomy ;  in  cancer  of  the  bowel,  do  resection 
with  end-to-end  approximation,  side-track  the  diseased  area  by  an  anasto- 
mosis, or  make  an  artificial  anus;  in  cancer  of  the  penis,  amputate  and  remove 
the  glands  of  the  groin.  Erysipelas  toxins  and  erysipelas  serum  have  been 
tried  in  inoperable  carcinoma,  but  without  any  positive  benefit.  Von  Leyden 
and  Blumenthal  ("Deutsche  medicinische  Wochenschrift,"  Sept.  4,  1902) 
report  benefit  to  human  beings  suffering  from  cancer  by  the  injection  of  serum 
expressed  from  carcinomatous  tumors.  Such  observations  require  many 
confirmatory  studies  before  we  can  assume  that  a  remedy  has  been  found. 
Pyoktanin,  thiosinamin,  trypsin,  and  many  other  materials  have  come  upon  the 
scene  like  plausil)le  confidence  men,  but  each  was  soon  exposed.  There  is  no 
drug  and  no  serum  at  present  known  to  be  capable  of  curing  cancer.  Honest 
investigators  have  at  times  been  lead  into  error  by  forgetting  that  at  times 
the  rate  of  growth  of  a  cancer  may  temporarily  lessen  or  that  growth  may 
for  a  time  actually  cease.  (See  Lewis  S.  Pilcher's  address  before  the  Surgi- 
cal Society  of  Brooklyn  in  Feb.,  1909.)  Fulguration  (application  of  powerful 
sparks  from  a  metal  electrode)  is  advocated  by  Czerny,  but  the  sparks  produce 


Cystomata  391 

a  local  effect  only  and  cannot  reach  involved  lymph-nodes.  The  :r-rays  are 
of  distinct  value  in  certain  cases  of  carcinoma.  Surface  growths  may  be  ap- 
parently cured,  although,  unfortunately,  they  are  apt  to  return  even  after  total 
disappearance.  Deej)er  growths  are  apparently  not  benefited.  The  knife  is 
to  be  preferred  to  the  .v-rays,  except  in  very  superficial  skin  cancer  about  the 
eyelid  or  nostril,  and  in  ino{)erable  cancer.  The  real  curative  power  of 
radium  is  as  yet  undetermined.  The  :v'-rays  and  radium  have  a  certain 
influence  in  lessening  the  pain  of  cancer.  In  some  cases  ligation  of  the  artery 
of  supply  or  extirpation  of  the  artery,  as  suggested  by  Dawbarn,  notably 
retards  growth.  I  have  been  able  to  confirm  this  statement.  In  cancer  of  the 
breast,  oophorectomy  occasionally  produces  benefit  or  even  cure  (Beatson's 
operation).  In  inoperable  cases  paUiative  operations  may  be  justifiable 
to  relieve  some  urgent  discomfort  or  get  rid  of  a  foul  or  bleeding  mass.  Gastro- 
_  enterostomy,  gastrostomy,  and  colostomy  are  palliative  operations.  In  a 
malignant  growth  of  the  nasopharynx  tracheotomy  may  be  required,  and  in  a 
malignant  growth  of  the  bladder  it  may  be  advisable  to  perform  suprapubic 
cystotomy.  In  an  inoperable  case  relieve  the  pain  by  opium,  giving  as  much  as 
may  be  required  to  secure  ease.  Opium  so  used  seems  not  only  to  reheve  pain, 
but  to  retard  the  growth  of  the  tumor  and  to  favor  the  development  of  fibrous 
tissue  in  the  stroma.  Some  surgeons  have  tried  injecting  serum  from  one  of 
the  lower  animals  suffering  from  the  disease,  but  results  are  entirely  incon- 
clusive.   Others  have  given  atoxyl.    Erysipelas  toxin  is  of  slight  value  in  cancer. 

Malignant  Growth  from  Congenital  Pigmented  Mole.— As  previ- 
ously stated,  the  embryonic  origin  of  the  pigment-producing  cells  is  uncertain. 
Some  regard  a  malignant  growth  of  a  congenital  pigmented  mole  as  epithelioma, 
others  as  alveolar  pigmented  sarcoma.     It  is  probably  carcinomatous. 

Malignant  change  seldom  occurs  before  the  fiftieth  year,  the  growth  rarely 
attains  a  large  size,  metastasis  takes  place  very  rapidly  by  the  blood  and  lymph- 
atics, and  the  patient  seldom  lives  more  than  a  year  after  mahgnant  change 
begins.     (See  Bloodgood,  in  "Progressive  Medicine,"  Dec,  1907.) 

Because  of  the  danger  of  subsequent  mahgnant  change  it  is  wise  to  remove 
large  pigmented  moles.  Every  pigmented  mole  which  is  irritated  or  begins  to 
enlarge  must  be  removed,  and  the  associated  lymph-nodes  should  also  be 
removed.  Bloodgood  knows  of  no  definite  cure  on  record  of  a  malignant 
tumor  arising  in  a  pigmented  mole.  Prevention  is  easily  secured  by  extirpa- 
tion before  the  onset  of  malignancy. 

Cystomata. — A  cystoma  is  a  benign  cystic  tumor  in  which  the  cells 
of  the  cyst- wall  constitute  the  new  growth.  The  cyst  contents  are  derived 
from  the  cells  of  the  wall.  The  tumor  is  the  cyst- wall;  the  cells  of  this  wall 
are  derived  from  the  epiblast,  the  hypoblast,  or  the  mesoblast,  and  are  either 
epithelial  or  endothelial.  The  cells  of  the  cyst-wall  adhere  to  connective 
tissue  which  seems  to  constitute  a  part  of  the  wall.  A  thick  wall  contains 
much  connective  tissue,  a  thin  wall  very  little.  The  nature  of  the  contents 
is  dependent  on  the  character  of  the  cells  which  constitute  the  tumor.  Cysts 
lined  by  endothelium  contain  serous  fluid;  a  cyst  of  the  thyroid  gland  usually 
contains  colloid  material;  a  cyst  lined  by  flat  epithelial  cells  contains  matter 
resulting  from  fatty  degeneration,  etc. 

Cystomata  may  be  congenital  or  acquired,  and  an  acquired  cystoma  may 
arise  after  injury  or  follow  inflammation.     The  cyst  may  increase  in  size 


392  Tumors  or  Morbid  Growths 

progressively  or  its  growth  ma\'  be  halted.  The  wall  may  become  calcareous 
or  even  bony.  When  a  cyst  has  one  cavity,  we  call  it  monolocular;  when 
there  are  several  or  many  cavities,  it  is  called  multilocular. 

Varieties  of  Cystomata. — The  chief  varieties  are :  Traumatic  epithelial; 
atheromatous;  mucous;  mesoblastic. 

Traumatic  Epithelial  Cystomata. — These  growths  ha\e  been  called 
traumatic  dermoids.  Such  a  growth  may  arise  after  an  injury  which  carries 
and  deposits  epithelial  cells  or  a  bit  of  skin  deep  into  the  connective  tissue. 
For  instance,  a  punctured  wound  of  the  hand  may  be  followed  by  an  epithelial 
cystoma.  It  may  arise  after  a  scalp  wound  or  in  the  scar  of  a  burn.  The 
cyst  grows  only  to  a  certain  size  and  then  remains  stationary.  It  is  Uned  by 
pavement  epitheUum  and  it  contains  products  of  the  fatty  degeneration  of 
epithelial  cells. 

Treatment. — Extirpation  of  the  wall. 

Atheromatous  Cystomata. — These  growths,  according  to  Senn,  are 
met  with  particularly  in  the  ovaries,  in  the  orbital  region,  and  at  the  base  of 
the  tongue,  but  they  can  arise  almost  amTvhere.  They  may  remain  small 
or  may  attain  a  great  size.  Such  a  cystoma  contains  epithelial  cells  which 
have  undergone  fatty  degeneration  and  sometimes  contains  oil.  An  athero- 
matous cystoma  is  deep  seated  and  is  not  connected  with  the  skin,  in  contrast 
to  a  sebaceous  cyst,  which  is  superficial  and  is  a  part  of  the  skin.  An  athero- 
matous cystoma  is  lined  with  epithelium,  but  not  with  skin.  A  dermoid  cyst  is 
lined  with  skin  or  other  definite  structures.  An  atheroma  is  due  to  the  dis- 
placement of  a  mass  of  epithelial  cells,  which  mass  was  the  matrix  of  the  cys- 
toma. "  The  displacement  of  the  matrix  of  an  atheroma  occurred  at  a  time 
prior  to  the  differentiation  of  the  epiblastic  cells  into  the  organs  representing 
the  appendages  of  the  skin,  while  the  matrix  of  a  dermoid  cyst  points  to 
a  later  displacement  of  the  matrix"  ("Pathology  and  Surgical  Treatment  of 
Tumors,"  by  Nicholas  Senn).  Atheromatous  cystomata  may  be  congenital^ 
but  may  not  appear  until  puberty  or  even  much  later. 

Treatment. — Extirpation  of  the  wall  of  the  cystoma. 

Mucous  Cystomata. — A  mucous  cystoma,  Uke  an  atheromatous  cystoma, 
is  due  to  the  displacement  of  epithelium,  but  in  the  former  condition  it  is  pave- 
ment epithehum  and  in  the  latter  it  is  columnar  epithelium.  The  one  is 
filled  with  fatty  debris  and  the  other  with  a  mucoid  material.  Such  a  mucous 
cystoma  must  not  be  confused  with  a  retention-cyst  of  a  mucous  membrane. 
Mucous  cystomata  are  found  particularly  about  the  hps,  mouth,  and  phar>'nx. 
They  rarely  attain  any  considerable  size.  Cystomata  lined  with  ciliated 
epithelium  may  arise  in  the  testicle,  the  liver,  and  the  brain. 

Treatment. — Incise,  cauterize,  and  drain.  The  wall  is  so  deUcate  that 
excision  is  rarely  possible. 

Mesoblastic  Cystomata. — They  are  lined  with  endothehal  cells.  They 
contain  serous  fluid,  often  grow  to  a  large  size,  and  sometimes  disappear 
spontaneously.  Mesoblastic  cystomata  are  probably  distended  lymph-spaces. 
Thev  are  congenital  and  are  most  common  in  the  neck,  axilla,  and  perineum. 
In  one  case  seen  by  the  author  such  a  cystoma  of  the  neck  appeared  late  in 
life,  but  it  is  probable  that  it  had  existed  in  childhood,  and  after  disappearing 
for  a  long  time  had  reappeared.  The  most  common  form  of  mesoblastic 
cyst  is  known  as  hydrocele  oj  the  neck. 


Teratomata  393 

Treatment. — Excision  is  very  difficult.  In  one  case  in  which  I  assisted 
Professor  Keen  it  was  successfully  accomplished.  The  usual  treatment  is 
to  tap  frequently,  after  each  tapping  washing  out  with  carbolic  acid  (2  to  5 
per  cent.),  and  applying  pressure. 

Cystomata  of  bone,  of  the  thyroid  gland,  of  the  mammary  gland,  etc.,  are 
considered  in  the  sections  on  Regional  Surgery. 

Teratomata. — The  teratomata  contain  tissues  or  higher  structures 
derived  from  two  or  all  of  the  blastodermic  layers.  The  tumors  we  previously 
considered  are  derived  from  only  one  of  these  layers.  The  elder  Senn,  in  his 
work  on  "Tumors,"  thus  defines  a  teratoma:  "A  teratoma  is  a  tumor  com- 
posed of  various  tissues,  organs,  or  systems  of  organs  which  do  not  normally 
exist  at  the  place  where  the  tumor  grows.  The  highest  type  of  a  teratoma 
is  a  foetus  in  foetu.  In  the  simpler  varieties  the  tumor  is  composed  of  hetero- 
topic tissue,  such  as  bone,  teeth,  skin,  mucous  membrane,  etc.  All  teratoid 
tumors  are  congenital;  that  is,  the  tumor  either  exists  at  the  time  of  birth  or 
the  patient  is  born  with  the  essential  tumor  matrix.  A  teratoma  never  springs 
from  a  matrix  of  post-natal  origin."  Any  human  structure  may  be  found  in 
a  teratoma.     Various  fetal  malformations  belong  to  this  group,  as  do  also 


Fig.  165. — Hj'drocele  of  neck  in  boy  nine  weeks  of  age. 

double  monsters,  in  which  one  of  the  embrj'os  is  rudimentary.  Teratomata 
are  divided  into  external  and  internal.  To  the  external  teratomata  belong  the 
parasitic  fetus  and  the  suppressed  fetus.  A  parasitic  fetus  is  the  result  of 
fusion  of  two  embryos,  one  having  gone  on  to  complete  development,  and  the 
other  developing  partially,  and  obtaining  nutrition  from  the  fully  developed 
embryo  to  which  it  is  attached.  A  suppressed  fetus  is  an  irregular  mass  attached 
to  the  posterior  surface  of  the  sacrum,  the  chest,  or  abdomen.  It  contains  a 
conglomeration  of  tissues  and  fragments  of  organs,  for  instance,  bone,  cartilage, 
lung  tissue,  kidney  tissue,  a  piece  of  intestine,  or  a  portion  of  liver.  In  a  case 
pictured  by  Sutton  a  leg  projects  from  the  sacral  region. 

An  internal  teratoma  may  be  found  in  the  cranium,  chest,  abdomen,  or 
pehis.  The  internal  teratoma  consists  of  a  conglomeration  of  the  tissues  and 
A-isceral  fragments  of  a  suppressed  fetus,  but,  unlike  the  external  teratoma,  it 
is  surrounded  by  a  cyst  wall.  The  members  of  this  group  most  often  seen  by 
the  surgeon  are  dermoid  cysts. 


394  Tumors  or  Morbid  Growths 

Dermoid  Cysts. — These  cysts  were  first  studied  and  described  by  Lebert. 
The  name  "dermoid"  implies  that  the  cyst  contains  skin,  and  it  does  contain 
skin  or  mucous  membrane,  the  chief  mass  of  the  tumor  being  derived  from 
proliferation  of  the  cells  of  a  portion  of  displaced  epiblast  or  hypoblast,  but  it 
also  contains  mesoblastic  derivatives.  There  are  two  varieties  of  dermoid: 
sequestration  dermoid  and  the  tubulo-derinoid.  In  this  section  we  speak  of  the 
first  form.  The  second  form  is  considered  on  page  398.  A  superficial  der- 
moid is  formed  by  the  inclusion  in  mesoblastic  tissues  of  a  portion  of  the 
epidermis  or  mucous  membrane.  Superficial  non-traumatic  dermoids  are 
situated  in  the  region  where  the  blastodermic  layers  were  in  contact.  A 
deep  dermoid  is  formed  from  a  collection  of  epithelial  cells  completely 
separated  from  the  epiblastic  tissue  from  which  they  originated.  When  a  cyst 
originates  from  epiblastic  cells  so  immature  that  the  skin  appendages  have 
not  as  yet  been  formed,  it  will  contain  only  atheromatous  material  like  that 
found  in  a  sebaceous  cyst.     When  a  cyst  arises  from  epiblastic  cells  after 


Fig.    i''(i.--'rr;iiini:iti(    fk-rmuid  t\'St. 

they  have  so  matured  that  the  appendages  of  the  skin  have  been  formed,  it 
will  contain  atheromatous  matter,  sweat,  sebaceous  matter,  and  hair.  The 
first  form  is  known  as  an  atheromatous  cystoma;  the  second,  as  a  dermoid. 
A  deep-seated  dermoid  may  contain  also  such  structures  as  prove  it  must 
have  taken  origin  from  "a  displaced  matrix  representing  different  tissues 
and  organs"  (Senn).  Such  a  dermoid  may  contain  portions  of  organs, 
bone,  cartilage,  and  teeth.  A  dermoid  cyst  may  be  defined  as  a  heterotopic 
cyst,  the  wall  of  which  is  composed  of  connective  tissue  lined  with  epithelium 
and  containing  material  formed  by  the  proliferation  of  epithelium  and  often 
hair,  teeth,  or  even  bone.  An  injury  may  displace  a  bit  of  epithelium  and 
lodge  it  in  connective  tissue  and  from  this  a  traumatic  dermoid  may  arise 
(Fig.  166).  Garre  called  them  traumatic  epithelial  cysts  (Fig.  166).  They  are 
most  often  encountered  in  the  palmar  surface  of  the  hand  or  fingers.  The 
skin  above  such  a  cyst  is  not  adherent  to  it  and  often  a  scar  is  visible.  The 
cyst  wall  is  composed  from  without  inward  of  connective  tissue  and  epithelial 
cells,  the  stratum  comeum  being  the  inner  layer  (Leo  Buerger,  in  "Annals  of 


Branchial  Cysts  and  Fistulae  395 

Surgery,"  August,  1907).  The  cyst  contains  desquamated  epithelium  and 
often  cholesterin.  The  causal  injury  is  usually  a  jnmcture,  but  may  Ije  a 
laceration,  a  contused  wound,  or  a  bite.  Sometimes  a  cyst  arises  in  the 
track  of  a  healed  sinus.  Pietzner  collected  re])orts  of  73  cases  ("Ueber 
Traumatische  Epithelcysten.  Dissert.  Rostock.,"  1905). 

Dermoid  cysts  are  most  commonly  found  in  the  ovary  and  in  regions 
where,  during  bodily  development,  the  blastodermic  layers  come  in  contact; 
for  instance,  in  the  neck,  the  eyelids,  the  orbital  angles,  the  lumbosacral  region, 
the  root  of  the  nose,  and  the  floor  of  the  mouth.  Such  cysts  are  also  found  in 
the  ovary,  testicle,  brain,  eye,  mediastinum,  lung,  omentum,  mesentery,  and 
carotid  sheath. 

A  dermoid  of  the  lumbosacral  region  may  be  mistaken  for  a  spina  bifida. 
Sarcoma  may  form  from  the  connective-tissue  elements  of  the  wall  of  a  der- 
moid cyst.  A  dermoid  cyst  may  become  cancerous,  or  innocent  epithelial 
tumors  may  originate  from  the  cyst  lining.  The  epithelial  cells  may  become 
fatty  and  an  oil-cyst  may  actually  form.  If  the  cyst  epitheUum  was  derived 
from  mucous  membrane,  mucus  may  gather  in  the  sac.  A  dermoid  cyst 
may  inflame  or  even  suppurate.  It  is  free  from  pain  unless  it  suppurates, 
inflames,  or  develops  into  a  mahgnant  tumor;  it  grows  slowly  and  rarely 
attains  any  considerable  size  unless  it  arises  in  the  ovary.  Such  cysts  tend 
to  appear  in  particular  regions.  A  subcutaneous  dermoid  may  or  may  not 
fluctuate.  It  is  not  in  the  skin  as  is  a  sebaceous  cyst,  but  the  skin  can  be 
moved  over  it.  A  sebaceous  cyst  moves  with  the  skin.  Subcutaneous 
dermoids  about  the  orbit  are  adherent  to  the  underlying  periosteum.  The 
matrix  of  a  true  dermoid  is  congenital,  but  the  cyst  often  does  not  appear 
until  puberty  or  later.  Teratoids  and  dermoids  connected  with  the  rectum 
require  special  consideration  (page  1160). 

Treatment. — Complete  extirpation.  If  any  of  the  epithelium  of  the  cyst- 
wall  is  left,  the  cyst  will  re-form.  A  superficial  dermoid  should  be  removed 
in  the  same  manner  as  a  sebaceous  cyst,  and  if  it  is  adherent  to  underlying 
periosteum  the  portion  of  this  membrane  to  which  it  adheres  should  also  be 
removed.  A  deep  dermoid  ought  to  be  removed  as  a  tumor  would  be  if 
operation  is  feasible. 

Branchial  Cysts  and  Fistulae. — When  a  branchial  cleft  fails  to  become 
completely  obliterated,  a  branchial  cyst  may  form.  The  branchial  clefts  are 
the  analogues  of  the  gill-slits  of  a  fish.  There  are  four  of  these  clefts  on  each 
side  of  the  neck.  They  are  called  clefts,  but  they  are  really  grooves,  and  each 
groove  on  the  skin  has  its  counterpart  in  the  mucous  membrane  of  the  pharynx. 
Each  pharyngeal  groove  is  covered  with  hypoblastic  epithelium;  each  cuta- 
neous groove  is  covered  with  epiblastic  epithehum,  and  the  two  grooves  ar<e 
separated  by  mesoblastic  structures.  When  the  sides  of  a  cleft  do  not  unite 
and  an  opening  forms  in  the  mucous  membrane,  a  complete  branchial  fistula 
{complete  congenital  cervical  fistula)  results.  When  the  sides  of  a  cleft  fail  to 
unite  and,  although  the  mucous  membrane  is  not  perforated,  the  skin  does  not 
cover  the  cleft,  a  branchial  sinus  or  an  incomplete  branchial  fistula  {incomplete 
congenital  lateral  cervical  fistula)  results.  When  the  sides  of  a  cleft  toward  the 
pharynx  fail  to  coalesce,  a  pharyngeal  diverticulum  is  produced.  When  the 
pharyngeal  surface  and  the  cutaneous  surface  both  close,  but  the  deeper  part 
of  a  cleft  remains  open  and  epithelial  cells  are  caught  in  mesoblastic  elements, 


396  Tumors  or  Morbid  Growths 

a  branchial  cyst  is  formed.    Sinuses  are  more  common  than  complete  fistulas  or 
cysts. 

The  essential  cellular  element  of  a  branchial  cyst  is  epithelium,  derived  either 
from  the  skin  or  pharynx;  hence  the  branchial  cyst  is  not  a  dermoid,  because 
its  histological  elements  are  derived  from  only  one  of  the  blastodermic  layers. 
Branchial  cysts  are  most  common  in  the  triangle  of  election  of  the  left  side. 
They  are  round,  smooth,  often  fluctuating,  and  are  very  deeply  situated,  bemg 
in  close  relation  with  the  great  vessels.  Some  cysts  contain  mucus,  others 
serous  fluid,  others  fatty  debris.  An  abscess  may  form.  The  origin  of  a  cyst 
or  fistula  is  usually  from  the  second  branchial  cleft,  but  Flint  has  reported  a 
fistula  of  the  first  branchial  cleft  ("Annals  of  Surgery,"  August,  igo8).  There 
may  be  one,  two,  or  three  openings.  Not  unusually  the  openings  are  bilateral. 
Hereditary  tendency  is  often  manifest.  The  cutaneous  openings  are  always 
along  the  anterior  margin  of  the  sternocleidomastoid  muscle.  At  the  external 
orifice  there  is  often  an  irregularly  shaped  bit  of  skin  and  cartilage,  which  is 
called  a  cervical  auricle. 

Treatment. — In  old  children  and  in  adults  it  may  be  possible  to  extirpate 
a  cyst  or  a  fistula,  although  this  is  very  difficult  and  often  impossible.  Other 
methods  employed  are  incision,  cauterization  with  the  Paquehn  cautery,  and 
packing  with  gauze;  frequent  tapping  and  injection  with  iodin;  incision  and 
drainage,  every  antiseptic  care  being  observed.  In  all  young  children  and  in 
some  older  persons  with  deep  cysts,  the  latter  plan  is  the  only  one  advised,  and 
it  will  often  fail,  but  will  sometimes  produce  a  cure. 

Cysts. — A  cyst  is  a  cavity,  abnormal  or  pathologic  in  character,  lined 
by  a  membrane  and  containing  material  usually  fluid  or  semifluid.  It  is 
necessary  to  bear  in  mind  the  distinction  between  a  cystoma  and  a  cyst.  Hek- 
toen  and  Riesman,  in  "American  Text-book  of  Pathology,"  insist  on  this 
distinction.  They  say:  "A  cystoma  is  a  true  tumor,  arising  from  active 
proliferation  of  a  matrix  destined  to  form  cystic  spaces;  whereas  a  cyst  is  a 
secondary  formation  not  i)rimarily  due  to  tissue  proliferation."  Cysts  are 
divided  into  the  following  classes:  Retention-cysts;  cysts  from  softening; 
tubulo-cysts;  and  parasitic  cysts  ("American  Text-book  of  Pathology"). 

Retention-cysts. — A  retention-cyst  is  formed  by  blocking  of  the  duct  of 
a  gland  or  by  failure  in  the  absor]:)tion  of  the  proper  amount  of  the  secretion  of 
a  ductless  gland.    A  few  characteristic  forms  of  retention-cysts  will  be  described. 

Sebaceous  Cysts  {Wens) . — These  arise  when  the  excretory  duct  of  a  seba- 
ceous gland  is  blocked  by  dirt  or  occluded  by  inflammation.  The  orifice  of  the 
duct  is  often  visible  as  a  black  speck  over  the  center  of  the  cyst.  They  are  very 
common  in  the  scalp,  being  known  as  wens,  and  upon  the  face,  neck,  shoulders, 
and  back.  Arising  in  the  skin,  and  not  under  it,  the  skin  cannot  be  freely 
moved  over  a  sebaceous  cyst.  A  sebaceous  cyst  is  lined  with  epithelium 
and  is  filled  with  foul-smeUing  sebaceous  material.  A  sebaceous  cyst  may 
suppurate.  When  a  cyst  ruptures  and  the  contents  become  hard,  a  horn  is 
formed.  Another  form  of  horn  has  been  previously  alluded  to  as  due  to 
horny  transformation  of  a  wart. 

Treatment. — To  treat  a  sebaceous  cyst,  incise  the  portion  of  skin  above  it, 
and  dissect  the  sac  entirely  away  with  scissors  or  a  dissector,  trying  not  to 
rupture  the  dehcate  waU.  If  even  a  small  particle  of  the  wall  is  left,  the  cyst 
will  re-form.     If  it  ruptures  during  removal  and  it  is  feared  that  some  portion 


Cysts  from  Softening 


397 


may  remain  paint  the  interior  of  the  wound  with  pure  carbohc  acid.  If  acid 
is  not  used,  close  without  drainage;  but  if  acid  is  used,  drain  for  twenty-four 
hours  If  an  abscess  forms  in  a  sebaceous  cyst,  open  it,  grasp  the  edges  of 
the  cyst-lining  with  forceps,  dissect  out  this  lining  with  scissors  curved  on  the 
flat,  cauterize  with  pure  carbolic  acid,  and  drain  for  twenty-four  hours. 


Fig.  167.— Multiple  sebaceous  tumors  of  the  scrotum  (Horwitz). 


Mucous  Cysts.-A  mucous  cyst  is  due  to  the  blocking  of  a  mucous  gland 
or  a  mucous  crvpt.  Mucous  cysts  occur  particularly  in  the  mucous  membrane 
of  the  mouth  'and  genito-urinary  organs,  and  are  filled  with  thick,  adhesive 
mucus  containing  numerous  epithelial  cells.  Such  a  cyst  is  of  spherical  out- 
line, and  the  epithehal  membrane  which  lines  it  is  strongly  adherent  to  tissues 

^^Treatment:  Incision,  curetment,  cauterization  with  pure  carboHc  acid, 
and  packing  or  extirpation  of  a  considerable  part  of  the  cyst,  and  curetment 
and  cauterization  of  the  part  remaining. 

Oil  Cysts.— An  oil  cyst  is  due  to  fatty  degeneration  of  epithelium  fining  a 
sebaceous  cyst,  or  a  milk  cyst  of  the  breast.  As  previously  noted,  a  dermoid 
may  result  in  an  oil  cyst. 

Treatment :  Extirpation,  as  for  sebaceous  cysts. 

Salivary  Cysts.-A  retention-cyst  of  a  salivary  gland  is  known  as  a  ranula 
(q.  v.).     These  cysts  are  most  common  in  the  submaxillary  or  sublingual 

gland.  .        . 

Lacteal  or  Milk  Cysts.— Such  a  cyst  occasionally  arises  in  the  mammary 
gland  during  lactation,  and  is  the  resufi  of  blocking  of  a  lactiferous  duct  (see 
Cysts  of  Mammary  Gland). 

Among  other  forms  of  retention-cysts,  most  of  which  are  discussed  in 
special  sections  of  this  book,  we  mention  hydrosalpinx,  a  cyst  due  to  blocking 
of  a  FaUopian  tube;  cysts  due  to  obstruction  of  the  bile-ducts  (the  most  com- 


398  Tumors  or  Morbid  Growths 

mon  form  is  known  as  hydrops,  which  is  a  dilated  gall-bladder  the  result 
of  obstruction);  cyst  of  the  thyroid  gland;  cyst  of  the  pancreas;  and  hydro- 
nephrosis, a  condition  produced  by  obstruction  of  the  ureter. 

Cysts  from  Softening. — These  cysts  are  formed  by  the  disintegration 
of  degenerated  tissues.  For  instance,  after  a  hemorrhage  into  the  brain, 
softening  may  follow  and  a  cyst  arise.  Cystic  changes  of  this  sort  are  fre- 
quently observed  in  sarcomata  and  carcinomata.  A  cyst  from  softening  has 
a  wall  of  connective  tissue,  but  there  is  no  endothelial  or  epithelial  layer. 

Tubulo-cysts. — This  name  was  given  by  J.  Bland  Sutton  to  cysts  formed 
in  certain  remains  of  embryonal  ducts,  which  vestiges  in  the  developed  body 
ought  to  have  been  destroyed.  A  small  cavity  is  left  unobliterated,  and  in 
this  space  fluid  gathers.  The  source  of  the  fluid  is  usually  the  hning  cells 
of  the  cavity.  Branchial  cysts  are  frequently  considered  under  this  head- 
ing. Among  the  commoner  tubulo-cysts  are  cysts  of  the  vitello-intestinal 
duct,  cysts  of  the  urachus,  and  thyroglossal  cysts.  Thyroglossal  cysts  and 
sinuses  are  considered  on  page  922. 

Mesenteric  cysts,  not  hydatid  and  not  due  to  carcinoma,  are  embrj-onic 
developments  from  remains  in  the  mesentery  of  the  vitelline  duct,  the  Wolffian 
ducts,  the  Wolffian  bodies,  and  the  Miillerian  ducts  (Moynihan) . 

What  are  called  "chyle  cysts"  of  the  mesentery  are  embryonal  cysts  placed 
in  such  close  adjacency  to  lacteals  that  chyle  enters  into  them  (E.  P.  Baumann, 
in  "Lancet,"  May  7,  1904). 

Cysts  of  the  Vitello-intestinal  Duct. — Such  a  cyst  presents  itself  as  a  small, 
bright  red,  globular  mass,  which  appears  to  arise  from  the  tmibilicus  of  a 
baby  or  a  young  child,  and  which  usually  has  a  distinct  pedicle,  but  may 
be  sessile.  A  cyst  of  this  character  forms  when  the  vitello-intestinal  duct 
atrophies  from  the  gut  toward  the  umbihcus,  but  a  remnant  at  the  umbihcus 
escapes  obhteration,  and  from  this  remnant  a  cyst  forms.  The  wall  of  such 
a  cyst  contains  unstriped  muscular  fiber  and  is  hned  with  mucous  membrane. 
Occasionally  the  duct  in  the  process  of  involution  is  not  destroyed, — its  caliber 
is  simply  lessened, — and  the  duct  remains  open  in  the  navel  and  feces  come 
from  it.  If  the  duct  fails  of  obliteration  at  the  intestinal  end,  a  diverticulum 
remains  at  this  point  (Meckel's  diverticulum). 

Treatment. — A  pedunculated  cyst  at  the  navel  is  treated  by  ligating  its  base 
and  cutting  the  stalk  beyond  the  Hgature.  A  cyst  with  a  thick  base  is  dis- 
sected out.  The  surgeon  must  be  careful  to  avoid  confounding  an  umbihcal 
hernia  with  a  cyst  of  the  navel. 

UracJml  Cysts. — The  urachus  is  the  obliterated  allantois  and  is  a  cord 
running  from  the  summit  of  the  bladder  to  the  umbihcus.  This  structure 
is  in  the  middle  line  of  the  abdomen  and  in  front  of  the  peritoneum.  A  por- 
tion of  the  allantois  may  not  be  obhterated  at  birth,  and  in  consequence  of 
this  failure  a  cyst  forms.  It  grows  to  a  considerable  size,  may  push  the  peri- 
toneum away  and  reach  the  pelvis,  may  communicate  with  the  bladder,  may 
break  through  the  umbilicus  or  grow  backward  toward  the  spine. 

Treatment. — Extirpation  of  the  lining  membrane,  partial  closure  of  the 
cavity  by  suture,  and  packing  the  unobhterated  part.  Complete  extirpation 
of  the  cyst  is  seldom  attempted.  W.  R.  Weiser  ("Annals  of  Surgery,"  Oct., 
1906)  collected  86  cases  of  cyst  of  the  urachus.     In  8  of  these  complete  extirpa- 


Parasitic  Cysts  399 

tion  was  performed  and  Macdonald  has  since  reported  a  successful  complete 
extirpation  ("Annals  of  Surgery,"  August,  1907). 

Parasitic  Cysts. — Parasitic  cysts  are  due  to  the  development  of  certain 
parasites  in  the  tissues.  The  form  most  often  encountered  is  known  as 
hydatid  disease. 

Hydatid  cysts  are  especially  common  in  Iceland,  and  are  frecjuent  in 
Australia  and  South  America,  but  are  very  rare  in  the  United  States.  .  In  the 
United  States  91  per  cent,  of  cases  occur  in  foreigners  (Lyon).  Hydatid  cysts 
are  due  to  echinococci.  The  adult  echinococcus  is  the  tapeworm  of  the  dog 
(taenia  echinococcus),  and  its  ova  or  larvae  gain  access  to  man's  body  by 
accompanying  the  food  he  eats  and  passing  into  the  alimentary  canal,  from 
w^hich  situation  they  are  transported  to  various  organs  by  the  blood.  Osier 
says  the  embryo  (which  has  six  booklets)  burrows  through  the  wall  of  the 
bowel  and  enters  the  peritoneal  cavity  or  muscles;  it  may  enter  the  p>ortal 
vessels  and  reach  the  liver,  or  may  enter  the  systemic  circulation  and  pass 
to  distant  parts.  The  danger  depends  on  two  factors :  "  the  situation  and 
the  liabiUty  of  the  cyst  to  suppurate"  (Sidney  Coupland).  The  organs  most 
usually  attacked  are  the  hver  and  lung.  In  60  per  cent,  of  cases  the  liver 
suffers,  and  in  12  per  cent,  the  lung  (Thomas).  Lyon  estimates  that  the  liver 
is  the  seat  of  disease  in  73  per  cent,  of  cases.  Cysts  sometimes  arise  in  the 
intestine,  genito-urinary  passages,  brain,  or  spinal  canal.  When  the  embr}'o 
lodges,  the  booklets  disappear  and  a  cyst  is  formed.  This  c}'St  is  composed 
of  two  layers,  an  outer  capsule  (cuticular  membrane)  and  an  inner  layer 
(endocyst) .  The  cyst  contains  clear  saline  fluid.  As  the  cyst  grows,  daughter- 
cysts  bud  out  from  the  wall  of  the  mother-cysts,  the  structure  of  the  daughter- 
cysts  being  identical  with  that  of  the  mother-cysts.  From  the  lining  mem- 
brane of  all  the  cysts,  after  a  time,  growths  arise  known  as  scolices,  which 
represent  the  head  of  the  echinococcus  and  exhibit  four  sucking  disks  and  a 
row  of  booklets  (Osier). 

The  fluid  is  not  albuminous,  is  occasionally  saccharine,  is  thin  and  clear, 
and  may  contain  scolices  or  booklets. 

A  hydatid  cyst  may  calcify,  may  rupture,  or  may  suppurate.  These 
cysts  are  very  firm,  but  usually  fluctuate.  Palpation  with  one  hand  while 
percussion  is  practised  with  the  other  gives  a  persistent  tremor  {hydatid 
fremitus).  If  the  cyst  can  be  safely  reached,  some  fluid  should  be  drawn 
and  examined  for  diagnostic  purposes.  WTien  a  cyst  suppurates,  positive 
constitutional  and  local  s\-mptoms  arise.  Hydatid  cysts  of  the  brain  and 
cord  tend  to  produce  death  in  the  same  manner  as  do  tumors.  A  cyst  of 
the  liver  may  rupture  into  the  pleural  sac,  into  the  belly  cavity,  into  the 
stomach,  or  into  the  bowel,  producing  shock,  hemorrhage,  and  probably 
death.  In  rare  cases  hydatid  cysts  rupture  into  the  pericardium  or  into  a 
great  abdominal  blood-vessel,  or  externally.  Rupture  into  the  bile-passages 
is  usually  followed  by  suppuration  of  the  cyst.  Suppuration  of  a  cyst  may 
follow  uncleanly  tapping.  It  has  been  recently  pointed  out  that  eosino- 
philia  is  noted  in  most  persons  suffering  from  hydatid  disease. 

Treatment:  An  unruptured  hydatid  cyst  of  a  superficial  structure  should 
be  incised  and  the  sac-wall  should  be  dissected  out.  Hydatids  of  the  brain 
have  been  successfully  removed  in  Australia.  A  cyst  of  the  kidney  is  re- 
moved through  a  lumbar  incision.     Omental  cvsls  should  be  radically  re- 


400  Tumors  or  Morbid  Growths 

moved  if  possible;  if  this  is  not  possible,  open  the  abdomen,  surround  the 
cyst  with  gauze,  evacuate  through  a  trocar,  stitch  the  cyst-wall  to  the  wound, 
incise,  irrigate,  and  drain  with  gauze.  Bond  advocated  evacuating  the 
cyst,  closing  it  with  sutures,  and  dropping  it  back  in  the  abdomen.  Gardner 
says  tapping  is  dangerous,  as  it  may  cause  rupture  of  the  cyst.  In  a  hydatid 
of  the  liver  the  abdomen  should  be  opened,  the  cyst  should  be  surrounded 
with  gauze  pads,  and  tapped  with  a  trocar  and  cannula.  When  the  cyst 
is  emptied  of  fluid  it  is  grasped  with  forceps  and  pulled  to  the  incision  in 
the  abdominal  wall;  it  is  sutured  to  this  incision,  the  trocar  opening  is  en- 
larged, and  the  endocyst  is  removed  by  irrigation.*  This  operation  is  called 
marsupialization.  If  the  cyst  is  on  the  summit  of  the  liver,  it  may  be  reached 
by  a  transpleural  hepatotomy.  If  aspiration  is  performed  to  settle  a  diagnosis, 
operate  at  once  after  doing  it,  because  of  fear  that  the  cyst  may  leak  and 
disseminate  the  disease  throughout  the  peritoneal  cavity.  If  hydatid  fluid 
is  disseminated  throughout  the  peritoneal  cavity,  it  may  or  may  not  lead 
to  the  development  of  new  cysts,  but  it  is  almost  certain  to  cause  a  febrile 
condidon  known  as  Jiydaiid  toxemia.  Brewer  ("Annals  of  Surgery,"  April, 
igo8),  in  operating  on  a  case  of  hydatid  cyst  of  the  liver,  wounded  the  portal 
vein  and  was  obliged  to  tie  it.  The  patient  recovered.  That  there  was  no 
failure  of  nutrition  Brewer  attributes  to  the  fact  that  the  vein  had  been  long 
pressed  upon  and  the  collaterals  were  dilated  when  ligation  was  performed. 
*  John  O'Conor,  of  Buenos  Ayres,  in  Annals  of  Surgery,  May,  1897. 


Wounds  of  the  Pericardium  and  Heart  401 

XVIII.    DISEASES   AND    INJURIES   OF  THE    HEART   AND 

VESSELS. 

Heart  and  Pericardium. — In  acute  pulmonary  congestion  the  venous 
side  of  the  heart  is  o\er(hstended  with  blood,  and  the  surgeon  in  desperate 
cases  may  tap  the  right  auricle  (see  Paracentesis  Auriculi).  Pericardial  effu- 
sion, if  severe,  calls  for  aspiration  or  incision,  and  purulent  pericarditis 
demands  incision  and  drainage. 

Rupture,  Wounds  and  Injuries.— Rupture.— The  heart  may  rupture 
and  cause  instant  death,  but  rupture  may  not  be  instantly  fatal.  Curtin 
reported  a  case  in  which  death  did  not  occur  for  over  twenty-four  hours. 
Eisner  reported  a  case  of  rupture  in  which  hfe  was  prolonged  for  ten  days. 
One  case  lived  eleven  days.  In  cases  in  which  death  does  not  occur  rapidly 
the  rupture  must  be  so  small  that  very  little  blood  escapes.  Rupture  occurs 
in  a  damaged  heart,  a  heart  in  which  the  muscular  fiber  is  fatty,  is  fibroid, 
or  is  necrotic  from  suppuration.  It  may  be  traumatic,  resulting  from  a 
fall  or  a  blow  upon  the  chest,  or  non-traumatic,  following  a  great  effort  or 
strain.  If  death  does  not  at  once  take  place  the  pulse  becomes  very  rapid, 
there  is  precordial  pain,  dyspnea,  cyanosis,  feeble  heart-sounds,  rapid  respira- 
tion, great  restlessness,  collapse,  and  syncope,  and  the  development  of  a  tri- 
angular area  of  dulness.  Positive  diagnosis  is  impossible.  Meyer  collected 
36  cases  of  rupture  of  the  heart  reported  since  1870.  Death  occurs  from 
accumulation  of  blood  in  the  pericardium.  Aspiration  is  useless,  as  fresh 
blood  replaces  what  is  withdrawn.  Suturing  must  fail  in  non-traumatic 
cases  because  of  the  badly  diseased  myocardium.  In  traumatic  cases  it 
may  possibly  succeed. 

Wounds  of  the  Pericardium  and  Heart.— Severe  wounds  usually, 
though  not  always,  produce  death,  but  slight  wounds  may  not  prove  fatal. 
It  is  a  popular  impression  that  the  expression  "stabbed  to  the  heart "  is  another 
way  of  saying  that  instant  death  has  occurred.  This  view  was  accepted  even 
by  surgeons  during  many  centuries.  During  the  sixteenth  century  sportsmen 
found  now  and  then  bullets  and  arrow-tips  healed  in  the  heart- walls  of  animals 
they  had  slain.  At  this  time  the  famous  case  of  a  duelist  was  pubhshed  by 
Pare.  This  man  received  a  sword  thrust  in  the  heart,  but  was  able  to  run 
after  his  opponent  many  hundred  feet  before  falling  down  in  death.  (See 
"An  Experimental  Investigation  of  the  Treatment  of  Wounds  of  the  Heart," 
by  Charles  A.  Elsberg,  in  "The  Journal  of  Experimental  Medicine,"  Sept. 
and  Nov.,  1899.)  From  Pare's  time  until  our  own  it  has  been  recognized 
by  surgeons  that  a  wound  of  the  heart  does  not  of  necessity  produce  immediate 
death  and  may  even  be  recovered  from. 

In  1867  G.  Fisher  published  a  study  of  452  cases  of  w^ound  of  the  heart, 
and  pointed  out  the  surprising  fact  that  from  7  to  10  per  cent,  of  such  cases 
recover.  In  recent  years  Rosenthal,  Block,  Del  Vechio,  and  others  have 
proved  by  animal  experimentation  not  only  that  cardiac  wounds  are  not  of 
necessity  instantly  fatal,  and  that  in  some  cases  they  may  be  recovered  from, 
but  that  the  suturing  of  such  wounds  is  possible  and  greatly  enhances  the 
chance  of  recovery.  L.  L.  Hill  ("Med.  Record,"  Nov.  29,  1902)  shows  that 
although  90  per  cent,  of  heart-wounds  are  penetrating,  only  19  per  cent,  are 
26 


402  Diseases  and  Injuries  of  the  Heart  and  V'essels 

immediately  fatal.  Sudden  death  occurs  when  Kronecker's  coordination 
center  is  damaged.  Several  times  during  post-mortem  examinations  on  human 
beings  healed  scars  have  been  found  upon  the  heart.  The  heart  has  been 
punctured  a  number  of  times  accidentally  or  intentionally,  and  death  has  not 
ensued.  John  B.  Roberts,*  of  Philadelphia,  suggested  in  1881  that  it  would 
be  proper  to  try  to  suture  wounds  of  the  heart. 

Symptoms. — A  wound  of  the  heart  causes  hemorrhage,  usually  copious; 
but  owing  to  the  interlocking  of  muscular  fibers  the  hemorrhage  is  often  shght. 
Bleeding  may  take  place  into  the  pericardial  sac  in  some  cases  where  the 
pericardium  has  been  injured  and  the  heart  has  escaped.  Such  an  injury 
is  occasionally  inflicted  by  the  sharp  end  of  a  fractured  rib.  The  wound  is 
rarely  at  or  near  the  apex  of  the  sac.  In  most  cases  the  pleural  cavity  is 
opened  and  severe  hemothorax  occurs.  The  lung  may  or  may  not  be  injured. 
A  wound  of  the  pericardium  or  heart  causes  profound  shock,  irregular  or 
very  weak  pulse,  sighing  respiration,  dyspnea,  and,  it  may  be,  the  signs  of 
hemopericardium,  pneumopericardium,  or  hemothorax.  In  hemopericar- 
dium  splashing  sounds  are  heard  with  the  heart-beats  and  the  heart  sounds 
are  very  feeble.  In  pneumopericardium  there  is  a  t}Tnpanitic  percussion- 
note  in  the  area  which  should  exhibit  the  cardiac  dulness.  There  may  or 
may  not  be  serious  external  bleeding.  Fatal  concealed  hemorrhage  may  occur. 
Pain  is  constant,  and  attacks  of  syncope  are  the  rule.  The  position  of  the 
wound  and  the  e\idences  of  hemorrhage  may  aid  in  making  the  diagnosis. 
Death  is  apt  to  occur  suddenly  from  shock,  hemorrhage,  and  inability  of  the 
heart  to  contract  because  of  the  severed  fibers,  or  inability  of  the  heart  to 
dilate  because  of  the  pressure  of  blood  in  the  pericardial  sac.  If  a  wound 
of  the  pericardium  or  heart  does  not  cause  death  during  the  first  day  or  two 
inflammation  follows  (traumatic  pericarditis  or  carditis)  and  the  patient  may 
die  of  suppurative  pericarditis  or  of  empyema. 

Treatment. — Wounds  of  the  pericardium  and  heart  should  be  sutured. 
We  should  explore  if,  from  the  location  of  the  wound  and  the  symptoms,  we 
suspect  a  cardiac  wound.  I  agree  with  Vaughn,  that  if  there  is  a  wound  in  the 
cardiac  region  and  if  the  symptoms  threaten  hfe,  exploration  should  be  per- 
formed at  once.  In  a  doubtful  case  exploration  should  be  made  by  enlarging 
the  wound  and  should  be  done  under  local  anesthesia.  In  operating  for  a 
heart-wound  the  cutaneous  surface  should  be  rapidly  disinfected,  and  ever}- 
efi^ort  must  be  made  to  antagonize  shock  during  the  operation.  The  patient 
should  be  WTapped  in  hot  blankets  and  surrounded  with  hot  bottles  or  hot- 
water  bags,  or  should  be  placed  upon  a  table  composed  of  pipes  in  which  hot 
water  circulates.  The  foot  of  the  bed  should  be  raised.  Hot  sahne  fluid  con- 
taining adrenahn  chlorid  should  be  infused  into  a  vein,  or,  in  desperate  cases, 
into  an  arter}-.  The  extremities,  except  the  one  selected  to  infuse  salt  solution 
in,  should  be  bandaged  (autotransf usion) ,  an  enema  of  hot  coflfee  and  whisky 
should  be  given,  and  atropin  should  be  injected  hypodermatically.  It  is  wiser, 
in  most  cases,  to  give  a  general  anesthetic  than  not  to  give  it.  Local  anesthesia 
is  slow  and  unsatisfactor}-.  Without  an  anesthetic  the  patient  will  probably 
struggle,  and  strugghng  is  xevy  dangerous,  as  it  loosens  clots  and  permits  hemor- 
rhage to  begin  again  (L.  L.  Hill  in  "Med.  Record,"  Sept.  19,  1908).  Chloro- 
form is  the  anesthetic  used.  If  the  patient  is  unconscious  and  the  corneal 
*  The  author,  in  Progressive  Medicine,  vol.  i,  1899. 


Treatment  of  Wounds  of  Pericardium  and  Heart  403 

reflex  is  abolished,  no  anesthetic  should  be  given.  The  heart  is  exposed 
by  resecting  several  ribs.  In  a  knife-wound  of  the  right  pleural  cavity  and 
right  side  of  the  pericardium,  Barth,  of  Danzig,  removed  i  inch  from  each 
of  three  right  costal  cartilages  (fifth,  sixth,  and  seventh),  close  to  the  side  of  the 
sternum,  and  removed  also  the  ensiform  cartilage  and  i  inch  of  the  sternum. 
The  same  surgeon,  in  the  case  of  a  man  stabbed  in  the  fourth  left  intercostal 
space,  removed  the  fourth  and  fifth  left  costal  cartilages  and  part  of  the  sternum 
("Deutsche  Zeitschrift  fur  Chirurgie,"  Bd.  Ixix,  No.  i).  Schv^^erin,  of  Berlin, 
in  a  stab-wound  of  the  chest  exposed  the  heart  by  resecting  the  fourth  and  a 
portion  of  the  fifth  left  ribs  (Proceedings  of  Oerman  Surgical  Congress,  1903). 
Wilms  (" Centralblatt  f.  Chirurgie,"  Leipzic,  vol.  xxxiii,  No.  22),  in  a  case  of 
gunshot-wound,  obtained  access  to  the  anterior  and  posterior  surfaces  of  the 
heart  by  a  simple  intercostal  incision.  Parrozzani  makes  a  trap-door  in  the 
chest,  the  hinges  of  the  door  being  the  rib  cartilages.  In  exposing  the  heart 
Giordono  enters  along  the  wound,  removing  any  obstacles  that  intervene 
(Barth).  It  is  needless  to  try  to  avoid  opening  the  pleura  if  a  flap  with  an 
internal  hinge  is  used;  it  has  usually  been  opened  by  the  accident,  and  in  any 
case  can  very  seldom  be  avoided.  Matas  advises  Spangaro's  intercostal 
incision.  The  mammary  vessels  are  tied  and  the  width  of  the  intercostal 
space  is  greatly  increased  by  strongly  retracting  the  ribs  and  cartilages.  If 
more  space  is  needed  the  incision  is  carried  upward  at  the  junction  of  the  carti- 
lages and  sternum.  The  heart  is  exposed,  clots  are  removed  from  the  peri- 
cardial sac,  and  the  sac  is  irrigated  with  hot  saline  fluid.  The  bleeding  may 
be  furious.  A  non-penetrating  wound  of  the  ventricle  may  bleed  so  profusely 
during  systole  as  to  resemble  a  penetrating  wound  (Sherman) .  A  penetrating 
wound  may  bleed  most  during  diastole.  The  motions  of  the  chest  make  ma- 
nipulation difficult.  It  is  wise  to  insert  two  traction  sutures  in  order  to  lift  the 
heart  toward  the  operator.  A  wound  in  the  heart  is  sutured  with  interrupted 
sutures  of  catgut,  which  are  passed  by  means  of  a  round,  curved  needle,  and  if  a 
cavity  of  the  heart  is  open  each  suture  includes  the  whole  thickness  of  the 
heart-wall  except  the  endocardium.  It  has  been  said  that  the  sutures  should 
be  tied  during  diastole,  othervdse  they  are  apt  to  cut  out,  but  Profs.  Gibbon  and 
Stewart  tell  me  that  in  their  cases  such  a  procedure  was  impossible  because  of 
the  very  rapid  action  of  the  heart.  As  few  stitches  are  used  as  will  efficiently 
close  the  wound.  Numerous  stitches  cause  extensive  degeneration  of  muscular 
fiber  and  stitch  holes  may  permit  leaking.  The  pericardium  is  sutured 
vrith  silk  or,  as  waS  done  in  one  successful  case  (Rehn),  the  sac  is  packed 
vrith  iodoform  gauze.  It  is  not  absolutely  necessary  to  drain  the  pericardial 
sac.  Clots  are  removed  from  the  pleural  sac  by  irrigation  with  hot  saline 
solution,  pulmonary  bleeding  is  arrested  by  the  suture  or  by  packing,  and  a 
wound  in  the  lung,  especially  if  it  communicates  with  the  air-passages,  is 
sutured  if  the  patient's  condition  justifies  prolonging  the  operation.* 

After  such  an  operation  the  patient  is  in  great  danger  and  every  effort 
should  be  made  to  save  him  from  shock.  In  performing  operations  upon  the 
heart  the  pleura  is  almost  always  opened,  and  if  it  is  open  there  is  always 
pneumothorax  and  grave  danger  of  pulmonary  collapse  and  overwhelming 
shock.  It  is  a  great  advantage  in  such  cases  to  have  at  hand  an  apparatus 
which  will  prevent  or  amend  pulmonary  collapse  (see  page  894). 

*  The  author,  on  "  Suture  of  the  Heart,"  in  Progressive  Medicine,  vol.  i,  1899. 


404  Diseases  and  Injuries  of  the  Heart  and  Vessels 

One  hundred  and  sixt}'  cases  of  heart  suture  are  now  upon  record.  In 
1881  Dr.  John  B.  Roberts,  of  Philadelphia,  suggested  that  heart-wounds 
should  be  sutured.  In  1887  Dr.  Harvey  Reed  sutured  a  wounded  pericar- 
dium and  the  patient  recovered.  In  1891  Dalton,  of  St.  Louis,  obtained 
recovery  by  a  similar  operation.  The  first  operation  on  a  wounded  human 
heart  was  performed  in  1896  by  Farina,  of  Rome.  The  patient  had  been 
stabbed  in  the  right  ventricle.  The  wound  was  sutured,  but  he  died  of  pneu- 
monia on  the  sixth  day.  Rehn,  of  Frankfort,  in  i8g6  sutured  a  wound  of 
the  heart  and  packed  the  pericardium  with  gauze,  and  the  patient  recovered. 
Among  others  reporting  cases  are  Cappelan,  Peyrot,  Williams,  Earth  (in  this 
case  the  internal  mammary  artery  was  also  injured),  Wilms,  Hill,  Sherman, 
Harte,  Gibbon,  Stewart,  Guinard,  Sultan,  Gumming  and  Beattie,  Wolff, 
Picque,  Lenormand,  and  Parozani.  There  have  been  3  successful  cases  in 
Philadelphia,  Gibbon's  case  and  Stewart's  2  cases.  I  have  never  operated 
for  a  wound  of  the  heart.  According  to  Hill,  the  right  ventricle  is  most  often, 
the  left  auricle  least  often,  injured;  wound  of  the  auricle  is  generally  con- 
sidered to  be  more  dangerous  than  wound  of  the  ventricle;  and  wound  of  the 
apex  is  less  dangerous  than  either.  Peck  points  out,  however,  that  there  are 
II  reported  cases  of  auricle  wounds  with  4  deaths,  a  mortality  of  36.3  per 
cent.,  while  the  general  mortality  of  heart  wounds  is  about  64  per  cent. 
("Annals  of  Surgery,"  July,  1909).  A  needle  puncture  rarely  causes  serious 
bleeding  from  a  ventricle,  but  is  very  apt  to  cause  severe  bleeding  from  an 
auricle.  A  wound  received  during  diastole  is  less  dangerous  than  one  received 
during  systole.  Wounds  of  the  right  heart  bleed  more  than  wounds  of  the  left 
heart.  Wolff  points  out  that  hgation  of  one  coronary  artery  can  be  done  and 
recovery  follow;  wounds  of  the  left  ventricle  give  the  best  prognosis  because 
the  wound  is  closed  by  thick  edges  of  muscle;  in  37  cases  the  left  pleura  was 
opened,  in  3  the  right  pleura,  and  in  2  the  pleura  was  uninjured.  In  bullet- 
wounds  death  usually  occurs  before  operation  can  be  done  (Wolf,  "Deutsche 
Zeitschrift  fiir  Chirurgie,"  Bd.  Ixix,  No.  i).  Without  operation  the  mortality 
.will  be  at  least  90  per  cent.     With  operation  it  ^\^ll  be  about  60  per  cent. 

Matas  ("Southern  Med.  Jour.,"  August,  1908)  discusses  160  cases  of  heart 
wound  with  43.83  per  cent,  of  recoveries.  In  134  cases  the  wound  was  sutured 
with  49  recoveries.  In  11  cases  it  was  exposed,  but  was  not  sutured,  and  5 
recovered.     In  5  cases  foreign  bodies  were  removed  with  success. 

In  Peck's  table  ("Annals  of  Surgery,"  July,  1909)  there  are  69  wounds  of 
the  right  ventricle  with  48  deaths  (69.6  per  cent.);  74  of  the  left  ventricle 
with  45  deaths  (60.8  per  cent.) ;  5  of  the  left  auricle  with  2  deaths  (40  per 
cent.);  6  of  the  right  auricle  with  2  deaths  (33.3  per  cent.);  and  7  mis- 
cellaneous cases  with  5  deaths  (71.5  per  cent.),  a  total  of  160  cases  with  58 
recoveries  and  102  deaths;  a  mortality  of  63.7  per  cent. 

The  immediate  dangers  of  the  operation  are  hemorrhage,  shock,  and  the 
entrance  of  air.  The  late  dangers  are  pericarditis,  empyema,  and  pneumonia 
(Vaughan) .  Traumatic  carditis  or  pericarditis  is  treated  in  the  same  way  as 
idiopathic  cases.  Pus  in  the  pericardial  sac  should  be  evacuated  by  resection 
of  the  fourth  left  costal  cartilage  and  incision  of  the  pericardium  (von  Eisel- 
berg's  case). 

Pericarditis. — Pericarditis  is  an  infectious  condition  that  may  be 
traumatic  or  non-traumatic.     If  pericarditis  follows  an  open  wound,  it  is 


Treatment  of  Pericarditis  405 

obvious  how  the  infection  must  have  entered;  if  it  follows  a  bruise  or  a  con- 
tusion, the  injury  has  rendered  the  pericardium  a  point  of  least  resistance. 
In  some  few  cases,  which  are  known  as  {jrimary  pericarditis,  it  is  impossible 
to  determine  how  the  micro-organisms  gained  entrance.  The  ordinary 
form  appears  as  a  compHcation  of  certain  infectious  diseases,  such  as  sep- 
ticemia, pneumonia,  rheumatism,  and  tuberculosis.  It  may  be  secondary  to 
some  adjacent  infection,  such  as  an  empyema.  A  tuberculous  abscess  may 
break  into  the  pericardium,  and  an  abscess  even  from  a  distant  point  may 
burrow  into  it.  It  may  arise  secondary  to  a  distant  infection,  as  a  suppurating 
wound,  osteomyelitis,  middle-ear  suppuration,  abscess  of  the  mastoid,  ton- 
sillitis, abscesses  anywhere,  peritonitis,  and  gastric  ulcer.  It  sometimes  fol- 
lows gastro-enterostomy  and  may  arise  in  an  individual  -with  Bright's  dis- 
ease. In  a  recently  born  child  infection  of  the  stump  of  the  umbilical  cord 
may  cause  pericarditis.  A  pericardial  effusion  in  a  newborn  child  is  in- 
variably purulent  and  in  a  3-oung  child  it  is  usually  purulent.  In  children 
the  condition  is  usually  associated  with  pulmonary  disease  (Poynton,  in  "Brit. 
Med.  Jour.,"  August  15,  1908) .  A  great  variety  of  bacteria  may  be  responsible 
for  pericarditis.  The  exudation  may  be  serofibrinous;  this  is  an  evidence  of  its 
being  a  mild  infection,  and  such  an  exudate  may  undergo  absorption.  On  the 
other  hand,  the  exudate  may  become  purulent,  and  in  such  a  case  cure  \nll 
never  be  obtained  by  absorption  of  the  pus.  In  pericarditis  there  is  usually 
some  pain  in  the  region  of  the  heart,  and  this  pain  is  apt  to  extend  into  the  left 
arm.  The  heart  is  overacting,  the  heart-sounds  are  indistinct,  the  pulse  is 
strong  and  very  rapid,  there  is  an  increased  area  of  cardiac  dulness,  and  the 
patient  complains  of  dyspnea.  The  temperature  is  elevated  and  a  double 
friction-sound  may  be  made  out  upon  auscultation. 

Treatment. — Ordinary  pericarditis,  without  pus  formation  or  extensive 
effusion,  is  managed  by  the  physician;  but  when  there  is  extensive  effusion 
it  may  be  necessary  to  open  the  pericardium,  and  if  there  is  purulent  effusion 
the  pericardium  must  be  opened.  The  procedure  usually  practised  in  the 
past  to  relieve  pericarditis  with  marked  effusion  was  aspiration.  This,  how- 
ever, is  dangerous.  The  heart  is  not,  as  formerly  taught,  pushed  back  and 
up  by  the  pericardial  effusion,  but  is  lifted  upward  and  forward,  and  may 
be  pushed  to  the  right  or  left  if  there  are  adhesions  between  the  pericar- 
dium and  heart;  and  it  is  impossible  to  select  any  place  for  aspiration  that 
assures  us  that  there  will  be  no  danger  of  puncturing  the  heart.  Le  Conte  and 
many  other  surgeons,  however,  do  not  fear  puncture  and  explore  by  inserting  a 
fine  needle  in  the  fourth  or  fifth  space  of  the  left  side  close  to  the  sternum. 
In  cases  of  extensive  pericardial  effusion,  and  also  in  cases  of  suppuration 
within  the  pericardium,  I  believe  that  i  inch  or  more  of  the  cartilage  of  the 
fourth  rib  of  the  left  side  should  be  removed  or  2  inches  of  the  fourth  rib 
itself,  and  the  pericardial  sac  should  be  exposed  and,  after  exploratory  punc- 
ture, formally  incised.  In  this  operation  it  may  be  necessary  to  tie  the  internal 
mammary'  arter)'.  In  pyopericardium  the  pleural  ca\ity  is  very  seldom 
invaded  because  the  pleural  space  in  front  of  the  pericardium  has  usually  been 
obliterated  by  the  spread  of  the  inflammation.  The  pericardial  sac  is  cleared 
of  purulent  material  and  fibrinous  masses  by  irrigation,  and  the  edges  of 
the  pericardial  wound  are  sutured  to  the  edges  of  the  superficial  wound 
and  gauze  drainage  is  introduced.     Incision   is   safer  and   more   certainly 


4o6  Diseases  and  Injuries  of  the  Heart  and  Vessels 

curative  than  aspiration;  for  whereas  aspiration  might  be  curative  in  peri- 
cardial effusion,  it  cannot  be  so  if  the  effusion  is  purulent.  In  41  cases  of 
purulent  pericarditis  (Roberts'  table  of  35  cases  and  Ljunggren's  6  cases)  oper- 
ated upon,  16  recovered.     Local  anesthesia  is  safer  than  general  anesthesia. 

Phlebitis,  or  Inflammation  of  a  Vein.— Acute  Phlebitis,— Phlebi- 
tis may  be  plastic  or  it  may  be  infective.  Plastic  phlebitis,  while  occa- 
sionally due  to  rheumatism,  to  gout,  to  advanced  phthisis,  to  a  febrile  malady, 
or  to  some  other  constitutional  condition,  usually  takes  its  origin  from  a  wound 
or  other  injur>',  from  the  extension  to  the  vein  of  a  perivascular  inflammation, 
or,  in  the  portal  region,  from  an  embolus.  Varicose  veins  are  particularly 
liable  to  phlebitis.  When  phlebitis  begins  a  thrombus  usually  forms  (see 
Thrombosis,  page  199)  because  of  the  destruction  of  the  endothelial  coat  of  the 
vessel,  and  this  clot  may  give  rise  to  emboli,  may  be  absorbed,  or  may  be  organ- 
ized. An  aseptic  clot  organizes  and  the  vein  becomes  permanently  narrowed 
or  blocked.  A  septic  clot  is  apt  to  soften  and  break  up.  In  the  lower  extrem- 
ities paraphlebitis  is  common  vd\h  slight  involvement  of  coats,  and  a  clot  may 
not  form.  Clot-formation  causes  edema.  Infective  phlebitis  is  a  suppurative 
inflammation  of  a  vein  arising  by  infection,  perhaps  from  suppurating  peri- 
vascular tissues  {infective  thrombophlebitis),  perhaps  from  the  blood-stream,  or 
in  the  portal  system,  perhaps  from  infective  embolism.  It  is  not  unusually 
met  with  in  cellulitis  or  phlegmonous  erj'sipelas,  may  arise  in  the  lateral  sinus 
as  a  result  of  mastoid  suppuration,  or  in  the  liver  from  appendicitis  or  phle- 
bitis of  the  rectal  veins.  Sometimes  as  the  convalescence  from  pneumonia 
begins,  phlebitis  arises  due  to  pneumococci.  A.  thrombus  forms,  the  vein-wall 
suppurates,  is  softened  and  in  part  destroyed,  and  the  infected  clot  softens  and 
gives  rise  to  emboli.  No  bleeding  occurs  when  the  vein  ruptures  or  is  opened, 
as  a  barrier  of  clot  keeps  back  the  blood-stream.  The  clot  of  suppurative 
phlebitis  cannot  be  absorbed  and  cannot  organize.  Septic  phlebitis  causes  pye- 
mia, and  the  infected  clots  of  pyemia  cause  phlebitis  at  the  points  of  lodgment. 

Post-operative  phlebitis  of  the  iliac,  femoral,  or  saphenous  veins  is  not  com- 
monly the  result  of  a  mild  or  attenuated  infection,  but  may  follow  an  abdominal 
operation  when  there  is  no  evidence  of  infection.  According  to  Cordier,  it 
occurs  in  2  per  cent,  of  abdominal  operations.  Strange  to  say,  it  is  most  apt 
to  attack  the  left  iliac,  femoral,  or  saphenous  veins;  it  matters  not  upon  which 
side  the  operation  was  performed.  In  over  90  per  cent,  of  cases  the  left 
femoral  or  left  saphenous  veins  are  attacked  (Cordier,  in  "Jour.  Am.  Med. 
Assoc,"  Dec.  9,  1905).  It  is  most  common  in  anemic  subjects,  especially 
when  anemia  results  from  blood  loss.  It  may  be  due  to  toxins  damaging  the 
inner  coat  of  the  vein,  but  feeble  circulation  is  a  powerful  factor  in  its  pro- 
duction. I  believe,  with  Clark,  that  powerful  traction  on  the  sides  of  an 
abdominal  wound  may  be  responsible  for  it  (see  Thrombosis  after  Abdominal 
Operations,  page  202).  Vanderveer  reported  4  cases  in  which  sepsis  was 
positively  absent  ("American  Medicine,"  July  13,  1901).  I  have  seen  it 
occur  in  the  left  iliac  vein  after  an  interval  operation  for  appendicitis. 
Phlebitis  may  arise  in  the  vein  of  one  extremity,  a  clot  may  form,  and  this 
may  be  absorbed  or  may  organize.  Another  extremity  may  be  involved 
afterward  or  simultaneously.  Post-operative  phlebitis  is  sometimes  responsi- 
ble for  embolic  pneumonia  and  cerebral  embolism.  Many  post-operative 
pneumonias  are  due  to  this  cause. 


Chronic  Phlebitis  407 

Symptoms. — The  symptoms  of  plastic  phlebitis  are  pain,  tenderness  in 
and  around  a  vein,  discoloration  over  it,  and  edema  below  the  seat  of  the 
disease.  Suppurative  phlebitis,  besides  these  conditions,  causes  the  con- 
stitutional symptoms  of  pyemia  (page  212).  Any  thrombus,  if  it  loosens, 
forms  emboli.  It  is  said  that  the  clot  resulting  from  pneumococcic  phlebitis 
forms  so  rapidly  that  it  adheres  slightly  and  is  peculiarly  apt  to  loosen  and  give 
rise  to  emboli  (Pierre,  in  "Gazette  des  Hopitaux,"  Sept.  3,  1904).  Septic 
thrombi  are  apt  to  cause  septic  pneumonia. 

Treatment. — The  treatment  of  plastic  phlebitis  of  an  extremity  com- 
prises rest  in  bed  from  four  to  six  weeks,  slight  elevation  of  the  part,  the 
use  of  cold  for  the  first  twenty-four  hours,  and  then  the  application  of  external 
heat  and  a  flannel  bandage.     If  the  patient  is  gouty  or  rheumatic,  appropri- 


Fig.  168. — Varicose  veins. 

ate  remedies  should  be  given.  A  clot  does  not  always  form  in  an  inflamed 
vein,  but  if  one  forms  there  is  danger  of  embolism;  hence  massage  and  both  ac- 
tive and  passive  movement  are  dangerous  until  the  clot  becomes  firm.  When  a 
vein  is  involved  in  a  suppurative  process  and  septic  thrombophlebitis  exists, 
ligate  or  compress  the  vein  by  packing,  if  possible,  above  and  below  the 
clot,  open  the  vessel,  and  wash  out  the  infected  clot,  or,  if  dealing  with  an 
accessible  vein,  extirpate  the  involved  portion.  This  plan  of  treatment  is 
always  to  be  appUed  in  infective  thrombophlebitis  of  the  lateral  sinus  and 
of  the  internal  saphenous  vein.  The  constitutional  treatment'  is  that  of 
pyemia. 

Chronic    Phlebitis. — This  rare  condition   is    kno\vn  as    phlebosderosis, 
and  it  is  a  chronic  inflammation  of  the  wall  of  a  vein,  producing  a  fibrous 


4o8 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


change  in  the  vascular  coats.  It  may  arise  in  a  part  the  seat  of  chronic  venous 
engorgement,  but  its  most  frequent  cause  is  syphilis.  It  is  met  with  often 
associated  with  arteriosclerosis. 

Varicose  Veins;  Phlebectasis,  Phlebectasia,  or  Varix  (Figs.  168 
and  169). — Definition  and  Causes. — \'aricose  veins  are  unnatural,  irregular 
and  permanently  dilated  veins  which  are  elongated  and  pursue  a  tortuous 
course.  This  condition  is  very  common,  and  20  per  cent,  of  adults  ex- 
hibit it  in  some  degree  in  one  region  or  another.  Some  facts  indicate  heredi- 
tary predisposition.  In  over  80  per  cent,  of  cases  the  trouble  begins  before 
the  age  of  twenty-five.  The  causes  of  varicose  veins  are  said  to  be  obstruc- 
tion to  venous  return  and  weakness  of  cardiac  action,  which  lessens  the  pro- 


Fig.  i6g. — Varicose  veins. 


pulsion  of  the  blood-stream.  A.  Pearce  Gould  says  obstruction  is  not  a 
cause,  because  in  pregnancy  varicose  veins  may  be  seen  early,  before  the 
womb  is  much  enlarged.  The  real  cause  is  probably  a  predisposition  to  the 
growth  of  vein-tissue,  which  leads  to  valve  failure  and  a  regurgitation  of 
blood  from  the  deep  veins  into  the  superficial  venous  channels  (A.  Pearce 
Gould,  in  "Lancet,"  March  i  and  15  and  June  7,  1902).  As  Billroth  said 
over  thirty  years  ago,  sudden  obstruction  causes  edema  and  gradual  ob- 
struction a  free  collateral  circulation.  Neither  sudden  nor  gradual  obstruc- 
tion can  cause  varicosity  unless  the  veins  are  predisposed  by  a  tendency 
hereditary  or  acquired. 

Varicose  veins  may  occur  in  any  portion  of  the  body,  but  are  chiefly  met 
with  on  the  inner  side  of  the  lower  extremity,  in  the  spermatic  cord,  and  in 
the  rectum.     Varix  in  the  leg  is  met  with  most  commonly  during  and  after 


Varicose  Veins;  Phlebectasis,  Phlebectasia,  or  Varix  409 

pregnancy  and  in  persons  who  stand  upon  their  feet  for  long  periods.  It  is 
especially  common  in  the  long  saphenous  vein,  which,  being  subcutaneous, 
has  no  muscular  aid  in  supporting  the  blood-column  and  in  urging  it  on. 
The  deep  as  well  as  the  superficial  veins  may  become  varicose.  Verneuil 
maintained  that  varix  of  the  superficial  veins  is  almost  always  secondary  to 
varix  of  the  deep  veins,  a  radical  view  which  seems  improbable.  It  is  cer- 
tain, however,  that  after  contusions  of  the  leg  it  is  not  unusual  for  the  deep 
veins  to  become  filled  with  clot  and  for  the  superficial  veins  to  dilate  nota- 
bly. By  the  term  "caput  meduscB"  is  meant  dilated  veins  radiating  from 
the  umbilicus.  The  veins  of  the  esophagus  may  become  varicose,  and  this 
malady  is  commonly  unrecognized  clinically.  Varicose  veins  are  in  rare 
instances  congenital;  but  they  are  most  often  seen  in  the  aged,  and  usually 
are  first  observed  between  the  ages  of  twenty  and  forty.  They  are  more  com- 
mon in  women  than  in  men,  owing,  it  is  believed,  to  the  influence  of  pregnancy. 

Varix  of  the  spermatic  cord  is  known  as  "varicocele."  It  is  apt  to  appear 
about  the  time  of  puberty,  and  most  adult  men  have  at  least  a  slight  varico- 
cele. Varix  is  more  likely  to  appear  in  the  left  spermatic  vein  than  in  the 
vein  of  the  right  side,  because  the  left  spermatic  vein  has  no  valves  (Brinton). 

Varicose  tumors  of  the  rectum  constitute  "hemorrhoids"  or  "piles." 
Piles  are  caused  by  obstruction  to  the  upward  flow  in  the  hemorrhoidal  veins, 
either  by  obstructive  liver  disease,  enlargement  of  the  uterus  or  prostate,  or 
the  presence  in  the  rectum  of  fecal  masses  in  a  person  habitually  constipated. 

A  vein  under  pressure  may  dilate  more  at  one  spot  than  at  another,  the 
distention  being  greatest  back  of  a  valve  or  near  the  mouth  of  a  tributary. 
The  valves  become  incompetent  and  the  dilatation  becomes  still  greater, 
Callender  has  pointed  out  that  varix  is  apt  to  begin  where  the  deep  vessels 
join  the  superficial  veins.  At  this  point  Treves  says  three  forces  meet:  the 
blood-column  above,  the  valve  below,  and  the  force  of  the  blood-current. 
At  the  spot  where  the  pressure  is  greatest  the  vein-wall  dilates,  and  from 
this  dilatation  the  blood-current  is  deflected  and  causes  another  dilatation 
higher  up  and  on  the  opposite  side  of  the  vessel.  The  blood  is  again  deflected 
and  causes  another  dilatation,  and  so  on  (Agnew).  The  vein- wall  may 
become  fibrous,  but  usually  it  is  thin  and  sometimes  it  ruptures.  The 
veins  not  only  dilate,  but  they  also  become  longer,  and  hence  do  not  remain 
straight,  but  twist  and  assume  a  characteristic  form.  It  seems  probable 
that  the  first  step  in  the  process  is  a  growth  of  new  venous  tissue  (A.  Pearce 
Gould)  and  then  foUow  lengthening,  tortuosity,  incompetence  of  the  valves, 
and  dilatation  of  the  vessel. 

Delbet*  points  out  that  varicose  veins  of  the  leg,  which  begin  in  the 
thigh,  result  from  valvular  incompetence;  varicose  ulcers  arise  from  variations 
of  pressiu-e  due  to  valvular  incompetence.  This  incompetence  of  the  valves 
does  harm  by  aUowing  the  intravenous  pressure  to  equal  the  pressure  in  the 
arterioles,  a  condition  which  arrests  capillary  circulation,  causes  conges- 
tion, and  greatly  lowers  tissue-resistance.  Incompetent  valves  also  favor 
ulceration  by  developing  a  vicious  venous  circle  first  described  by  Trendelen- 
burg. Blood  passing  through  this  circle  loses  nutritive  elements.  Tren- 
delenbiu-g  has  described  the  vicious  circle  as  foUows:  Blood  in  the  saphenous 
vein  flows  toward  the  periphery  instead  of  toward  the  center,  because  of  in- 
*  Sem.  med.,  Oct.  13,  1897. 


4IO  Diseases  and  Injuries  of  the  Heart  and  Vessels 

competent  valves — it  passes  into  the  veins  which  connect  the  superficial  veins 
with  the  deep  veins  and  then  enters  the  tibial  and  peroneal  veins.  It  passes 
from  the  tibial  and  peroneal  into  the  pophteal  and  femoral  veins,  and  some 
of  it  leaves  the  femoral  vein  and  again  enters  the  saphenous. 

The  skin  over  varicose  veins  in  the  leg  is  often  discolored  by  pigmenta- 
tion due  to  red  blood-cells  having  escaped  from  the  vessel  and  broken  up. 
The  tissues  around  a  varicose  vein  become  atrophied  from  pressure,  and  it 
is  not  unusual  to  meet  with  a  very  large  vein  whose  thin  walls  are  in  close 
contact  with  skin.  In  this  condition  rupture  and  hemorrhage  are  probable. 
When  the  vein-wall  forms  a  pouch-like  dilatation  the  condition  is  spoken 
of  as  a  cyst.  Varicose  veins  are  apt  to  inflame,  and  thrombosis  frequently 
occurs.  When  a  thrombus  forms,  emboli  may  be  broken  off  and  carried  into 
the  circulation,  especially  if  the  patient  walks  about.  The  formation  of  emboli 
is  not  nearly  so  common  as  a  result  of  thrombosis  in  a  varicose  vein  as  in 
thrombosis  in  an  undistended  and  unelongated  vessel.  In  varicose  veins 
of  the  thigh,  however,  the  chance  of  embolism  following  thrombosis  is  much 
greater  than  when  the  veins  of  the  leg  alone  are  involved.  In  some  elderly 
people  thrombus  actually  effects  spontaneous  cure.  When  a  thrombus 
organizes,  more  or  less  calcification  is  apt  to  ensue,  and  a  vein-stone  or  phleb- 
olith  is  formed.  After  middle  life  many  varicosities  remain  stationary 
or  cease  to  give  trouble.  The  chief  complications  of  varicose  veins  of  an 
extremity  are  thrombosis,  edema,  violent  hemorrhage  from  rupture,  phlebitis, 
eczema,  and  chronic  ulceration. 

Treatment. — The  treatment  of  varix  may  be  palliative  or  curative,  but 
whichever  plan  is  followed,  the  surgeon  should  endeavor  first  of  all  to  remove 
the  exciting  cause.  An  essential  part  of  palliative  treatment  is  to  attend  to 
the  general  health,  to  keep  up  the  force  and  activity  of  the  circulation,  and 
to  prevent  constipation.  Massage  is  useful,  especially  alcohol  frictions,  if 
eczema  is  absent,  and  cold  baths  are  always  forbidden  (Bennett).  The  patient 
should  exercise  regularly  in  the  open  air  and  should  lie  down  for  a  time,  if  possi- 
ble, every  afternoon.  Instead  of  lying  down  for  a  time  during  each  day,  he  may 
sit  down  and  elevate  the  legs,  resting  them  on  a  table,  and  thus  assuming  a 
position  supposed  to  be  peculiarly  American.  If  there  is  no  pain,  distinct 
discomfort,  or  edematous  swelling,  a  support  is  unnecessary,  but  if  these  con- 
ditions exist  it  is  needed.  If  a  support  is  required  in  varix  of  the  leg,  use 
a  flannel  roller  or  a  perforated  rubber  bandage  applied  over  a  long  stocking. 
Such  a  bandage  supports  the  veins  and  drives  the  blood  into  the  deeper  ves- 
sels which  have  muscular  support.  The  use  of  a  rubber  pad  filled  with 
glycerin  and  applied  over  the  saphenous  vein  so  as  to  support  the  blood-col- 
umn and  act  as  a  valve,  has  been  recommended.  Locally,  in  varicocele,  pour 
cold  water  upon  the  scrotum  twice  a  day  and  order  the  patient  to  wear  a 
suspensory  bandage.  Locally,  in  hemorrhoids,  use  injections  of  ice-water 
and  astringent  suppositories.  A  purely  local  varix  should  be  excised,  because 
there  is  always  danger  of  injury,  and  consequently  of  hemorrhage  or  throm- 
bosis. If  the  superficial  veins  have  dilated  because  of  thrombosis  of  the  deep 
veins  and  edema  exists,  operation  is  contraindicated,  as  its  performance 
might  lead  to  permanent  edema.  If  the  disease  involves  the  leg  only,  opera- 
tive treatment  is  rarely  required  and  may  even  do  harm.  Such  cases  are 
operated  upon  if  there  are  cyst-like  dilatations,  if  thrombi  form,  and,  as 


Acute  Arteritis  411 

Bennett  points  out,  if  a  thin-walled  vein  crosses  the  tibia,  and  is  thus  exposed 
to  the  danger  of  injury  and  thrombosis.* 

If  the  leg  is  involved  in  the  process,  and  the  saphena  in  the  thigh  is  also 
varicose,  operation  should  be  performed. 

If  a  thrombus  forms  in  a  varicose  vein,  tie  the  vein  above  and  below  the 
clot,  divide  the  vessel  in  two  places,  and  remove  the  vein  and  the  clot  within 
it.  Thrombosis  of  a  varicose  vein  is  not  so  apt  to  lead  to  emboli  as  throm- 
bosis in  a  non-varicose  vein,  but  it  may  do  so,  and  the  condition  is  dangerous. 

If  edema  is  marked,  and  increases  in  spite  of  properly  applied  bandages, 
etc.,  it  probably  signifies  clot-formation,  and  the  patient  should  remain  in 
bed  until  this  question  is  determined.  Hemorrhage  from  a  ruptured  varicose 
vein  of  an  extremity  is  usually  readily  arrested  by  compression  and  elevation. 

The  radical  treatment  of  varix  of  the  leg  often  does  good,  often  relieves 
some  annoying  condition,  but  rarely  absolutely  cures  (W.  H.  Bennett). 
There  are  several  methods  of  operation:  ligation  with  excision  of  part  of  the 
vein,  exposure  and  ligation  of  the  vein  below  the  saphenous  opening,  or  cir- 
cular incision  around  the  leg  (see  Operations  upon  Vessels). 

Nevus. — (See  Tumors.) 

Arteritis,  or  inflammation  of  an  artery,  is  acute  or  chronic. 

Acute  Arteritis. — Shght  inflammation  is  by  no  means  unusual,  but 
severe  arteritis  is  decidedly  rare.  It  may  follow  direct  injury  or  arise  secon- 
darily to  a  perivascular  inflammation.  An  artery  is  very  resistant  to  the 
spread  of  inflammation,  but  we  sometimes  encounter  suppurative  arteritis 
in  a  suppurating  area.  Arteritis  may  arise  in  the  course  of  an  infective 
malady,  being  produced  by  germs,  but  it  is  also  found  in  intoxications,  and 
is  then  due  purely  to  toxins.  It  may  occiur  in  the  eruptive  fevers,  in  influ- 
enza, typhoid  fever,  acute  rheumatism,  gout,  syphilis,  and  diphtheria,  sep- 
ticemia and  septic  intoxication.  Ford  points  out  that  acute  arteritis  devel- 
oping during  acute  or  chronic  infections  is  particularly  apt  to  arise  in  the 
lower  extremities  (Ford,  "These  de  Paris, "  1901).  Toxins  or  bacteria  usually 
reach  the  artery  in  the  main  blood-stream,  but  may  be  lodged  in  the  vessel- 
wall  by  the  lymph  or  the  flow  in  the  vasa  vasorum.  The  inner  coat  of  a  portion 
of  an  artery  becomes  lined  with  inflammatory  exudate  and  the  coats  are  infiltra- 
ted with  small  cells.  Often  parietal  thrombi  form.  Sometimes,  though  rarely, 
the  vessel  is  completely  blocked  by  thrombosis.  In  acute  suppurative  arter- 
itis pus  accumulates"  in  the  arterial  wall,  a  clot  forms  in  the  lumen,  and  the 
coats  of  the  vessel  undergo  necrosis  and  give  way.  Violent  hemorrhage  may 
thus  arise,  but  often,  in  thrombo-arteritis  as  in  thrombophlebitis,  rupture  does 
not  cause  hemorrhage.  Acute  arteritis,  if  non-bacterial  in  origin,  is  usually 
recovered  from  with  slight  structural  change.  Infective  arteritis  is  recovered 
from  if  the  causative  germ  is  not  very  virulent  or  if  the  toxin  is  not  present  in 
excessive  quantity.  Acute  arteritis  may  terminate  in  arterial  obstruction 
with  or  without  gangrene,  permanent  dilatation,  arterial  rupture,  or  chronic 
arteritis. 

Symptoms. — The  symptoms  may  be  merged  with  those  of  an  acute  or 
chronic  intoxication  or  infection,  or  with  those  of  a  local  perivascular  inflam- 
mation.    In  arteritis  arising  during  infections  the  symptoms  appear  abruptly 
and  the  onset  is  marked  by  great  pain.     Ford  studied  18  cases  in  influenza. 
*W.  H.  Bennett,  Lancet,  Oct.  15,  1898. 


412  Diseases  and  Injuries  of  the  Heart  and  Vessels 

He  says  it  attacks  particularly  persons  over  thirty  years  of  age,  occurs  in  one 
leg  or  both,  arises  most  commonly  during  convalescence,  but  may  not  begin 
until  the  individual  is  apparently  well.  There  is  pain  and  tenderness  over  the 
vessels,  low  surface  temperature,  paresthesia,  and  mottled  skin  (Ford,  "These 
de  Paris,"  1901).  The  artery  may  be  obstructed,  and  if  a  large  vessel  is 
blocked,  the  pulse  below  the  clot  is  lost.  The  block  may  be  temporary  or 
persistent.  Gangrene  may  follow.  Ford  points  out  that  if  the  artery  only 
is  blocked,  the  gangrene  is  dry;  but  if  the  vein  also  is  occluded  it  may  be 
moist.     I  have  seen  two  cases  of  dry  gangrene  following  influenza. 

Treatment. — Secure  rest  in  bed;  elevate  the  extremity  shghtly,  relax  it, 
smear  the  skin  over  the  inflamed  vessel  with  ichthyol  ointment,  or  mercurial 
ointment,  or  follow  Ford's  ad\dce  and  use  methyl  saUcylate  or  an  ointment 
of  salicyHc  acid,  turpentine,  and  belladonna.  Wrap  the  part  in  cotton  and 
siUTOund  it  with  bottles  or  bags  filled  with  warm  water.  If  a  patient  is  very 
restless,  a  sphnt  must  be  used.  It  may  be  necessary  to  give  morphin  for  pain 
and  any  infection  or  toxemia  must  be  combated  with  appropriate  remedies. 

If  gout,  rheumatism,  or  syphilis  is  regarded  as  causative,  proper  remedies 
must  be  given.  It  is  most  important  to  maintain  the  secretion  of  the  kidneys. 
If  abscesses  form  in  a  septic  case,  they  must  be  opened  and  drained.  If  a 
large  artery  of  an  extremity  becomes  occluded,  raise  the  foot  about  two  inches 
from  the  bed,  ^^Tap  the  foot  and  leg  in  cotton  wool,  apply  a  flannel  bandage 
from  the  toes  up,  and  surround  the  hmb  with  bags  of  warm  water — not  hot 
water.  Hot  water  would  take  more  blood  to  the  region  of  the  block  than 
could  be  distributed.     If  gangrene  occurs,  amputation  is  necessary. 

Chronic  Endarteritis  (Arteriosclerosis,  Atheroma,  Arteriocapil- 
lary  Fibrosis). — By  these  terms  we  mean  thickening  of  the  walls  of  the 
arteries,  hmited  in  area  or  widespread,  due  to  inflammation  or  degeneration 
of  the  middle  coat,  the  media  undergoing  hypertrophy,  and  the  intima  fibrous 
hyperplasia  (Wm.  Russell,  "Brit.  Med.  Jour.,"  June  4,  1904)-  Atheroma 
is  used  to  designate  the  disease  when  it  attacks  the  large  vessels  and  is  char- 
acterized by  advanced  degeneration.  Chronic  endarteritis  is  due  to  increase 
of  blood-pressure.  Increase  of  blood-pressure  means  increase  of  arterial 
tension,  because  the  lumen  of  the  vessels  is  lessened  and  the  heart  works  more 
strongly  to  lu-ge  the  blood  along,  and  finally  hypertrophy  of  the  middle  coat 
occurs.  The  persistence  of  arterial  contraction  which  causes  increase  of 
blood-pressure  may  be  brought  about  by  kidney  disease,  hard  work,  violent 
strains,  heart  disease,  care  and  anxiety,  worry  and  mental  strain,  habitual 
gluttony,  syphihs,  gout,  rheumatism,  lead-poisoning,  diabetes,  and  acute  infec- 
tions like  typhoid  fever  and  influenza.  It  may  arise  in  an  old  man  who  has 
not  suffered  particularly  from  any  of  the  above-named  causes,  or  may  occur 
prematurely  from  heredity.  It  is  a  true  saying  of  Cazahs  that  "A  man  is  as 
old  as  his  arteries,"  and  a  young  man  debihtated  by  syphihtic  disease  or 
alcohol  may  have  diseased  arteries,  and  hence  be  really  older  than  a  heahhy 
man  of  sixty.  The  aorta,  of  all  vessels,  is  most  prone  to  suffer.  The  large 
vessels  are  more  apt  to  be  diseased  than  the  small,  but  even  the  arterioles  can 
be  involved.  The  arteries  of  the  stomach,  liver,  and  mesentery  are  rarely 
sclerotic.  In  arteriosclerosis  connective  tissue  is  substituted  for  the  normal 
elements  of  the  vascular  wall  and  this  tissue  undergoes  hyperplasia  and  sub- 
sequent contraction  and  induration.     If  the  mass  of  prohferating  fibroblasts 


Chronic  Endarteritis  4^3 

undergoes  fatty  degeneration,  atheroma  is  said  to  exist,  and  an  atheromatous 
vessel  may  be  calcified  l)y  deposition  of  lime  saUs.  When  fatty  degeneration 
occurs,  the  endotheUum  is  destroyed,  the  vessel- wall  is  damaged,  and  the  blood 
may  obtain  access  to  the  deeper  coats.  Atheroma  is  a  frequent  cause  of 
thrombosis,  aneurysm,  senile  gangrene,  and  apoplexy. 

A  sclerosed  artery  is  rigid,  non-contractile,  and  inelastic,  and  the  parts  it 
supplies  are  cold,  congested,  and  ill-nourished,  and  often  edematous.  When 
the  caliber  of  arteries  remains  narrowed  because  of  persistent  contraction 
or  of  arteriosclerosis,  the  heart  is  obliged  to  overwork  and  in  consequence 
undergoes  hypertrophy.  The  hypertrophied  heart  finally  dilates.  If  a 
hyper trophied  heart  exists  with  diseased  arteries,  apoplexy  or  aneurysm 
is  apt  to  occur  (Nammack,  "Med.  Record,"  Oct.  26,  1901).  Syphilitic 
arteritis  is  characterized  by  an  enormous  growth  of  granulation  tissue  from 
the  inner  coats  of  arteries  of  small  size  {obliterative  endarteritis).  Calcifi- 
cation of  an  artery  may  be  secondary  to  fatty  change,  or  may  occur  primarily 
from  deposit  of  lime  sahs  in  the  middle  coat.  Periarteritis  is  inflammation  of 
the  sheath  and  outer  coat.  An  acute  arteritis  is  always  local,  but  a  chronic 
arteritis  may  be  general.  If  obhterative  endarteritis  exists  in  a  Hmb  the  veins 
are  almost  certain  to  be  involved  as  well  as  the  arteries.  For  this  condition 
of  veins  and  arteries,  Buerger  suggests  the  term  thrombo-angiitis  obliterans 
("Jour.  Am.  Med.  Assoc,"  April  24,  1909). 

Treatment  of  Chronic  Arteritis  .—In  treating  chronic  arteritis,  endeavor  to 
antagonize  the  dangers  to  which  the  patient  is  obviously  liable.  Forbid 
alcohol  as  a  beverage,  though  a  Httle  whiskey  may  be  taken  at  meals  to  aid 
digestion.  Maintain  the  activity  of  the  skin  by  daily  baths,  and  of  the  kidneys 
by  diuretic  waters.  A  daily  bowel  movement  should  be  secured.  The  diet 
is  to  be  plain  and  is  to  contain  a  minimum  of  nitrogen.  If  syphihs  has  existed, 
occasional  courses  of  iodid  of  potassium  are  to  be  given.  If  the  arterial 
tension  at  any  time  becomes  inordinately  high,  administer  nitroglycerin. 
One  danger  to  which  the  patient  is  liable  is  apoplexy;  hence  excitement  and 
violent  exercise  are  to  be  avoided.  Another  danger  is  senile  gangrene;  hence 
the  patient  should  wear  woolen  stockings,  put  a  bottle  or  bag  of  warm  water 
to  his  feet  at  night,  and  be  careful  to  avoid  injuring  his  toes  or  feet  especially 
when  cutting  his  corns.  A  bag  of  very  warm  water  is  dangerous  and  may 
actually  excite  gangrene.  When  a  patient  with  atheroma  has  dyspnea  and 
is  of  a  livid  color,  or  when  the  arterial  tension  is  very  high,  a  moderate  blood- 
letting (sixteen  to  eighteen  ounces)  does  good,  and  may  prevent  or  arrest 
€dema  of  the  lungs.  Still  another  danger  is  aneurysm,  which  may  appear 
suddenly  from  rupture  or  gradually  from  progressive  distention. 

Treatment  of  Endarteritis  .—It  has  recently  been  suggested  that  endarte- 
ritis threatening  gangrene  should  be  treated  by  an  anastomosis  between  the 
common  femoral  artery  and  the  femoral  vein,  in  order  that  the  blood  may  be 
directed  from  blocked  to  open  channels,  and  hence  may  still  nourish  the  extrem- 
ity. The  operation  is  only  to  be  advised  when  pulsation  is  absent  in  the  tibials, 
when  the  femoral  high  up  seems  normal,  and  when  the  deep  veins  are  patent. 
Buerger  suggests  the  following  test  of  the  patency  of  the  deep  veins 
("  Jour.  Amer.  Med.  Assoc,"  April  24,  1909) :  "  I  allow  the  hmb  to  hang,  watch 
for  the  advent  of  the  erythema,  and  wait  until  a  fair  degree  of  cyanosis  has 
become  established.     This  may  take  considerable  time— five  to   ten  minutes. 


414  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  veins  are  then  obliterated  above  the  knee  by  means  of  a  Martin  bandage 
properly  applied.  The  limb  is  then  raised  high  and  the  bandage  loosened 
just  enough  so  as  to  remove  pressure  from  the  deep,  but  not  from  the  super- 
ficial veins.  If  the  cyanosis  is  slow  in  disappearing  or  fails  to  disappear,  it 
may  be  concluded  that  the  function  of  the  deep  veins  is  impaired." 

The  cperarion  of  arteriovenous  anastomosis  has  been  performed  at  least 
four  times  for  obHterative  endarteritis,  viz.,  by  Lilienthal  in  1907  (death  in 
thirty  hours);  by  Wieting  in  1908  (intubation  of  the  femoral  artery  below 
the  profunda  into  the  femoral  vein  below  the  saphenous;  a  success);  Wieting's 
second  case  (anastomosis  between  .the  popliteals;  failure  because  of  thrombo- 
sis); Lurel  in  1908  (temporary  improvement). 

Aneurysm. — An  aneur}-sm  is  a  pulsating  sac  containing  blood  and  com- 
municating with  the  cavity  of  an  arter\',  and  formed  partly  or  entirely  by  the 
arterial  walls  or  a  fusiform  dilatation  of  an  artery.  Some  restrict  the  term 
"true  aneurvsm"  to  a  condition  of  dilatation  involving  all  the  coats  of  the 
vessel.  We  shall  consider,  with  Heath,  a  true  aneurysm  to  be  one  in  which 
the  blood  is  included  in  one  or  more  of  the  arterial  coats,  and  a  false  aneurysm 
to  be  a  condition  in  which  the  vessel  has  ruptured  or  has  atrophied  and  the 
aneurvsmal  wall  is  formed  by  a  condensation  of  the  perivascular  tissues. 

Forms  of  Aneurysm. — The  following  forms  of  aneurysm  are  recognized: 

1.  True  aneurysm — one  whose  sac  is  formed  of  one  or  more  arterial 
coats. 

2.  False  aneurysm — one  whose  sac  is  formed  of  condensed  perivascular 
tissues  and  contains  no  arterial  coat. 

3.  Traumatic  diffuse  aneurysm — a  false  aneiirysm  due  to  a  wound  or 
traumatic  rupture  of  a  blood-vessel.  At  first  the  blood  is  widely  diffused  and 
unhmited  by  any  sac  or  capsule,  later  a  limitation  or  encapsulation  may  occur 
by  the  condensation  of  tissue,  any  wound  being  healed.  A  traumatic  diffuse 
aneurysm  may  follow  a  puncture  or  an  incised  wound  of  an  artery,  the  injur)' 
causing  the  aneurysm  directly.  It  may  follow  an  effort  or  a  strain,  the  injury 
indirectly  causing  the  aneur}-sm  by  acting  on  a  diseased  vessel.  As  Barwell 
says,  the  term  travmiatic  diffuse  aneur}^sm  is  an  extremely  bad  one,  as  the  term 
aneurysm  conveys  the  idea  of  some  sort  of  a  sac.  In  this  condition  there 
is  no  true  sac  and  blood  is  either  unhmited  or  limited  only  by  condensed 
tissue. 

4.  Diffused  aneurysm — a  term  used  to  mean  a  ruptiu-ed  aneurysm,  the 
blood  being  diffused  in  the  tissues  and  either  unhmited  or  limited  only  by  con- 
densed tissues.  The  term  should  be  hmited  to  conditions  in  which  the  effusion 
of  blood  is  slow  and  trivial.  If  the  eft"usion  is  large  and  rapid  the  term  rup- 
tured aneurysm  is  preferable. 

5.  Consecutive  aneurysm — results  from  the  rapid  gro\\'th  of  a  sacculated 
aneur}'sm.  At  a  certain  portion  of  the  sac  of  a  true  aneurysm  the  arterial  coats 
give  way  completely  and  at  this  point  blood  is  limited  only  by  clot  and  by 
condensed  perivascular  tissue.  The  blood  is  not  dift'used  but  is  encapsuled, 
partly  by  the  old  sac,  partly  by  condensed  tissues,  aided  it  may  be  by  bone 
and  fascia. 

6.  Fusiform  or  tubulated  aneurysm — a  variety  of  true  aneurysm,  the  sac 
being  spindle-shaped  and  formed,  as  Matas  states,  "at  the  expense  of  the 
artery,"  the  artery  dilates,  the  continuity  of  the  parent  artery  is  interrupted 


Forms  of  Aneurysm  415 

for  a  variable  length,  and  is  lost  in  the  sac,  to  be  restored  once  more  as  a  normal 
vessel  at  the  outlet  of  the  aneurysm  ("Transactions  of  Am.  Surg.  Assoc," 
1905).  Such  an  aneurysm  has,  of  course,  two  openings.  This  form,  accord- 
ing to  Matas,  comprises  66.6  per  cent,  of  all  aneurysms. 

7.  Sacculated  aneurysm — a  common  form  of  aneurysm,  in  which  the 
dilatation  is  like  a  pouch,  arising  from  a  part  of  the  arterial  circumference 
and  joining  the  lumen  of  the  vessel  by  a  single  aperture.  As  Matas  points  out, 
the  parent  artery  is  involved  in  but  a  portion  of  its  circumference,  the  con- 
tinuity of  the  vessel  is  not  lost,  the  arterial  caliber  is  maintained  at  a  nearly  nor- 
mal diameter,  and  "the  sac  is  simply  grafted  or  attached  to  the  artery  by  a 
narrow  neck,  forming  a  sort  of  diverticulum  of  variable  shape  and  dimensions  " 
("Proceedings  of  Am.  Surg.  Assoc,"  1905).  Such  a  sac  has  but  one  orifice. 
The  opening  from  the  artery  into  the  sac  is  called  the  mouth;  around  and  just 
above  the  mouth  is  the  neck;  the  balance  of  the  sac  is  much  larger  than  the 
neck  and  is  called  the  body.  A  sacculated  aneurysm  may  arise  from  an  artery 
of  normal  size,  from  a  dilated  artery  or  from  a  fusiform  aneurysm.  A  sac- 
culated aneurysm  of  unknown  cause  is  called  a  spontaneous  aneurysm;  one 
which  is  due  to  injury  is  called  a  traumatic  aneurysm.  The  first  step  in  the 
formation  of  a  sacculated  aneurysm  is  stretching  or  giving  way  of  an  area 
of  the  middle  coat  (media),  followed  by  a  gradually  advancing  stretching  and 
dilatation  of  corresponding  areas  of  the  outer  coat  (adventitia)  and  the 
inner  coat  (intima). 

8.  Dissecting  aneurysm  (Shekelton's  aneurysm) — a  pouch-like  dilatation 
of  an  artery  due  to  the  blood  which  has  gained  access  to  the  middle  coat  through 
an  atheromatous  ulcer  or  a  minute  rupture  of  the  inner  coat.  It  used  to  be 
taught  that  the  blood  flows  between  the  media  and  adventitia;  we  now  know 
that  it  flows  between  the  layers  of  the  middle  coat.  The  outer  wall  of  the 
aneurysm  consists  of  adventitia  and  a  portion  of  the  middle  coat.  It  may 
or  may  not  join  the  lumen  of  the  artery  at  another  point  by  a  fresh  aperture 
in  the  intima.  Dissecting  aneurysm  is  practically  only  met  with  in  the  aorta. 
It  is  most  common  in  the  thoracic  aorta.  About  eighty  cases  have  been 
reported.* 

9.  Arteriovenous  aneurysm,  which  is  divided  into  aneurysmal  varix,  or 
Pott's  aneurysm,  where  there  is  direct  communication  between  a  vein  and 
an  artery;  and  varicose  aneurysm,  where  there  is  communication  between  an 
artery  and  a  vein  by  means  of  an  interposed  sac. 

10.  Acute  aneurysm — a  cavity  in  the  walls  of  the  heart,  which  cavity  com- 
municates with  the  interior  of  this  organ,  and  which  is  due  to  suppuration 
in  the  course  of  acute  endocarditis  or  myocarditis. 

11.  Aneurysm  by  anastomosis  (see  Angiomata). 

12.  Aneurysm  of  bone — an  inaccurate  clinical  term  used  to  designate  a 
pulsatile  tumor  of  bone. 

13.  Circumscribed  aneurysm — when  the  blood  is  circumscribed  by  distinct 
walls. 

14.  Cirsoid  aneurysm — a  mass  of  dilated  and  elongated  arteries  shaped 
like  varicose  veins  and  pulsating  with  each  heart-beat. 

15.  Cylindrical  aneurysm — a  dilatation  which  maintains  the  same  dimen- 
sions for  a  considerable  space. 

*  Coleman,  in  Dublin  Jour.  Med.  Sciences,  .\ug.,  1898 


41 6  Diseases  and  Injuries  of  the  Heart  and  Vessels 

1 6.  Embolic  or  capillary  aneurysm — dilatation  of  terminal  arteries  due  to 
emboli. 

17.  Spontaneous  aneurysm — non-traumatic  in  origin. 

18.  Miliary  aneurysm — a  minute  dilatation  of  an  arteriole. 

19.  Secondary  aneurysm — one  which,  after  apparent  cure,  again  pulsates, 
the  blood  entering  by  means  of  the  anastomotic  circulation. 

20.  Vermhwus  aneurysm-— ont  containing  a  parasite.  This  form  of 
aneurysm  is  met  with  in  the  mesenteric  arten'  of  the  horse. 

The  sac  of  a  sacculated  aneurj'sm  is  at  first  composed  of  at  least  two  of  the 
arterial  coats,  reinforced  by  the  sheath  and  perivascular  tissues.  After  a 
time  the  blood-pressure  distends  the  sac,  and  the  inner  and  middle  coats  either 
stretch  with  interstitial  growth  or — what  is  more  common — are  worn  away 
and  lost.  When  all  the  coats  are  lost,  and  the  blood  is  sustained  only  by 
the  sheath  and  surrounding  tissue,  a  true  aneurysm  becomes  a  false  or 
consecutive  aneur}-sm.  the  limiting  tissues  and  sheath  being  condensed, 
thickened,  and  glued  together.  This  limiting  process  is  deficient  in  the  brain; 
hence  cerebral  aneur^'sms  break  soon  after  their  formation.  WTien  all  the 
arterial  coats  are  lost,  the  blood-pressure,  acting  on  the  tissues,  finds  some 
spots  less  resistant  than  others,  the  blood  follows  the  lines  of  least  resistance, 
the  aneurysm  grows  with  great  rapidity,  and  soon  ruptures  externally  or  into 
a  cavity. 

An  aneur}'sm  may  rupture  into  a  cavity  (pleural,  pericardial,  or  peritoneal), 
into  the  perivascular  tissues,  or  through  the  skin.  Rupture  into  the  tissues 
may  produce  pressure-gangrene.  \Mien  rupture  occurs  through  the  skin  the 
hemorrhage  is  not  often  instantly  fatal,  but  during  several  days  recurs  again 
and  again  in  larger  and  larger  amounts.  The  pressure  of  an  aneurysm  causes 
atrophy  of  tissues,  hard  and  soft,  bones  and  cartilages  being  as  easily  destroyed 
as  muscles  and  fat.  Sometimes  the  perivascular  tissues  inflame  and  suppurate, 
and  the  sac  is  opened  rapidly  by  sloughing.  An  aneur^-sm  usually  progresses 
toward  rupture,  the  slowest  in  this  progression  being  the  fusiform  dilatation, 
which  may  exist  for  many  years,  but  which  finally  is  converted  into  the  sac- 
culated variety. 

In  some  rare  instances  there  takes  place  spontaneous  cure,  which  may 
result  from  laminated  fibrin  being  deposited  upon  the  walls  of  the  sac  as  the 
blood  circulates  through  it.  This  laminated  fibrin  is  known  as  an  "  active 
clot,"  and  eventually  fills  the  sac.  The  weaker  and  slower  the  blood-stream, 
the  greater  is  the  tendency  to  the  formation  of  an  active  clot ;  hence  any  agent 
impeding,  but  not  abolishing,  the  circulation  aids  in  the  deposition.  This 
weakening  and  slowing  of  circulation  may  be  brought  about  by  great  activity 
of  the  collateral  circulation  diverting  most  of  the  blood  from  the  area  of 
disease.  Sometimes  a  clot  breaks  off  from  the  sac-wall  and  plugs  the  artery 
beyond  the  aneurysm,  and  the  anastomotic  vessels,  enlarging,  divert  the 
blood-stream.  A  large  aneur^-sm,  falling  over  by  its  own  weight  upon  the 
vessel  above  the  mouth  of  the  sac,  may,  in  \tr\  unusual  cases,  diminish  the 
blood-stream.  The  development  of  another  aneurysm  upon  the  same  vessel 
nearer  to  the  heart  weakens  the  circulation  in  and  may  cure  the  older  one. 
Inflammation  occasionally  forms  a  clot.  The  tissues  about  an  aneur}'sm 
tend  to  contract  when  arterial  force  is  lessened;  hence  tissue-pressure  may 
more  than  counteract  blood-pressure  when  the  circulation  is  feeble.     Clotting 


Symptoms  of  Aneurysm  417 

of  the  blood  contained  within  a  sac,  circulation  through  the  aneurysm  having 
ceased,  causes  a  "passive  clot."  A  passive  clot,  which  occasionally  induces 
cure,  may  arise  from  a  twist  of  the  neck  of  the  sac  preventing  the  passage  of 
blood;  from  the  lodgment  of  a  clot  in  the  mouth  of  the  sac;  and  from  inflam- 
mation.    Spontaneous  cure  is,  unfortunately,  very  rare. 

Causes  of  Aneurysm. — Gradual  distention  of  arterial  coats  which  are  in 
a  condition  of  arterial  sclerosis,  or  of  coats  whose  resi.sting  power  is  lowered 
because  of  atheroma,  may  cause  aneurysm.  Hence  the  causes  of  sclerosis 
and  atheroma  are  also  causes  of  aneurysm.  The  principal  cause  of  aneurysm 
is  increased  blood-pressure.  This  increase  may  be  brought  about  by  severe 
labor;  by  sudden  strains,  as  in  lifting;  by  violent  efforts,  as  in  rowing  in  a 
boat-race;  by  chronic  interstitial  nephritis;  by  hypertrophy  of  the  heart; 
by  alcohohc  excess;  and  by  syphilis.  xArterial  disease  is  commonest  in 
the  larger  vessels,  and  in  the  aged,  but  it  may  occur  in  youth.  When  an 
aneurysm  follows  a  strain,  it  may  be  due  to  laceration  of  the  media  and  loss 
of  resistance  at  a  narrow  point.  The  intima  may  lacerate,  permitting  the 
blood  to  come  in  contact  with  the  media  or  causing  blood  to  diffuse  between 
the  coats  (dissecting  aneurysm).  When  an  embolus  lodges  in  an  artery  the 
vessels  may  become  aneurysmal  on  the  proximal  side  of  the  clot.  The  em- 
bolus, if  infective,  causes  softening,  and  if  calcareou.":  causes  laceration  (Osier). 
Colonies  of  micrococci  may  cause  aneurysm.*  The  parasite  strongylus  arma- 
tus  causes  aneurysm  of  the  mesenteric  arteries  in  horses.  Suppuration  around 
a  vessel  weakens  its  coats  and  tends  to  aneurysm  by  inducing  acute  arteritis 
and  softening.  Sometimes  an  individual  develops  multiple  aneurysms  the 
origins  of  which  are  absolutely  unknown.  A  bruise  of  a  vessel  may  be  followed 
by  aneurysm.  A  cut  or  puncture  of  a  healthy  artery  may  lead,  after  the  surface 
wound  heals,  to  the  development  of  an  aneurysm.  Such  an  aneurysm  does 
not  differ  in  symptoms  or  treatment  from  the  other  form. 

The  constituent  parts  of  an  aneurysm  are  (i)  the  wall  of  the  sac;  (2)  the 
cavity;  (3)  the  mouth;  and  (4)  the  contents. 

Symptoms  of  Aneurysm. — The  formation  of  an  aneurysm,  when  sudden, 
is  occasionally,  though  rarely,  appreciated  by  the  patient,  and  is  described 
by  him  as  a  feeling  of  something  having  given  way.  In  most  instances  the 
feeling  of  beating  and  the  discovery  of  the  lump  are  the  first  intimations  that 
anything  is  wrong.  An  oval  or  globular,  soft,  elastic,  and  pulsatile  protrusion 
develops  in  the  line  of  an  artery.  It  is  usually  quite  evident  to  the  touch  that 
the  sac  contains  fluid,  but  sometimes  in  old  aneurysms  the  sac  feels  firm  or 
even  hard,  because  of  the  deposit  of  fibrin  upon  its  inner  surface.  In  a  par- 
tially consolidated  aneurysm  pulsation  may  be  slight  or  even  inappreciable. 
The  protrusion  instantly  ceases  to  pulsate  and  almost  disappears  on  making 
firm  pressure  on  the  artery  above.  On  relaxing  the  pressure  the  pulsatile 
enlargement  at  once  reappears.  Direct  pressure  upon  the  tumor  may  cause 
it  to  almost  disappear.  Pressure  upon  the  artery  below  causes  the  tumor 
to  enlarge.  The  pulsation  is  expansile — that  is,  the  sac  expands  in  all  direc- 
tions during  every  cardiac  contraction — and  if  an  index-finger  be  laid  on  each 
side  of  the  tumor  so  that  the  points  nearly  touch,  each  pulsation  not  only  hfts 
the  fingers  but  it  also  separates  them.  It  is  important  to  remember  that  a 
large  intrathoracic  aneurysm  which  is  in  contact  with  the  chest  may  not  exhibit 

*  See  Osier  on  "  Malignant  Endocarditis." 
27 


4i8  Diseases  and  Injuries  of  the  Heart  and  Vessels 

expansive  pulsation,  but  simply  transmit  pulsation  from  the  blood-stream 
(Sidney  Lange,  in  "N.  Y.  Med.  Jour.,"  Nov.  21,  1908).  On  placing  a  stetho- 
scope over  the  aneurysm  or  over  the  vessel  below  the  aneurysm  there  is  im- 
parted to  the  ear  a  distinct  bruit  which  travels  in  the  direction  of  the  l/lood- 
stream,  is  systolic  in  time,  and  is  usually  blowing  in  character.  In  some  cases 
bruit  is  absent  (when  a  sacculated  aneurysm  has  a  very  small  mouth,  when  the 
circulation  is  tranquil,  or  when  the  sac  is  full  of  blood  and  clot) .  When  bruit  is 
absent,  it  may  sometimes  be  developed  by  muscular  exercise  or  raising  the 
afifected  limb  (Halloway).  In  rare  cases  there  may  be  a  double  bruit.  Occa- 
sionally in  fusiform  aortic  aneurysm  linked  with  aortic  regurgitation  a  diastolic 
bruit  exists.  A  bruit  is  arrested  by  pressing  upon  the  artery  between  the 
aneurysm  and  the  heart.  A  patient  who  has  an  aneur}'sm  of  an  extremity 
complains  of  a  sensation  of  beating,  of  weakness  or  stiffness  of  the  hmb.  fre- 
quently of  pain  in  a  nerve,  a  feeUng  of  fatigue  in  the  muscles,  and  edema  and 
dilated  veins  are  apt  to  develop  because  of  pressure  upon  large  veins  and  loss  of 
vis  a  tergo  in  the  circulation.  The  skin  over  an  aneurysm  may  be  normal,  may 
be  discolored,  may  ulcerate,  or  even  slough.  The  pulse  below  an  aneurysm  is 
weaker  than  the  pulse  of  a  corresponding  part  of  the  opposite  limb.  This  is 
well  shown  by  sphygmographic  ti-acings  (Fig.  1 70) .     The  tracings  taken  below 


Fig.  170.— Radial  pulse-tracings  in  aneurysm  of  right  brachial  artery  :   i,  Left  radial  pulse  ;  2,  right 

radial  pulse  (after  Mahomed  1. 

an  aneurysm  are  rounded  without  a  sudden  rise  or  an  abrupt  fall.  In  inter- 
nal aneurysms  pressure-symptoms  are  marked.  Thoracic  aneurysm  causes 
intercostal  pain;  iliac  aneurysm  causes  pain  in  the  thigh.  Aneurysm  of  the 
thoracic  aorta  pressing  upon  the  pneumogastric  nerve  causes  spasmodic 
dyspnea,  and  upon  the  recurrent  laryngeal,  causes  hoarseness,  which  may 
be  associated  with  loss  of  voice,  cough,  and  laryngeal  spasm,  and  is  due  to 
unilateral  abductor  paralysis.  Pressure  upon  a  bronchus  or  the  trachea 
causes  dyspnea  from  -obstruction,  dysphagia,  and  cough  from  laryngeal 
spasm.  Pressure  upon  the  cervical  sympathetic  first  causes  dilatation  and 
later  contraction  of  the  pupil  of  the  same  side.  An  aneurysm  in  the  neck 
may  interfere  with  the  cerebral  circulation  and  produce  vertigo  and  even 
attacks  of  unconsciousness.  The  evidences  of  rupture  of  an  aneurysm  of 
an  extremity  into  the  tissues  are  loss  of  distinctness  of  outline  and  increase 
in  area  of  the  tumor,  weakening  or  disappearance  of  both  bruit  and  pulsation, 
absence  of  pulse  below  the  aneurysm,  severe  pain,  edema  and  coldness  of 
the  surface,  shock,  and  possibly  syncope.  External  hemorrhage  may 
arise;  the  tissues  may  become  extensively  infiltrated  with  blood;  sloughing 
or  gangrene  may  ensue.     Death  is  frequent,  and  only  in  very  rare  cases  does 


Treatment  of  Aneurysm  419 

spontaneous  cure  take  place.     Rupture  of   a  large  aneurysm  into  a  cavity 
causes  intense  pallor,  advancing  weakness,  syncope,  and  death. 

Diagnosis. — A  cyst  or  abscess  over  a  vessel  may  show  transmitted  pulsa- 
tion which  is  not  expansile,  and  the  tumor  does  not  disappear  when  pressure 
is  made  upon  the  vessel  above  it.  The  pulsation  ceases  when  the  growth  is 
lifted  off  the  vessel,  or  when  the  position  is  changed  so  as  to  permit  it  to  fall 
away  from  the  vessel.  There  is  no  true  bruit,  and  the  history  is  widely 
different.  A  growth  under  a  vessel  may  lift  the  vessel  and  simulate  an 
aneurysm,  but  the  pulsation  is  not  noted  in  the  entire  growth,  the  growth 
does  not  disappear  on  proximal  pressure,  and  there  is  only  a  false,  and  never 
a  true,  bruit.  The  larger  the  growth  under  a  vessel,  the  less  is  the  pulsation, 
because  of  pressure  narrowing  the  caliber  of  the  vessel.  A  sarcoma,  especially 
a  soft  sarcoma  attached  to  the  bone,  and  also  a  nevoid  mass,  pulsate  and 
often  have  a  bruit;  the  tumor  never  disappears  from  proximal  pressure, 
though  it  may  slowly  diminish  in  size,  to  gradually  enlarge  again  when  pressure 
is  withdrawn.  These  growths  do  not  feel  fluid,  and  are  rarely  circumscribed. 
An  aneurysm  may  cease  to  pulsate  from  consolidation  leading  to  cure,  or 
from  rupture.  Rupture  of  a  large  aneurysm  into  a  cavity  induces  deadly 
pallor,  syncope,  and  rapid  death.  Rupture  of  an  aneurysm  of  an  extremity 
into  the  tissues  is  made  manifest  by  a  sensation  of  something  breaking,  by 
pain,  by  sudden  increase  in  size,  by  diminution  or  absence  of  bruit  and  pulsa- 
tion, by  absence  of  pulse  below  the  aneurysm,  by  swelling  and  coldness  of 
the  limb,  and  by  shock. 

Treatment. — (For  the  history  of  the  evolution  of  the  treatment  of  aneurysm, 
see  "Studies  in  Aneurysm,"  by  James  G.  Mumford,  "Cleveland  Med.  Jour.," 
Feb.,  1908.)  In  inoperable  aneurysms,  general,  medical,  and  dietetic  treat- 
ment must  be  tried,  A  chief  element  in  treatment  is  rest  in  bed  to  diminish 
the  rapidity  and  force  of  the  circulation  and  favor  fibrinous  deposit.  Valsalva 
long  ago  suggested  rest,  occasional  bleeding,  and  a  diet  just  above  the  point 
of  starvation.  Tuffnell's  plan  is  to  reduce  the  heart-beats  by  rest  and  mental 
quiet,  and  to  rigidly  restrict  the  diet  so  as  to  diminish  the  total  amount  of  blood 
and  render  it  more  fibrinous.  Liquids  are  restricted  in  amount,  and  the  patient 
lives  through  each  twenty-four  hours  upon  4  ounces  of  bread,  a  very  httle 
butter,  8  ounces  of  milk,  and  3  ounces  of  meat.  This  plan  is  pursued  for 
several  months  if  possible,  or  it  is  employed  for  several  weeks,  intermitted 
for  a  short  period,  the  rigid  diet  again  returned  to,  and  so  on,  over  and  over 
again.  There  can  be  no  doubt  that  Tuffnell's  treatment  sometimes  cures 
aneurysm  by  decidedly  lowering  the  blood-pressure.  Many  who  suffer  from 
aneurysm  may  be  permitted  to  go  about,  taking  their  time  about  everything 
and  avoiding  work,  worry,  and  excitement.  The  diet  should  be  low  and  non- 
stimulating,  and  the  bowels  must  be  maintained  in  a  loose  condition. 

Even  in  an  operable  case  diet  and  rest  are  of  importance.  The  patient 
should  remain  in  bed  for  a  number  of  days  before  operation,  the  daily  diet 
consisting  of  ten  or  twelve  ounces  of  solid  food  with  a  pint  of  milk.  If  the 
circulation  is  very  active,  use  aconite  and  allay  pain  by  morphin. 

lodid  of  potassium  in  doses  of  20  grains  undoubtedly  does  good  in  aneurysm 
and  not  only  in  syphilitic  cases.  It  seems  to  lower  the  blood-pressure.  Bal- 
four taught  that  it  thickened  the  walls  of  the  sac.  Osier  says  it  relieves  the 
pain.     Iron,  acetate  of  lead,  and  ergotin  are  prescribed  by  some.     Digitalis 


420  Diseases  and  Injuries  of  the  Heart  and  Vessels 

is  contraindicated,  as  it  raises  tlie  blood-pressure.  S.  Solis  Cohen  has  used 
with  some  success  the  hydrated  chlorid  of  calcium.  Morphin  and  bromid  of 
potassium  are  occasionally  useful  to  tranquilize  the  circulation,  allay  pain,  or 
secure  sleep.     Aconite  and  veratrum  viride  have  long  been  employed. 

Lancereaux  and  others  claim  that  hypodermatic  injections  of  gelatin  at 
some  indifferent  point  may  cure  aortic  and  subclavian  aneurysm.  In  1896 
Dastres  and  Floresco  proved  that  gelatin  injected  in  the  blood  increases 
coagulability.  Later  Lancereaux  and  Paulesco  showed  that  injections  into 
the  subcutaneous  tissue  act  similarly.  Carnot  pointed  out  that  gelatin 
applied  to  a  wound  may  arrest  bleeding.  How  gelatin  acts  is  uncertain,  but 
that  it  does  increase  blood-coagulability  seems  proved.  The  value  of  injec- 
tions of  gelatin  for  aneurysm  is  in  dispute.  Lancereaux  warmly  advocates  its 
use  for  sacculated  aneurysm  and  says  that  after  the  first  dose  the  aneurysm 
is  seen  to  shrink  and  the  pulsation  is  observed  to  lessen.  He  injects  it 
slowly  and  with  aseptic  care  into  the  subcutaneous  tissue  of  the  thigh,  using 
normal  salt  solution  containing  from  5  to  10  per  cent,  gelatin.  He  never 
injects  less  than  5  gm.  He  gives  an  injection  every  tenth  to  fifteenth  day  and 
administers  from  ten  to  twenty  injections.  But  the  treatment  is  not  free  from 
danger;  several  deaths  have  taken  place,  and  several  persons  have  died  from 
tetanus.  Care  must  be  taken  not  to  inject  gelatin  into  a  vessel,  and  it  must 
never  be  thrown  about  the  aneurysmal  sac.  It  irritates  the  kidneys  and 
its  use  is  contraindicated  in  renal  disease.  The  injections  cause  much  pain, 
and  it  is  very  doubtful  if  they  do  any  real  good  in  aneurysm.  If  used,  it 
should  be  given  at  the  temperature  of  the  body,  and  not  over  3  gm.  should 
be  administered  at  one  dose.  A  10  percent,  solution  is  the  proper  strength 
and  from  10  to  20  c.c.  the  correct  dose.  Gelatin  can  be  given  by  the  mouth. 
When  thus  given  it  is  not  so  powerful,  but  its  coagulating  property  is  not 
destroyed  by  digestion.  Gelatin  in  normal  salt  solution  is  known  as  Car- 
not's  solution.  Carnot's  solution  is  best  prepared  by  Sailer's  formula,  as 
follows  (Joseph  Sailer,  in  "Therapeutic  Gazette,"  August,  1901):  Take  5 
gm.  of  common  salt,  i  liter  of  distilled  water,  and  100  gm.  of  gelatin.  Bring 
the  water  to  a  temperature  of  80°  C.  and  slowly  stir  in  the  gelatin  until  it 
is  all  in  solution.  Remove  the  solution  from  the  stove,  cool  it  to  40°  C,  add 
to  it  the  white  of  one  egg,  and  stir  for  several  minutes,  and  then  put  the  flask 
on  the  stove  and  boil  the  fluid.  The  white  of  egg  coagulates  and  clears  the 
solution.  Filter  through  gauze  and  then  through  paper.  Place  the  fluid  in 
test-tubes,  each  of  which  will  contain  10  c.c,  and  insert  a  cotton  plug  in  the 
mouth  of  each  tube.  Sterilize  by  putting  the  tubes  in  a  steam  sterilizer  for 
fifteen  minutes  on  three  successive  days.  When  we  wish  to  use  a  tube, 
place  it  in  a  cup  of  hot  water  until  the  gelatin  liquefies,  pour  the  gelatin 
into  a  sterile  glass,  and  draw  it  up  into  a  sterile  syringe.  When  kept  several 
weeks  the  tubes  dry  out. 

Other  expedients  sometimes  used  in  the  treatment  of  aneurysm  are:  the 
kneading  of  the  sac  to  release  a  clot,  in  the  hope  that  it  will  plug  the  mouth 
of  the  sac  or  the  artery  beyond  it — this  is  dangerous;  electricity;  electrolysis; 
the  injection  of  an  astringent  liquid;  the  insertion  of  a  fine  aspirating  needle 
and  the  pushing  through  it  into  the  sac  of  a  large  quantity  of  silver  wire,  in 
the  hope  that  it  will  aid  in  whipping  out  fibrin.  Some  physicians  have  in- 
serted needles  and  horsehair. 


Treatment  of  Aneurysm  421 

Treatment  hy  Pressure. — Instrumental  pressure  is  made  by  applying  two 
Signorini  tourniquets  or  some  specially  devised  apparatus  to  limit  the  flow 
of  blood  through  an  aneurysm  without  entirely  stopping  it,  the  aneurysmal 
sac  being  felt  to  still  slightly  })ulsate.  In  some  situations  Lister's  abdominal 
tourniquet  is  applied;  in  other  regions  we  may  use  Tuffnell's  compress,  which 
is  like  a  spring  truss  and  is  stra[)ped  in  place.  A  heavy  body  suspended  over 
the  artery  and  resting  part  of  its  weight  upon  the  vessel  has  occasionally 
brought  about  cure.  Compressing  instruments  can  be  worn  for  from  twelve 
to  sixteen  hours  at  a  time;  usually  they  are  removed  to  permit  sleep  and  are 
reapplied  the  next  day,  and  so  on  for  several  days.  Before  applying  the 
compress  be  sure  the  sac  is  full  of  blood,  and  render  this  certain  by  applying 
for  a  few  minutes  distal  compression.  This  method  may  cure,  but  it  is  very 
painful.  It  cannot  be  ifsed  successfully  in  treating  aneurysm  of  the  axillary, 
subclavian,  or  carotid  artery.     It  aids  in  the  formation  of  an  active  clot. 

Digital  pressure,  made  with  the  thumb  aided  by  a  weight,  and  maintained 
for  many  hours  by  a  relay  of  assistants,  has  cured  many  cases.  This  method 
may  be  used  alone  or  may  be  used  as  an  accessory  to  instrumental  pressure. 
Its  chief  field  is  in  the  treatment  of  aneurysm  for  which  other  methods  are 
inapplicable  (orbit  and  root  of  neck).  It  entirely  cuts  off  the  blood  and  pro- 
motes the  formation  of  a  passive  clot.  If  cure  does  not  take  place  in  three 
days,  abandon  pressure.  It  must  often  be  abandoned  far  earlier  because  of 
pain. 

Direct  pressure  upon  the  sac  has  been  used  in  aneurysm  of  the  popliteal 
artery,  the  pressure  being  obtained  by  flexing  the  leg;  and  in  aneurysm  of  the 
brachial  artery  pressure  has  been  applied  at  the  bend  of  the  elbow  by  flexing 
the  elbow.  The  pressure  of  a  hollow  rubber  ball  has  been  used  in  aneurysm 
of  the  subclavian. 

Rapid  pressure  completely  arrests  the  passage  of  blood  through  the  sac 
for  a  limited  time,  and  is  applied  while  the  patient  is  under  the  influence  oi 
an  anesthetic.  Take,  for  example,  a  case  of  popliteal  aneurysm:  the  patient 
is  placed  under  the  influence  of  ether ;  two  Esmarch  bandages  are  used, 
one  being  applied  to  the  limb  from  the  toes  up  to  the  lower  limit  of  the 
aneurysm,  and  the  other  from  the  groin  down  to  the  upper  limit  of  the  sac, 
and  the  Esmarch  band  is  fastened  above  the  upper  bandage.  This  pro- 
cedure stagnates  the  blood  both  in  the  veins  and  in  the  arteries,  and  the 
sac  remains  full  of  blood.  Pressure  is  thus  maintained  for  three  or  four 
hours,  and  on  removing  the  Esmarch  apparatus  a  tourniquet  is  put  on  the 
artery  above  the  aneurysm  and  partly  tightened  in  order  to  limit  the  amount 
of  blood  passing  through  and  thus  prevent  the  washing  away  of  clot.  This 
method  of  rapid  pressure  sometimes  cures  by  forming  a  passive  clot,  but  it 
sometimes  results  in  gangrene.     It  was  devised  by  John  Reid. 

Operative  Treatment:  By  the  Ligature  and  by  Sutures. — Ligation  of  the  main 
artery  was  the  operation  employed  by  most  surgeons  until  the  Matas  opera- 
tion was  introduced.  The  methods  of  ligation  are:  (i)  the  method  of  Antyllus; 
(2)  extirpation  of  the  sac;  (3)  the  method  of  Anel;  (4)  the  method  of  Hunter; 
(5)  the  method  of  Wardrop;  and  (6)  the  method  of  Brasdor. 

The  method  of  Antyllus  (Fig.  171),  a  Roman  successor  to  Galen,  who  Hved 
in  the  third  century,  a.  d.,  is  usually  described  as  a  method  involving  a  direct 
attack  upon  the  sac  itself.     The  artery   is   hgated  immediately  above   and 


422  Diseases  and  Injuries  of  the  Heart  and  Vessels 

below  the  sac,  the  sac  is  opened  and  its  contents  turned  out,  or  the  sac  is 
extirpated.  As  a  matter  of  fact,  Antyllus  advocated  applying  a  ligature  on 
each  side  of  the  sac  and  opening  the  sac  in  order  to  evacuate  its  contents, 
but  he  distinctly  opposed  exdrpation  because  of  its  danger.  All  we  know  of 
Antyllus  is  found  in  the  writings  of  Oribasius,  \^'ho  Uved  in  the  fourth  cen- 
tury. Syme  maintained  many  years  ago  that  incision  of  the  sac  is  the  proper 
operation  for  aneurysm  of  the  gluteal,  iliac,  carotid,  and  axillary  arteries,  but 
Syme's  method  is  productive  of  fearful  hemorrhage  and  the  plan  of  Antyllus  is 
vastly  better.  Syme  opened  the  sac,  inserted  his  finger,  and  plugged  the 
artery  toward  the  heart  until  a  ligature  was  applied  and  tied.  He  then  packed 
the  sac  with  lint. 

Extirpation  of  the  sac,  if  practised,  should  be  carried  out  after  applying 
a  ligature  on  each  side,  after  the  method  of  Antyllus.  It  was  originally  ])rac- 
tised  by  Philagrius  and  was  reintroduced  by  Purmann  in  1699  (Moynihan,  in 
"Annals  of  Surgery,"  July,  1898). 

Extirpation  finds  warm  advocates  in  Delbet,  Littlewood,  and  Moynihan. 
Moynihan  claims  that,  as  compared  with  distal  ligature,  there  is  a  greater 
chance  of  recover)^,  no  chance  of  recurrence,  less  risk  of  gangrene,  and  com- 
plete recovery  from  troubles  due  to  nerve  interference  ("Annals  of  Surgery," 
July,  1898).     Extirpation  is  regarded  by  some  surgeons  as  the  best  operation 


D 


Fig.  171. — Old  operation  of  Antyllus  Fig.  172.— Anel's  operation  for    aneu- 

for   aneurysm    ("Am.    Text-Book    of  rysm  ("  Am.  Text- Book  of  Surgery  ")• 

Surgery  "). 

for  traumatic  aneurysm,  but  if  the  vessel  is  seriously  diseased  near  the  sac 
some  other  method  should  certainly  be  employed.  In  aneurysm  of  the  com- 
mon carotid  after  extirpation  (as  after  ligation)  there  is  grave  risk  of  cerebral 
emboHsm,  and  it  will  be  wise  to  attempt  a  re-establishment  of  the  circulation 
by  circular  suture  of  the  two  ends,  or,  as  Lexer  did  in  the  axillary  artery, 
autoplasty  with  a  piece  of  the  internal  saphenous  vein.  In  the  extremities 
there  is  much  less  danger  of  gangrene  after  Matas's  operation  than  after 
extirpation. 

The  Method  ofAjiel. — Anel,  of  Turin,  devised  and  performed  this  operation 
in  1710.  In  Anel's  method  the  artery  is  ligated  above  the  sac,  and  so  close 
to  it  that  there  are  no  anastomotic  branches  between  the  sac  and  the  ligature 
(Fig.  172).  It  is  used  only  for  traumatic  aneurysms,  and  is  never  employed 
when  the  vessel  is  diseased  beyond  the  aneurysm.  Either  extirpation  or 
Matas's  operation  is  preferable  to  Anel's  operation. 

The  Method  of  Hunter. — This  operation,  which  is  the  modern  method  of 
ligation,  was  devised  by  the  illustrious  John  Hunter  and  was  first  employed  by 
him  in  January,  1786.  He  is  said  by  Sir  Everard  Home  to  have  recognized  the 
fact  that  the  vessel  adjacent  to  an  aneurysm  was  apt  to  be  diseased,  and  he 
discovered  the  anastomotic  circulation.  Putting  together  these  two  facts, 
he  devised  the  operation  which  goes  by  his  name.     It  consists  in  applying  a 


Treatment  of  Aneurysm 


423 


ligature  between  the  heart  and  the  aneurysm,  but  so  far  above  the  sac  that 
collateral  branches  are  given  off  between  it  and  the  point  of  ligation  (Fig.  173). 
This  operation,  which  is  done  upon  a  healthy  portion  of  the  artery,  does  not 
permanently  cut  off  all  blood,  but  so  diminishes  the  force  and  frequency  of 
the  circulation  that  an  active  clot  forms  within  the  sac.  Thus  are  lessened  the 
dangers  of  secondary  hemorrhage  and  gangrene.  According  to  Stimson 
("New  York  Med.  Jour.,"  July,  1884),  Hunter  really  builded  better  than  he 
knew,  for  he  sought  only  to  tie  the  artery  without  opening  the  sac  and  at  a 
healthy  point,  but  said  not  a  word  about  the  necessity  of  having  branches 
between  the  sac  and  the  ligature  or  about  the  desirability  of  diminishing 
the  fiow  of  blood  instead  of  cutting  it  off  completely  (Moynihan,  in  "Annals 
of  Surgery,"  July,  1898).  Hunter  tied  the  artery  in  the  region  now  known 
as  Hunter's  canal.  Scarpa  introduced  the  custom,  which  we  still  follow,  of 
tying  it  in  Scaqm's  triangle.  The  Hunterian  method  was  for  many  years 
regarded  by  most  surgeons  as  the  proper  operation  for  aneurysm  in  the 
majority  of  cases.  In  some  cases  pulsation  does  not  return  after  tightening  the 
ligature;  in  most  cases,  however,  it  reappears  for  a  time  after  about  thirty-six 


■mn 


Fig.  173. — Hunter's  method  of  ligating  for  aneurysm:  a,  The  aneurysm;  b,  point  of  liga- 
tion; c,  the  branches  between  the  aneurysm  and  the  ligature.  The  arrow  shows  the  direction 
of  the  blood-current. 


hours,  but  is  weak  from  the  start,  constantly  diminishes,  and  finally  disappears 
permanently.  Previous  prolonged  compression  by  enlarging  the  collateral 
branches  permits  strong  pulsation  to  recur  soon  after  ligation,  and  thus  militates 
against  cure;  hence  it  is  a  bad  plan  to  use  pressure  in  cases  admitting  of  liga- 
tion, and  in  which  the  success  of  pressure  is  very  doubtful.  Occasionally  after 
Hunter's  operation  the  sac  suppurates,  producing  symptoms  like  those  of  ab- 
scess. Suppuration  may  occur  between  the  first  and  the  thirty-second  week 
after  ligation.*  When  pus  forms,  open  freely,  as  we  would  open  an  abscess,  and 
if  no  blood  flows,  treat  as  an  abscess,  but  have  a  tourniquet  loosely  applied  for 
several  days  ready  to  screw  up  at  the  first  sign  of  danger.  If  hemorrhage 
occurs,  tie  the  vessel  above  and  below  the  aneurysm,  open  the  sac,  and  pack 
with  iodoform  gauze.  If  bleeding  recurs,  there  is  no  use  reapplying  the 
ligature  and  there  is  little  use  tying  higher  up.  If  dealing  with  an  arm,  try  the 
application  of  a  ligature  higher  up;  if  dealing  with  a  leg,  amputate  at  once. 

Distal  Ligation. — When  an  aneurysm  is  so  near  the  trunk  that  Hunter's 
operation  is  impracticable,  or  when  the  artery  on  the  cardiac  side  of  the 

*  See  the  case  described  by  Sir  Astley  Cooper. 


424 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


tumor  is  greatly  diseased,  distal  ligation  may  be  employed.  Distal  ligation 
forms  a  barrier  to  the  onflow  of  blood,  collateral  branches  above  the  aneurysm 
enlarge,  the  blood-current  is  gradually  diverted,  and  a  clot  may  form  within 
the  aneurysm.  Distal  ligation  is  used  in  some  a.neurysms  of  the  aorta,  iliacs, 
innominate,  carotids,  and  subclavians.  It  occasionally  causes  rupture  of  the 
sac  of  the  aneurysm.  I  have  obtained  two  notably  successful  results  in  aneu- 
rysms of  the  innominate  artery  by  ligation  of  the  common  carotid  and  subclavian 
of  the  right  side.  In  each  of  these  cases  I  tied  both  vessels  at  one  seance, 
tying  the  carotid  first.  In  one  case  I  tied  the  third  part  of  the  subclavian  and 
in  the  other  the  first  part. 

The  operation  of  Bmsdor  consists  in  tying  the  main  trunk  some  little 
distance  below  the  aneurysm  (Fig.  174).  It  completely  arrests  circulation 
in  the  sac.  The  operation  was  introduced  in  1760  by  the  French  surgeon 
Brasdor. 

The  operation  of  Wardrop  consists  in  tying  one  of  the  branches  of  the 
artery  below  the  aneurysm.  Wardrop  originally  advocated  ligation  at  a 
point  where  there  is  no  intervening  branch  between  the  sac  and  the  ligature. 


Fig.  174.  —  Brasdor's  operation  (Holmes). 


Fig.  175. — Wardrop's  operation  (Holmes). 


Later  he  advocated  ligation  at  a  point  where  there  is  an  intervening  branch. 
Since  then  it  is  the  custom  to  consider  Wardrop's  operation  to  be  the  ligation 
of  one  branch  below  the  aneurysm,  as  shown  in  Fig.  175.  The  circulation  is 
but  partially  arrested  by  Wardrop's  operation.  The  operation  was  introduced 
in  1825.  An  .x-ray  picture  should  be  taken  in  every  case  of  aortic  aneurysm. 
Such  a  picture  may  aid  us  in  coming  to  a  conclusion  as  to  which  vessel  or  vessels 
to  tie. 

Matas's  Operation  {Aneurysmorrliaphy) . — This  procedure  was  first  prac- 
tised by  Matas  in  1889  on  a  negro  suffering  from  traumatic  aneurysm  of  the 
brachial  artery  in  the  middle  of  the  arm.  The  operation  was  a  complete 
success.  In  1900  he  began  again  to  use  this  method,  and  in  1902  described  it  to 
the  profession  ("Transactions  of  Am.  Surg.  Assoc,"  1902;  "Annals  of 
Surg.,"  Feb.,  1903;  "Transactions  of  Am.  Surg.  Assoc,"  1905). 

One  procedure,  applicable  to  ordinary  fusiform  aneurysms,  \?  called 
obliterative  endo-anenrysniorrhaphy  without  arterio plasty  (Fig.  176).  "No  at- 
tempt is  made  to  reconstruct  the  parent  artery  (arterioplasty) ,  and  the  arterial 
orifices  are  simply  obliterated    by   suture."     By  sutures  applied  within  the 


Treatment  of  Aneurysm  425 

incised  sac,  the  sac  is  cut  off  from  the  circulation  without  disturbing  ad- 
jacent collaterals  and  without  interfering  with  the  nutrition  of  the  sac  walls. 
After  this  operation  there  is  very  seldom  secondary  hemorrhage,  gangrene, 
or  relapse. 

A  modification  of  the  above  o[)eration  ai)plied  to  sacculated  aneurysms 
in  which  there  is  one  orifice  of  communication  with  the  artery  is  called  endo- 
aneurysmorrhaphy  with  partial  arterioplasty  (Fig.  176).  The  sac  is  opened, 
clots  are  washed  away,  the  opening  of  the  aneurysm  into  the  artery  is  closed  by 
a  continuous  suture  passing  through  all  the  coats  of  the  sac  at  the  edge  of  the 
opening  into  the  artery.  Blood  is  thus  excluded  from  the  sac,  the  lumen  of  the 
artery  is  not,  however,  obliterated,  and  the  blood-supply  of  parts  beyond  is 
not  interfered  with.  After  closing  the  cut  in  the  arterial  wall  the  sac  is  ob- 
literated by  rows  of  sutures  inserted  in  its  walls.  Matas  reports  4  cases  oper- 
ated upon  successfully  by  this  plan.  In  a  fusiform  aneurysm  with  a  firm  and 
resisting  sac  wall,  and  in  which  there  are  two  openings  near  together  on  the 
floor  of  the  sac,  endo-aneurysmorrhaphy  with  complete  arterioplasty  may  be 
performed  (Fig.  176).  This  operation  restores  arterial  continuity,  a  new 
channel  being  made  out  of  the  sac  walls  "by  simply  holding  these  over  a  rub- 
ber guide  (tube  or  catheter)  and  suturing  them  firmly  together  so  as  to  restore 
the  continuity  of  the  artery  lost  in  the  sac."  The  catheter  is  withdrawn  before 
the  final  sutures  are  tied.  This  operation  has  been  performed  successfully  by 
Morris  and  also  by  Craig.  Some  surgeons  are  fearful  that  such  an  operation 
will  be  followed  by  relapse,  and  one  of  the  reported  cases  did  relapse.  Matas 
says  that  preservation  of  the  arterial  lumen  is  "only  indicated  positively  in 
the  sacciform  aneurysms  with  a  single  opening  where  the  parent  artery  already 
exists  as  a  formed  vessel  and  in  which  the  closure  of  the  fistulous  opening  can 
be  accomplished  with  the  greatest  facility  and  simplicity"  (address  deUvered 
at  the  Medical  Assoc,  of  Alabama,  April  22, 1906).  It  is  not  probable  that  the 
artery  remains  patent  long,  because  the  seat  of  aneurysm  is  a  diseased  vessel  and 
vascular  disease  will  probably  cause  clotting,  but  even  a  temporary  restora- 
tion of  circulation  if  followed  by  gradual  aboHtion  prevents  gangrene.  The 
Matas  operation  dilTers  notably  from  the  Antyllus  operation  in  the  fact  that  it 
saves  certain  collaterals  which  the  Antyllus  method  destroys,  and  the  reten- 
tion of  these  collaterals  may  prevent  gangrene  in  the  limb.  It  differs  from  it 
further  in  the  fact  that  it  occludes  certain  small  vessels  which  after  the  An- 
tyllus method  continue  to  convey  blood  into  the  sac.  It  is  superior  to  extir- 
pation because  it  does  not  destroy  the  vascular  walls  of  the  sac,  the  blood- 
vessels of  which,  if  unblocked,  aid  in  preventing  gangrene. 

Matas  points  out  that  suture  of  an  aneurysm  is  indicated  only  when  cer- 
tain essentials  exist. 

1.  The  situation  of  the  aneurysm  must  admit  of  the  control  of  the  circu- 
lation temporarily  on  the  proximal  side  of  the  sac.  In  most  aneurysms  of 
the  extremities  this  is  done  by  the  elastic  band  of  Esmarch.  In  the  neck 
and  abdomen  both  the  cardiac  and  peripheral  sides  of  the  main  vessels  must 
be  secured  by  traction  loops  and  compression. 

2.  The  sac  must  be  freely  opened  in  a  longitudinal  direction.  Its  wall 
must  not  be  dissected  and  must  be  separated  as  little  as  possible  from  sur- 
rounding tissue. 

3.  Every  orifice  opening  into  the  sac  must  be  thoroughly  exposed  so  that 


426  Diseases  and  Injuries  of  the  Heart  and  Vessels 

they  can  be  closed  by  sutures.  The  suture  material  is  chromic  gut,  the  num- 
ber being  i,  2,  or  3,  according  to  the  size  of  the  aneurysm. 

Fig.  176,  A  to  H,  shows  Matas's  various  operations.  For  a  full  descri])tion 
of  them  see  the  previously  quoted  articles  of  the  author.  I  believe  that  the 
Matas  operation  is  a  very  notable  advance  in  surgery,  that  it  is  the  most  im- 
portant work  that  has  been  done  in  aneurysm  since  the  studies  of  John  Hunter, 
that  it  is  safer  than  older  methods,  and  much  less  apt  to  be  followed  by  gan- 
grene. The  idea  seems  to  be  general  that  Matas  always  seeks  to  restore 
arterial  lumen.  This  is  not  the  case.  He  only  seeks  to  do  this  in  exceptional 
cases.  The  essence  of  his  method  is  to  cure  the  aneurysm  by  sutures 'within 
the  sac  and  by  obliteradon  of  the  sac.  I  have  performed  the  Matas  operation 
(obliterative  endo-aneurysmorrhaphy)  successfully  on  a  case  of  ruptured  fusi- 
form popliteal  aneurysm  and  on  a  case  of  ruptured  sacculated  pojjliteal 
aneurysm.  In  the  latter  case  there  was  profuse  hemorrhage  during  the 
operation  from  vessels  opening  into  the  sac. 

Matas,  in  "Jour.  Am.  Med.  Assoc,"  Nov.  14,  1908,  has  collected  85  cases 
(excluding  arteriovenous  aneur\'sm) . 

VESSEL  EWOLVED. 

Abdominal  aorla 2  Posterior  tibial i 

External  iliac i  External  carotid i 

Gluteal I  Subclavian i 

Iliofemoral 5  Subclavio-axillary 2 

Femoral 18  Axillary i 

Popliteal 50  Brachial 2 

There  were  78  recoveries,  2  cases  of  secondary  hemorrhage,  4  cases  of 
gangrene,  and  4  relapses  (all  of  them  after  reconstructive  operations) . 

Halsted's  Method  by  Partial,  Progressive,  and,  finally,  Complete  Occlusion  by 
Metal  Band. — This  method  is  applied  only  to  the  aorta  and  other  very  large 
arteries.  A  number  of  surgeons  have  sought  a  method  to  gradually  and  safely 
occlude  the  abdominal  aorta  in  order  that  they  may  attempt  to  cure  aneurysm 
of  the  aorta  or  of  the  iliac  arteries.  The  usual  thought  was  to  leave  a  metal 
instrument  fixed  to  the  aorta,  the  handle  projecting  from  the  abdominal  wound, 
and  a  metal  clamp  or  a  snare  of  silk  or  catgut  being  around  the  vessel,  so  that, 
by  means  of  a  screw  arrangement,  pressure  could  be  gradually  increased. 

Halsted  showed  that  by  this  plan  sepsis  almost  certainly  occurs  along  the 
track  of  the  instrument  (see  W.  S.  Halsted,  in  "  Johns  Hopkins  Bulletin,"  1905, 
xvi,  346;  "Jour.  Am.  Med.  Assoc,"  1906,  xlvii;  "Jour.  Experimental  ^ledi' 
cine,"  vol.  xi.  No.  2,  1909).  Halsted  sought  for  a  method  "permitting,  in 
each  entre-act,  complete  closure  of  the  wound."  He  uses  a  band  of  alu- 
minium curled  in  cyhnder  form  about  the  vessel.  This  material  admits  of 
easy  readjustment  at  a  future  operation,  and  it  is  tightened  with  the  fingers. 

Halsted's  band,  when  used  to  partially  occlude,  seldom  causes  macroscopic 
alteration  in  the  wall  of  the  vessel;  when  used  to  completely  occlude,  the  vessel 
may  undergo  atrophy.  Ideal  closure  is  when  the  lumen  was  nearly  but  not 
c[uite  occluded,  spontaneous  obliteration  ha\ing  arisen,  the  arterial  wall 
embraced  by  the  band  having  undergone  conversion  into  "a  sohd  cylinder 
of  living  tissue." 

Halsted  ha?  made  numerous  experiments  on  dogs  and  has  used  the  band 


Trealmenl  of  Aneurysm 
B 


427 


Fig.  176. — The  radical  cure  of  aneurysm  based  upon  arteriorrhaphy  (Matas):  A.  First  tier  of 
sutures  in  a  fusiform  aneurysm  ;  B,  second  tier  of  sutures,  some  of  which  are  tied  ;  C,  sutures  to  ap- 
proximate the  walls  of  the  aneurysm  ;  D,  suturing  the  opening  in  a  sacculated  aneurysm— the 
main  artery  is  not  obliterated;  £■,  opening  completely  closed  ;  i^,  diagram  of  cross-section  of  parts 
after  complete  obliteration  of  sac  but  with  restoration  of  blood-channel ;  C,  diagram  of  cross-section 
of  parts  after  complete  obliteration  of  sac  and  blood-vessel ;  //,  operation  for  fusiform  aneurysm 
when  we  wish  to  restore  the  blood-channel— sutures  applied  over  a  rubber  tube,  most  of  the  sutures 
tied,  tube  withdrawn,  and  remaining  sutures  tied. 


42J 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


with  encouraging  results  on  the  human  being  (partial  occlusion  of  the  innom- 
inate, twice,  common  carotid,  four  times). 

In  getting  the  band  ready  for  application  it  is  rolled  by  means  of  the  instru- 
ment shown  in  Fig.  177. 

Treatment  After  Operation  for  Aneurysm. — After  operating  for  aneu- 
r}-5m  of  an  extremity  Ijy  the  ligature  or  by  sutures,  elevate  the  limb  slightly, 
keep  it  warm  by  ^Tapping  in  cotton  and  surrounding  with  bags  of  warm  water, 
and  subdue  arterial  excitement.  When  gangrene  of  a  limb  follows  ligation, 
await  a  line  of  demarcation,  and  when  it  forms,  amputate.  Rupture  of  the  sac 
after  ligation  may  produce  gangrene  or  be  associated  with  suppuration,  the 
first  condition  demanding  amputation,  and  the  second  incision  for  drainage. 


Fig.  177. — Halsted's  improved  band  roller:    The  instrument  shown  in  full  length  is  unloaded; 
in  the  abbreviated  cut  the  band  is  about  to  be  expelled  from  the  roller  (Halsted). 

Injection  of  coagulating  agents  into  the  sac  (ergot,  perchlorid  of  iron,  etc.) 
is  ver}-  dangerous  and  is  to  be  utterly  condemned.  It  may  lead  to  suppura- 
tion, gangrene,  rupture,  or  embolism. 

Manipulation  to  break  up  the  clot  was  suggested  by  Sir  "\Vm.  Fergusson 
and  has  been  practised.  The  object  aimed  at  is  to  have  a  fragment  of  clot 
block  up  the  vessel  upon  the  peripheral  side  of  the  artery  and  act  like  a  distal 
ligature.  The  method  is  dangerous,  especially  in  carotid  aneurysm,  and 
should  never  be  employed. 

Amputation,  instead  of  distal  ligation,  is  performed  in  some  perilous  cases 
of  subclavian  aneur}-sm. 

Electrolysis. — An  attempt  may  be  made  to  at  once  coagulate  the  blood  in 
the  sac,  or  from  time  to  time  an  endeavor  may  be  made  to  produce  fibrinous 
deposits,  but  the  first  method  is  the  better.  It  is,  however,  seldom  possible  to  at 
once  occlude  a  sac,  and  pulsation,  which  is  for  a  time  abolished,  usually  recurs 
as  the  gas  present  is  absorbed.  Use  the  constant  current.  Take  from  three 
to  six  cells  which  stand  in  point  of  size  between  those  used  for  the  cauter}' 
and  those  used  for  ordinar}'  medical  purposes.  A  platimmi  needle  is  attached 
to  the  positive  pole  and  a  steel  needle  to  the  negative  pole,  each  needle  being 
insulated  by  \-ulcanite  at  the  spot  where  the  tissues  will  touch  it.  The  asepti- 
cized needles  are  plunged  into  the  sac  where  it  is  thick,  and  they  are  kept  near 


Treatment  of  Aneurysm  429 

together.  The  current  is  passed  for  a  varialjlc  period  (from  half  an  hour  to 
an  hour  and  a  half).  This  operation  is  not  dangerous.  Pressure  stops  the 
bleeding.  Electrolysis  often  ameliorates,  and  sometimes,  though  very  rarely, 
cures,  aortic  aneurysms.* 

Acupuncture  consists  of  the  partial  introduction  of  a  number  of  ordinary 
sewing  needles  into  an  aneurysmal  sac  and  leaving  them  in  it  for  five  or  six 
days  or  more.  Professor  Macewen  introduces  a  needle,  and  with  it  irritates 
the  interior  of  the  sac  of  an  aneurysm,  hoping  thus  to  cause  deposition  of 
leukocytes  and  clot-formation. 

Intyoduction  0}  Wire. — Insert  into  the  sac  a  hypodermatic  or  small  aspirat- 
ing needle,  and  push  through  the  needle  or  cannula  a  considerable  quantity 
of  aseptic  gold  wire,  which  is  allowed  to  remain  permanently.  Electrolysis 
should  be  combined  with  the  introduction  of  wire.  This  operation  was 
first  proposed  by  Corradi.  Loreta  and  Barwell  both  inserted  wire  into  an 
aneurysm  before  Corradi,  but  Corradi  inserted  wire  and  also  used  electricity. 
Corradi 's  operation  can  be  used  when  distal  ligation  cannot  be  carried  out, 
and  can  be  used  even  when  the  vessel  is  extremely  atheromatous.  It  finds 
its  chief  use  in  aneurysms  of  the  thoracic  aorta  and  innominate.  In  some 
cases  of  abdominal  aneurysm  the  belly  has  been  opened  and  the  operation 
carried  out.  The  operation  has  not  many  elements  of  danger.  There  are  on 
record  over  60  operations  for  thoracic  aneurysm  by  this  method  and  8  for  ab- 
dominal aneurysm.  Some  cases  have  been  notably  improved.  The  operation 
is  performed  vdth  aseptic  care.  If  the  thoracic  aorta  is  to  be  operated  upon, 
an  anesthetic  is  not  required.  If  the  abdominal  aorta  is  to  be  wired,  the  patient 
must  be  anesthetized,  because  the  abdomen  needs  to  be  opened.  The  wire 
used  must  have  been  previously  drawn,  so  that  it  will  easily  pass  through  a 
hypodermatic  needle  and  will  coil  up  spirally  within  the  sac.  The  best  wire 
is  of  silver  or  gold.  It  is  a  great  mistake  to  introduce  a  large  quantity. 
Stewart  decided  that  a  globular  sac  3  inches  in  diameter  requires  from  3 
to  5  five  feet,  and  a  sac  5  inches  in  diameter  requires  from  8  to  10  feet.  A 
hypodermatic  needle,  insulated  up  to  \  inch  of  the  point,  is  carried  into  the 
interior  of  the  aneurysm  through  a  fairly  thick  portion  of  the  sac.  The 
shoulder  of  the  needle  is  not  insulated  and  must  not  be  permitted  to  touch  the 
skin,  because  if  it  did  so  it  would  cause  a  burn  by  electrolysis.  The  required 
amount  of  wire  is  introduced.  The  Avire  is  attached  to  the  positive  pole  of  the 
battery.  The  negative  pole  is  fastened  to  a  large  flat  piece  of  clay  or  a  pad  of 
moistened  absorbent  cotton,  and  the  negative  electrode  is  placed  upon  the  back 
or  abdomen.  The  current  is  turned  on  gradually  until  the  necessary  strength 
is  obtained  (40  to  80  ma.).  When  ready  to  terminate  the  operation  the 
current  is  lowered  gradually  to  zero,  the  needle  is  withrdawn,  the  wire  is 
cut  ofif  close  to  the  skin,  the  end  is  pushed  under  the  skin,  and  the  puncture  is 
covered  with  iodoform  collodion.  The  entire  operation  requires  from  three- 
quarters  of  an  hour  to  one  and  a  half  hours,  f  A  clot  forms  with  considerable 
rapidity  and  expansile  pulsation  may  lessen  or  cease.  It  requires  from  a 
number  of  days  to  several  weeks  for  the  clot  to  become  hard.  The  operation 
can  be  repeated  if  necessary. 

*  See  John  Duncan,  in  Heath's  Dictionary. 

fThe  above  description  is  condensed  from  that  of  D,  D.  Stewart,  in  "  Phila.  Med. 
Jour.,"  Nov.  12,  1898. 


430  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Cure  is  not  obtained.  As  Hare  says,  "  adjacent  tissues  of  the  vessel  sooner 
or  later  give  way,  because  the  effort  is  like  an  effort  to  mend  a  rotten  hose, 
though  mended  at  one  spot  it  breaks  at  another.  The  operation  causes 
promptly  notable  diminution  of  pain,  an  amelioration  usually  spoken  of  by 
the  patient  before  he  leaves  the  operating  table.  Dyspnea  is  also  benefited 
and  just  as  rapidly"  (H.  A.  Hare,  in  "Therapeutic  Gazette,"  April,  1908). 

Treatment  of  Aneurysm  Following  Wound  of  a  Healthy  Artery. — 
The  prognosis  in  such  a  case  is  usually  extremely  good.  The  treatment  is 
as  for  the  other  forms.  Extirpation  is  particularly  adapted  to  such  direct 
traumatic  aneurysms  in  the  neck  and  Matas's  operation  to  those  in  the  ex- 
tremities. 

Diffuse  Traumatic  Aneurysm.— When  an  artery  ruptures  or  an  aneu- 
rysm ruptures  and  a  large  mass  of  blood  is  extravasated  into  the  tissues,  no 
complete  sac  exists,  and  the  condition  is  usually  called  diffuse  traumatic 
aneurysm.  In  diffuse  traumatic  aneurysm  a  large  oblong,  fluctuating  swell- 
ing is  found.  If  the  rent  is  large,  there  are  bruit  and  pulsation.  There  is 
no  pulsation  in  the  artery  below  the  aneurysm,  and  the  Hmb  is  cold  and  swol- 
len.    The  skin  is  at  first  of  a  natural  color,  but  later  becomes  thin  and  purple 

Treatment.— If  an  aneurysm  ruptures,  cut  down  upon  the  aneurysm,  in- 
cise the  sac  longitudinally,  and  perform  Matas's  operation.     Some  surgeons 


Fig.  1 7cS.— Dilatation  of  veins  m  arteriovenous  aneurysm  of  the  femoral  vessels. 

cut  down  to  the  aneurysm,  tie  on  each  side  of  the  tear,  open  the  sac,  and  pack 
it  (the  operadon  of  Antyllus),  but  Matas's  operadon  is  the  preferable  pro- 
cedure. If  an  artery  is  ruptured,  empty  the  limb  of  blood,  apply  an  Esmarch 
band  above,  and  expose  the  seat  of  rupture  by  incision.  If  possible,  suture  the 
opening;  if  this  is  not  possible,  tie  the  vessel  on  each  side  of  the  rupture  and 
excise  the  intervening  pordon.  If  the  main  vein  is  also  ruptured,  amputate  if 
suture  of  the  vessels  is  impossible. 

Arteriovenous  aneurysm  was  first  described  by  Wm.  Hunter  in  1757. 
By  this  term  we  mean  an  unnatural  passageway  between  a  vein  and  an  artery, 
through  which  passage  blood  circulates.    There  are  two  forms:  {a}  aneurysmal 


Arteriovenous  Aneurysm 


431 


varix,  or  Poll's  aneurysm,  a  vein  and  an  artery  directly  communicating;  and 
(b)  varicose  aneurysm,  a  vein  and  an  artery  communicating  through  an  in- 
tervening sac.  These  conditions  arise  usually  from  punctured  wounds,  the 
instrument  passing  through  one  vessel  and  into  the  other,  blood  flowing  into 
the  vein,  the  subsequent  inflammation  gluing  the  two  vessels  together,  and 
the  aperture  faihng  to  close  (aneurysmal  varix,  Fig.  179).  After  the  infliction 
of  the  wound  the  two  vessels  may  separate;  the  blood  continuing  to  flow 
from  artery  into  vein,  and  the  blood-pressure,  by  consolidating  tissue,  forming 
a  sac  of  junction  (varicose  aneurysm,  Fig.  180).  Wounds  produced  by  small 
bullets  may  result  in  arteriovenous  aneurysm  (Matas,  in  "Transactions  of 
Am.  Surg.  Assoc,"  vol.  xi.\).  Aneurysmal  varix  is  a  less  grave  disorder  than 
varicose  aneurysm.    Arteriovenous  aneurysm  used  to  be  most  frequent  at  the 


Fig.  179.— Plan  of  aneurysmal  varix. 


Fig.  180.— Varicose  aneur>sm  (Spence). 


bend  of  the  elbow,  the  vessels  being  injured  during  venesection.  The  condi- 
tion may  occur  in  the  neck,  the  axilla,  the  extremities,  or  the  groin.  I  assisted 
Professor  Keen  in  an  operation  upon  an  aneurj'smal  varix  of  the  common 
carotid  and  internal  jugular  vein,  and  assisted  Professor  Hearn  in  operating 
on  a  varicose  aneurysm  involving  the  external  iliac  vessels.  Sir  Frederick 
Treves  operated  on  a  case  involving  the  internal  ma.xillary  vessels.  Very 
rarely  an  arteriovenous  aneurysm  forms  spontaneously.  Spontaneous  arterio- 
venous aneurysm  is  most  frequent  between  the  aorta  and  vena  cava.  There 
is  no  tendency  to  spontaneous  cure  in  arteriovenous  aneurysm.  Edema  is 
the  rule,  muscular  atrophy  is  common,  and  ulceration  or  even  gangrene  of  a 
limb  may  occur.  Matas  has  collected  17  cases  of  arteriovenous  aneurysm  of 
the  subclavian  vessels  ("Transactions  of  Am.  Surg.  Assoc,"  vol.  xix).  In  this 
list  is  the  celebrated  case  of  his  own,  a  traumatic  (gunshot)  arteriovenous 
aneurysm  in  which  cure  followed  operation;  in  the  operation  it  was  necessary 
to  obliterate  the  artery  by  ligatures,  but  the  venous  orifice  was  closed  by 
sutures  without  obliterating  the  lumen  of  the  vein.  In  the  analysis  of  Matas's 
paper  15  cases  are  used,  2  having  been  noted  too  late  for  incorporation;  9 
of  the  cases  resulted  from  "stab  or  penetrating  cut  wounds,"  6  from  bullets — 
in  5  of  the  cases  the  brachial  plexus  was  injured.  In  8  out  of  the  11  un- 
operated  cases  the  time  after  the  injury  when  symptoms  of  arteriovenous 
aneurysm  was  noted  is  stated;  in  i  signs  were  definite  within  four  hours, 
in  3  they  were  noted  on  the  second  day,  in  3  on  the  third  day,  in  i  on  the 
sixth  day,  in  i  on  the  eighth  day,  in  i  on  the  ninth  day,  and  in  i  a  few 
days  later.  In  3  of  the  15  cases  secondary  hemorrhage  followed  the  injury. 
Eleven  of  the  15  cases  were  treated  expectantly;  i  died  from  secondary 
hemorrhage  and  sepsis  3  weeks  after  the  injury  and  10  "sur\-ived  the  imme- 
diate effects  of  the  injury,  their  wounds  healing  after  the  cessation  of  the 
primary  hemorrhage." 


432  Diseases  and  Injuries  of  the  Heart  and  Vessels 

In  4  of  the  15  cases  operation  was  performed.  In  3  the  operation 
was  done  soon  after  the  injury  because  of  violent  secondary  hemorrhage. 
In  I  (Matas's  own  case)  operation  was  done  deliberately  to  prevent  com- 
plications. Three  of  these  cases  recovered  (including  Matas's);  i  died  of 
renewed  secondary  hemorrhage  on  the  twenty-fourth  day  after  opera- 
tion. Matas  points  out  the  fact  that  in  stab  wounds  of  the  subclavian  vessels 
the  largest  proportion  of  cases  die  of  primary  hemorrhage  before  assistance 
is  obtained,  but  in  a  considerable  number  of  cases  temporary  hemostasis 
occurs,  which  is  followed  by  secondary  hemorrhages  or  arteriovenous  aneu- 
rysm. 

Symptoms  of  Aneurysmal  Varix. — The  arterial  blood  is  cast  forcibly 
into  the  vein  and  as  a  consequence  the  vein  becomes  enlarged,  tortuous,  and 
thickened.  The  scar  of  a  wound  is  almost  invariably  apparent.  At  the  seat 
of  vascular  trouble  the  most  marked  dilatation  exists  and  it  is  of  bluish  color. 
The  tumor  pulsates  markedly,  imparts  a  sensation  to  the  finger  Hke  that  felt 
when  the  hand  is  laid  upon  the  back  of  a  purring  cat.  This  thrill  or  vibration 
is  very  characteristic.  A  sound  of  a  hissing  or  buzzing  nature  can  be  easily 
heard.  The  tumor  at  once  disappears  on  pressure  being  made  upon  it  or  on 
the  artery  between  it  and  the  heart.  It  is  diminished  in  size  by  raising  the 
limb,  is  increased  in  size  by  a  dependent  position  of  the  limb  and  by  com- 
pressing the  vein  between  the  heart  and  the  tumor.  The  adjacent  veins  are 
dilated  and  often  the  dilatation  is  manifested  over  a  wide  area  above  and 
below  (Fig.  178).  and  the  thrill  and  bruit  are  transmitted  a  considerable  dis- 
tance. If  an  extremity  is  involved  it  is  usually  edematous.  The  parts  as 
a  rule  are  painful.  The  condition  progresses,  but  very  slowly,  and  sometimes 
years  may  elapse  without  any  notable  aggravation. 

Symptoms  of  Varicose  Aneurysm. — In  this  condition  we  find  many  of 
the  symptoms  of  aneurysmal  varix,  but  in  varicose  aneurysm  pressure  over 
the  artery  of  supply  between  the  heart  and  the  lesion  does  not  cause  the  entire 
disappearance  of  the  tumor;  the  veins  collapse,  it  is  true,  but  a  distinct  sac 
remains,  which  may  be  emptied  by  direct  pressure. 

Treatment. — The  prognosis  after  operation  is  better  than  in  ordinary 
aneurysm,  but  nevertheless  it  is  wisest  to  refrain  from  operating  on  aneu- 
rysmal varix  so  long  as  the  condition  is  not  progressing  obviously,  is  borne 
without  inconvenience,  and  is  not  leading  to  compHcations.  Varicose  aneu- 
rysm should  be  operated  upon.  If  we  refrain  from  operating  upon  aneurys- 
mal varix  the  patient  should  wear  a  support;  but  if  the  part  becomes  painful 
or  if  there  seems  to  be  danger  of  rupture  of  the  vein,  operation  should  be  per- 
formed. Until  recently,  when  operation  was  indicated,  surgeons  advised  that 
each  vessel  should  be  tied  above  and  below  the  opening  and  a  portion  of  each 
vessel  should  be  excised,  the  excised  area  including  the  opening.  In  varicose 
aneurysm  it  was  the  custom  to  tie  each  vessel  above  and  below  the  sac,  and 
excise  the  sac  with  a  portion  of  each  vessel.  At  the  present  time  surgeons 
prefer  the  Matas  operation  for  both  varicose  aneurysm  and  aneurysmal  varix. 
In  some  cases  of  varicose  aneurysm,  however,  the  sac  is  extirpated  and  the 
openings  in  the  vessels  closed  by  suture,  and  in  some  cases  of  aneurysmal 
varix  the  adherent  vessels  are  separated  and  the  opening  in  each  is  sutured. 

Cirsoid  aneurysm,  or  aneurysm  by  anastomosis,  consists  in  great 
dilatation  with  pouching  and  lengthening  of  one  or  several  arteries.     The 


Contused  and  Incised  Wounds  433 

disease  progresses  and  after  a  time  involves  the  veins  and  capillaries.  The 
walls  of  the  arteries  become  thin  and  the  vessels  tend  to  rupture.  Cirsoid 
aneurysm  is  most  commonly  met  with  upon  the  forehead  and  scalp  of  young 
people,  where  it  sometimes  takes  origin  from  a  nevus.  It  is  sometimes  seen 
upon  the  back  or  upper  extremity.  The  cause  is  unknown.  Usually  there 
is  no  assignable  cause,  but  occasionally  the  condition  follows  an  injury. 
Pregnancy  causes  a  cirsoid  aneurysm  to  grow  rapidly,  and  so  usually  does 
the  onset  of  puberty.  Occasionally  some  of  the  enlarged  vessels  fuse  and 
form  a  great  cavity.  If  rupture  occurs,  desperate  hemorrhage  inevitably 
ensues. 

Symptoms. — There  is  a  pulsating  mass,  irregular  in  outline,  composed 
of  dilated,  elongated,  and  tortuous  vessels  that  empty  into  one  another.  The 
mass  is  soft,  can  be  much  reduced  by  direct  pressure,  and  is  diminished  by 
compression  of  the  main  artery  of  supply.     A  thrill  and  a  bruit  exist. 

Treatment. — In  treating  a  cirsoid  aneurysm  the  ligation  of  the  larger 
arteries  of  supply  is  a  wretched  failure.  Subcutaneous  ligation  at  many 
points  of  the  diseased  area  has  effected  cure  in  some  cases,  but  it  has  failed 
in  more.  Direct  pressure  is  also  entirely  useless.  Ligation  in  mass  has  been 
successful.  Destruction  by  caustic  has  its  advocates.  Electropuncture  with 
circular  compression  of  the  arteries  of  supply  has  once  or  twice  effected  a 
cure.  Injection  of  astringents  has  been  recommended.  Verneuil  ligated 
the  afferent  arteries,  incised  the  tissues  around  the  tumor,  and  sank  a  con- 
stricting Hgature  into  the  cut.  The  proper  method  of  treatment  is  excision 
after  exposure  and  ligation  of  every  accessible  tributary  of  supply.  In  a  very 
extensive  mass  extirpation  is  impossible;  hence  one  of  the  other  methods 
suggested  must  be  employed.  A  very  considerable  mass  can  be  excised,  and 
the  resulting  wound  should  be  covered  with  Thiersch  skin-grafts. 

Wounds  of  arteries  are  divided  into  contused,  incised,  lacerated, 
punctured,  and  gunshot-wounds,  and  vascular  ruptures. 

Contused  and  Incised  Wounds. — A  contusion  may  destroy  vitality  and 
be  followed  by  sloughing  and  hemorrhage.  A  contusion  may  rupture  a 
blood-vessel,  and  is  especially  apt  to  do  so  if  the  vessel  is  diseased.  Blood 
is  at  once  effused  at  the  seat  of  rupture.  If  an  artery  is  ruptured,  there  may 
or  may  not  be  a  bruit  and  pulsation  over  the  seat  of  rupture,  pulse  is  absent 
below,  and  the  leg  below  the  injury  swells  and  becomes  cold.  If  a  large 
vein  ruptures,  a  blood  tumor  forms,  which  does  not  pulsate  and  has  no  bruit, 
and  the  limb  below  becomes  intensely  edematous.  Gangrene  is  apt  to  follow 
the  rupture  of  a  main  blood-vessel  of  an  extremity.  A  contusion  may  rupture 
the  internal  and  middle  coats  of  an  artery,  the  external  coat  remaining  intact. 
When  this  happens  the  internal  coat  curls  up  and  the  middle  coat  contracts 
and  retracts,  the  blood-stream  is  arrested,  and  a  large  clot  forms  within  the 
artery.  If  the  clot  blocks  up  many  collaterals,  gangrene  will  follow,  and, 
as  has  been  pointed  out,  the  gangrene  will  not  be  preceded  by  swelling  at  the 
seat  of  injury,  which  always  occurs  if  a  vessel  is  ruptured.  A  contused 
wound  may  do  little  damage,  or  it  may  produce  gangrene  from  thrombosis, 
or  it  may  cause  secondary  hemorrhage.  In  an  incised  wound  of  an  artery 
there  is  profuse  hemorrhage.  The  artery  after  a  time  is  apt  to  contract  and 
retract,  bleeding  being  thus  arrested.  A  transverse  wound  causes  profuse 
bleeding,  but  there  is  a  better  chance  for  natural  arrest  than  in  an  oblique 
28 


434  Diseases  and  Injuries  of  the  Heart  and  Vessels 

or  in  a  longitudinal  wound.  The  clot  which  forms  within  a  cut  artery  is 
known  as  the  "internal  clot."  It  used  to  be  taught  that  the  internal  clot 
always  reaches  as  high  as  the  first  collateral  branch,  and  subsequently  is 
replaced  by  fibrous  tissue,  which  permanently  obliterates  the  vessel,  and  con- 
verts it  into  a  shrunken  fibrous  cord.  -  As  a  matter  of  fact,  when  the  parts  are 
aseptic  after  a  ligation  the  clot  is  rarely  bulky  and  is  often  very  scanty,  repair 
being  quickly  effected  by  proliferation  of  endothelial  cells.  Between  the 
vessel  and  its  sheath,  over  the  end  of  the  vessel,  and  in  the  surrounding  peri- 
vascular tissues  is  the  "external  clot"  (Fig.  i8i). 

A  lacerated  wound  of  an  artery  causes  little  primary  hemorrhage.  The 
internal  coat  curls  up,  the  circular  muscular  fibers  of  the  media  contract 
upon  it,  the  longitudinal  fibers  retract  and  draw  the  vessel  within  the  sheath, 
and  the  external  coat  becomes  a  cap  over  the  orifice  of  the  vessel.  All  of 
these  conditions  favor  clotting.  The  vessel-wall  is  so  damaged  that  secondary 
hemorrhage  is  usual. 

Punctured  Wounds. — In  punctured  v^ounds  primary  hemorrhage  is 
slight   unless   a   large   vessel   is   punctured.     Secondary   hemorrhage   is   not 


Fig.  i8i. — Clots    formed  after  division  of  an  artery:    i,  2,    3,  Outer,  middle,  and  inner  coats;   c,   c, 
branches  ;  d,  d,  internal  clot ;  e,  e,  external  clot. 

common.  Traumatic  aneurysm  and  arteriovenous  aneurysm  are  not  unusual 
results. 

Gunshot-wounds  of  arteries  by  pistol  balls  and  the  balls  of  large-caliber 
rifles  are  apt  to  be  contusions  which  may  eventuate  in  sloughing  and 
secondary  hemorrhage  or  thrombosis  and  gangrene.  A  shell-fragment  makes 
a  lacerated  wound.  A  modern  rifle-bullet  makes  a  clean-cut  division  of  an 
artery.  Secondary  hemorrhage  after  gunshot-wounds  is  most  likely  to  occur 
during  the  third  week  after  the  injury.  Partial  rupture  of  an  artery  may 
cause  sloughing  and  secondary  hemorrhage,  thrombosis  and  gangrene,  or 
aneurysm.  A  complete  rupture  constitutes  a  lacerated  wound,  and  is  a  con- 
dition accompanied  by  diffuse  hemorrhage  into  the  tis.sues. 

Wounds  of  veins  are  classified  as  are  wounds  of  arteries.  The  symptom 
of  any  vascular  wound  is  hemorrhage. 

Hemorrhage,  or  Loss  of  Blood. 
Hemorrhage  may  arise  from  wounds  of  arteries,  veins,  or  capillaries,  or 
from  wounds  of  the  three  combined.  In  arterial  hemorrhage  the  blood  is 
scarlet  and  appears  in  jets  from  the  proximal  end  of  the  vessel,  which  jets 
are  synchronous  with  the  pulse-beats;  the  stream,  however,  never  intermits. 
The  stream  from  the  distal  end  is  darker  and  is  not  pulsatile.  Venous  hemor- 
rhage is  denoted  by  the  dark  hue  of  the  blood  and  by  the  continuous  stream. 


Hemorrhage  435 

In  capillary  hemorrhage  red  blood  wells  up  like  water  from  a  squeezed  sponge, 
and  the  color  is  between  the  bright  red  of  arterial  blood  and  the  dark  color  of 
venous  blood. 

In  subcutaneous  hemorrhage  from  rupture  of  a  large  blood-vessel  there 
are  great  swelling,  cutaneous  discoloration,  and  systemic  signs  of  hemorrhage. 
If  a  main  artery  ruptures  in  an  extremity,  there  is  no  pulse  below  the  rupture, 
and  the  limb  becomes  cold  and  swollen.  At  the  seat  of  rupture  a  large 
fluctuating  swelling  forms,  and  sometimes  there  are  bruit  and  pulsation. 
If  a  vein  ruptures  in  an  extremity,  a  large,  soft,  non-pulsatile  swelling  arises, 
there  is  no  bruit,  and  intense  edema  occurs  below  the  seat  of  rupture.  Profuse 
hemorrhage  induces  constitutional  symptoms,  and  death  may  occur  in  a  few 
seconds.  Loss  of  half  of  the  blood  will  usually  cause  death  (from  four  to  six 
pounds),  though  women  can  stand  the  loss  of  a  greater  relative  proportion 
of  blood  than  men.  Young  children,  old  people,  individuals  exhausted  by 
disease,  drunkards,  sufferers  from  Bright's  disease,  diabetes,  and  sepsis 
stand  loss  of  blood  very  badly.  An  individual  with  obstructive  jaundice  is 
apt  to  suffer  from  persistent  oozing  of  blood  after  operation,  an  oozing  which 
is  particularly  persistent  and  dangerous  in  obstruction  of  the  bile-ducts  due 
to  malignant  disease.  It  not  unusually  causes  death.  Generally,  after  bleed- 
ing has  gone  on  for  a  time,  syncope  occurs.  Syncope  is  Nature's  effort  to 
arrest  hemorrhage,  for  during  this  state  the  feeble  circulation  and  the  increased 
coagulability  of  blood  give  time  for  the  formation  of  an  external  clot.  When 
reaction  occurs,  the  clot  may  hold  and  be  reinforced  by  an  internal  clot,  or  it 
may  be  washed  away  with  a  renewal  of  bleeding  and  syncope.  These  episodes 
may  be  repeated  until  death  supervenes.  Nausea  exists  and  there  may  be 
regurgitation  from  the  stomach.  Vertigo  is  present.  There  is  dimness  of 
vision  or  everything  looks  black;  black  specks  float  before  the  eyes  (muscae 
volitantes),  or  the  patient  sees  flashes  of  light  or  colors.  There  is  a  roaring 
sound  in  the  ears  (tinnitus  aurium).  The  patient  yawns,  is  restless,  tosses 
to  and  fro,  and  great  thirst  is  complained  of.  The  mind  may  be  clear,  but 
delirium  is  not  unusual,  and  convulsions  often  occur.  After  a  profuse  hemor- 
rhage an  individual  is  intensely  pale  and  his  skin  has  a  greenish  tinge;  the 
eyes  are  fixed  in  a  glassy  stare  and  the  pupils  are  widely  dilated,  and  react 
slowly  to  light;  the  respirations  are  shallow  and  sighing;  the  skin  is  covered 
with  a  cold  sweat;  the  legs  and  arms  are  extremely  cold,  and  the  body-tempera- 
ture is  below  normal.  The  pulse  is  soft,  small,  compressible,  fluttering,  or 
often  cannot  be  detected;  the  heart  is  very  weak  and  fluttering,  and  the  arterial 
tension  is  almost  abolished.  There  is  muscular  tremor;  the  patient  tosses 
about,  and  asks  often  and  in  a  feeble  voice  for  water.  The  suffering  from 
thirst  is  terrible  and  no  amount  of  water  gives  relief.  There  is  often  dreadful 
dyspnea,  and  a  man  who  is  bleeding  to  death  grasps  at  his  chest,  rises  up 
upon  his  elbow,  and  then  fafls  back  in  a  dead  faint.  Usually  reaction  occurs, 
though  the  patient  is  obviously  weaker  than  before;  again  a  faint  may  happen, 
and  so  there  is  fainting  spell  after  fainting  spell  until  death  ensues.  Con- 
vulsions frequently  precede  death.  In  hemorrhage  the  hemoglobin  is  greatly 
diminished  in  amount.  In  an  intra-abdominal  hemorrhage  the  above  symp- 
toms are  noted,  and,  except  in  splenic  hemorrhage,  blood  gathers  in  both 
loins,  and  dulness  on  percussion  exists  which  gradually  rises  and  shifts  as  the 
patient's  position  is   shifted.     The   blood   also   gathers   in   the   rectovesical 


43^  Diseases  and  Injuries  of  the  Heart  and  Vessels 

pouch  in  the  male,  and  in  the  recto-uterine  pouch  in  the  female,  and  may  be 
detected  by  digital  examination.  If  the  spleen  is  wounded,  the  blood  clots 
quickly,  and  an  area  of  dulness,  which  does  not  shift  and  which  progressively 
increases,  is  noted  in  the  splenic  region.  " 

Treatment. — When  such  a  dangerous  condition  is  due  to  an  intra- 
abdominal hemorrhage,  the  surgeon  at  once  opens  the  abdomen  and  arrests 
bleeding  while  the  assistants  apply  the  treatment  advised  in  the  following 
remarks.  If  a  large  vessel  in  an  extremity  has  been  divided,  temporarily 
arrest  bleeding  by  digital  pressure  in  the  wound,  or  the  application  of  an 
Esmarch  band  above  the  wound  (if  the  bleeding  is  arterial).  In  some  cases 
forced  flexion  is  used.  In  any  case  lower  the  head,  and  have  compression 
made  upgn  the  femorals  and  subclavians,  so  as  to  divert  more  blood  to  the 
brain,  or  bandage  the  extremities  (autotransfusion).  Apply  artificial  heat. 
The  valufe  of  adrenalin  in  restoring  or  maintaining  arterial  tension  has  been 
demonstrated  by  Crile.  We  should  give  the  patient  by  hypodermoclysis  one 
pint  of  hot  normal  salt  solution  containing  one  dram  of  the  i  :  looo  solution 
of  adrenalin  chlorid.  The  fluid  is  allowed  to  run  in  the  subcutaneous  tissue 
beneath  the  breast.  The  infusion  of  one  pint  or  more  of  hot  salt  solution 
into  a  vein  is  a  very  valuable  remedy,  it  gives  the  heart  something  to  contract 
upon  and  thus  maintains  cardiac  action.  If  the  depression  is  very  severe, 
inject  ether  hypodermatically,  then  brandy,  and  then  atropin.  Strychnin 
may  be  given  hypodermatically  in  doses  of  gr.  -oVi  but  atropin  is  of  more 
service.  Digitalin  is  advised  by  some,  but  it  is  not  sufficiently  rapid  in 
action.  Give  enemata  of  hot  coffee  and  brandy.  Apply  mustard  over  the 
heart  and  spine.     Lay  a  hot-water  bag  over  the  heart. 

In  hemorrhage  from  a  vessel  of  an  extremity,  we  temporarily  arrest  bleeding 
while  bringing  about  reaction.  As  soon  as  reaction  is  established  permanently 
arrest  bleeding  by  the  ligature.  In  intra-abdominal  or  concealed  hemorrhage 
it  is  not  possible  to  temporarily  arrest  it  and  wait  for  reaction,  but  the  abdomen 
must  be  opened  and  the  work  proceeded  with  in  spite  of  the  patient's  condi- 
tion.    Every  moment  we  wait  he  is  growing  worse. 

A  severe  hemorrhage  is  apt  to  be  followed  by  fever,  due  to  the  absorption 
of  fibrin  ferment  from  extravasated  blood  and  its  action  upon  a  profoundly 
debilitated  system.  After  a  severe  hemorrhage  leukocytes  are  increased,  not 
only  relatively,  but  absolutely.  Red  corpuscles  are  diminished  both  relatively 
and  absolutely.  Hemoglobin  diminishes;  many  of  the  corpuscles  become 
irregular  and  microcytes  are  noticed. 

In  treating  a  patient  who  has  thoroughly  reacted  after  a  severe  hemor- 
rhage, apply  cold  to  the  head.  Fluids  and  ice  are  grateful.  Frequently 
sponge  the  skin  with  alcohol  and  water.  Milk  punch,  koumiss,  and  beef- 
'peptonoids  are  given  at  frequent  intervals. 

Hemostatic  agents  comprise  (i)  the  ligature  and  suture;  (2)  torsion; 
(3)  acupressure;  (4)  elevation;  (5)  compression;  (6)  styptics;  (7)  the  actual 
cautery;  and  (8)  forced  flexion  of  limbs. 

The  ligature  was  known  to  the  ancients,  but  was  rediscovered  by  Ambroise 
Pare.  The  ligature  may  be  made  of  silk,  floss-silk,  or  catgut.  Whatever 
material  is  used  must,  of  course,  be  rendered  aseptic.  A  ligature  should 
be  about  ten  inches  long.  The  vessel  to  be  tied  must  be  drawn  out  with 
forceps  and  separated  for  a  short  distance  from  its  sheath,  but  must  not  be 


Hemostatic  Agents 


437 


separated  to  any  considerable  extent;  to  do  so  may  lead  to  necrosis  of  the 
vessel  and  secondary  hemorrhage.     The  hemostatic  forceps  (Figs.  182,  183, 


Fig.  182. — Halsted's  straight  artery  forceps. 


1S4)  is  in  most  cases  a  better  instrument  than  the  tenaculum  (Fig.  185).     The 
tenaculum    makes  a  hole  in  the  vessel,  and  sometimes  a  slit-like  tear.     A 


Fig.  183. — Curved  hemostatic  forceps. 

portion  of  this  opening  may  remain  back  of  the  tied  ligature,  the  vessel  may 


Fig.  184. — Straight  hemostatic  forceps. 

retract  a  little,  or  the  ligature  may  slip  slightly,  and  bleeding  may  occur. 
When  the  artery  lies  in  dense  tissues  or  is  retracted  deeply  in  muscle  or  fascia, 


438 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


the  tenaculum,  when  carefully  used,  is  the  better  instrument.     The  ligature 
is  tied  in  a  reef-knot  (Fig.  i86),  not  in  a  granny-knot  (Fig.  187),  and  not  in  a 


Fig.  185.— Tenaculum. 

surgeon's  knot  (Fig.  188).  It  is  often  the  purpose  of  the  surgeon  to  divide  the 
internal  and  middle  coats  of  the  ves.sel,  and  if  such  is  his  desire  the  first  knot 
is  firmly  tied.  The  second  knot  must  not  be  tied  too  tightly,  or  it  will  cut  the 
hgature.     The  ligature  must  not  be  jerked  as  it  is  being  tied.     If  a  third 


Fi{7.  186. — Method  of  tying  square 
or  reef-knot. 


Fig.  187.— Method  of  tying  granny- 
knot. 


knot  overlies  the  first  two,  the  ligature  can  be  cut  off  close  to  the  knot; 
otherwise  it  is  cut  off  so  that  short  ends  are  left.  Both  ends  of  a  divided 
vessel  should  be  ligated.  If  a  vessel  is  atheromatous,  it  is  not  desirable 
to  divide  the  internal  and  middle  coats.  In  this  case  a  ligature  should  be 
applied  firmly  rather  than  tightly,  and  another  ligature  should  be  put  on 
above  it,  or  ligation  can  be  effected  by  the  stay  knot.  If  an  artery  is  incom- 
pletely divided,  a  ligature  should  be  appHed  on  each  side  of  the  wound  and 
the  vessel  divided  between  the  hgatures. 

When  the  parts  about  an  artery  are  so  thickened  that  the  vessel  cannot 
be  drawn  out,  arm  a  Hagedorn  needle  (Fig.  189)  with  catgut  and  pass  the 


Fig.  188. — Method  of  tying  surgeon's  knot. 


latter  around  the  vessel  in  such  a  manner  that  the  catgut  will  include  the 
vessel  with  some  of  the  surrounding  tissue.  Then  tie  the  ligature  (Fig.  191). 
This  method  is  known  as  the  application  of  a  suture-ligature,  and  is  pur- 
sued in  necrosis,  atheroma,  scar-tissue,  sloughing,  etc.  Never  include  a 
nerve  of  any  size  in  the  ligature.  If  this  mode  of  ligation  fails,  we  may  try 
acupressure. 


Hemostatic  Agents 


439 


Doyen,  when  about  to  tie  a  thick  pedicle,  crushes  it  by  means  of  a  very 
powerful  instrument  and  then  ties  a  ligature  about  the  crushed  and  attenuated 
area.  The  vessels  are  closed  by  laceration  wide  of  the  ligature  and  the 
ligature  does  not  tend  to  slip.     Some  trust  such  a  stump  without  a  ligature, 


Fig.  189. — Hagedorn's  needles. 


Fig.  190. — Method  of  controlling  hemorrhage 
by  ligature  (after  Esmarch):  a,  Artery  ligated; 
h,  lateral  ligature  of  vein. 


but  most  surgeons  prefer  to  ligate.  This  instrument  is  known  as  the  vaso- 
tribe  or  angiotribe  and  is  used  particularly  in  hysterectomy.  Fig.  192  shows 
a  vasotribe. 

If  a  large  vein  is  torn  we  vdih,  if  possible,  to  control  hemorrhage  without 
obliterating  the  lumen  of  the  vein.     If  the  wound  is  not  greater  in  length  than 

the  measure  of  the  diameter  of  the  lumen,  a 
lateral  ligature  may  be  used.  It  is  practi- 
cally always  used  in  small  transverse  wounds. 
In  order  to  apply  a  lateral  ligature  the  two 
lips  of  the  vein  wound  are  seized  by  forceps 
and  drawn  out  into  a  tit  (Figs.  190  and  207). 
A  ligature  is  placed  around  the  base  of  the 
cone  and  tied.  The  pull  in  the  cone  is 
relaxed  while  the  first  knot  is  being  tied  in 
order  that  the  ligature  may  constrict  tightly. 
In  a  large  vessel  the  thread  should  be  passed 
by  a  needle  through  the  outer  coats  of  the  vein  before  it  is  used  to  encircle 
the  cone.     This  plan  prevents  slipping. 

Phleborrhaphy  is  suture  of  a  vein,  vdih  preser\-ation  of  the  lumen  of  the 
vessel.  It  is  used  when  complete  ligation  is  undesirable  (as  in  a  large  vein), 
and  when  lateral  ligation  without  obliteration  of  lumen  is  impossible.  It  is 
commonly  employed  for  longitudinal  wounds  and  for  wounds  in  any  direction 
when  the  length  of  the  wound  is  greater  than  the  diameter  of  the  vessel.  Fine 
catgut  or  silk  may  be  used.     An  intestinal  needle  threaded  with  silk  is  entirely 


Fig.  igi. — Arrest  of  hemorrhage  by 
passing  a  suture-ligature. 


440 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


satisfactory.  The  thread  is  passed  through  the  external  coat  and  part  of  the 
middle  coat  on  each  side  of  the  wound.  Interrupted  sutures  are  employed  and 
thus  the  two  lif)s  of  the  wound  are  approximated.     A  vein  completely  divided 


Fig.  192. — Vasotribe  of  Doyen. 

across  can  be  united  ])y  end-to-end  suturing.     Fig.  193  shows  the  operation 
of  phleborrhaphy. 

By  suturing  I  successfully  closed  a  tear  in  the  innominate  vein  inflicted 
during  the  removal  of  a  retrosternal  goiter,  and  also  a  considerable  longitudinal 
tear  in  the  internal  jugular  vein  inflicted  during  the  removal  of  lymph-nodes. 


Fig.  193. — Phleborrhaphy:   Forceps  are  seen  everting  lip  of  wound  for  passage  of  needle  and 
interrupted  sutures  (Bickham). 


Murphy  and  Damar  Harrison  each  succeeded  in  suturing  a  wound  of  the 
inferior  vena  cava. 

Arteriorrhaphy. — The  studies   of    Carrel,    Murphy,    Matas,    Abbe,    and 


Hemostatic  Agents 


441 


others  have  shown  that  wounded  arteries  can  be  repaired  by  suturing;  that  a 
portion  of  an  artery  can  be  removed  and  repair  be  obtained  by  end-to-end 
suturing,  implantatit)n,  or  lateral  anastomosis;  that  an  artery  can  be  obliter- 
ated by  suturing  the  intima  from  within;  that  an  artery  can  be  anastomosed 
into  a  vein,  and  that  after  resection  of  a  portion  of  an  artery  vascular  integ- 
rity may  be  restored  by  suturing  into  the  gap  a  portion  of  a  vein  or  artery 
recently  resected. 

We  now  suture  many  wounds  in  large  vessels  which  until  very  recently 
would  have  caused  us  to  completely  Hgate  the  artery.  In  extirpating  malig- 
nant tumors  it  may  be  necessary  to  remove  large  arteries  or  veins.    This  causes 


Fig.  194. — Arteriorrhaphy  in  complete  circular  division  of  an  artery  (Murphy's  method) . 
A,  Intussusceptum,  with  sutures  passing  through  outer  and  middle  coats;  B,  intussuscipiens 
(split  to  aid  invagination),  with  sutures  passing  through  all  coats;  C,  showing  all  sutures 
tied   (Bickham). 


grave  danger  of  gangrene  and  we  now  attempt  to  prevent  gangrene  by  the 
restoration  of  vascular  continuity. 

The  wonderful  experiments  of  Carrel  on  the  transplantation  of  organs  and 
the  brilliant  studies  and  operations  of  Murphy  have  been  the  great  influences 
that  have  brought  vessel  suture  into  the  field  of  practical  surgery. 

There  is  yet  much  to  learn.  What  we  do  know  is  really  little,  but  we  are 
probably  at  the  threshold  of  great  events. 

We  know  that  we  can  close  by  suture  a  lateral  wound  or  a  transverse  wound 
of  less  than  half  the  circumference  of  the  vessel;  that  we  can  perform  end-to- 
end  suturing;  that  we  can  insert  a  piece  of  resected  vein  to  re-establish  vascular 
continuity;  and  that  after  such  an  operation  the  blood-current  will  be  re- 
estabUshed.  We  do  not  know  how  long  the  circulation  will  continue  after 
re-establishment.  A  sutured  artery  will  certainly  carry  blood  for  a  time,  but 
in  most  cases,  at  least,  only  for  a  time,  the  ultimate  fate  of  the  vessel  being  ob- 
literation by  endothelial  proliferation.    If  the  vessel  operated  upon  is  diseased, 


442 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


obliteration  by  clot  is  practically  certain  to  ensue.  But  even  temporary  re- 
establishment  of  circulation  is  of  the  greatest  value.  Even  though  the  lumen 
is  finally  closed,  the  closure  is  gradual.  While  the  vessel  is  closing  the  collaterals 
are  dilating.  By  the  time  one  source  of  supply  for  the  tissues  is  cut  ofif,  another 
has  taken  its  place.     Thus  gangrene  is  prevented.     There  appears  to  be  a 


Fig.  195. — Repair  of  longitudinal  wound 
of  artery  by  combination  cobbler's  stitch 
through  all  coats,  and  interrupted  sutures 
through  outer  coats,  as  suggested  by  the 
author:  A,  Beginning  of  cobbler's  stitch 
through  all  coats;  B,  B,  needles  in  act  of 
passing  through  same  opening  in  opposite 
directions,  in  characteristic  cobbler  fashion; 
C,  C,  three  interrupted  sutures  through  outer 
coats,  ready  to  be  tied;  D,  D,  two  interrupted 
sutures  tied,  passing  through  outer  coats 
(Bickham). 


t\ 


Fig.  196. — Repair  of  complete  trans- 
verse division  of  artery  by  combination  cob- 
bler's stitch  through  all  coats,  followed  by 
interrupted  sutures  through  outer  coats,  as 
suggested  by  the  author:  A,  A,  Needles  pass- 
ing in  opposite  directions  through  all  coats, 
in  act  of  placing  cobbler's  stitch;  B,  super- 
ficial tier  of  interrupted  stitches  through 
outer  coats,  showing  three  untied  and  two 
tied  (Bickham). 


certain  amount  of  danger  of  the  development  of  aneurysm  at  the  seat  of  sutur- 
ing. In  a  longitudinal  w^ound  of  an  artery  or  in  a  transverse  w^ound  of  not  over 
half  the  circumference  of  the  vessel,  the  w^ound  may  be  closed  by  interrupted 
sutures,  passing  the  threads  through  the  two  outer  coats  and  bringing  the  wound 
edges  together  without  inversion.    Floss  silk  is  used,  and  it  should  be  as  large 


Hemostatic  Agents 


443 


as  the  eye  of  a  curved  conjunctival  needle  will  carry  to  lessen  the  danger  of 
leaking  of  blood  through  the  stitch  holes.  The  sheath  is  sutured  over  the  stitch 
line  ("Bickham's  Operative  Surgery"). 

A  better  plan  in  such  wounds  is  that  of  Bickham,  viz. :  A  cobbler's  stitch 
through  all  the  coats  to  bring  the  intima  of  each  lip  together  and  interrupted 
sutures  through  the  outer  coats  (Fig.  196).  An  oblique  wound  may  be  repaired 
in  the  same  manner.  If  a  vessel  is  divided  transversely  through  more  than  half 
of  its  circumference  Murphy  believes  that  the  di\ision  should  be  made  com- 
plete as  a  preliminary  to  suturing. 

Complete  circular  diWsion  may  be  treated  by  Murj^hy's  plan,  viz.,  invagina- 
tion of  one  end  of  the  cut  vessel  into  the  other  end  split  to  receive  it  (Figs.  194 


Fig.  197. — Circular  arteriorrhaphy  in  complete  division  of  an  artery:  A,  Method  of 
Salomoni  and  Tomaselli — interrupted  sutures  through  aU  coats;  B,  method  of  Gluck — inter- 
rupted sutures  through  outer  coats,  protected  by  cylinder  of  decalcified  bone,  ivory,  or  rubber 
(Bickham). 


and  196),  by  Bickham's  plan  of  a  cobbler's  stitch  followed  by  interrupted 
sutures,  or  by  the  plan  sho^Ti  in  Fig.  197. 

Depage  has  successfully  sutured  the  common  carotid  arter}-  ("Journal  de 
Chir.  et  Ann.  de  la  Soc.  Beige  de  Chir.,"  Jan.  and  Feb.,  1902).  Pringle 
sutured  a  wound  of  the  external  iliac  arterv'.  The  wound  was  one-quarter 
of  an  inch  in  length.  During  the  operation  pressure  was  made  upon  the 
aorta  ("Scottish  Med.  and  Surg.  Jour.,"  Oct.,  1901).  Dujemil  Pasha  suc- 
cessfully sutured  a  lacerated  wound  of  the  axillary  arter\'  ("General  Sur- 
ger}',"  by  John  B.  Murphy,  1905,  p.  127).  Torrance  sutured  a  brachial 
artery  on  the  eighth  day  after  a  crush  ("Annals  of  Surger}-,"  July,  1904). 
The  author  succesfully  sutured  a  small  laceration  in  the  axillarv'  arter}'. 
Stewart  removed  a  clot  from  the  femoral  and  sutured  the  vessel.  Murphy 
removed  a  clot  from  the  external  iliac  and  sutured  the  vessel.  Braun  ("  Zentral- 
blatt  fiir  Chirurgie,"  August  29, 1908)  resected  a  portion  of  the  aorta  along  with 


444  Diseases  and  Injuries  of  the  Heart  and  Vessels 

a  tumor  and  performed  circular  suture.  Martin  sutured  a  lacerated  wound  of 
the  femoral  artery  ("Annals  of  Surgery,"  Oct.,  1905).  Henderson  sutured 
a  transverse  wound  extending  half  across  the  femoral  artery  ("American 
Medicine,"  Jan.  14,  1905).  A.  E.  Halstead  cut  two-thirds  through  the  cir- 
cumference of  the  axillary  artery  and  sutured  the  wound  directly  instead  of 
making  the  wound  first  of  all  a  complete  division,  as  advised  by  Muqjhy. 
Two  months  later  the  radial  pulse  was  present. 

Faykiss  made  an  end-to-end  suture  of  a  divided  carotid  artery  ("Centralb. 
fur  Chirurgie,"  1908,  xxxv). 

Lexer  ("Archiv.  fiir  klinische  Chirurgie,"  1907,  No.  2)  resected  the  sac  of  a 
traumatic  arteriovenous  aneurysm  of  the  popliteal  vessels,  removing  at  the 
same  time  5  cm.  of  arterj'  and  as  much  vein. 

He  performed  end-to-end  anastomosis  of  each  vessel  over  a  thin  magnesium 
tube  (Payr's  tubes).  The  pulse  was  restored.  Nine  months  after  operation 
the  pulse  was  present  below  the  seat  of  operation,  but  was  weaker  than  it  had 
been  some  months  before.  In  this  paper  Lexer  speaks  of  a  case  of  diffuse 
aneurysm  of  the  axillar}'  artery.  The  surgeon  resected  the  sac  and  a  portion  of 
the  artery.  The  gap  of  over  3  inches  was  filled  by  a  piece  of  internal  saphenous 
vein  sutured  in  place  (autoplasty) .  The  circulation  was  re-established  in  the 
limb,  but  the  patient  died  of  complications.  Post  mortem  demonstrated  that 
the  transplanted  vein  was  patent  and  the  sutures  firm.  There  was  a  clot  above 
the  piece  of  vein  due  to  the  action  of  the  clamp  upon  a  sclerotic  artery.  Gan- 
grene began  on  the  fourth  day  after  operation. 

Manteuffel  successfully  sutured  a  wound  of  the  femoral.  This  was 
the  first  case  to  be  recorded  (Bloodgood,  in  "Progressive  Medicine," 
Dec.  I,  1908),  although  Hallowell,  in  1759,  successfully  closed  a  wound  in 
the  brachial  artery  by  means  of  a  harelip  pin  and  a  ligature  (Mumford) . 
Bloodgood  in  the  same  article  notes  that  Korte,  in  1904,  performed  lateral 
suture  of  the  popliteal  artery  and  vein,  and  that  Garre  closed  a  wound  in 
the  popliteal  artery  by  suture,  and  in  the  vein  of  the  same  patient  by  lateral 
ligature. 

Murphy  was  the  first  surgeon  to  succeed  in  resecting  a  portion  of  a  large 
artery  (the  femoral)  and  doing  end-to-end  suturing  ("Med.  Record,"  Jan.  16, 
1897). 

Lund  ("Annals  of  Surgery,"  March,  1909)  sutured  a  double  stab-wound  of 
the  femoral  arter}'  and  vein,  and  six  months  later  there  was  a  pulse  in  the  dor- 
saHs  pedis. 

Among  other  surgeons  reporting  successful  cases  of  arterial  suture  are 
Heidenhain,  Orlow,  Pean,  Baum,  Sherman,  Krause,  Payr,  Kummell,  Seggel, 
Lindner,  and  Brougham. 

Torsion. — Torsion  was  practised  by  the  ancients,  but  was  reintroduced 
in  modern  times,  particularly  by  Amu.ssat,  Velpeau,  Syme,  and  Bryant  of 
London.  By  means  of  torsion  the  internal  and  middle  coats  are  ruptured, 
and  the  external  coat  is  twisted.  The  middle  coat  retracts  and  contracts,  and 
the  inner  coat  inverts  into  the  lumen  of  the  artery.  It  is  a  safe  procedure,  and 
is  practised  upon  vessels  as  large  as  the  femoral  by  many  surgeons  of  high 
standing.  Before  the  days  of  asepsis  torsion  possessed  the  signal  merit  of 
not  introducing  possible  infection  in  ligatures.     At  the  present  time  it  offers 


Hemostatic  Agents  445 

no  particular  advantage.  It  is  no  quicker  than  the  ligature,  and  damages 
the  vessel  so  much  that  necrosis  may  occur.  It  cannot  be  used  if  the  vessels 
are  diseased.  In  what  is  known  as  free  torsion  the  vessel  is  gras})ed,  drawn 
out  and  twisted  until  the  free  end  of  the  vessel  is  twisted  off.  Limited  tor- 
sion is  more  often  used.  The  vessel  is  drawn  out  of  its  sheath  by  a  pair  of 
forceps  held  horizontally,  and  is  grasped  a  little  distance  above  its  extremity 
by  another  pair  of  forceps  held  vertically  (Fig.  ig8).  The  first  instrument  is 
used  to  twist  the  artery  six  to  eight  times. 

Acupressure  is  pressure  applied  by  means  of  a  long  pin.     The  method 
of  hemostasis  by  acupressure  was  devised  by  Sir  James  Y.  Simpson.     A  pin 


Fig.  198. — Method  of  controlling  hemorrhage  by  torsion. 

is  simply  passed  under  a  vessel  (transfixion),  leaving  a  little  tissue  on  each 
side  between  the  pin  and  vessel.  A  pin  can  be  passed  under  a  vessel,  and 
a  wire  be  thrown  over  the  needle  and  twisted  (circumclusion) .  The  pin  can 
be  inserted  upon  one  side,  passed  through  half  an  inch  of  tissues  up  to  the 
vessel,  be  given  a  quarter-twist,  and  be  driven  into  the  tissues  across  the 
artery  (torsoclusion).  Some  tissue  may  be  picked  up  on  the  pin,  folded  over 
the  vessel,  and  pinned  to  the  other  side  (retroclusion).  Acupressure  is  occa- 
sionally used  to  arrest  hemorrhage  in  inflamed  or  atheromatous  vessels,  in 
sloughing  wounds,  in  scar-tissue,  and  when  a  ligature  will  not  hold  firmly. 

Elevation  is  used  as  a  temporary  expedient  or  in  association  with  some 
other  method.  It  is  of  use  in  a  wound  of  a  bursa,  in  bleeding  from  a  ruptured 
varicose  vein,  and  is  frequently  used  with  compression. 

Compression  is  either  direct  or  indirect — that  is,  in  the  wound  or  upon 
its  artery  of  supply.  In  the  removal  of  the  upper  jaw  arrest  bleeding  by 
plugging.  In  injury  of  a  cerebral  sinus,  plug  with  gauze.  Compression 
and  hot  water  (11 5°-: 20°  F.)  will  stop  capillary  bleeding.  A  graduated 
compress  was  formerly  recommended  in  hemorrhage  from  the  palmar  arch. 
A  compress  will  arrest  bleeding  from  superficial  veins.  The  knotted  bandage 
of  the  scalp  will  arrest  bleeding  from  the  temporal  artery.  Long-continued 
pressure  causes  pain  and  inflammation. 

Indirect  compression  is  used  to  prevent  hemorrhage  or  to  temporarily 
arrest  it.  It  may  be  effected  by  encircling  a  limb  above  a  bleeding  point 
with  an  Esmarch  band  or  by  applying  a  tourniquet  or  an  improvised  tourniquet 
(Fig.  201).  It  may  also  be  effected  by  a  clamp.  Crile  has  devised  a  clamp  to 
effect  temporary  closure  of  the  carotid  artery.     In  operations  about  the  head 


446 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


one  or  both  carotids  may  be  closed  for  a  considerable  time  and  bleeding  may 
thus  be  largely  prevented.  In  lo  cases  Crile  temporarily  closed  both  carotids. 
A  hypodermatic  injection  of  atropin  is  given  to  prevent  inhibition,  the  vessels 
are  exposed,  and  the  clamps  are  applied  with  just  sufficient  firmness  to  ap- 
proximate the  vessel-walls.     No  clot  will  form  if  the  walls  are  not  compressed. 

The  patient  is  in  the  Trendelenburg  position. 
If  it  is  found  that  respiratory  difficulty  occurs,  one 
clamp  must  be  loosened.  After  the  completion  of 
the  operation  the  patient  must  be  brought  to  the 
horizontal  before  the  clamps  are  removed  (Crile, 
in  "Annals  of  Surgery,"  April,   1902). 

Digital  compression  is  a  form  of  indirect  com- 
pression. It  can  be  maintained  for  only  a  few  min- 
utes by  one  person,  but  a  relay  of  assistants  can 


Fig.  IQ9. — Tamponade  of  inter- 
costal artery  (after  Von  Langen- 
beck). 


Fig.  200. — Conical  aseptic  tampon  compressing  an  arter>' 
(Senn). 


carry  it  out  for  a  considerable  time.  In  compressing  the  subclavian  artery, 
wrap  a  key  as  shown  in  Fig.  202,  and  compress  the  artery  against  the  outer 
surface  of  the  first  rib.  The  shoulder  must  be  depressed  and  pressure  applied 
in  the  angle  between  the  posterior  border  of  the 
sternocleidomastoid  and  the  upper  border  of  the 
clavicle.  The  direction  of  the  pressure  should 
be  downward,  backward,  and  inward. 


Fig.  201. — Impromptu  tourniquet  for  compressing  an 
artery  with  a  handkerchief  and  a  stick. 


Fig.  202.— Handle  of  door-key, 
padded. 


The  brachial  artery  can  be  compressed  against  the  humerus.  In  the  upper 
part  of  the  course  of  the  artery  the  pressure  should  be  from  within  outward 
(Fig.  203),  in  the  lower  part  from  before  backward  (Fig.  204).  The  abdom- 
inal aorta  can  be  compressed  by  Macewen's  method  {q.  v.).  The  common 
iliac  can  be  compressed  through  the  rectum  by  means  of  a  round  piece  of 
wood  known  as  Davy's  lever.  The  femoral  artery  can  be  compressed  just 
below  Poupart's  ligament  against  the  psoas  muscle  and  head  of  the  femur 


Hemostatic  Agents 


447 


(Fig.   205).     The  pressure  should   be  directly  backward.      In  the  middle 
third  of  the  thigh  digital  compression  is  unsatisfactory,  and  a  tourniquet 
should  always  be  used  or  an 
Esmarch  band  be  employed. 

Forced  flexion  is  a  variety 
of  indirect  compression  intro- 
duced by  Adelmann.  It  will 
arrest  bleeding  below  the  point 
compressed,  but  soon  becomes 
intensely  painful.  Forced  flex- 
ion can  be  maintained  by  ban- 
dages. Brachial  hyperflexion 
is  maintained  by  tying  the  fore- 
arm to  the  arm.  It  is  often 
associated  with  the  use  of  a 
pad    in    front    of    the    elbow. 

Genuflexion  is  maintained  by  tying  the  foot  to  the  thigh, 
in  efficiency  by  placing  a  pad  in  the  popliteal  space. 

Styptics. — Chemicals  are  now  rarely  used  to  arrest  hemorrhage.  In  epis- 
taxis  we  may  pack  with  plugs  of  gauze  saturated  with  a  10  per  cent,  solution 
of  antipyrin.  In  bleeding  from  a  tooth-socket  freeze  with  chlorid  of  ethyl 
spray,  and  then  pack  with  gauze  soaked  with  10  per  cent,  solution  of  antipyrin 
or  pack  with  dry  sponge  or  styptic  cotton  (absorbent  cotton  soaked  in  Monsel's 


Fig.  203.— Digital  compression  of  the  brachial  artery. 


It  is  increased 


Fig.  204.— Digital  compression  of  the 
brachial  artery. 


Fig.  205.  — Digital  compression  of  the 
femoral  arterv. 


solution  and  dried) .  A  bit  of  cork  may  be  forced  into  the  socket.  In  bleeding 
from  an  incised  urinary  meatus  pack  with  styptic  cotton  and  compress  the 
lips  of  the  meatus.  Cold  water,  chlorid  of  ethyl  spray,  and  ice  act  as  styptics 
by  producing  reflex  vascular  contraction.  Hot  water  produces  contraction 
and  coagulates  the  albumin.  The  temperature  should  be  from  115°  to 
120°  F.  A  mixture  of  equal  parts  of  alcohol  and  water  stops  capillary 
oozing. 


448  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  Use  oj  Gelatin  in  Controlling  Hemorrhage. — It  seems  very  positively 
proved  that  gelatin  increases  the  coagulability  of  the  blood,  if  given  hvpo- 
dermatically.  It  has  been  shown  by  Horatio  C.  Wood,  Jr.  ("American 
Medicine,"  May  3,  1902),  that,  even  when  administered  by  the  stomach, 
digestion  does  not  destroy  its  coagulating  effect  upon  the  blood.  Carnot,  of 
Paris,  used  it  locally  and  with  success  to  control  epistaxis  in  a  sufferer  from 
hemophilia.  He  then  employed  it  to  arrest  bleeding  from  hemorrhoids, 
tumors,  and  incised  wounds;  and  demonstrated  in  animals  that  it  will  arrest 
oozing  from  the  cut  surface  of  the  liver.  Carnot  used  a  5  or  10  per  cent, 
solution.  It  has  been  employed  with  success  to  control  hemorrhage  in 
many  situations,  is  of  value  when  applied  locally,  and  possibly  of  use  when 
injected  subcutaneously. 

Intravenous  injections  are  extremely  dangerous,  and  are  apt  to  be  fol- 
lowed by  embolism.  Subcutaneous  injections  are  decidedly  painful,  and 
are  not  altogether  safe,  producing  albuminuria  and  occasional  embolism. 
Another  danger  that  may  follow  the  subcutaneous  administration  of  gelatin 
is  the  development  of  tetanus,  and  several  cases  have  been  reported.  The 
existence  of  disease  of  the  kidneys  contraindicates  the  hypodermatic  use  of 
gelatin. 

It  has  been  successfully  used  as  an  enema  in  intestinal  hemorrhage,  and 
as  an  injection  in  hemorrhage  from  the  bladder.  I  have  used  it  with  success 
in  arresting  bleeding  from  the  cut  surface  of  the  human  liver;  to  check 
bleeding  from  an  incised  wound  in  a  victim  of  leukemia;  to  arrest  the  post- 
operative oozing  in  sufferers  from  cholemia;  and  in  several  cases  of  severe 
epistaxis. 

When  employed  locally  in  solution,  it  should  be  of  a  strength  of  from  2  to 
5  per  cent,  in  normal  salt  solution.  For  hypodermatic  use  some  employ  a 
5  per  cent.,  some  a  2  per  cent.,  and  some  a  i  per  cent,  solution.  In  using 
a  I  or  2  per  cent,  solution  a  very  large  amount  of  fluid  must  be  injected. 
This  causes  pain;  and  Sailer  maintains  that  the  pain  is  slight  or  absent,  if  the 
solution  is  not  turbid  and  if  but  10  c.c.  of  a  10  per  cent,  solution  are  injected. 
The  injection  may  be  repeated  until  from  i  to  3  gm.  of  gelatin  have  been 
administered.  It  should  be  injected  on  the  outer  side  of  the  thigh,  under 
the  breast,  or  between  the  shoulder-blades.  If  the  drug  is  given  by  mouth, 
100  c.c.  of  a  10  per  cent,  solution  is  the  dose;  and  this  may  be  repeated  every 
two  or  three  hours. 

On  account  of  the  possible  danger  of  *the  development  of  lockjaw,  great  care 
in  .sterihzing  must  always  be  exercised.  The  method  of  preparation  suggested 
by  Joseph  Sailer  will  be  found  of  the  greatest  value.  (For  the  formula  for  this 
see  page  420) . 

In  view  of  the  fact  that  gelatin  is  such  an  excellent  culture-material, 
whenever  it  is  used  in  the  rectum,  nose,  pharynx,  vagina,  or  bladder,  it  should 
be  mixed  with  some  antiseptic  agent. 

The  exact  mode  in  which  gelatin  acts  in  producing  coagulation  is  not 
certain.  Floresco  maintains  that  it  acts  Uke  an  acid.  Laborde  states  that 
undissolved  particles  of  gelatin  ser\'e  as  centers  for  coagulation.  Other 
experimenters  insist  that  gelatin  destroys  the  leukocytes,  and  thus  liberates 
fibrin  ferment. 


Hemostatic  Agents  449 

Suprarenal  extract  is  a  valuable  agent  to  control  capillary  oozing.  It 
constricts  capillaries,  and  if  applied  to  a  mucous  membrane  will  rapidly  blanch 
it.  It  is  extensively  used  to  check  bleeding  during  operations  on  the  nose, 
throat,  larynx,  and  ear,  and  to  arrest  epistaxis  and  bleeding  from  the  uterus. 
The  solution  to  employ  is  adrenalin  chlorid  of  a  strength  of  from  i  :  10,000 
to  I  :  1000.  A  piece  of  cotton  soaked,  in  this  solution  is  pressed  lightly 
upon  the  part  or  it  is  sprayed  upon  the  part  by  an  atomizer  ("Practical 
Therapeutics,"  by  H.  A.  Hare). 

CJiIorid  of  calcium,  given  internally,  favors  coagulation  of  the  blood  and 
is  used  to  check  oozing  or  to  prevent  hemorrhage.  It  is  used  particularly 
in  jaundice  cases  when  operation  must  be  performed.  If  given  several  times 
a  day  for  two  or  three  days  it  increases  the  coagulability  of  the  blood;  but 
if  given  for  more  than  four  days,  actually  diminishes  it.     The  initial  dose  is 


Fig.  206. — Paquelin  cautery. 

from  15  to  30  grains,  then  gr.  v  every  hour  are  given  until  five  or  six  doses 
have  been  taken.  It  is  apt  to  provoke  gastric  irritability,  and  it  is  often 
advisable  to  give  it  by  the  rectum. 

The  actual  cautery  is  a  very  ancient  hemostatic.  It  is  still  used  occasion- 
ally after  excising  the  upper  jaw,  in  bleeding  after  the  removal  of  some 
malignant  growths,  in  continued  hemorrhage  from  the  prostatic  plexus  of  veins 
after  lateral  lithotomy,  and  to  stop  oozing  after  the  excision  of  venereal  warts. 
We  are  often  driven  to  its  use  in  "  bleeders  "—that  is,  those  persons  who  have 
a  hemorrhagic  diathesis,  and  who  may  die  from  having  a  tooth  pulled  or  from, 
receiving  a  scratch.  It  will  arrest  hemorrhage,  but  the  necrosed  tissue  sepa- 
rates, and  when  it  separates  secondary  hemorrhage  is  apt  to  set  in.  The  iron 
for  hemostatic  purposes  must  be  at  a  cherry  heat.  The  old-fashioned  iron, 
which  was  heated  in  a  charcoal  furnace,  is  rarely  used.  It  is  large,  clumsy, 
and  cools  quickly  if  the  bleeding  is  profuse.  In  an  emergency  we  may  heat 
a  poker  or  a  coil  of  telegraph  wire.  The  best  instrument  is  the  Paquelin 
cautery.  The  PaqueHn  cautery  consists  of  an  alcohol  lamp,  a  metal  chamber 
containing  benzene,  a  tube  of  entrance  for  air  containing  two  bulbs,  an  exit 
tube,  and  a  wooden-handled  cautery  instrument,  the  tip  of  which  is  hollow 
29 


45°  Diseases  and  Injuries  of  the  Heart  and  Vessels 

and  composed  of  platinum  (Fig.  206).  This  can  be  kepc  hot  even  when 
bleeding  is  profuse.  If  the  iron  is  very  hot,  it  will  not  stop  bleeding  com- 
pletely. In  order  to  use  the  Paquelin  cautery,  light  the  lamp,  heat  the  cautery- 
tip  in  the  flame,  until  it  becomes  red,  remove  it  from  the  flame,  and  squeeze 
the  bulb  repeatedly  until  the  tip  becorhes  bright  red.  Each  time  the  bulb 
not  covered  with  netting  is  squeezed  air  is  driven  through  the  metal  chamber 
into  the  tube  and  cautery,  and  this  air  carries  with  it  the  vapor  of  benzene, 
which  passes  to  the  hot  tip  and  takes  fire.  The  degree  of  heat  maintained 
depends  upon  the  rapidity  with  which  the  bulb  is  squeezed. 

Skene  has  devised  a  method  known  as  electrohemostasis.  He  grasps  the 
vessel  or  tissue  with  specially  constructed  forceps,  an  electric  current  generates 
heat,  the  tissue  is  cooked,  and  the  walls  of  the  vessel  united.  A  heat  of  from 
i8o°-i9o°  F.  is  required.  For  the  small  instrument  Skene  uses  a  current 
of  2  ma.  and  for  the  larger  instrument  a  current  of  8  ma.* 

Downes  has  devised  an  instrument  to  apply  electrothermic  hemostasis  in 
abdominal  and  pelvic  operations.  He  asserts  that  by  this  method  an  intra- 
abdominal operation  can  be  rendered  bloodless;  that  the  lymph-ducts  are 
sealed  and  the  stump  is  sterile;  that  adhesions  are  less  apt  to  form;  and  that 
there  is  less  post-operative  pain  than  if  the  ligature  were  used  ("  Boston  Med. 
and  Surg.  Jour.."  July  10,  1902). 

Rules  jor  Arresting  Primary  Hemorrhage. — i.  In  arterial  hemorrhage 
tie  the  artery  in  the  wound,  enlarging  the  wound  if  necessary  (Guthrie's  rule). 
In  tying  the  main  artery  of  the  limb  in  continuity  for  bleeding  from  a  point 
below  w-e  fail  to  cut  off  the  bleeding  from  the  distal  extremity,  and  hemor- 
rhage is  bound  to  recur.  If  the  surgeon  does  not  look  into  the  wound, 
he  cannot  know  what  is  cut:  it  may  be  only  a  branch,  and  not  a  main 
trunk.     The  same  rule  obtains  in  secondary'  hemorrhage. f 

2.  We  can  safely  ligate  veins  as  we  would  arteries. 

3.  In  a  wound  of  the  superficial  palmar  arch  tie  both  ends  of  the  divided 
vessel . 

4.  In  a  wound  of  the  deep  palmar  arch  enlarge  the  wound,  if  necessary, 
in  the  direction  of  the  flexor  tendons,  at  the  same  time  maintaining  pressure 
upon  the  brachial  artery.  Catch  the  ends  of  the  arch  with  hemostatic  forceps 
and  tie  both  ends.  If  the  arter\-  can  be  caught  by,  but  cannot  be  tied  over 
the  point  of,  the  forceps,  leave  the  instrument  in  place  for  four  days.  If  the 
artery  cannot  be  caught  with  forceps,  use  a  tenaculum.  The  ends  of  the 
divided  vessel  can  be  caught  and  must  be  caught  even  if  large  incisions  are 
needed  to  effect  it.  An  incision  which  will  probably  always  expose  the  vessel 
is  as  follows :  Make  a  cut  on  a  hne  with  the  injur}-  from  the  web  of  the  fingers 
to  above  the  carpus,  separating  the  metacarpal  and  carpal  bones,  until  the  artery 
is  reached.  (This  is  really  Mynter's  incision  for  excision  of  the  wrist.)  In 
former  days,  if  the  surgeon  found  trouble  in  grasping  the  ends  of  the  vessel, 
he  appHed  a  graduated  compress  (Fig.  200).  This  is  applied  as  follows:  Insert 
a  small  piece  of  gauze  in  the  depths  of  the  wound,  put  over  this  a  larger  piece, 
and  keep  on  adding  bit  after  bit,  each  successive  piece  larger  than  its  prede- 
cessor, until  there  exists  a  conical  pad,  the  apex  of  which  is  at  the  point  of  hem- 

*Ne\v  York  Medical  Journal,  Feb.  18,  1898. 

I  For  Murphy's  observations  on  anastomosis  of  vessels,  see  page  444. 


Hemostatic  Agents  451 

orrhage  and  the  base  of  which  is  external  to  the  surface  of  the  palm.  Ban- 
dage each  finger  and  the  thumb,  put  a  piece  of  metal  over  the  pad,  wrap 
the  hand  in  gauze,  place  the  arm  upon  a  straight  splint,  apply  firmly 
an  ascending  spiral  reverse  bandage  of  the  arm,  starting  as  a  figure-of- 
eight  of  the  wrist,  and  hang  the  hand  in  a  sling.  Instead  of  applying 
a  splint,  we  may  place  a  pad  in  front  of  the  elbow  and  flex  the  forearm  on 
the  arm.  The  palmar  pad  is  left  in  place  for  six  or  seven  days  unless 
bleeding  continues  or  recurs.  The  graduated  compress  is  unreliable,  hence  it  is 
a  dangerous  method  of  treatment.  It  is  an  evasion.  It  should  be  employed 
at  the  present  time  only  as  a  temporary  expedient,  until  ligatures  can  be 
applied.  The  old  rule  of  surgery  was  as  follows:  If  bleeding  is  main- 
tained or  begins  again  after  application  of  a  graduated  compress,  ligate  the 
radial  and  ulnar  arteries.  If  this  maneuver  fails,  we  know  that  the  interos- 
seous artery  is  furnishing  the  blood  and  that  the  brachial  must  be  tied  at 
the  bend  of  the  elbow.  If  this  fails,  amputate  the  hand.  At  the  present 
day  it  is  hard  to  conceive  of  such  radical  procedures  being  necessary  for 
hemorrhage. 

5.  In  primary  hemorrhage,    if  the  bleeding  ceases,  do  not  disturb  the 
parts  to  look  for  the  vessel.     If  the  vessel  is  clearly  seen  in  the  wound,  tie  it; 


Fig.  207.— Application  of  lateral  ligature  to  a  vein. 


Otherwise  do  not,  as  the  bleeding  may  not  recur.  This  rule  does  not  hold 
good  when  a  large  artery  is  probably  cut,  when  the  subject  will  require  trans- 
portation (as  on  the  battle-field),  when  a  man  has  delirium  tremens,  mania, 
or  delirium,  or  when  he  is  a  heavy  drinker.  In  these  cases  always  look  for 
an  artery  and  tie  it. 

6.  When  a  person  is  bleeding  to  death  from  a  wound  of  an  extremity, 
arrest  hemorrhage  temporarily  by  digital  pressure  in  the  wound  and  apply 
above  the  wound  a  tourniquet  or  Esmarch  bandage.  Bring  about  reaction 
and  then  Hgate,  but  do  not  operate  during  collapse  if  the  bleeding  can  be 
controlled  by  pressure. 

7.  If  a  transverse  cut  incompletely  divides  an  artery,  it  may  be  found 
possible  and  may  be  considered  desirable  to  suture  the  cut.  Longitudinal 
cuts  can  certainly  be  sutured.  If  suturing  is  impossible,  or  if  the  surgeon 
prefers  not  to  attempt  it,  apply  a  ligature  on  each  side  of  the  vessel- wound 
and  then  sever  the  artery  so  as  to  permit  of  complete  retraction. 

8.  If  a  branch  comes  off  just  below  the  ligature,  tie  the  branch  as  well  as 
the  main  trunk. 

9.  If  a  branch  of  an  artery  is  divided  very  close  to  a  main  trunk,  the  rule 
used  to  be,  tie  the  branch  and  also  the  main  trunk.     It  was  thought  that  if 


452  Diseases  and  Injuries  of  the  Heart  and  Vessels 

the  branch  alone  were  tied,  the  internal  clot,  being  very  short,  would  be 
washed  away  by  the  blood-current  of  the  larger  vessel.  We  now  know  that 
the  clot  is  not  required  in  repair,  and  under  aseptic  conditions  it  is  trivial  in 
size  and  rarely  reaches  the  first  collateral  branch.  Repair  is  effected  by 
endothelial  proliferation. 

10.  If  a  large  vein  is  slightly  torn,  put  a  lateral  ligature  upon  its  wall 
(Fig.  207).  Gather  the  rent  and  the  tissue  around  it  in  a  forceps  and  tie  the 
pursed-up  mass  of  vein-wall.  It  is  a  wise  plan  to  pass  the  ligature  through  the 
two  outer  coats  by  means  of  a  needle  and  tie  the  knot  subsequently.  This 
expedient  prevents  slipping.  If  a  longitudinal  wound  e.xists  in  a  large  vein, 
take  an  intestinal  needle  and  fine  silk  and  sew  it  up  with  a  Lembert  suture. 
Transverse  wounds  can  also  be  sutured. 

11.  When  a  branch  of  a  large  vein  is  torn  close  to  the  main  trunk,  tie 
the  branch,  and  not  the  main  trunk.     Apply  practically  a  lateral  ligature. 

12.  If,  after  tying  the  cardial  extremity  of  a  cut  artery,  the  distal  ex- 
tremity cannot  be  found,  even  after  enlarging  the  wound  and  making  a  careful 
search,  firmly  pack  the  wound. 

13.  In  bleeding  from  diploe  or  cancellous  bone,  use  Horsley's  antiseptic 
wax,  or  break  in  bony  septa  with  a  chisel,  or  plug  with  threads  of  gauze  or 
scrapings  of  catgut.  If  the  bleeding  is  very  free,  wax  will  not  stick  and  mash- 
ing the  bone  edges  usually  fails.  The  expedient  suggested  by  \'aughan  should 
then  be  employed,  viz.,  a  piece  of  muscle  or  other  tissue  is  cut  off,  and,  by 
means  of  the  fingers  or  a  knife  handle,  forcibly  rubbed  against  the  bleeding 
bone  surface.  Minute  fragments  of  the  soft  dssue  })lug  the  open  vessels  and 
arrest  the  bleeding  (George  Tully  Vaughan,  in  "Jour.  Am.  IMed.  Assoc," 
Nov.  9,  1907). 

14.  In  bleeding  from  a  vessel  in  a  bony  canal,  plug  the  canal  with  an  anti- 
septic stick  and  break  the  wood,  or  fill  up  the  orifice  of  the  canal  with  antiseptic 
wax  or  a  separated  bit  of  tissue.     If  this  fails,  ligate  the  artery  of  supply. 

15.  In  bleeding  from  the  internal  mammary  artery  the  old  rule  was  to 
pass  a  large  curved  needle  holding  a  piece  of  silk  into  the  chest,  under  the 
vessel  and  out  again,  and  tie  the  thread  tightly;  but  it  is  better  to  make  an 
incision  and  ligate  the  artery. 

16.  In  bleeding  from  an  intercostal  artery  make  pressure  upward  and 
outward,  by  a  tampon  (Fig.  199),  or  throw  a  Hgature  by  means  of  a  curved 
needle  entirely  over  a  rib,  tying  it  externally;  or,  what  is  better,  resect  a  rib 
and  tie  the  artery. 

17.  In  collapse  due  to  puncture  of  a  deep  vessel,  the  bleeding  having 
ceased,  do  not  hurry  reaction  by  stimulants.  Give  the  clot  a  chance  to  hold. 
Wrap  the  sufferer  in  hot  blankets.  If  the  condition  is  dangerous,  however, 
stimulate  to  save  life. 

18.  In  punctured  wounds,  as  a  rule,  try  pressure  before  using  ligation. 

19.  After  a  severe  hemorrhage  always  put  the  patient  to  bed  and  elevate 
the  damaged  part  (if  it  be  an  extremity  or  the  head). 

20.  A  clot  which  holds  for  twelve  hours  after  a  primary  hemorrhage  will 
probably  hold  permanently;  but  even  after  twelve  hours  be  watchful  and 
insist  on  rest. 

21.  If  recurrence  of  a  hemorrhage  from  a  limb  is  feared,  mark  with  anilin 
or  iodin  the  spot  on  the  main  artery  where  compression  is  to  be  applied, 


Hemostatic  Agents 


453 


apply  a  tourniquet  loosely,  and  order  the  nurse  to  screw  it  up  and  to  send  for 
the  physician  at  the  first  sign  of  renewed  bleeding.  This  must  often  be  done 
in  gunshot  wounds. 

22.  When  the  femoral  vein  is  divided  high  up,  the  advice  commonly 
given  is  to  ligate  the  vein  and  also  the  femoral  artery.  Braune  taught  that 
because  of  the  venous  valves  there  is  no  collateral  circuladon,  and  to  tie  the 
vein  alone  renders  gangrene  inevitable.  Xiebergall  shows  that  the  valves 
may  be  overcome  by  moderate  arterial  pressure,  and  thus  collateral  circula- 
tion be  established.  Hence,  when  the  femoral  vein  is  divided  tie  the  vein, 
but  leave  the  artery  untied,  so  as  to  furnish  the  necessary  pressure.* 

23.  In  extradural  hemorrhage,  trephine.  The  side  to  be  trephined  is 
determined  by  the  symptoms,  and  not  by  the  situation  of  the  injurv.  The 
opening  is  made  on  a  level  with  the  upper  orbital  border  and  one  and  a  quarter 
inches  behind  the  external  angular  process.  This  opening  exposes  the 
middle  meningeal  and  its  anterior  branch.  If  this  does  not  expose  a  clot, 
trephine  over  the  posterior  branch,  on  the  same  level  and  just  below 
the  parietal  eminence.  When  the  clot  is  found,  enlarge  the  opening  with 
the  rongeur,  scoop  out  the  clot,  and  arrest  the  bleeding  by  passing  catgut 
Kgatures  on  each  side  of  the  injury  in  the  vessel  through  the  dura,  under  the 
artery  and  out  again,  and  then  tying  them.  If  the  artery  lies  in  a  bonv  canal, 
plug  the  canal  with  Horsley's  wax.  In  subdural  hemorrhage  open  the  dura 
and  endeavor  to  hgate.  If  this  procedure  is  impossible,  pack  with  one  piece 
of  iodoform  gauze. 

24.  In  hemorrhage  from  a  cerebral  sinus  catch  the  edges  of  the  opening 
with  forceps,  if  possible,  and  apply  a  lateral  ligature,  or  leave  the  forceps  in 
place  for  forty-eight  hours,  or  compress  tirmly  with  one  large  piece  of  iodo- 
form gauze. 

25.  In  extramedullary  spinal  hemorrhage  rapidly  advancing  and  threaten- 
ing life  perform  a  laminectomy  and  arrest  the  hemorrhage. 

26.  In  bleeding  from  a  tooth-socket  use  chlorid  of  ethyl  sprav  or  ice. 
If  this  treatment  fails,  plug  with  gauze  infiltrated  with  tannin  or  soaked  in 
antipyrin  solution  of  a  strength  of  10  per  cent.,  or  in  Carnot's  solution  of 
gelatin,  close  the  jaws  upon  the  plug,  and  hold  them  with  Barton's  bandage. 
If  this  expedient  fails,  soak  the  plug  in  Monsel's  solution,  or  plug  with  a  bit 
of  cork  or  dr\-  sponge,  and  if  this  is  futile,  use  the  cauter}-.  Pressure  on  the 
carotid  and  ice  over  the  jaw  and  neck  are  indicated.  It  may  be  necessary  to 
tie  the  external  carotid  arter}\ 

27.  In  intra-abdominal  hemorrhage  open  the  belly.  In  intra-abdominal 
hemorrhage  it  is  necessary  to  operate  during  shock.  If  the  blood  accumulates 
so  rapidly  as  to  prevent  the  location  of  the  bleeding  point,  compress  the 
aorta  or  pack  the  abdominal  cavity  with  large  sponges.  In  seeking  for  the 
bleeding-point  remove  the  sponges  one  by  one,  or  have  the  pressure  momen- 
tarily relaxed  from  time  to  time.  In  parenchymatous  hemorrhage  from  the 
liver  try  packing  with  iodoform  gauze.  If  this  fails,  suture  the  torn  edge  or 
use  the  cautery.  Severe  wounds  of  the  spleen  demand  splenectomy.  Wounds 
of  the  kidney  may  be  sutured,  but  may  require  partial  or  complete  nephrec- 
tomy. Mesenteric  vessels  are  Hgated  en  masse  with  silk  (Senn).  Wounds 
of  the  stomach  and  intestines  causing  hemorrhage  require  stitching  of  their 
edges.     WTaen  there  are  a  great  many  points  of  bleeding,  take  a  number 

*Niebergall,  Deut.  Zeit.  f.  Chir.,  vol.  xxxvii,  Nos.  3  and  4. 


454 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


of  sponges,  tie  a  piece  of  tape  firmly  to  each  one,  pack  many  places  in  the 
belly  with  the  sponges,  bring  the  tapes  out  of  the  wound,  and  remove  the 
sponges  from  below  upward  one  at  a  time,  securing  the  bleeding  points  as 
they  come  into  view. 

28.  In  abdominal  secdon  for  disease  of  the  female  pelvic  organs  bleeding 
is  hmited  by  the  clamp  or  by  pressure-forceps.  Ligation  en  masse  is  often 
practised.  Use  silk.  A  large  mass  can  be  transfixed  and  tied  in  sections 
Bleeding  edges  are  stitched.  Areas  of  oozing  are  treated  with  temporary 
pressure  and  hot  water,  or,  if  this  fails,  by  the  cautery.  Packing  can  be 
used  as  a  tamponade,  which  is  a  gauze  pouch,  pieces  of  gauze  being  packed 
into  this  pouch  after  its  insertion  into  the  belly  (Fig.  42). 

29.  A  ruptured  varicose  vein  requires  a  compress,  a  bandage  from  the 
periphery  up,  and  elevation. 

30.  Most  cases  of  capillary  bleeding  can  be  controlled  by  compression 
with  gauze  pads  soaked  in  water  at  a  temperature  of  115°  to  120°  F.  This 
contracts  the  vessels  and  seals  them  with  coagulated  albumin.  Keetly  in 
1878  impressed  the  profession  with  the  value  of  hot  water  as  a  styptic.  Cen- 
turies ago  surgeons  used  hot  oil  for  the  same  purpose.  Capillary  bleeding 
can  often  be  controlled  by  the  application  of  gauze  soaked  in  Carnot's  solution 


Fig.  208.— Pluggiiifif  the  nares  for  epistaxis  (Guerin). 

of  gelatin.  A  solution  of  suprarenal  extract  may  control  capillary  oozing.  If 
other  means  fail  to  control  capillary  hemorrhage,  the  cautery  must  be  used. 
Understand  that  the  term  capillary  bleeding  does  not  so  much  mean  bleed- 
ing from  genuine  capillaries  as  it  does  bleeding  from  arterioles  and  venules. 

31.  Pressure  above  a  wound  arrests  arterial  hemorrhage,  but  aggravates 
venous  bleeding.  Pressure  below  a  wound  arrests  venous  hemorrhage,  but 
increases  arterial  bleeding.     Remember  these  facts  when  applying  pressure. 

32.  A  moderate  epistaxis  may  be  arrested  by  an  injection  of  peroxid  of 
hydrogen,  an  injection  of  a  solution  of  antipyrin,  or  an  injection  of  Carnot's 
solution  of  salt  and  gelatin.  Favorite  domestic  expedients  are  keeping  the 
arms  raised  above  the  head  and  applying  ice  to  the  back  of  the  neck.     In 


Hemostatic  Agents  455 

severe  epistaxis,  or  bleeding  from  the  nose,  examine  the  nose  by  means  of 
a  head-mirror  and  a  speculum.  If  a  little  point  of  ulceration  is  found,  touch 
it  with  a  hot  iron.  If  the  bleeding  is  a  general  ooze,  if  it  is  high  up,  or  if  the 
cautery  does  not  arrest  it,  pack  the  nares.  It  may  be  necessary  to  pack  one 
nostril  or  both.  Pass  a  Bellocq  cannula  (Fig.  208)  along  the  floor  of  one 
nostril  into  the  pharynx,  project  the  stem  into  the  mouth,  tie  a  plug  of  lint 
or  gauze  wet  with  Carnot's  solution  of  salt  and  gelatin  to  the  stem,  and  with- 
draw it.  Hold  the  double  string  which  emerges  from  the  nostril  in  the  hand 
and  pack  gauze  wet  with  gelatin  solution  from  before  backward.  Tie  the 
strings  together  over  the  plug;  if  both  nostrils  are  plugged,  the  strings  from 
one  nostril  are  fastened  to  the  strings  from  the  other.  Do  not  use  subsulphate 
of  iron,  as  it  forms  a  disgusting,  clotty,  adherent  mass.  If  a  Bellocq  cannula 
is  not  obtainable,  push  a  soft  catheter  into  the  pharynx,  catch  it  with  a  finger, 
pull  it  forward,  and  tie  the  plug  to  it.  Remove  the  plug  in  two  or  three  days. 
Do  not  leave  it  longer.  It  blocks  up  decomposing  fluids  and  may  lead  to 
blood-poisoning.  Pick  out  the  front  plug  first,  hold  the  string  of  the  second 
plug  in  the  hand,  push  the  plug  back  into  the  pharynx,  catch  it  with  forceps, 
and  withdraw  plug  and  string  through  the  mouth. 

33.  In  gunshot-wounds  the  primary  hemorrhage  is  slight  unless  a  large 
vessel  is  cut.  The  bleeding  may  be  visible  or  may  be  internal  (concealed), 
the  blood  running  into  a  natural  cavity  or  among  the  muscles.  Capillary  ooz- 
ing is  arrested  by  very  hot  water  and  compression.  Venous  bleeding  is  usually 
arrested  by  compression.  If  a  large  vessel  is  the  source  of  bleeding,  enlarge 
the  wound  and  tie  the  vessel.  If  the  artery  cannot  be  found  in  the  wound, 
tie  the  main  trunk. 

34.  In  prolonged  bleeding  from  a  leech-bite  try  compression  over  a  plug 
saturated  with  alum  or  with  tannin.  If  this  fails,  pass  under  the  wound  a 
harelip  pin  and  encircle  it  with  a  piece  of  silk.  If  this  fails,  use  the  actual 
cautery  or  excise  the  bite  and  suture  the  incision. 

35.  In  severe  bleeding  from  the  ear  elevate  the  head,  put  an  ice-bag  over 
the  mastoid,  give  opium  and  acetate  of  lead,  and,  if  blood  runs  into  the  mouth, 
plug  the  Eustachian  tube  with  a  piece  of  catheter. 

36.  Umbilical  hemorrhage  in  infants  requires  pressure  over  a  plug  con- 
taining tannin,  alum,  or  gelatin  solution.  If  compression  fails,  pass  harelip 
pins  under  the  navel  and  apply  a  twisted  suture.  If  this  fails,  use  the  actual 
cautery. 

37.  Rectal  bleeding  requires  elevation  of  the  buttocks,  insertion  of  pieces 
of  ice,  ice  to  the  anus  and  perineum,  astringent  injections  (alum),  and  the 
internal  use  of  opium  and  acetate  of  lead.  If  these  means  fail,  plug  the 
bowel  over  a  catheter,  or  insert  and  inflate  a  Peterson  bag  or  a  colpeurynter, 
or  tampon  and  use  a  T-bandage.  If  the  bleeding  persists  or  if  a  considerable 
vessel  is  bleeding,  stretch  the  sphincter,  catch  the  bowel  and  draw  it  down, 
seize  the  vessel,  and  tie  it  if  possible;  if  not,  leave  the  forceps  in  place.  Failing 
in  this,  the  actual  cautery  must  be  used. 

38.  Subcutaneous  hemorrhage,  if  severe  and  persistent,  demands  that 
an  incision  be  made  and  ligatures  be  applied. 

39.  Bleeding  from  a  cut  urethral  meatus  requires  the  insertion  of  styptic 
cotton  and  the  application  of  pressure.  Moderate  bleeding  from  the  deeper 
urethra  can  usually  be  arrested  by  a  very  warm  bougie,  by  very  warm  in- 
jections, or  by  tying  a  condom  over  a  catheter,  and,  after  inserting  it,  inflat- 


456 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


ing  the  condom  by  blowing  through  the  catheter  and  plugging  the  orifice  of 
the  instrument,  thus  using  pressure.  Sitting  with  the  perineum  on  a  thickly 
folded  towel  is  useful.  Ice  to  the  perineum  does  good.  The  patient  can 
lie  down,  have  a  folded  towel  applied  to  the  perineum,  and  a  crutch-handle 
pushed  upon  the  towel,  the  lower  end  of  the  crutch  being  jammed  against 
the  foot  of  the  bed.  If  a  solid  bougie  has  been  first  introduced,  firm  pressure 
can  be  made  by  this  method.  If  these  means  are  futile,  perform  an  external 
urethrotomy  and  reach  the  bleeding  point. 

40.  Hemorrhage  from  the  prostate  requires  hot  injections,  the  introduction 
of  a  large  bougie  first  dipped  in  very  warm  water,  and  the  retention  of  a 
catheter  for  two  days.  Perineal  section  may  be  required,  or  suprapubic 
cystotomy  with  packing  which  does  not  occlude  the  ureteral  orifices. 

41.  Vesical  hemorrhage  usually  ceases  spontaneously,  in  which  case  the 
urine  must  be  drawn  off  and  the  viscus  be  washed  out  frecjuently  with  a 
solution  of  boric  acid,  to  prevent  septic  cystitis.  If  blood-clots  prevent  the 
flow  of  urine,  break  them  up  with  a  catheter  or  a  lithotrite  and  inject  vinegar 
and  water,  a  2  per  cent,  solution  of  carbolic  acid,  or  a  solution  of  bicarbonate 
of  sodium.  Perfect  quiet  is  to  be  maintained,  cold  acid  drinks  given, 
ice-bags  put  to  the  perineum  and  hypogastric  region,  and  opium  with 
acetate  of  lead,  or  gallic  acid  to  be  given  by  the  mouth.  If  the  hemorrhage 
is  severe  or  persistent,  perform  a  suprapubic  cystotomy,  wash  out  the  bladder, 
and,  if  necessary,  plug  the  bladder  with  gauze,  leaving  the  ureters  uncovered. 

42.  In  hemorrhage  after  lateral  lithotomy,  ligate  if  possible.  If  the 
vessel  can  be  caught  but  cannot  be  ligated,  leave  the  forceps  in  place.  If 
it  is  not   possible  to    catch  the  vessel  with  forceps,  use  a  tenaculum.     If 

the  tenaculum  fails,  pass  a  threaded  curved  needle 
through  the  tissues  around  the  vessel  and  tie  the 
ligature  (suture  ligature).  Plugs  of  ice  and  injec- 
tions of  hot  water  may  be  tried.  These  means 
failing,  pressure  is  indicated.  Take  a  cannula, 
fasten  to  it  a  chemise  (Fig.  209),  empty  clots  from 
the  bladder,  insert  the  instrument  into  the  viscus, 
and  "pack  gauze  between  the  sides  of  the  cannula 
and  the  chemise.  The  chemise  is  bulged  out  and 
pressure  is  made.  Tie  the  cannula  by  means  of 
tapes  to  a  T-bandage.  Pressure  is  thus  combined 
with  vesical  drainage.  Buckstone  Brown  makes 
pressure  by  inflating  a  rubber  bag  with  air.  The 
hot  iron  may  occasionally  be  demanded. 

43.  Renal  bleeding  requires  ice  to  the  loin,  tan- 
nic acid  and  opium,  gallic  acid  or  sulphuric  acid 
internally,  and  perfect  quiet.  The  use  of  a  cysto- 
scope  will  show  from  which  ureter  blood  is  emerg- 
ing. If  the  bleeding  threatens  life  and  the  diseased 
organ  is  identified,  make  a  lumbar  incision,  and 
suture  or  perform  nephrectomy;  if  not  sure  which  organ  is  diseased,  per- 
form an  exploratory  laparotomy. 

44.  Vaginal  hemorrhage  requires  the  ligature  or  the  tampon. 

45.  Severe  uterine  hemorrhage  (unconnected  with  pregnancy)  requires 
the  tampon.     Persistent  hemorrhage  due  to  morbid  growths  may  require 


Fig.  209. — Cannula  S  chemise. 


Reactionary  or  Recurrent  Hemorrhage  457 

removal  of  the  tubes  and  appendages,  ligation  of  the  uterine  and  ovarian 
arteries,  or  hysterectomy. 

46.  Hematemesis,  or  bleeding  from  the  stomach,  is  treated  by  the  swallow- 
ing of  ice,  giving  tannic  acid  (dose,  20  or  30  grains)  or  Monsel's  solution  (3 
drops).  Gelatin  by  the  mouth  is  recommended.  Never  give  tannic  acid 
and  Monsel's  solution  at  the  same  time,  as  they  mix  and  form  ink.  Opium 
is  usually  ordered.  Acetate  of  lead  and  opium  and  gallic  acid  are  favorite 
remedies,  and  ergot  is  used  by  many.  Give  no  food  by  the  stomach.  If  life 
is  threatened  by  bleeding  from  an  ulcer,  open  the  belly  and  excise  the  ulcer 
and  suture  the  wound.  If  severe  hemorrhage  follows  injury,  perform  an  ex- 
ploratory laparotomy.  Always  remember  that  furious  and  even  fatal  gastro- 
intestinal hemorrhage  may  be  due  to  cirrhosis  of  the  liver,  and  a  slight  injury 
may  be  the  exciting  cause  of  such  a  hemorrhage.  In  this  condition,  of 
course,  operation  is  useless. 

47.  In  bleeding  from  the  small  bowel  give  acetate  of  lead  and  opium, 
sulphuric  acid,  or  Monsel's  salt  in  pill  form  (3  grains),  allow  no  food  for  a 
time,  and  insist  on  liquid  diet  for  a  considerable  period.  If  hemorrhage 
threatens  life,  do  a  celiotomy  and  find  the  cause.  If  ulcer  exists,  excise  it 
and  suture,  or  suture  a  perforation  without  previously  excising.  If  violent 
hemorrhage  follows  injury,  explore  to  discover  the  cause. 

48.  In  bleeding  from  the  large  bowel,  use  styptic  injections  (10  grains 
of  alum  or  5  grains  of  bluestone  to  oj  of  water).  If  bleeding  is  low  down, 
use  small  amounts  of  the  solution;  if  high  up,  large  amounts.  Do  not  use 
absorbable  poisons.  In  dangerous  cases  perform  an  exploratory  operation 
to  find  the  cause.     (For  rectal  bleeding  see  37,  p.  455.) 

49.  Hemoptysis  or  bleeding  from  the  lung,  is  treated  by  morphin  hypo- 
dermatically,  by  perfect  rest,  by  dry  cups  or  ice  over  the  affected  spot  if  it 
can  be  located,  and  by  the  administration  of  gallic  acid,  which  drug  aids 
coagulation.*     Of  late,  nitrite  of  amyl  by  inhalation  has  given  good  results. 

50.  In  hemorrhage  from  wound  of  the  lung  do  not  open  the  chest  unless 
life  is  threatened.  If  life  is  endangered,  resect  a  rib,  allow  the  lung  to  col- 
lapse, and  see  if  this  arrests  bleeding.  If  bleeding  still  continues,  remove 
several  ribs,  find  the  bleeding  point,  ligate  or  employ  forcipressure.  A  small 
cavity  may  be  packed  with  gauze.  If  a  large  surface  is  bleeding,  fill  the 
pleural  sac  with  gauze  and  pack  more  gauze  against  the  oozing  surface. f 

Reactionary  or  Recurrent  Hemorrhage  (called  also  Consecutive, 
Intermediate,  or  Intercurrent). — This  form  of  hemorrhage  comes  on  during 
reaction  from  an  accident  or  an  operation — that  is,  during  the  first  forty- 
eight  hours,  but  usually  within  twelve  hours.  It  is  bleeding  from  a  vessel  or 
vessels  which  did  not  bleed  during  the  shock  which  accompanied  operation, 
and  which  vessels  were  overlooked  and  not  tied.  It  may  be  due  to  faultily 
applied  ligatures.  It  is  favored  by  vascular  excitement  or  hypertrophied 
heart.  The  bleeding  is  rarely  sudden  and  severe,  but  is  usually  a  gradual 
drop  or  trickle.  The  Esmarch  apparatus  is  not  unusually  the  cause.  The 
constricting  band  paralyzes  the  smaller  arteries,  which  do  not  bleed  during 
shock  and  do  not  contract  as  shock  departs;  hence  bleeding  comes  on  with 

*  The  use  of  ergot  is  a  general  but  questionable  practice.  Bartholow  and  others  hold 
that  this  drug  does  harm  ;  it  contracts  all  the  arterioles,  and  hence  more  blood  flows  from  an 
area  where  there  is  damage.  Purgatives  do  good  in  bleeding  from  the  lung  by  taking  blood 
to  the  abdomen  and  lowering  blood-pressure. 

f  See  author's  case,  Annals  of  Surgery,  Jan.,  1898. 


458  Diseases  and  Injuries  of  the  Heart  and  Vessels 

reaction.  To  lessen  the  danger  of  the  Esmarch  apparatus  use  a  broad  con- 
stricting band  rather  than  a  rubber  tube.  After  an  amputation,  when  the 
larger  vessels  have  been  tied,  gauze  pads  wet  with  hot  water  (115°  to  120°  F.) 
should  be  placed  between  the  flaps.  This  not  only  arrests  capillary  oozing, 
but  stimulates  vessels  and  shows  points  of  bleeding  which  were  not  previously 
visible,  and  these  points  are  Hgated.  During  reaction  after  an  amputation, 
if  slight  hemorrhage  occurs,  elevate  the  stump  and  compress  the  flaps.  If 
the  hemorrhage  persists  or  at  any  time  becomes  severe,  make  pressure  on 
the  main  artery  of  the  limb,  open  the  flaps,  turn  out  the  clots,  find  the  bleeding 
point,  ligate,  asepticize,  close,  drain,  and  dress.  In  any  severe  reactionary 
hemorrhage  open  the  wound  at  once  and  ligate. 

Secondary  hemorrhage  may  occur  at  any  time  in  the  period  between 
forty-eight  hours  after  the  accident  or  operation  and  the  complete  cicatriza- 
tion of  the  wound.  Secondary  hemorrhage  may  be  due  to  atheroma,  to 
slipping  of  a  Hgature,  to  inclusion  of  nerve,  fascia,  or  muscle  in  the  ligature, 
to  sloughing,  to  erysipelas,  to  septicemia,  to  pyemia,  to  gangrene,  and  to 
overaction  of  the  heart.  The  great  majority  of  cases  of  secondary  hemor- 
rhage are  due  to  infection,  and  the  appHcation  of  modern  surgical  principles 
has  rendered  secondary  bleeding  a  rare  calamity.  If  during  an  operation 
the  vessels  are  found  atheromatous,  a  thread  should  be  passed,  by  means  of 
a  Hagedorn  needle,  around  the  vessel,  including  a  cushion  of  tissue  in  the 
loop  of  the  ligature  (this  prevents  cutting  through,  Fig.  191).  Acupressure 
may  be  used  in  such  a  case.  If  the  surgeon  decides  to  employ  the  ligature, 
he  must  not  tie  tightly,  but  must  endeavor  to  approximate  the  coats  rather 
than  to  cut  them.  Two  ligatures  can  be  appHed  6r  the  stay-knot  may  be 
used.  One  great  trouble  with  atheromatous  arteries  is  that  their  coats 
cannot  contract;  another  trouble  is  that  the  ligature  cuts  entirely  through 
them.  If  after  an  operation  the  pulse  is  found  to  be  forcible,  rapid,  and 
jerking,  give  aconite,  opium,  and  low  diet.  The  bleeding  may  come  on 
suddenly  and  furiously,  but  is  usually  preceded  by  a  bloody  stain  in  wound- 
fluids  which  had  become  free  from  blood. 

Treatment  of  Secondary  Hemorrhage. — Suppose  a  case  of  leg- 
amputation  in  which,  several  days  after  the  operation,  a  little  oozing  is  detected: 
the  treatment  is  to  elevate  the  stump,  apply  two  compresses  over  the  flaps, 
and  carry  a  firm  bandage  up  the  leg.  If  the  bleeding  is  profuse  or  becomes 
so,  make  pressure  on  the  main  artery,  open  and  tear  the  flaps  apart  with  the 
fingers,  find  the  bleeding  vessel  and  tie  it,  turn  out  the  clots,  asepticize,  close, 
drain,  and  dress.  If  the  bleeding  begins  at  a  period  when  the  stump  is  nearly 
healed,  cut  down  on  the  main  artery  just  above  the  stump  and  hgate.  In 
secondary  hemorrhage  from  a  blood-vessel  in  nodular  tissue,  apply  a  suture- 
ligature  or  tie  higher  up,  or,  if  this  fails,  amputate.  When  secondary  hemor- 
rhage arises  in  a  sloughing  wound  apply  a  tourniquet  or  an  Esmarch  bandage, 
tear  the  wound  open  to  the  bottom  with  a  grooved  director,  look  for  the 
orifice  of  the  vessel,  dissect  the  artery  up  until  a  healthy  point  is  reached, 
cut  it  across,  and  tie  both  ends.  If  this  fails,  apply  a  suture-hgature  or 
use  acupressure.  In  secondary  hemorrhage  from  atheromatous  vessels,  use 
the  suture-hgature,  double  ligature  with  a  stay-knot,  or  employ  acupressure. 

Secondary  hemorrhage  may  occur  after  ligation  in  continuity,  the  blood 
usually  coming  from  the  distal  side.  If  the  dressings  are  slightly  stained 
with  blood,  put  on  a  graduated  compress.     If  the  bleeding  continues  or  is 


Operation  for  Wound  of  the  Heart  459 

severe,  make  pressure  on  the  main  artery  of  the  limb,  oi)en  the  wound  and 
ligate,  wrap  the  part  in  cotton,  elevate,  and  surround  with  hot  bottles.  If 
this  religation  is  done  on  the  femoral  and  fails,  do  not  ligate  higher  up,  as 
gangrene  will  certainly  occur,  but  amputate  at  once,  above  the  point  of  hemor- 
rhage. If  deahng  with  the  brachial  artery,  do  not  amputate,^  but  ligate 
higher  up  and  make  compression  in  the  wound.  In  a  secondary  hemorrhage 
from  the  innominate,  tie  the  innominate  again  and  also  tie  the  vertebral. 

Operations  on  the  Vascular  System. 

Paracentesis  auriculi,  or  tapping  the  heart-cavity,  has  been  suggested 
for  the  relief  of  an  overdistended  heart  from  pulmonary  congestion.  The 
right  auricle  can  be  tapped.  Push  the  aspirator  needle  directly  backward 
at  the  right  edge  of  the  sternum,  in  the  third  interspace.  This  operation  is 
not  recommended,  as  it  is  highly  dangerous  and  is  of  questionable  value.     . 

Paracentesis  pericardii,  or  tapping  the  pericardial  sac,  is  done  only 
when  life  is  endangered  by  effusion.  Introduce  the  needle  two  inches  to 
the  left  of  the  left  edge  of  the  sternum,  in  the  fifth  interspace,  and  push  it 
directly  backward  (thus  avoiding  the  internal  mammary  artery).  The 
operation  of  tapping  is  extremely  dangerous.  The  heart  is  lifted  up  and 
pushed  forward  by  an  effusion  and  the  needle  is  apt  to  enter  it.  The  puncture 
of  a  ventricle  may  do  no  harm,  although  it  is  apt  to,  but  the  puncture  of  an 
auricle  is  liable  to  be  followed  by  fatal  hemorrhage.  It  is  wiser  and  safer 
to  expose  the  pericardium  and  incise  it,  as  is  done  for  pericardial  suppuration. 

Operation  for  Pericardial  Effusion  or  Suppuration.— The  oper- 
ation of  tapping  should  be  abandoned  in  favor  of  a  safer  but  more  radical 
procedure.  There  is  no  spot  where  we  can  introduce  the  needle  with  perfect 
safety,  and  the  heart  or  pleura  may  be  wounded ;  further,  as  Brentano  shows,* 
tapping  will  not  completely  empty  the  sac.  In  a  purulent  case  tapping  gives 
practically  no  chance  of  cure.  No  general  anesthetic  should  be  used.  A 
portion  of  the  fifth  rib  or  the  cartilage  on  the  fifth  rib  should  be  excised,  the 
pericardium  exposed  and  punctured  in  order  to  determine  the  nature  of  the 
fluid  present.  If  the  fluid  is  serous,  it  can  be  drained  away  through  a  small 
incision,  and  the  pericardium  may  either  be  sutured  or  drained  with  gauze. 
If  the  fluid  be  purulent,  the  pericardium  should  be  stitched  to  the  chest-wall 
and  opened.  Clots  should  be  removed  by  irrigation  with  hot  salt  solution 
and  a  drainage-tube  should  be  introduced. 

Operation  for  Wound  of  the  Heart.— In  many  cases  it  is  obviously 
impossible  to  administer  an  anesthetic,  but  when  possible  it  should  be  given 
because  the  movements  of  the  patient  while  under  the  knife  make  operation 
difficult  and  increase  bleeding.  Ether  may  be  used  or  we  may  take  Hill's 
advice  and  give  chloroform.  Hill  would  give  an  anesthetic  unless  the  patient 
is  unconscious  and  the  corneal  reflex  is  abolished.  Personally,  I  would  be 
disposed  to  use  chloroform  unless  the  patient's  general  condition  forbade 
it  (see  page  402).  The  pericardium  can  be  exposed  freely  and  Rotter's  incision 
gives  excellent  access,  although  it  always  opens  the  pleura.  This  exposure  is 
described  by  Hill  in  the  "Medical  Record,"  November  29,  1902,  and  was  em- 
ployed in  his  successful  case.  Begin  an  incision  over  the  third  rib  five-eighths 
of  an  inch  from  the  left  edge  of  the  sternum  and  carry  it  outward  along  the  rib 
*Deut.  med.  Woch.,  Feb.  ii,  1890. 


460  Diseases  and  Injuries  of  the  Heart  and  Vessels 

for  4  inches.  Begin  an  incision  over  a  corresponding  point  of  the  sixth  rib 
and  carry  it  out  for  a  lilce  distance.  Join  the  outer  extremities  of  these  cuts. 
Cut  through  the  ribs  and  pleura  with  bone  forceps  and  scissors.  Raise  the  flap 
upon  its  hinges  of  cartilages,  and  have  an  assistant  grasp  the  lung  to  prevent 
collapse.  The  pericardium  thus  exposed  is  opened  more  widely  if  necessary. 
Hill  advises  us  to  steady  the  heart  by  pressing  the  hand  under  it  and  lifting  it. 
Parrozzani  did  this  by  inserting  a  finger  in  the  wound.  Other  surgeons 
have  used  traction  sutures  of  silk.  Interrupted  sutures  are  preferred  to  the  con- 
tinuous suture.  Either  silk  or  catgut  can  be  used.  They  should  be  inserted 
with  a  round-edged  needle,  and  should,  if  possible,  be  passed  and  tied  during 
diastole.  "As  few  as  possible  should  be  passed  commensurate  with  safety 
against  leakage,  as  they  cause  a  degeneration  of  the  muscular  fiber. "  It  does 
no  harm  apparently  if  they  enter  a  heart  chamber,  but  it  is  wiser  not  to  have 
them  do  so.  If  the  heart  fails,  use  heart  massage  (L.  L.  Hill,  in  "Medical 
Record,"  Nov.  29,  1902).  The  pericardial  and  pleural  sacs  are  cleansed  with 
salt  solution.  The  question  of  drainage  is  still  sub  judice.  The  pleural  sac  is 
treated  according  to  indications  in  each  case. 

Geo.  TuUy  Vaughan,  in  reporting  his  second  case  of  heart  suture  and  a  table 
of  150  operations  ("Jour.  Am.  Med.  Assoc,"  Feb.  6,  1909),  mentions  five 
methods  for  exposing  the  heart,  and  states  that  no  single  method  has  yet  been 
agreed  on  as  the  best.  The  kind  of  operation  is  often  determined  by  the  ex- 
ternal wound,  and,  begun  as  an  exploration,  the  subsequent  steps  depend  on  the 
necessities  which  arise  during  its  progress.  The  five  methods  mentioned  by 
Vaughan  are:  (a)  Through  an  intercostal  space,  with  or  without  the  division  of 
one  or  two  cartilages;  (h)  resection  of  one  or  more  cartilages,  with  or  without  a 
portion  of  rib;  (r)  flap  method  across  the  sternum,  dividing  the  sternum  and 
cartilages  (this  avoids  opening  the  pleura) ;  {d)  flap  of  cartilages  and  ribs  with 
an  external  hinge;  {e)  flap  of  cartilages  and  ribs  with  an  internal  hinge. 

Vaughan's  table  shows  that  in  46  patients  the  pericardium  was  drained,  with 
25  recoveries  and  21  deaths;  in  44  the  pericardium  was  not  drained,  with  25 
recoveries  and  19  deaths;  in  42  both  the  pericardium  and  pleura  were  drained, 
with  21  recoveries  and  21  deaths;  in  19  both  pericardium  and  pleura  were  closed 
without  drainage,  with  12  recoveries  and  7  deaths;  in  72  the  pleura  was  drained, 
with  30  recoveries  and  42  deaths;  in  21  the  pleura  was  not  drained,  with  13 
recoveries  and  8  deaths.  These  figures  would  indicate  that  drainage  should 
not  be  the  rule.  It  should  be  used  though  if  bleeding  continues  or  if  we  greatly 
fear  infection.  Of  course,  drainage  causes  irritation,  prevents  the  lung  expand- 
ing, and  makes  secondary  infection  more  probable  (Vaughan  in  "Jour.  Am. 
Med.  Assoc,"  Feb.  6,  1909). 

In  Vaughan's  table  of  150  cases  we  find  that  98  died  and  52  recovered,  a 
mortality  of  65  per  cent;  32  patients  died  in  less  than  twenty  hours  after 
the  operation  for  the  injury  and  15  died  on  the  table  or  just  after  the  opera- 
tion. In  all  but  I  of  these  cases  death  was  due  to  hemorrhage.  In  i  it  was  due 
to  pneumothorax  on  opening  the  pleura.  The  remaining  66  deaths  occurred 
in  from  twenty-four  hours  to  five  months  after  the  operation;  6  died  of 
pleurisy,  5  of  pericarditis,  21  of  combined  pleurisy  and  pericarditis,  3  of  pneu- 
monia, 3  of  peritonitis,  2  of  pericarditis  and  nephritis,  i  of  pleurisy  and  cerebral 
abscess,  i  of  pleurisy  and  wound  of  the  tricuspid  valve,  i  of  pleurisy  and  double 
pneumonia,  i  of  gangrene  of  the  lung,  i  of  two  wounds,  one  of  which  was  not 


Trendelenburg's  Operation  461 

sutured,  3  of  bleeding  into  the  pleura,  2  of  bleeding  into  the  pericardium,  i  of 
clot  in  the  tricuspid  opening,  and  15  of  unassigned  causes. 

Cardiolysis. — As  a  result  of  pericarditis  the  heart  may  adhere  to  the 
pericardium  and  the  pericardium  to  the  chest  wall.  This  condition  is  dan- 
gerous, and,  if  unrelieved,  will  eventually  prove  fatal. 

Delorme  has  suggested  that  the  pericardial  sac  be  opened  and  the  adhe- 
sions be  broken  down  with  the  finger,  a  very  dangerous  procedure,  which  is 
almost  certain  to  inflict  serious  injurv'  upon  the  heart. 

Brauer's  method  consists  in  removing  the  ribs  and  portion  of  the  sternum 
to  which  the  pericardium  adheres.  The  periosteum  is  to  be  removed  with 
the  bone  to  prevent  the  formation  of  new  bone.  This  is  the  preferable 
operation. 

Operation  for  Varix  of  Leg. — Many  cases  do  not  require  operation. 
In  some,  operation  is  positively  harmful.  In  some  selected  cases  operation  is 
very  useful  to  remove  certain  complications  (ulcer,  eczema,  etc.),  and  to  relieve 
the  patient  from  annoyance,  but  the  operation  rarely  absolutely  cures  the 
condition.  As  Blake  points  out  a  cure  cannot  be  claimed  until  at  least  one 
year  has  passed  after  operation  without  reappearance  of  the  varix  ("Boston 
Med.  and  Surg.  Jour.,"  Sept.  25, 1902).  The  indications  and  contraindications 
are  discussed  on  page  410.  Never  operate  if  phlebitis  exists,  except  to  treat 
thrombosis.  After  any  operation  for  varicose  veins  of  the  leg  follow  Bennett's 
advice  and  keep  the  patient  in  bed  for  three  weeks  and  do  not  let  him  resume 
active  work  for  three  weeks  more  ("Lancet,"  Nov.  22,  1902). 

Trendelenburg's  Operation. — I  have  employed  this  with  much  satis- 
faction in  cases  of  varix  of  the  leg  following  involvement  of  the  saphenous 
in  the  thigh.  Trendelenburg  beheves  that  in  varix  the  valves  in  the  saphenous 
become  incompetent  because  of  high  central  pressiire.  The  veins  of  the  leg 
distend,  as  they  are  unable  to  support  such  a  long  colimin  of  blood,  and  finally 
the  blood  begins  to  flow  in  the  wTong  direction  in  the  saphenous,  a  "vicious 
circle  "  being  estabHshed.  We  determine  whether  a  case  is  a  suitable  one 
for  Trendelenburg's  operation  as  follows:  While  the  patient  is  lying  down, 
raise  the  extremity  as  though  we  intended  to  empty  it  of  blood  previous  to 
amputation.  After  three  minutes  compress  the  saphenous  vein  about  the 
lower  third  of  the  thigh  by  means  of  a  moist  gauze  bandage,  which  must  not 
be  so  tight  as  to  shut  off  the  deeper  vessels.  Lower  the  leg  and  have  the 
patient  stand  up.  If  blood  flows  into  the  saphenous  from  above  and  distends 
the  portion  of  the  vein  above  the  compress,  the  valves  are  incompetent  and 
Trendelenburg's  operation  may  be  performed.  The  operation  is  performed  as 
follows :  ISIake  an  incision  about  four  inches  long  over  the  internal  saphenous 
vein  at  the  junction  of  the  lower  and  middle  thirds  of  the  thigh.  Expose  the 
vein,  Ugate  each  visible  branch,  hgate  the  saphenous  at  the  lower  end  of  the 
wornid  and  also  at  the  upper  end,  and  remove  the  portion  of  vein  included 
between  the  ligatures.  By  this  operation  the  central  pressure  is  intercepted 
and  the  dilated  veins  in  consequence  shrink.  Some  surgeons  have  advised 
the  removal  of  the  entire  length  of  the  long  saphenous  vein.  If  Trendelen- 
burg's operation  fails  and  a  relapse  occurs,  extirpate  the  varicose  veins  of 
the  leg. 

Madehing  cuts  down  over  the  varices  and  ligates  at  various  points.  Schede 
makes  a  circular  cut  (a  circumcision)  completely  around  the  leg  at  the  junc- 


462  Diseases  and  Injuries  of  the  Heart  and  Vessels 

tion  of  the  upper  and  middle  thirds,  the  incision  reaching  to  the  deep  fascia. 
All  bleeding  points  are  hgated  and  the  edges  of  the  incision  are  stitched 
together.  Fergusson  ties  the  saphenous  vein  near  the  femoral  and  removes 
a  section  from  it.  This  makes  the  varices  clearly  evident.  A  semilunar  in- 
cision is  made  to  surround  the  varices,  which  incision  reaches  to  the  deep 
fascia.  The  flap  is  raised  and  dissected  up,  the  vessels  are  tied,  and  the  flap 
is  sutured  in  place.  The  author  of  this  operation  claims  that  it  is  most 
satisfactory  and  certain.  Phelps  advises  multiple  ligation,  which  may  be  de- 
scribed as  follows :  At  several  points  over  the  long  saphenous  vein  he  makes 
skin  incisions  in  the  long  axis  of  the  vessel.  Each  incision  is  two  inches 
long.  At  each  point  two  ligatures  are  placed  one  inch  apart  and  the  portion 
of  vein  between  them  is  removed.  Sir  Wm.  H.  Bennett  thinks  that  in  ordinary 
cases  the  best  operation  consists  in  removing  a  portion  of  the  long  saphenous 
in  the  thigh  and  also  in  removing  3  inches  of  the  vein  from  below  the  knee. 
If  there  are  cystic  dilatations  above  the  knee  he  removes  the  saphenous  from 
the  thigh.     Some  local  varices  he  dissects  out  ("Lancet,"  Nov.  22,  1902). 

Open  Operation  for  Varicocele.— The  open  operation  is  by  far  the 
best  procedure  for  varicocele. 

The  patient  is  placed  in  a  recumbent  position.  He  may  be  given  a 
general  anesthetic  or  Schleich's  fluid  may  iDe  injected.  A  fold  of  skin  is 
pinched  up  on  the  scrotum,  and  the  surgeon  transfixes  it  in  the  line  of  the 
cord,  so  that  he  will  have  an  incision  about  one  and  a  half  inches  long  run- 
ning downward  from  below  the  external  ring.  The  skin  and  fascia  are  cut 
with  a  scalpel,  the  veins  are  well  exposed,  and  the  cord  is  located  and  held 
aside.  A  double  ligature  of  strong  catgut  or  chromicized  gut  is  passed  under 
the  veins  by  an  aneurysm  needle.  The  threads  are  separated  one  inch,  tied 
tightly,  and  the  ends  are  left  long.  The  veins  between  the  Hgatures  are  ex- 
cised. The  two  gut  Hgatures  are  tied  together  and  cut.  This  shortens  the 
cord.  The  scrotum  is  sewed  up  with  silkworm-gut,  a  small  drainage-tube  be- 
ing used  for  twenty-four  hours. 

Bloodgood  points  out  that  it  is  well  to  avoid  dividing  the  genital  branch 
of  the  genitocrural  nerve  which  supplies  the  cremaster  muscle.  If  this  nerve 
should  be  divided,  the  cremaster  will  become  lax  and  return  of  the  varicocele 
will  be  favored.  Bloodgood  makes  the  incision  over  the  external  ring, 
draws  the  veins  up  and  resects  them.  A  wound  so  placed  heals  more  certainly 
and  promptly  than  does  a  wound  of  the  scrotum.  Of  late  years  I  have  always 
followed  this  plan. 

Subcutaneous  Ligature  for  Varicocele.— In  this  operation  employ 
every  antiseptic  precaution.  The  patient  stands,  and  the  operator,  sitting 
in  front  of  him,  holds  the  veins  in  a  fold  of  skin  away  from  the  vas  deferens 
by  means  of  the  thumb  and  index-finger  of  the  left  hand.  A  large  straight 
needle  carrying  a  double  piece  of  strong  silk  is  passed  entirely  through  the 
scrotum,  between  the  veins  and  the  vas.  The  needle  is  again  inserted  at 
the  puncture  from  which  it  emerged,  is  carried  around  under  the  skin  and 
in  front  of  the  veins,  and  emerges  at  its  original  point  of  entry.  The  veins 
are  thus  surrounded  by  the  silk.  The  patient,  who  now  lies  down,  is  placed 
under  the  first  stage  of  ether,  and  the  double  ligatures  are  separated  as  far 
as  possible  from  each  other,  tied,  and  cut  off,  the  knots  slipping  in  through 
the  puncture.  This  operation  presents  certain  dangers.  The  veins  may  be 
wounded  and  the  vas  or  other  structures  may  be  included.     In  an  operation 


Transfusion  of  Blood 


463 


Fig.  210. — Incisions  for 
venesection  (Bernard  and 
Huette). 


Fig.  211 .  —  Superficial 
veins  in  front  of  elbow 
(Bernard  and  Huette). 


it  is  always  best  to  be  able  to  see  what  we  are  doing;  and  the  open  operation, 
being  safe,  is  preferred  to  the  subcutaneous. 

Phlebotomy,  or  Venesection. — The  instrument  used  in  venesection 

is  a  lancet  or  bistoury.     A  fillet  or  tape,  an  antiseptic  pad,  and  a  bandage  are 
required.     A  stick  should  be  at  hand  for  the  patient  to  grasp. 

Operation. — The  patient  sits  on  a  chair  "with  the  arm  abducted,  ex- 
tended, and  inclined  outward"  (Barker).  The  parts  are  asepticized  and  a 
tape  is  tied  around  the  arm  just  above  the  elbow.  The  surgeon  stands  to 
the  right  of  the  arm,  holds  the  elbow  with  his  left  hand,  and  puts  his  thumb 
upon  the  vein  below  the  intended  point  of  puncture.  The  patient  grasps  a 
stick  firmly  and  works  his 
fingers  in  order  to  cause  the 
veins  to  distend.  Either  the 
median  cephalic  or  the  me- 
dian basilic  may  be  opened 
(Figs.  210,  211).  The  median 
basilic  is  the  more  distinct, 
and  is  the  vein  usually  se- 
lected. In  opening  it  do  not 
cut  too  deep,  as  nothing  but 
the  bicipital  fascia  separates 
it  from  the  brachial  artery. 
The  median  cephalic  may  be  se- 
lected (we  thus  avoid  endanger- 
ing the  brachial  artery);  under 
this  vein  lies  the  external  cutaneous  nerve  (Fig.  211).  Steady  the  vein  with  the 
thumb  and  open  it  by  transtixion,  making  an  oblique  cut  which  divides  two- 
thirds  of  it.  Remove  the  thumb  and  allow  bleeding  to  go  on,  instructing  the 
patient  to  work  his  fingers.  When  faintness  begins,  remove  the  fillet,  put  an 
antiseptic  pad  over  the  puncture,  apply  a  spiral  reversed  bandage  of  the 
hand  and  arm  and  a  figure-of-eight  bandage  of  the  elbow,  and  place  the  arm 
in  a  sling  for  several  days. 

Transfusion  of  Blood. — This  operation  has  been  a  recognized  pro- 
cedure since  1824,  though  it  has  been  known  since  1492,  when  transfusion 
was  employed  in  the  case  of  Pope  Innocent  VIII.  Its  chief  use  was  in  severe 
hemorrhage,  especially  post-partum,  in  which  it  served  to  replace  the  blood 
lost  and  supplied  something  for  the  heart  to  contract  upon  until  new  blood 
formed.  Senn  insisted  that  the  operation  had  proved  an  absolute  failure,  that 
it  did  not  prevent  death  from  hemorrhage,  and  that  the  transferred  blood- 
elements  did  not  retain  vitahty.  Von  Bergmann  maintained  that  after  severe 
hemorrhage  we  do  not  need  to  inject  nutritive  elements,  but  do  need  to  re- 
store the  greatly  diminished  intracardiac  and  intravascular  pressure.  At  the 
present  day  a  saline  fluid  is  usually  infused  in  preference  to  transfusing  blood . 
In  fact,  the  operation  of  transfusion  had  become  all  but  extinct  until  Crile 
revived  it.  The  old  operation  exposed  the  patient  to  the  danger  of  embolism 
and  infection,  its  employment  required  material  and  instruments  often  difficult 
to  obtain  in  an  emergency,  and  it  seemed  to  have  no  single  element  of  value 
beyond  that  secured  by  the  use  of  salt  solution,  except  in  cases  overcome  by 
illuminating  gas,  in  which  a  more  prolonged  good  effect  was  known  to  be 
produced  than  by  salt  solution. 


464  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Arteriovenous  Anastomosis  for  Transfusion  of  Blood  (Crile's  Opera- 
tion) . — This  is  a  method  of  the  very  greatest  value  in  the  treatment  of  the  con- 
dition resulting  from  violent  or  prolonged  hemorrhage.  It  is  incomparably 
the  best  treatment  for  severe  hemorrhage.  It  can  be  employed  during  the  per- 
formance of  an  exhausting  operation  and  its  use  will  bring  not  a  few  cases  to 
operation  which,  without  its  aid,  would  be  esteemed  inoperable.  It  should 
be  used  for  severe  typhoid  hemorrhage  and  in  jaundiced  cases  requiring  opera- 
tion, but  showing  very  slow  coagulation.  It  seems  devoid  of  value  in  blood 
diseases.  There  are  certain  dangers  in  it  unless  there  is  time  to  examine  the 
blood  of  both  donor  and  recipient.  It  is  known  that  admixture  of  certain 
bloods  results  in  thrombosis.  If  the  corpuscles  of  the  donor  are  not  aggluti- 
nated by  the  serum  of  the  recipient,  and  vice  versa,  the  operation  is  safe. 

In  Crile's  operation  the  vascular  system  of  the  donor  is  united  to  the  vascular 
system  of  the  recipient,  intima  coming  in  contact  with  intima.  This  is  ac- 
complished by  means  of  a  modification  of  Payre's  magnesium  tube,  Crile's 


Fig.  212. — Brewer's  tubes  for  direct  transfusion. 

tube  being  of  German  silver.  The  vein  of  the  recipient  is  drawn  through  the 
tube,  is  everted,  and  is  tied  into  the  second  groove  on  the  tube. 

The  end  of  the  tube  with  the  everted  vessel  over  it  is  passed  into  the  vein 
of  the  recipient  and  fixed  temporarily  by  a  ligature.  The  left  arm  of  each 
subject  is  usually  employed  and  the  radial  artery  of  the  donor  is  anastomosed 
to  a  superficial  vein  of  the  recipient.  Each  patient  should  be  on  a  table  the 
head  of  which  can  be  raised  or  lowered  at  will.  The  region  over  the  radial 
artery  of  the  donor  is  exposed  under  local  anesthesia.  Every  small  branch 
over  the  artery  is  carefully  tied  in  order  to  prevent  obscuration  by  blood.  The 
artery  is  bared  for  a  distance  of  about  3  cm.,  tied  distally,  lightly  clamped  with 
a  screw  clamp  proximally,  and  divided.  The  vein  of  the  recipient  is  bared, 
clamped,  and  divided,  the  tube  (dipped  in  sterile  ohve  oil)  is  inserted  into  the 
vein,  the  cuff  of  everted  vessel  is  formed  over  the  end,  and  the  artery  is  pulled 
over  the  tube  and  the  cufif  of  vein,  and  held  by  a  ligature  tied  into  the  first 
groove  (see  Bevan,  in  "General  Surgery,"  by  Lexer-Bevan). 

The  flow  is  at  first  slow,  but  after  eight  or  ten  minutes  becomes  more 
rapid,  especially  if  warm  salt  solution  is  run  into  the  wounds.  The  amount 
used  depends  on  the  strength  of  the  donor  and  the  needs  of  the  recipient. 


Intravenous  Infusion  of  Saline  Fluid 


465 


I  have  used  Brewer's  tube  in  this  operation  with  much  satisfaction.  It 
makes  the  procedure  vastly  easier  of  execution.  Fig.  212  shows  Brewer's 
tubes. 

I  am  indebted  to  Dr.  George  Emerson  Brewer  for  describing  in  a  note  to 
me  the  technic  of  his  operation.     The  description  follows: 

"  After  thorough  sterilizarion,  the  tubes  are  prepared  by  dipping  them  in 
melted  i)araffin,  shaking  them  out,  and  allowing  them  to  cool;  or,  immersing 
them  in  a  solution  of  paraffin  in  benzine.  The  radial  artery  of  the  donor  is 
exposed  in  the  usual  manner,  and  also  the  median  basilic  or  some  other  avail- 
able vein  of  the  donee.  The  proximal  end  of  the  artery  is  next  drawn  over 
one  extremity  of  the  glass  tube,  and  secured  by  a  silk  ligature.  This  is 
facilitated  by  expanding  the  lumen  of  the  artery  by  means  of  three  mosquito 
forceps  or  artery  clamps.  When  all  is  ready  to  insert  the  free  extremity  of  the 
tube  into  the  vein  of  the  donee,  the  arterial  clamp  is  temporarily  released  and  a 
few  jets  of  blood  allowed  to  pass  through  the  tube,  which  is  then  quickly  placed 
within  the  lumen  of  the  vein  and  secured  by  another  silk  ligature.  If  the 
vein  of  the  donee  is  large,  the  distal  end  of  the  glass  tube  may  be  inserted  through 
a  longitudinal  slit  in  the  vein,  after  the  manner  usually  adopted  when  introduc- 
ing the  cannula  for  salt  infusion.  When  sufficient  blood  has  been  transfused 
the  tube  is  removed,  the  vessels  ligated,  and  the  cutaneous  wounds  closed. 
In  certain  rare  instances  where  it  is  advisable  to  transfuse  from  an  adult  into 


Fig.  213. — Intravenous  saline  infusion.    Manner  of  incising  vein  and  inserting  glass  tube  (Senn). 


an  infant,  the  popliteal  vein  of  the  infant  may  be  employed,  as  the  subcutaneous 
veins  are  generally  too  small  to  admit  of  the  introducdon  of  the  tube.  In  these 
cases  a  tube  of  diminishing  caliber  should  be  used,  the  larger  end  for  the  donor's 
artery,  the  smaller  for  the  donee's  vein." 

Intravenous  infusion  of  saline  fluid  is  used  after  severe  hemorrhage, 
in  shock,  in  diabetic  coma,  in  post-operative  suppression  of  urine,  and  occa- 
sionally in  sepsis.     After  a  hemorrhage  its  beneficial  effects  are  often  prompt 
30 


466 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


and  obvious.  This  saline  fluid  increases  the  arterial  tension,  gives  the 
heart  enough  matter  to  contract  upon,  and  so  restores  the  activity  of  the 
circulation,  and  does  not  destroy  the  red  corpuscles  as  plain  water  would  do. 
We  may  use  a  simple  apparatus  consisting  of  a  rubber  tube,  a  funnel,  and 
an  aspirating  neeHlp.  Some  employ  an  Aveling  syringe,  and  others  Collin's 
apparatus  (Fig.  214).  The  last-named  instrument  can  be  used  without  any 
danger  of  air  entering  with  the  fluids.  Spencer's  instrument  (Fig.  215)  is 
convenient  and  useful.     Normal  salt  solution  is  the  fluid  usually  employed, 

of  a  strength  of  0.6  per  cent,  (a  heap- 
ing teaspoonful  of  common  salt  to  a 
quart  of  warm  boiled  water).  Some 
surgeons  employ  an  artificial  serum 
which  contains  50  grains  of  chlorid  of 
sodium,  3  grains  of  chlorid  of  potas- 
sium, 25  grains  of  sulphate  of  sodium, 
25  grains  of  carbonate  of  sodium,  and 
2  grains  of  phosphate  of  sodium  in  a 
quart  of  boiled  water.  Szumann's  so- 
lution consists  of  6  parts  of  common 
salt,  I  part  of  sodium  carbonate,  and 
1000  parts  of  water.  The  following  so- 
lution is  used  by  Locke  and  Hare:  cal- 
cium chlorid,  25  gm.;  potassium  chlo- 
rid, I  gm. ;  sodium  chlorid,  g  gm. ;  ster- 
ile water  sufficient  to  make  I  liter.  One 
bottle  of  the  commercial  fluid  when 
diluted  to  i  liter  gives  a  solution  of  the  above  composition.  The  results 
from  artificial  serum  containing  many  elements  are  no  better  than  from 
normal  salt  solution.  Whatever  fluid  is  used,  it  should  be  at  a  temperature 
of  105°  F.  or  over  as  it  enters  the  vein.  The  stimulant  effect  of  the  heat 
is  of  great  value.  The  fluid  must  not  be  allowed  to  cool;  and  a  nurse  gives 
constant  attention  to  the  temperature  of  the  fluid  in  the  reservoir.  This  de- 
gree of  heat  will  not  damage  the  corpuscles;  in  fact,  Dawbarn  has  used 
saline  fluid  at  a  temperature  of  118°  F.  without  doing  damage  to  cor- 
puscles and  with  great  benefit  to  the  patient.  From  h  pint  to  2  pints  or 
even  more  are  slowly  injected,  the  condition  of  the  patient  determining  the 
amount  given.  In  one  case  of  violent  hemorrhage  the  author  used  over  2 
quarts.  In  order  to  infuse  this  fluid,  tie  a  fillet  well  above  the  elbow,  and 
expose  by  dissection  the  median  basilic  vein,  or  the  basihc  vein  in  the  por- 
tion of  its  course  where  it  is  superficial  to  the  deep  fascia.  Tie  the  vein. 
Incise  it  above  the  ligature,  insert  a  fine  cannula,  and  hold  the  cannula 
firmly  in  lumen  by  tightening  a  second  ligature  (Figs.  213,  214).  Remove 
the  fillet.  Slowly  and  gradually  introduce  the  fluid,  carefully  watching  the 
pulse.  Occupy  at  least  ten  minutes  in  introducing  a  pint,  except  in  a  very 
desperate  case  of  hemorrhage,  when  the  rapidity  of  the  flow  may  be  acceler- 
ated. When  the  tension  of  the  pulse  returns,  withdraw  the  cannula,  tie  the 
second  ligature  tightly,  sew  up  the  wound,  and  dress  it  aseptically.  In  very 
severe  operations  an  assistant  should  conduct  the  infusion  while  the  surgeon 
is  operating.     It  may  be  necessary  to  repeat  the  operation  if  the  circulation 


rig.  214.— Intravenous  injection  of  saline  fluid 


Hemophilia,  Hemorrhagic  Disease,  or  Hemorrhagic  Diathesis    467 


fails  again.  The  infusion  of  a  very  large  amount  of  saline  fluid  may  do 
harm.  It  may  embarrass  the  heart  and  cause  acute  dilatation,  may  lead  to 
edema  of  the  lungs  or  brain,  and  cause  marked  anemia  which  endures  for 
days.  The  giving  of  salt  solution  intravenously  should  never  be  regarded  as 
routine  treatment,  judgment  is  required  in  determining  that  it  should  be  used, 
when  it  should  be  used,  and  how  much  is  required,  and  there  is  a  distinct 
element  of  danger  in  the  procedure. 

Arterial  Transfusion  and  Infusion  of  Saline  Fluid  in  Arteries. — 
Hueter  preferred  the  arterial  method  of  transfusion,  in  order  to  send  the  blood 
more  gradually  to  the  heart,  and 
thus  prevent  sudden  disturbance 
of  the  circulation.  A  little  air  in 
an  artery  will  do  no  harm,  and 
the  danger  of  venous  embolism 
is  avoided.  Saline  fluid  can  be 
infused  into  an  artery.  The 
radial  artery  is  exposed  and  sur- 
rounded by  three  ligatures,  and 
the  thread  toward  the  heart  is  at 
once  tied.  The  distal  Ugature  is 
slightly  tightened  to  cut  off 
anastomotic  blood-supply.  The 
artery  is  cut  transversely  half 
through;  the  syringe  is  inserted, 
pointed  toward  the  periphery, 
and  fastened  by  the  third  Ugature; 
the  second  hgature  is  loosened 

and  the  material  is  injected.  On  finishing,  the  peripheral  thread  is  tied 
tightly  and  that  portion  of  the  artery  which  held  the  cannula  is  excised. 
Dawbarn  puts  a  hypodermatic  needle  into  the  radial  artery  and  injects 
sahne  fluid. 

Crile  (Crile  and  DoUey,  in  "Jour,  of  Exper.  Med.,"  Dec,  1906)  has  shown 
that  when  a  patient  is  nearly  dead  or  apparently  dead  that  the  introduction  of 
saline  fluid  by  a  vein  may  overwhelm  the  heart.  He  gives  it  in  these  cases  by 
an  artery  and  has  succeeded  in  resuscitating  those  apparently  dead.  The  tube 
of  the  apparatus  is  quickly  inserted  into  the  carotid  artery  and  toward  the  heart. 
The  reservoir  is  raised,  and  as  the  saline  fluid  begins  to  flow  the  tube  is  punc- 
tured with  a  hypodermic  needle  and  adrenahn  is  added  to  the  saHne  stream. 
If  the  heart  starts  to  beat  blood  will  appear  in  the  tube  and  then  the  adminis- 
tration is  discontinued.  By  this  method  we  may  re-estabhsh  blood-pressure  in 
the  coronary  arteries  (see  Fig.  216). 

Hemophilia,  Hemorrhagic  Disease,  or  Hemorrhagic  Diathesis.— 
The  term  hemophiha  expresses  the  existence  in  an  individual  of  a  tendency  to 
profuse  or  even  uncontrollable  hemorrhage  spontaneously  or  as  a  result  of  some 
very  trivial  injury. 

Hemorrhage  may  take  place  from  mucous  or  serous  membranes  or  from 
wounds  of  the  cutaneous  surface,  into  tissue,  into  organs,  into  a  joint,  under  the 
scalp,  or  into  the  external  genitals.  In  a  hemophiliac,  if  a  cut  is  made,  the  hem- 
orrhage from  the  larger  vessels  is  easily  arrested,  but  capillary  oozing  continues. 


Fig.  215. — Spencer's  apparatus  for  the  infusion  of 
saline  fluid  into  a  vein.  The  cannula  can  be  plunged 
directly  into  the  vessel  without  preliminary  incision. 


468 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


The  condition  is  far  more  common  in  males  than  in  females,  and  if  it 
exists  in  a  female,  which  it  rarely  does,  it  is  not  usually  provocative  of  danger- 
ous hemorrhage.  The  disease  is  nearly  always  transmitted  by  heredity.  It 
is  usually  transmitted  to  a  son  by  a  mother  who  is  free  from  the  disease,  but 
whose  father  had  it,  and  the  son  bleeds  dangerously  from  slight  causes.  Some 
recently  reported  cases  were  transmitted  in  the  male  Hne  (Goodall,  in  "Scottish 
Med.  and  Surg.  Jour.,"  Feb.,  1905).  The  existence  of  the  tendency  is  rarely 
suspected  until  the  first  dentition,  and  possibly  not  till  puberty;  "70  per  cent, 
of  cases  appear  before  the  fifth  year."*  The  discovery  of  the  existence  of  such 
a  condition  may  not  be  made  until  a  tooth  is  pulled,  and  extraction  is  followed 
by  persistent  bleeding.  It  is  alleged  that  the  tendency  may  disappear  in  mid- 
dle life.     The  victims  of  this  hemorrhagic  tendency  are  called  bleeders. 

The  cause  of  the  condition  is  unknown.  It  has  been  assumed  that  there 
is  a  condition  of  the  blood  which  prevents  coagulation.     There  is,  however,  an 


Fig.  216. — Injection  of  saline  solution  and  adrenalin  by  the  method  of  Crile. 

acquired  form  of  hemophilia.  The  blood  changes  are  not  characteristic.  The 
blood  is  similar  to  that  found  in  secondary  anemia,  the  red  corpuscles  are  di- 
minished, but  the  hemoglobin  is  diminished  more  distinctly,  hence  there  is  a 
low  color  index.  The  white  corpuscles  are  not  increased  as  in  scurvy  and 
purpura,  and  often  there  is  a  positive  leucopenia.  Blood  coagulation  is  slow 
and  often  imperfect.  In  some  cases  coagulation  occurs  in  nine  minutes,  but 
in  one  of  Wright's  cases  it  required  over  an  hour.  It  is  important  to  remember 
as  against  failure  of  coagulating  elements  as  the  cause  that  Agnew  had  a 
case  in  which  hemophilia  was  Umited  to  the  head  and  neck,  and  that  there  have 
been  cases  in  which  bleeding  occurred  into  one  joint  or  from  one  kidney. 
Some  maintain  that  there  is  structural  defect  in  the  capillaries.  In  a  case  of 
hemophilia  in  the  Jefferson  Medical  College  Hospital,  in  which  it  was  ab- 
solutely necessary  to  amputate  a  finger  because  of  a  crush,  a  careful  study 
of  the  vessels  of  the  finger  by  Dr.  Coplin  failed  to  show  any  disease  of  the 
*R.  C.  Cabot,  in  "  International  Text-book  of  Surgery." 


Ligation  of  Arteries  in  Continuity  469 

blood-vessels.  A  surgeon  must  be  on  the  lookout  for  this  condition,  and 
should  inquire  for  it  before  deciding  to  do  an  operation.  If  it  exists,  only  an 
operation  of  imperative  necessity  should  be  undertaken.  It  is  now  well  recog- 
nized that  joint  lesions  may  occur  in  hemophilia  {hemophilic  arthritis).  The 
condition  is  most  common  in  children.  As  a  rule,  more  than  one  joint  is  in- 
volved, but  only  a  few  joints  suffer.  In  Rugh's  case  only  one  knee-joint 
suffered  ("Annals  of  Surg.,"  May,  1907).  The  involvement  is  not  of 
necessity  symmetric. 

The  acute  form  resembles  acute  rheumatism  and  lasts  about  ten  days. 
In  the  subacute  form  the  temperature  is  lower,  the  symptoms  less  intense,  and 
the  duration  shorter.  In  both  forms  joint  function  is  restored  (Frolich,  "Cen- 
tralb.  fiir  Chir.,"  1905,  vol.  xxxii).  The  chronic  form  resembles  tuberculous 
arthritis  or  acute  osteomyelitis.  In  this  form  there  is  a  tendency  to  loss  of 
function,  but  there  is  no  reaction  to  tuberculin. 

A  child  who  is  a  "  bleeder  "  must  be  unceasingly  watched  and  guarded.  .\  ten- 
dency to  profuse  oozing  exists  in  leukemia  because  of  the  condition  of  the  blood, 
but  this  is  not  hemophilia.    A  tendency  to  oozing  also  exists  during  jaundice. 

Treatment. — The  oozing  is  difficult  and  often  impossible  to  control, 
although  most  of  these  cases,  in  the  long  run,  recover.  In  the  acquired  form 
the  prognosis  is  better  than  in  the  congenital  form  (Weil,  in  "Zentralb.  flir 
Chir.,"'  1907,  vol.  xxxiv).  The  internal  administration  of  such  drugs  as  ergot, 
gallic  acid,  and  acetate  of  lead  is  useless.  It  is  claimed  that  chlorid  of  calcium 
internally  is  of  sernce.  Lactate  of  calcium  is  sometimes  used  by  the  mouth 
and  rectum.  Milk  may  be  given  by  rectum  in  order  to  obtain  the  combination 
of  salts  of  milk  unchanged  by  gastric  juice  (Solt,  in  "Zentralb.  fiir  Chir.," 
1907,  vol.  xxxiv).  The  local  use  of  astringents  is  of  no  avail.  Prolonged 
elevation  may  in  rare  cases  succeed.  In  the  case  in  the  Jefferson  ^ledical 
College  Hospital  the  bleeding  was  arrested,  after  numerous  expedients  failed, 
by  compression  and  hot  water.  Xurses  sat  by  the  bed  for  several  days,  con- 
stantly compressed  the  wound  \\\\h  gauze  pads  soaked  in  hot  water,  and 
changed  the  pads  as  soon  as  they  cooled.  The  local  use  of  Camot's  solution 
of  gelatin  has  apparently  saved  several  cases  from  death.  It  has  been  ad- 
vised to  take  some  blood  from  a  healthy  man  and  put  it  in  the  cut,  in  the 
hope  that  a  firm  clot  \\\\\  form.  Th}Toid  extract  should  be  tried,  as  in  some 
cases  it  seems  to  have  been  of  value.  Eugene  Fuller's  case  of  hemophilia 
("Med.  News,"  Feb.  28,  1903)  was  apparently  cured  by  the  administration 
of  gr.  v  of  thyroid  extract  three  times  a  day.  In  a  recent  case  of  hemophilia 
in  the  Jefferson  Hospital  thyroid  extract  apparently  arrested  the  bleeding.  In 
Rugh's  case,  after  incision  of  a  knee-joint,  bleeding  was  profuse  and  continued, 
but  ceased  in  eight  days.  The  patient  was  given  gr.  v  of  th\Toid  extract  three 
times  a  day.  The  cases  are  particularly  interesting  in  connection  \\ith  W.  J. 
Taylor's  observation  that  thyroid  extract  increases  the  rapidity  of  blood 
coagulation  in  jaundice  cases  and  lessens  the  tendency  to  post-operative  oozing 
in  such  cases.     Horse  serum  is  perhaps  a  promising  remedy. 

Ligation  of  Arteries  ix  Coxtixuitv. 

The  instruments  used  in  this  operation  are  two  scalpels  (one  small, 
one  medium),  two  dissecting  forceps,  several  hemostatic  forceps,  blunt  hooks 
or  broad  metal  retractors,  an  Allis  dissector,  an  aneur}-sm  needle,  for  superfi- 


470 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


cial  arteries  the  instrument  of  Saviard  (Fig.  217),  for  deep  vessels  the  needle 
of  Dupuytren  (Fig.  218),  ligatures  of  catgut,  of  chromicized  gut,  or  of  silk, 
curved  needles  and  a  needle-holder,  sutures  of  silkworm-gut,  and  the  re- 
flector or  electric  forehead-lamp  for  deep  vessels. 

The  position  in  which  the  patient  is  placed  varies  according  to  the  vessel 
to  be  ligated,  though  the  body  is  supine  except  when  ligation  is  to  be  performed 


Fig.  217. — Aneurysm  needle  of  Saviard. 


on  the  gluteal,  sciatic,  or  popliteal  artery.  The  operator,  as  a  rule,  stands 
upon  the  affected  side,  cutting  from  above  downward  on  the  right  side,  and 
from  below  upward  on  the  left  side. 

Operation. — Accurately  determine  the  line  of  the  artery,  and  make  an 
incision  at  a  slight  angle  to  this  line,  avoiding  subcutaneous  veins,  and  holding 

the  scalpel  like  a  fiddle-bow  or  a  dinner-knife 
while  cutting  the  superficial  parts,  and  like 
a  pen  while  incising  the  deeper  parts.  On 
reaching  the  deep  fascia  make  out  the  re- 
quired muscular  gap  by  the  eye  and  finger,  so 
moving  the  extremity  as  to  bring  individual 
muscles  into  action.  Treves  cautions  us  not 
to  depend  upon  the  yellow  line  of  fat,  which 
often  cannot  be  seen  in  emaciated  people  or 
when  an  Esmarch  bandage  is  employed;  nor 
upon  the  white  line  due  to  attachment  to  the 
fascia  of  an  intermuscular  septum.  In  open- 
ing the  deep  portion  of  the  wound  relax  the 
bounding  muscles  by  altering  the  posture. 
Open  a  muscular  interspace  with  a  sharp 
knife,  not  with  a  dissector.  Make  the  depths 
of  the  wound  as  long  as  the  superficial  incision. 
Do  not  tear  structures  apart  with  a  grooved  director;  cut  them.  Arrest 
hemorrhage  as  it  occurs.  Try  to  find  the  situation  of  the  artery  with  the 
finger.  Pulsation  is  present,  but  it  may  be  very  feeble  and  hard  to  detect. 
The  artery  feels  like  a  very  thin  rubber  tube;  it  is  compressible,  though  not 
so  easily  as  a  vein,  and  when  compressed  feels  like  a  flat  band  which  is  thinner 
in  the  center  than  at  the  edges  (Treves).  A  nerve  feels  like  a  hard,  round 
cord.  The  veins  are  soft,  larger  than  their  related  arteries,  and  so  very  com- 
pressible that  they  can  scarcely  be  felt  when  pressed  upon,  and  compression 
causes  distal  distention.  If  the  wound  can  be  seen  into  clearly,  it  will  be 
noted,  as  Treves  asserts,  that  "  the  nerves  stand  out  as  clear,  rounded,  white 
cords;  that  the  veins  are  of  a  purple  color  and  of  somewhat  uneven  and  wavy 
contour;  that  the  artery  is  regular  in  outline  and  of  a  pale-pink  or  pinkish- 
yellow  tint,  the  large  vessels  being  of  lighter  color  than  the  small."  Each 
artery  of  the  upper  extremity  and  each  artery  below  the  knee  is  accom- 
panied by  two  veins,  known  as  "venae  comites."  The  arteries  of  the  head 
and  neck,  except  the  lingual,  have  each  a  single  attending  vein;  the  lingual 


Fig.  218.— Dupuytren's  aneurysm 
needles. 


LIGATIONS. 


Plate  2. 


I.  Opening  the  Sheath  for  Ligation  of  an  Artery  (Guerin).  2.  Sheath  of  Artery  Open  (Guerin). 
3.  Tightening  the  Knot  in  Ligation  (Guerin).  4.  Anatomy  of  the  Iliac  Arteries,  and  showing  the 
lines  of  incision  for  their  ligation:  I,  Abernethy's  incision  (Guerin).  5,  6.  Ballance  and  Ed- 
munds' Stay-knots. 


Ligation  of  Arteries  in  Continuity  471 

has  venae  comites.  Most  of  the  smaller  arteries  of  the  trunk  (pudic,  internal 
mammary,  etc.)  have  venae  comites.  These  companion  veins  may  lie  on 
each  side  of  the  artery  or  in  front  and  back  of  it,  and  they  communicate  with 
one  another  by  transverse  branches  crossing  the  artery.  On  reaching  the 
sheath  pick  up  this  structure  with  toothed  forceps  so  as  to  make  a  transverse 
fold,  and  thus  avoid  catching  the  artery  or  vein;  lift  the  fold  to  see  that  it  is 
free,  and  open  the  sheath  by  cutting  toward  the  edge  of  the  forceps  with  a 
scalpel  held  obliquely  with  its  back  toward  the  vessel,  thus  making  a  small 
longitudinal  incision  (PI.  2,  Figs.  1,2).  Hold  the  edge  of  the  incised  sheath 
with  the  forceps;  pass  a  metal  dissector  under  the  vessel  and  from  the  forceps; 
this  clears  one-half  of  the  vessel.  Grasp  the  other  edge  of  the  sheath  and  pass 
the  blunt  dissector  all  the  way  around  the  vessel.  Pass  an  aneur}'sm  needle 
under  the  cleared  vessel,  away  from  the  forceps  holding  the  sheath  and  away 
from  the  vessel's  most  dangerous  neighbor.  Thread  the  needle  and  withdraw 
it.  If  venae  comites  are  in  the  way,  try  to  separate  them;  but  if  this  proves 
difficult,  include  them  in  the  ligature.  In  small  vessels  always  include  them 
if  they  are  in  the  way,  as  this  saves  trouble.  If,  in  passing  the  needle,  a  large 
vein  is  severely  wounded  (such  as  the  femoral),  Jacobson  advises  the  em- 
ployment of  digital  pressure  in  the  lower  portion  of  the  wound  while  the 
artery  is  being  tied  on  a  level  above  or  below  that  of  the  vein-injury,  and 
after  hgation  the  maintenance  of  pressure  on  the  wound  for  a  couple  of  days. 
A  shght  puncture  in  a  vein  merely  requires  a  lateral  hgature.  A  small 
wound  can  be  closed  with  Lembert  sutures  of  fine  silk.  After  getting  a 
ligature  under  an  artery  press  for  a  moment  upon  the  artery  over  the  ligature, 
which  is  held  taut;  this  pressure  will  arrest  pulsation  below  if  the  ligature 
is  around  the  main  artery  and  there  is  not  a  double  vessel.  Tie  the  thread 
at  right  angles  to  the  vessel  with  a  reef-knot  (Fig.  219),  rupturing  the  internal 
and  middle  coats.  As  the  ligature  is  -tightened  place  the  extended  index- 
fingers  along  the  hgature  up  to  the  artery  (PI.  2,  Fig.  3),  using  the  middle 
joints  as  the  fulcrum  of  a  lever  by  placing  them  against  each  other. 

Ballance  and  Edmunds  have  recently  claimed,  as  Scarpa  and  Sir  Philip 
Crampton  did  long  since,  that  it  is  not  neces- 
sary to  divide  the  internal  and  middle  coats 
to  insure  obliteration.  If  this  claim  be  true, 
the  danger  of  secondary  hemorrhage  can  be 
greatly  lessened.  Holmes,  however,  thinks  the 
older  method  the  more  certain  of  the  two. 
Ballance  and  Edmunds  use   floss   silk   as  a  Fig.  219.— Reef-knot. 

ligature  material,  because  it  is  soft,   broad, 

and  flat,  and  they  surround  the  artery  with  a  double  ligature.  Ballance 
and  Edmunds  thus  describe  the  application  of  the  stay-knot:  "The  best 
way  of  tying  two  ligatures  is  to  make  on  each  separately,  and  in  the  same 
way,  the  first  hitch  of  a  reef-knot,  and  to  tighten  each  separately  so  that  the 
loop  lies  in  contact  with  the  vessel  without  constricting  it.  Then  taking  the 
ends  on  one  side  together  in  one  hand  and  the  two  ends  on  the  other  side 
in  the  other  hand,  constrict  the  vessel  sufiiciently  to  occlude  it,  and  finally 
complete  the  reef-knot.  The  simplest  way  of  completing  the  knot  is  to 
treat  the  two  ends  in  each  hand  as  a  single  thread  and  to  tie  as  if  completing 
a  single  reef-knot."     This  knot  is  shown  in  PI.  2,  Figs.  5,  6.     The  stay-knot 


472  Diseases  and  Injuries  of  the  Heart  and  Vessels 

applied  by  this  method  is  of  great  value  if  a  vessel  be  atheromatous.     Fig. 
220  shows  an  arterial  scar  after  ligation.     Fig.  221  shows  an  intravenous  scar. 

The  chief  dangers  after  ligation  are  secondary  hemorrhage  and  gangrene. 
Rigid  asepsis  usually  prevents  the  first;  rest,  elevation,  and  heat  antagonize 
the  second. 

Radial  Artery.— The  line  of  the  radial  artery  is  from  the  middle  of 
the  front  of  elbow -joint  to  the  ulnar  side  of  the  styloid  process  of  the  radius. 
The  line  in  the  tabatiere  is  from  the  apex  of  the  styloid  process  to  the  posterior 
angle  of  the  first  interosseous  space  (Fig.  222). 

Anatomy  (PI.  3,  Fig.  5). — The  radial  artery,  though  smaller  than  the 
ulnar,  is  the  direct  continuation  of  the  brachial.  It  arises  from  the  bifurcation 
of  the  brachial  half  an  inch  below  the  bend  of  the  elbow,  runs  down  the  radial 
side  of  the  forearm  to  the  front  of  the  styloid  process  of  the  radius,  passes 
beneath  the  extensor  muscles  of  the  first  metacarpal  bone  and  of  the  first 
phalanx  of  the  thumb,  and  over  the  carpus  to  the  first  interosseous  space. 
It  is  crossed  by  the  tendon  of  the  extensor  secundi  internodii  pollicis,  enters 
into  the  palm  between  the  heads  of  the  first  dorsal  interosseous  muscle,  and 
forms  the  deep  palmar  arch.  The  artery  in  the  upper  two-thirds  of  its  course 
is  somewhat  overlaid  by  the  supinator  longus  muscle;  in  the  lower  one-third 
of  the  forearm  it  is  superficial.  In  the  upper  third  of  the  forearm  it  lies 
between  the  supinator  longus  on  the  outside  and  the  pronator  radii  teres  on 
the  inside ;  in  the  lower  two-thirds  of  the  forearm  it  lies  between  the  supinator 
longus  on  the  outside  and  the  flexor  carpi  radialis  on  the  inside.  Two  venae 
comites  attend  the  vessel.  The  radial  nerve  is  to  the  outer,  or  radial,  side 
of  the  artery,  well  removed  from  the  artery  in  the  upper  third,  nearer  to  the 
artery  in  the  middle  third,  far  external  to  the  artery  in  the  lower  third,  the 
nerve  at  this  point  passing  beneath  the  supinator  longus  muscle.  The  radial 
artery,  from  above  downward  rests  upon  the  biceps  tendon,  the  supinator 
brevis,  the  flexor  sublimis,  the  pronator  radii  teres,  the  flexor  longus  pollicis, 
the  pronator  quadratus  muscles,  and  the  radius.  The  best  guide  to  the 
radial  artery  in  the  forearm  is  the  outer  edge  of  the  flexor  carpi  radialis  muscle 
or  the  inner  edge  of  the  supinator  longus  muscle. 

The  tabatiere  anatomique  of  Cloquet,  or  the  anatomical  snuff-box,  is  a 
triangle  whose  base  is  the  lower  edge  of  the  posterior  annular  ligament,  the 
ulnar  side  being  formed  by  the  extensor  secundi  internodii  pollicis  tendon, 
the  radial  side  by  the  extensor  ossis  metacarpi  and  the  extensor  primi  internodii 
pollicis  tendons;  the  floor  consists  of  the  trapezium,  scaphoid,  their  dorsal 
ligaments,  and  the  base  of  the  first  metacarpal  bone. 

Operations. — Ligation  in  the  tabatiere  is  a  dissecting-room  operation  of 
but  little  practical  use.  The  patient  is  placed  in  a  recumbent  position,  the 
arm  is  abducted,  and  the  forearm  is  placed  midway  between  pronation  and 
supination  (Barker).  The  surgeon  stands  upon  the  side  operated  upon. 
An  incision  two  inches  in  length  is  made  along  the  radial  border  of  the  ex- 
tensor secundi  internodii  pollicis  muscle.  The  skin  and  superficial  fascia 
are  cut  and  some  venous  branches  are  divided.  The  deep  fascia  is  incised 
and  the  vessel  is  easily  found  and  tied  before  it  passes  between  the  heads  of 
the  first  dorsal  interosseous  muscle  (Barker). 

Ligation  of  the  Lower  Third. — In  this  operation  (PI.  3,  Fig.  6,  and  Fig.  222) 
the  patient  is  placed  supine,  the  arm  is  abducted,  the  forearm  is  supinated,  is 


Radial  Artery 


473 


Intima. 


Partly  formed  connective 
tissue  from  endothelia. 


Proliferated 
onnective 
ssue  in 
men. 


Endothelial  ^z::.^ — 
prolifera- 
tion. 


Fig.  220.— Cross-section  of  obliterated  artery,  exhibiting  the   histologic   appearances   of  the   intra- 
vascular scar  (X  240)  (Senn). 


Prolifera- 
tion o  f 
connec- 
tive tis- 
sue. 


Endothe- 
lial pro- 
lifera- 
tion. 


Fig.  221.— Histologic  structure  of  intravenous  scar,  right  internal  jugular  vein,  forty-nine  days  after 
ligation.    Transverse  section  between  ligatures  (X  240)  (Senn). 


474  Diseases  and  Injuries  of  the  Heart  and  Vessels 

rested  upon  a  table,  and  is  held  by  an  assistant.  The  surgeon  stands  on  the 
side  operated  upon,  and  cuts  from  above  downward  on  the  right  forearm  and 
from  below  upward  on  the  left  forearm.  The  line  of  the  vessel  should  be 
determined,  and  may  be  indicated  with  iodin  or  anilin.  An  incision  one  and 
a  half  inches  long  is  made  at  a  slight  angle  to  this  line  and  midway  between 
the  supinator  longus  and  the  fle.xor  carpi  radialis  muscles,  which  incision 
must  not  extend  below  the  level  of  the  tuberosity  of  the  scaphoid  bone.  In 
the  superficial  fascia  watch  for  the  superficial  radial  vein,  and  if  it  comes  into 
view  push  it  aside.  Incise  the  superficial  fascia  and  locate  each  guide-tendon. 
Open  the  deep  fascia  in  the  length  of  the  first  cut;  try  to  separate  the  veins, 
but  if  they  strongly  adhere  include  them  in  the  ligature.  There  is  no  special 
fascial  sheath.  The  radial  nerve  will  not  be  seen,  but  a  division  of  the  anterior 
cutaneous  nerve  is  frequently  found  in  relation  with  the  vessel.  The  needle 
can  be  passed  in  either  direction.  A  high  origin  of  the  superficialis  volae 
artery  is  confusing. 

Ligation  0}  the  Middle  Third. — In  this  operation  the  position  of  the  patient 
should  be  the  same  as  in  the  preceding.  x\  two-inch  incision  is  made.  Veins 
of  the  subcutaneous  tissues  are  avoided.  Lying  upon  the  deep  fascia  is  the 
anterior  division  of  the  musculocutaneous  nerve.  Open  the  fascia;  find  the 
inner  edge  of  the  supinator  longus  muscle  and  draw  it  outward,  flexing  the 
elbow  partly  if  necessary.  Be  sure  not  to  cut  external  to  this  muscle.  Find 
the  vessel  where  it  is  bound  down  by  connective  tissue  to  the  pronator  radii 
teres  muscle,  separate  the  veins,  and  pass  the  ligature  from  without  inward. 
The  nerv^e  is  external. 

Ligation  oj  the  Upper  Third  (PI.  3,  Fig.  6,  and  Fig.  222). — In  this  oper- 
ation the  incision  is  as  described  above,  only  higher  up.  The  artery  is  be- 
tween the  supinator  longus  and  the  pronator  radii  teres,  which  muscles  are 
at  once  dift'erentiated  by  the  different  direction  of  their  fibers.  The  artery 
is  usually  covered  by  the  supinator  longus  muscle,  which  must  be  retracted 
externally.  The  nerve  is  not  seen.  The  ligature  may  be  passed  in  either 
direction. 

Ulnar  Artery. — No  one  line  will  overlie  the  entire  ulnar  artery.  The 
line  of  the  upper  third  runs  from  the  middle  of  the  front  of  the  elbow-joint 
to  the  point  of  junction  of  the  upper  and  middle  thirds  of  the  ulna.  The 
line  of  the  lower  two-thirds  runs  from  the  tip  of  the  internal  condyle  of  the 
humerus  to  the  radial  side  of  the  pisiform  bone  (PI.  3,  Figs.  5,  6;  Fig.  222). 

Anatomy  (PI.  3,  Fig.  5). — The  ulnar  artery  arises  from  the  brachial 
bifurcation  and  runs  obliquely  inward  under  the  median  nerve  and  a  group 
of  muscles  from  the  internal  condyle;  it  turns  down  the  arm,  being  covered 
in  the  middle  third  of  its  course  by  the  fle.xor  carpi  ulnaris  muscle.  In  the 
lower  third  it  is  superficial,  between  the  tendons  of  the  fle.xor  carpi  ulnaris 
on  the  inside  and  the  flexor  sublimis  digitorum  on  the  outside,  the  vessel 
being  a  little  overlapped  by  the  flexor  carpi  ulnaris.  This  vessel  rests  first 
upon  the  brachialis  anticus  muscle,  next  upon  the  flexor  profundus,  to  which 
it  is  bound  by  a  distinct  process  of  fascia,  and  ne.xt  upon  the  annular  ligament, 
which  structure  it  crosses  to  become  the  superficial  palmar  arch.  Two  venae 
comites  attend  the  vessel.  In  the  upper  third  the  nerve  is  well  internal,  but 
in  the  lower  two-thirds  the  nerve  lies  near  the  artery  and  to  its  ulnar  side. 
The  guide  is  the  outer  edge  of  the  flexor  carpi  ulnaris. 


LIGATIONS. 


Plate  3. 


Brachial  Artery  475 

Operations  (PI.  3,  Fig.  6,  and  Fig.  222). — Ligation  of  the  Lower  Third. — 
Tile  position  in  this  operation  is  the  same  as  for  ligation  of  the  radial  artery. 
Make  a  two-inch  incision  to  the  radial  side  of  the  tendon  of  the  flexor  carpi 
ulnaris,  which  incision  should  not  be  taken  lower  than  a  j)oint  one  inch  above 
the  pisiform  bone.  Avoid  the  superficial  ulnar  vein  in  the  subcutaneous  tissue. 
Open  the  deep  fascia,  find  the  tendon  of  the  flexor  carpi  ulnaris,  flex  the  wrist 
and  draw  the  tendon  inward,  open  a  second  layer  of  fascia,  clear  the  vessel, 
separate  the  veins,  and  pass  the  ligature  from  within  outward  to  avoid  the 
nerve.  On  the  artery  is  the  palmar  cutaneous  branch  of  the  ulnar  nerve,  and 
this  branch  must  not  be  included  in  the  ligature. 

Ligation  of  the  Middle  Third  (PI.  3,  Fig.  6). — In  this  operation  the  posi- 
tion is  the  same  as  in  the  preceding  one,  the  incision  being  three  inches  long. 
Avoid  the  anterior  ulnar  vein  and  the  branches  of  the  internal  cutaneous 
nerve  in  the  superficial  fascia.  Open  the  deep  fascia  a  little  external  to  the 
superficial  cut  (Treves).  Find  the  space  between  the  flexor  carpi  ulnaris 
and  the  superficial  flexor,  feeling  with  the  index-finger,  and  when  the  space 
is  discovered  flex  the  wrist,  retract  the  flexor  carpi  ulnaris  inward  and  the 
flexor  sublimis  digitorum  outward,  open  the  fascia,  find  the  ulnar  nerve,  look 
external  to  it  for  the  artery,  clear  the  vessel,  separate  the  venae  comites,  and 
pass  the  needle  from  within  outward.  The  ulnar  artery  should  not  be  ligated 
in  continuity  in  the  upper  third  of  its  course. 

Brachial  Artery. — The  line  of  the  brachial  artery  is  from  the  junc- 
tion of  the  anterior  and  middle  thirds  of  the  outlet  of  the  axilla,  the  arm  being 
abducted  and  the  forearm  supinated,  to  the  middle  of  the  front  of  the  elbow- 
joint  (Fig.  222). 

Anatomy  (PI.  3,  Fig.  i). — The  brachial  artery  is  the  prolongation  of  the 
axillary,  and  extends  from  the  lower  edge  of  the  teres  major  muscle  to  half 
an  inch  below  the  bend  of  the  elbow,  where  it  divides  into  the  radial  and 
ulnar  arteries.  It  lies  first  to  the  inner  side  of  the  arm,  but  passes  to  the 
front  of  the  elbow.  It  is  crossed  by  no  muscle,  and  is,  in  fact,  superficial, 
barring  its  being  somewhat  overlaid  in  part  of  its  course  by  the  edge  of  the 
biceps  muscle.  The  median  nerve  is  external  above,  crosses  over  the  vessel 
about  the  middle  of  the  arm,  and  reaches  the  inner  side  of  the  artery.  The 
coracobrachialis  and  biceps  muscles  are  external,  and  both  often  overlap 
the  vessel.  The  ulnar  nerve  is  internal  above,  and  the  median  nerve  is 
internal  below  the  middle.  The  basilic  vein  is  to  the  inner  side  of  the  artery, 
being  outside  the  deep  fascia  to  near  the  middle  of  the  arm,  at  which  point 
it  pierces  it.  The  artery  above  is  separated  from  the  long  head  of  the  triceps 
by  the  musculospiral  nerve  and  superior  profunda  artery  and  vein;  it  rests 
from  above  down  on  the  inner  head  of  the  triceps,  the  coracobrachialis,  and 
the  brachialis  anticus  muscles.  The  artery  is  covered  by  skin,  by  superficial 
fascia,  and  by  deep  fascia.  The  internal  cutaneous  nerve  lies  in  front  of 
the  artery,  upon  the  deep  fascia,  until  it  pierces  the  fascia  along  with  the 
basilic  vein.  The  artery  has  venae  comites,  and  in  its  upper  half  has  also 
the  basilic  vein  to  its  inner  side.  The  guide  to  the  brachial  is  the  inner  edge 
of  the  biceps  muscle.  Just  in  front  of  the  elbow-joint  the  artery  lies  in  a 
triangle,  the  base  of  which  is  formed  by  an  imaginary  transverse  line  above 
the  condyles,  and  the  apex  by  the  junction  of  the  pronator  radii  teres  and 
the  supinator  longus  muscles.     The  outer  line  is  the  supinator  longus,  the 


476  Diseases  and  Injuries  of  the  Heart  and  Vessels 

inner  line  is  the  pronator  radii  teres,  and  the  tloor  is  formed  by  the  brachialis 
anticus  and  the  supinator  brevis  muscles.  From  within  outward  the  triangle 
contains  the  median  nerve,  brachial  artery,  tendon  of  the  biceps,  anastomosis 
of  the  superior  profunda  and  radial  recurrent  arteries,  and  the  musculospiral 
nerve. 

Operations. — Ligation  at  the  Bend  0}  the  Elbow. — In  this  operation  (PI.  3, 
Fig.  2,  and  Fig.  222)  the  patient  is  placed  supine,  the  arm  is  moderately 
abducted  and  extended,  and  is  allowed  to  lie  upon  its  posterior  aspect.  The 
forearm  is  supinated.  The  surgeon  stands  upon  the  side  operated  upon,  and 
cuts  from  above  downward  on  the  right  side  and  from  below  upward  on  the  left 
side.  The  tendon  of  the  biceps  and  the  median  basilic  vein  must  be  accu- 
rately located.  An  incision  is  made  parallel  with  the  inner  edge  of  the  biceps 
tendon  and  two  inches  in  length,  the  center  of  this  cut  being  in  the  crease 
of  the  elbow.  On  exposing  the  median  basilic  vein,  retract  it  downward 
and  inward,  open  the  bicipital  fascia,  clear  the  artery  of  fat,  separate  the 
venae  comites,  and  pass  the  ligature  from  within  outward  to  avoid  the  median 
nerve.     The  above  operation  is  not  frequently  performed. 

Ligation  in  the  Middle  of  the  Arm  (Fig.  222). — In  this  operation  the  patient 
is  placed  supine,  the  arm  is  abducted,  and  the  forearm  is  supinated.  An 
assistant  holds  the  forearm,  but  the  arm  should  not  rest  upon  the  table,  because, 
if  it  be  allowed  to  do  so,  the  inner  head  of  the  triceps  will  be  forced  forward 
and  may  overlie  the  artery,  and  thus  complicate  the  operation.  Locate  the 
inner  edge  of  the  biceps,  which  is  the  guide.  Make  an  incision  three  inches 
long  in  the  line  of  the  artery.  Incise  the  skin  and  fascia,  flex  the  elbow  slightly, 
retract  the  biceps  outward,  feel  for  the  artery,  open  the  sheath,  separate  its 
venae  comites,  and,  having  located  the  median  nerve,  pass  the  hgature  from 
it.  In  the  middle  of  the  arm  the  nerve  is  in  front  of  the  vessel,  above  the 
middle  it  is  external  to  it,  and  below  the  middle  it  is  internal  to  it.  High  up 
the  arm  the  inner  edge  of  the  coracobrachialis  is  the  guide,  rather,  than  the 
biceps.  Above  the  middle  of  the  arm  the  basilic  vein  is  beneath  the  deep 
fascia  and  passes  along  by  the  inner  side  of  the  artery;  hence,  high  up,  the 
artery  has  three  companion  veins,  the  venae  comites  and  the  basilic  vein, 
and  there  is  seen  the  ulnar  ner\-e  to  the  inside  of  the  artery. 

Axillary  Artery. — To  determine  the  line  of  the  axillary  artery  place  the 
arm  at  a  right  angle  to  the  body,  with  the  patient  supine,  and  lay  down  a 
line  from  the  middle  of  the  clavicle  to  the  humerus  near  the  inner  border 
of  the  coracobrachialis.  The  line  of  the  third  portion  can  be  approximated 
by  projecting  the  line  of  the  brachial  upward  (Fig.  222). 

Anatomy  (PI.  3,  Fig.  3;  PI.  4,  Fig.  i). — The  axillary  artery  is  the  con- 
tinuation of  the  subclavian,  and  runs  from  the  lower  margin  of  the  first  rib 
to  the  inferior  border  of  the  teres  major  muscle.  It  is  divided  into  three 
portions  by  the  pectoralis  minor  muscle.  The  first  portion  is  above,  the 
second  portion  is  behind,  and  the  third  portion  is  below,  the  pectoralis  minor. 
The  position  of  the  artery  varies  with  the  position  of  the  limb.  When  the 
arm  is  parallel  with  the  body  the  artery  is  far  from  the  surface  and  forms 
a  curve  whose  convexity  is  upward  and  outward.  \\'hen  the  arm  is  at  a 
right  angle  to  the  body  the  vessel  is  nearer  the  surface  and  straight.  \\Tien 
the  arm  is  raised  above  a  right  angle  the  artery  comes  near  the  surface  and 
forms  a  curve  with  the  convexity  downward. 


Axillary  Artery  477 

The  first  jiortion  of  the  axillary  artery  is  occasionally  ligated.  It  lies  u[)on 
the  first  intercostal  muscle  and  the  first  serration  of  the  great  serratus  muscle, 
and  has  behind  it  the  posterior  thoracic  nerve;  the  brachial  plexus  is  external 
and  posterior  to  the  vessel;  on  its  inner  side  is  the  axillary  vein;  in  front  of 
it  are  the  clavicle,  the  great  pectoral  muscle,  the  subclavius  muscle,  the  costo- 
coracoid  membrane,  the  cephalic  and  acromiothoracic  veins,  and  the  external 
anterior  thoracic  nerve.  The  branches  of  the  first  part  of  the  axillary  artery 
are  the  superior  thoracic  and  the  acromiothoracic.  The  second  part  of  the 
artery  is  not  ligated.  The  brachial  plexus  surrounds  the  second  portion. 
The  third  part  is  covered  in  front,  above,  by  the  great  pectoral,  but  is  covered 
below  by  skin  and  fascia;  behind,  it  has  the  tendon  of  the  subscapularis, 
the  latissimus  dorsi,  and  the  teres  major  muscles;  the  coracobrachiahs  is  on 
the  outer  side;  the  axillary  vein  is  on  the  inner  side.  It  is  important  to  re- 
member that  there  may  be  three  veins,  one  external  and  two  internal.  The 
axillary  vein  is  formed  by  the  venae  comites  of  the  brachial  artery  joining, 
and  this  new  vein  effecting  a  junction  with  the  basilic  vein.  The  median 
nerve  lies  upon  the  axillary  artery  in  the  upper  part  of  the  third  portion  of 
the  vessel's  course,  and  passes  to  the  outer  side.  The  musculocutaneous 
nerve  is  external,  but  it  is  only  seen  high  up;  the  ulnar  nerve  is  internal; 
the  lesser  internal  and  the  internal  cutaneous  nerves  are  internal;  the  muscu- 
lospiral  and  the  circumflex  nerves  are  behind.  The  branches  of  the  third 
portion  of  the  axillary  artery  are  the  subscapular  and  the  anterior  and  pos- 
terior circumflex. 

Operations. — Ligation  oj  the  Third  Portion  (PI.  3,  Fig.  4,  and  Fig.  222). — 
The  position  of  the  patient  should  be  supine,  with  the  shoulders  raised  and  the 
arm  abducted  to  a  right  angle.  The  surgeon  stands  between  the  patient's  arm 
and  side,  with  his  back  toward  the  subject's  feet.  An  incision  is  made  three 
inches  in  length.     It  begins  half-way  up  the  axilla  opposite  to  the  head  of  the 


Fig.  222. — Lines  of  incision   for  ligation  of   the  axillary  (third   portion),  brachial,  radial,  and  ulnar 

arteries  (MacCorniae). 

humerus,  and  is  taken  downward  parallel  to  the  lower  edge  of  the  great  pectoral 
muscle  and  crosses  the  junction  of  the  anterior  and  middle  thirds  of  the  outlet 
of  the  axilla.  The  integuments  and  fascia  are  incised.  The  vein  or  veins  will 
be  prominent  to  the  inner  side  and  may  overlie  the  vessel.  To  the  inner  side 
with  the  veins  are  the  ulnar  and  internal  cutaneous  nerves.  The  median 
nerve  is  upon,  and  the  external  cutaneous  is  to  the  outer  side  of,  the  artery. 
Feel  for  the  pulsations  of  the  artery,  find  the  median  nerve,  and  draw  it  out- 
ward, draw  the  nerves  and  veins  which  lie  to  the  inner  side  inward,  ?lear  the 


478  Diseases  and  Injuries  of  the  Heart  and  Vessels 

artery  from  the  venae  comites,  and  pass  the  hgature  from  within  outward. 
Apply  the  hgature  well  below  the  circumflex  branches. 

Ligation  of  the  First  Part. — This  operation  (PI.  4,  Fig.  2,  and  Fig. 
225)  was  first  performed  in  1815  by  Chamberlaine,  of  Jamaica.  The 
patient  is  placed  supine,  the  upper  part  of  the  body  being  raised,  a  sand- 
pillow  being  placed  between  the  scapuke  to  insure  carrying  back  of  the 
point  of  the  shoulder,  and  the  arm  being  brought  down  along  the  side. 
In  operating  on  the  left  side  the  surgeon  stands  on  the  outer  side  of 
the  left  arm;  in  operating  on  the  right  side  he  stands  to  the  right  of 
the  subject's  head  and  leans  over  his  shoulder.  The  incision,  which  is 
slightly  curved  downward,  begins  external  to  the  sternoclavicular  joint 
and  ends  internal  to  the  margin  of  the  deltoid,  thus  avoiding  the  cephalic 
vein.  The  incision  is  half  an  inch  below  the  clavicle  (Fig.  225).  Incise  the 
skin,  platsyma  myoides  muscle,  and  deep  fascia.  In  the  outer  angle  of  the 
wound  watch  for  the  acromiothoracic  artery  and  the  cephalic  vein.  Incise 
the  pectoralis  major;  draw  the  pectoralis  minor  downward;  retract  the  lower 
margin  of  the  wound,  cut  through  the  costocoracoid  membrane  close  to  the 
coracoid  process  and  the  upper  border  of  the  lesser  pectoral  muscle.  Bring 
the  arm  to  the  side  so  as  to  relax  the  structures.  Find  the  brachial  plexus, 
feel  for  the  artery  internal  to  it,  clear  the  vessel,  draw  the  vein  internally,  and 
pass  the  needle  from  within  outward.  This  avoids  the  dangerous  neighbor, 
which  is  the  axillary  vein.  This  operation  is  difficult,  dangerous,  and  unusual, 
and  in  its  performance  the  axillary  vein,  which  has  a  close  attachment  to  the 
costocoracoid  membrane,  is  apt  to  be  torn. 

Subclavian  Artery. — The  subclavian  artery  was  first  successfully  tied 
by  Post,  of  New  York,  who  applied  a  ligature  about  the  third  portion  of 
the  vessel  in  181 7.  The  first  part  of  the  subclavian  was  first  tied  by  Colics 
in  1818  (Treves's  "Manual  of  Surgery").  At  the  present  day  the  first  and 
second  portions  are  rarely  ligated.  Professor  Halsted  successfully  tied  the 
first  portion  of  the  left  side  for  aneurysm.  Schumpert  tied  it  successfully  for 
aneurysm.  I  assisted  Dr.  Nassau,  of  St.  Joseph's  Hospital,  Philadelphia,  in  a 
ligation  of  the  first  part  of  the  right  subclavian.  The  man  suffered  from  a  rup- 
tured traumatic  aneurysm  of  the  third  portion  of  the  vessel.  The  operation 
was  followed  by  recovery.  Chilton  produced  a  cure  of  an  aneurysm  of  the 
third  portion  of  the  subclavian  of  the  right  side  by  tying  the  first  portion  and 
twenty-four  hours  later  tying  the  first  portion  of  the  axillary.  There  is  no  line 
for  this  vessel. 

Anatomy  (PI.  4,  Fig.  i). — The  subclavian  artery  of  the  right  side  arises 
from  the  innominate;  that  of  the  left  side,  from  the  arch  of  the  aorta.  The 
subclavian  is  divided  into  three  parts.  The  first  part  runs  from  the  origin 
of  the  vessel  to  the  inner  border  of  the  scalenus  anticus  muscle;  the  second 
part  lies  behind  the  scalenus  anticus  muscle;  and  the  third  part  runs  from  the 
outer  edge  of  the  muscle  to  the  lower  border  of  the  first  rib.  The  third  portion 
is  contained  in  the  subclavian  triangle  (Fig.  224),  and  is  superficial.  It  rises, 
as  a  rule,  to  half  an  inch  above  the  clavicle.  The  subclavian  vein  is  below 
the  artery,  being  separated  from  it  by  the  scalenus  anticus  muscle.  The 
brachial  plexus  is  above  and  external  to  the  artery.  The  vessel  rests  upon 
the  first  rib,  and  behind  it  is  the  scalenus  medius  muscle.  The  suprascapular 
and  transversalis  colli  arteries  and  veins  and  branches  of  the  cervical  plexus 


Vertebral  Artery  479 

of  nerves  lie  in  front  of  the  artery,  and  the  external  jugular  vein  crosses  it  at 
its  inner  side.     The  third  portion  gives  ofT  no  branches. 

Ligation  of  the  Third  Part. — (See  PI.  4,  Fig.  2,  and  Fig.  225).  The  patient 
is  placed  upon  his  back,  the  shoulders  are  raised,  the  head  is  extended  and 
turned  toward  the  opposite  side,  the  arm  is  pulled  down  and  held  by  pushing  the 
forearm  under  the  patient's  back  (Treves).  This  pulls  down  the  clavicle,  thus 
increasing  the  size  of  the  subclavian  triangle.  The  operator  stands  facing 
the  shoulder,  with  his  back  toward  the  patient's  feet.  The  skin  over  the  sub- 
clavian triangle,  at  a  point  half  an  inch  above  the  clavicle,  is  drawn  down 
until  it  overlies  the  bone  and  is  incised.  This  maneuver  enables  the  surgeon 
to  avoid  the  external  jugular  vein  and  to  make  an  incision  in  the  skin  half  an 
inch  above  the  collar-bone.  The  incision  reaches  from  the  anterior  edge  of 
the  trapezius  to  the  posterior  border  of  the  sternocleidomastoid  (PI.  4,  Fig.  2, 
and  Fig.  225),  and  is  about  three  inches  long.  This  incision  divides  the  skin, 
superficial  fascia,  the  platysma  myoides,  the  vein  running  from  the  cephahc  to 
the  external  jugular,  and  some  superficial  nerves.  The  deep  fascia  is  opened. 
The  external  jugular  vein  is  drawn  into  the  inner  angle  of  the  wound,  and  is 
not  divided  unnecessarily,  if  forced  to  divide  the  vein,  tie  with  two  ligatures 
and  cut  between  them.  The  surgeon  seeks  to  find  the  outer  edge  of  the  an- 
terior scalene  muscle,  and  runs  the  finger  down  along  it  to  the  tubercle  on 
the  first  rib.  The  posterior  belly  of  the  omohyoid  muscle  is  drawn  upward 
by  an  assistant.  The  surgeon,  with  a  finger  on  the  tubercle,  recalls  the  facts 
that  the  vein  is  in  front  of  the  finger  and  the  artery  is  behind  it,  and  that  the 
subclavian  vein  is  on  a  lower  plane  than  the  artery.  The  artery  is  felt  beating 
as  it  lies  upon  the  rib.  The  artery  is  cleared  and  the  lower  cord  of  the  brachial 
plexus  is  exposed.  The  vein  must  be  guarded  with  the  finger  and  the  needle 
is  passed  from  above  downward,  as  the  plexus,  which  is  in  more  danger  than 
the  vein,  is  to  be  avoided.  In  this  operation  the  transversalis  colli  and  supra- 
scapular arteries  must  not  be  cut,  as  they  are  necessary  to  the  future  anasto- 
motic circulation.  If  the  field  of  operation  is  too  small,  the  trapezius  or 
sternocleidomastoid,  or  both,  should  be  incised  transversely. 

Results. — According  to  Joseph  D.  Bryant,  there  have  been  134  deaths 
in  250  ligations  ("Operative  Surgery").  I  have  twice  tied  this  vessel  with 
success. 

The  vertebral  artery  was  first  successfully  ligated  by  Smythe,  of 
New  Orleans,  in  1864.  He  had  ligated  the  innominate  for  aneurysm  of  the 
subclavian  and  at  the  same  time  tied  the  common  carotid.  Secondary  hemor- 
rhage occurred,  the  blood  coming  from  the  brain.  He  arrested  it  by  tying 
the  vertebral. 

Anatomy. — This  vessel  is  the  largest  branch  of  the  subclavian,  and  is 
the  first  branch  coming  from  the  first  portion  of  the  subclavian.  The  verte- 
bral artery  ascends  and  enters  the  foramen  in  the  transverse  process  of  the 
sixth  cervical  vertebra  (in  rare  cases  the  fifth  or  the  seventh),  and  ascends 
through  foramina  in  the  cervical  vertebrae,  passes  behind  the  articular  process 
of  the  atlas  and  over  the  posterior  arch  of  this  first  vertebra,  pierces  the  pos- 
terior occipito-atloid  ligament,  and  enters  the  skull  by  way  of  the  foramen 
magnum  (see  Gray).  It  joins  its  fellow  of  the  opposite  side  to  form  the 
basilar  artery.  At  its  point  of  origin  the  vertebral  artery  has  in  front  of  it  the 
internal  jugular  vein  and  inferior  thyroid  artery.     Gray  says  that  near  the 


480  Diseases  and  Injuries  of  the  Heart  and  \^essels 

spine  it  lies  between  the  longus  colli  and  scalenus  anticus  muscles,  with  the 
thoracic  duct  to  the  left  and  in  front. 

Ligation. — The  position  of  the  patient  is  the  same  as  for  ligation  of  the 
carotid  artery.  Alexander  thus  describes  the  operation:  "An  incision  3  or  4 
inches  long  is  made  in  an  upward  and  outward  direction  along  the  hollow 
which  exists  between  the  scalenus  anticus  and  the  sternomastoid  muscles. 
The  incision  should  begin  just  outside  and  on  a  level  with  the  point  where  the 
external  jugular  vein  dips  over  the  edge  of  the  sternomastoid  muscle,  or,  if 
the  vein  is  invisible,  about  half  an  inch  above  the  clavicle.  The  external 
jugular  vein  is  drawn  inward  with  the  sternomastoid  muscle.  The  connective 
tissue  now  appearing,  the  wound  is  opened  by  a  blunt  dissector,  until  the 
scalenus  anticus  muscle,  the  phrenic  nerve,  and  the  transverse  cervical  artery 
are  seen.  It  cannot  be  too  well  remembered  that  the  pleura  is  at  the  inner 
side  of  the  wound,  while  below  lies  the  subclavian  artery.  It  is  now  only 
necessary  to  separate  the  edges  of  the  scalenus  anticus  and  the  longus  colli 
muscles  to  see  the  vertebral  artery  lying  in  the  space  between  them.  The 
artery  is  generally  completely  covered  by  the  vein,  which  is  drawn  aside,  and 
the  artery  is  then  ligatured"  (cjuoted  in  Bryant's  "Operative  Surgery"). 
When  the  vessel  is  cleared  and  tied,  branches  of  the  inferior  cervical  ganglion 
are  damaged  and  possibly  included  in  the  ligature,  and  as  a  consequence  the 
pupil  contracts.  Jacobson  tells  us  to  remember  that  the  phrenic  nerve  lies 
on  the  scalene  muscle,  the  pleura  is  internal,  the  internal  jugular,  inferior 
thyroid,  and  vertebral  veins  are  over  the  vessel,  and  the  thoracic  duct  on  the 
left  side  crosses  it  from  within  outward. 

Results. — In  36  ligations  of  the  vertebral  artery  there  were  3  deaths 
(Joseph  D.  Bryant). 

The  Inferior  Thyroid  Artery. — Anatomy. — The  inferior  thyroid 
artery  is  a  branch  of  the  thyroid  axis.  It  ascends  the  neck,  passes  back  of 
the  carotid  sheath  and  the  sympathetic  nerve,  and  reaches  the  thyroid  gland. 
The  recurrent  laryngeal  nerve  lies  behind  the  artery.  The  phrenic  nerve 
is  external  to  the  artery  and  near  to  it  in  the  first  part  of  its  course  (up 
to  the  point  of  origin  of  the  ascending  cervical  branch).  The  ascending 
cervical  branch  t3kes  origin  just  before  the  artery  begins  to  dip  behind 
the  carotid.  In  front  of  the  beginning  of  the  inferior  thyroid  artery  of  the 
left  side  the  thoracic  duct  crosses.  The  artery  is  ligated  in  the  second 
part  of  its  course  (between  its  distribution  and  the  origin  of  the  above-named 
branch) . 

Ligation. — The  position  of  patient  and  the  incision  are  the  same  as  for 
the  ligation  of  the  common  carotid  artery  in  the  triangle  of  necessity  (page 
484).  After  exposing  the  sternocleidomastoid  muscle  retract  it  outward, 
and  then  draw  outward  the  common  carotid  artery  and  also  the  internal 
jugular  vein.  The  inferior  thyroid  artery  will  be  found  a  Httle  below  the 
carotid  tubercle.  It  is  cleared  and  ligated.  Treves  advises  ligation  close 
to  the  level  of  the  carotid,  so  as  to  avoid  the  recurrent  laryngeal  nerve. 

Innominate  Artery. — First  successfully  ligated  by  Smythe,  of  New 
Orleans,  in  1864.     It  is  an  extremely  fatal  operation. 

Anatomy. — The  innominate  artery  arises  from  the  beginning  of  the  trans- 
verse portion  of  the  arch  of  the  aorta,  passes  to  the  back  of  the  right  sterno- 
clavicular  joint,    and   divides    into    the    common    carotid    and    subclavian 


Innominate  Artery 


481 


vessels.  It  rests  upon  the  trachea.  It  has  upon  its  outer  side  the  pleura, 
the  right  innominate  vein,  and  the  pneumogastric  nerve.  Upon  its  inner 
side  are  the  remnant  of  the  thymus  gland  and  the  beginning  of  the  left 
carotid  artery.  In  front  of  it  are  the  inferior  thyroid  veins  of  the  right  side, 
the  left  innominate  vein,  the  sternohyoid  and  sternothyroid  muscles,  the 
remnant  of  the  thymus  gland,  and  sometimes  a  branch  from  the  right  pneumo- 
gastric nerve. 

Ligation. — Place  the  patient  supine,  with  the  shoulders  a  little  raised, 
and  the  head  thrown  back.  Carry  an  incision  from  the  upper  margin  of 
the  sternum  for  three  inches  along  the  anterior  margin  of  the  sternomastoid. 


Fig.  223. — Successful  ligation  of  the  first  part  of  common  parotid  and  first  part  of  subclavian 

for  innominate  aneurj'sm. 

Make  another  cut  of  the  same  length  along  the  upper  border  of  the  clavicle 
to  meet  the  first  cut.  Dissect  up  the  flap  of  skin  and  fascia.  Divide  the 
sternal  origin  and  a  part  of  the  clavicular  portion  of  the  sternocleidomastoid 
muscle,  and  cut  the  sternohyoid  and  sternothyroid  muscles  just  above  their 
sternal  origins  (Joseph  Bell).  Retract  the  inferior  thyroid  veins.  Divide 
the  dense  leaflet  of  cervical  fascia.  Find  the  common  carotid  artery,  and 
trace  back  along  this  vessel  until  the  innominate  comes  into  view.  Retract 
the  left  innominate  vein  downward.  The  needle  is  passed  from  without 
inward  to  avoid  the  right  innominate  ^■ein  and  right  pneumogastric  nerve. 
If  the  needle  is  kept  close  to  the  artery,  the  pleura  and  trachea  will  not  be 
injured.* 

*  See  the  exceedingly  clear  and  terse  account  in  that  excellent  book,  "  A  Manual  of 
Surgical  Operations,"  by  Joseph  Bell. 

31 


482 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


Results. — Three  cases  have  recovered  out  of  31  reported  (Burrell's, 
Banks's,  and  Smythe's).  Burrell  ligated  the  innominate  in  1895  and  the 
patient  Hved  over  three  months,  dying  finally  from  cardiac  disease.  Mitchell 
Banks's  case  lived  over  three  months. 

Region  of  the  Neck.^Anatomy. — The  side  of  the  neck  is  that  space 
between  the  median  line  in  front  and  the  anterior  edge  of  the  trapezius  muscle 
behind,  which  space  is  limited  below  by  the  clavicle  and  above  by  the  body 
of  the  jaw  and  an  imaginary  line  running  from  the  angle  of  the  jaw  to  the 
mastoid  process.  The  sternocleidomastoid  muscle  divides  this  space  into  an 
anterior  and  a  posterior  triangle,  and  each  of  the  triangles  is  subdivided  by 
other  structures,  the  anterior  into  four  spaces  and 
the  posterior  into  two  (Fig.  224). 

Anterior  Triangle. — The  anterior  triangle  is 
bounded  in  front  by  the  median  line  of  the  neck, 
behind  by  the  anterior  margin  of  the  sternocleido- 
mastoid muscle,  and  above  by  the  body  of  the 
lower  jkw  and  an  imaginary  line  drawn  from  the 
angle  of  the  jaw  to  the  mastoid  process.  This 
space  is  subdivided  into  four  smaller  triangles — 
namely,  the  inferior  carotid,  the  superior  carotid, 
the  submaxillary,  and  the  submental. 

The  inferior  carotid  triangle  is  called  the  "tri- 
angle of  necessity,"  because  the  common  carotid 
artery  in  this  region  is  ligated,  not  from  choice, 
but  through  force  of  necessity.  It  is  bounded  in 
front  by  the  median  line,  above  by  the  anterior 
belly  of  the  omohyoid  muscle  and  the  hyoid  bone, 
and  below  by  the  anterior  edge  of  the  sterno- 
mastoid  muscle.  The  floor  of  this  triangle  is 
composed  of  the  longus  colli,  the  scalenus  anticus, 
the  rectus  capitis  anticus  major,  the  sternohyoid, 
and  sternoth^Toid  muscles. 
The  superior  carotid  triangle  is  known  as  the  "  triangle  of  election,"  be- 
cause, if  the  carotid  arter}'  must  be  tied,  the  surgeon,  whenever  possible, 
elects  or  chooses  to  tie  it  in  this  triangle.  In  this  region  the  carotid  is  super- 
ficial, and  there  can  be  tied  either  the  external,  the  internal,  or  the  common 
carotid  artery,  as  may  be  desired.  The  triangle  is  bounded  behind  by  the 
anterior  edge  of  the  sternocleidomastoid,  above  by  the  posterior  belly  of  the 
digastric,  and  below  by  the  anterior  belly  of  the  omohyoid  muscles.  Its 
floor  is  composed  of  the  inferior  and  middle  constrictors  of  the  pharynx  and 
the  thyrohyoid  and  hyoglossus  muscles. 

The  submaxillary  triangle  is  bounded  above  by  the  body  of  the  jaw  and 
an  imaginary  line  drawn  from  the  angle  of  the  jaw  to  the  mastoid  process, 
behind  by  the  posterior  belly  of  the  digastric  muscle  and  the  stylohyoid  muscle, 
and  in  front  by  the  anterior  belly  of  the  digastric  muscle.  Its  floor  is  composed 
of  the  mylohyoid  and  hyoglossus  muscles. 

The  submental  triangle  is  bounded  on  either  side  by  the  anterior  belly  of 
one  digastric  muscle;  its  base  is  the  hyoid  bone  and  its  floor  is  the  mylohyoid 
muscle. 


Fig.  224. — The  triangles  of 
the  neck,  right-sided  view:  i, 
Submaxillarj-  triangle;  2,  "  tri- 
angle of  election,"  or  superior 
carotid  triangle;  3,  submental 
triangle;  4,  "triangle  of  ne- 
cessity," or  inferior  carotid 
triangle;  5,  occipital  triangle; 
6,  subclavian  triangle  (after 
Keen). 


LIGATIONS. 


Plate  4. 


Common  Carotid  Arlery-  483 

The  posterior  triangle  is  bounded  in  front  by  the  posterior  border  of  the 
sternocleidomastoid  muscle,  behind  by  the  anterior  edge  of  the  trapezius 
muscle,  and  below  by  the  clavicle.  The  posterior  belly  of  the  omohyoid 
muscle  subdivides  it  into  two  smaller  spaces,  the  occipital  and  subclavian 
triangles. 

The  occipital  triangle  is  bounded  in  front  by  the  posterior  edge  of  the 
sternocleidomastoid  muscle,  behind  by  the  anterior  border  of  the  trapezius 
muscle,  and  below  by  the  posterior  belly  of  the  omohyoid  muscle. 

The  subclavian  triangle  is  bounded  above  by  the  posterior  belly  of  the 
omohyoid  muscle,  below  by  the  clavicle,  and  in  front  by  the  posterior  border 
of  the  sternocleidomastoid  muscle.  Its  floor  is  formed  by  the  first  rib  and 
the  first  serration  of  the  serratus  magnus  muscle. 

Common  Carotid  Artery. — The  common  carotid  was  tied  to  arrest 
bleeding  by  Abernethy  in  1798,  and  was  first  ligated  successfully  for  aneu- 
rysm by  Sir  Astley  Cooper  in  1806.  The  line  of  the  common  carotid  arter}- 
is  from  the  sternoclavicular  articulation  to  midway  between  the  angle  of  the 
jaw  and  the  mastoid  process,  the  head  being  turned  toward  the  opposite  side. 

Anatomy  fPl.  4,  Fig.  3). — The  right  common  carotid  arises  from  the 
innominate  opposite  the  sternoclavicular  joint;  the  left  common  carotid  arises 
from  the  arch  of  the  aorta.  In  the  neck  the  two  carotids  possess  identical 
relations.  The  common  carotid  runs  upward  and  outward  from  behind 
the  sternoclavicular  articulation  to  a  level  with  the  upper  border  of  the  th}Toid 
cartilage,  at  which  point  it  divides  into  the  external  and  internal  carotid. 
The  common  carotid  is  contained  in  a  sheath  derived  from  the  cervical  fascia. 
This  sheath  also  contains,  in  separate  compartments,  the  internal  jugular 
vein  on  the  outer  side  of  the  arter\-  and  the  pneumogastric  nen^e  between 
the  vein  and  artery,  but  more  deeply  placed.  The  anterior  edge  of  the  sterno- 
cleidomastoid muscle  lies  over  the  artery*  and  is  a  guide.  Low  in  the  neck 
the  common  carotid  is  deep,  being  covered  by  skin,  superficial  fascia,  platysma, 
deep  fascia,  and  the  sternocleidomastoid,  sternohyoid,  and  the  sternothyroid 
muscles.  Above  the  omohyoid  muscle  the  vessel  is  more  superficial,  being 
covered  by  the  skin,  superficial  fascia,  platysma,  deep  fascia,  and  the  anterior 
edge  of  the  sternocleidomastoid  muscle.  Upon  the  sheath  (occasionally  within 
it),  above  the  crossing  of  the  omohyoid  muscle,  lies  the  descendens  noni 
nerve — the  descending  branch  of  the  ninth  pair  of  Willis  (the  h\-poglossal). 
This  nerve  is  a  valuable  guide  to  the  sheath  in  the  triangle  of  election. 

The  sternomastoid  branch  of  the  superior  th}Toid  arten,-  crosses  the  carotid 
artery  a  little  below  its  bifurcation,  and  the  sufjerior  thyroid  \tm  also  crosses 
it  in  this  region;  the  middle  th}Toid  vein  crosses  the  artery  near  its  middle, 
and  the  anterior  jugular  vein  crosses  low  down.  The  common  carotid  rests 
upon  the  longus  colli  and  rectus  capitis  anticus  major  muscles,  the  sympa- 
thetic nerve  lying  between  the  last-named  muscle  and  the  vessel,  outside  the 
carotid  sheath.  The  recurrent  larymgeal  nen-e  passes  behind  the  carotid 
below  the  omohyoid  muscle,  and  the  inferior  th\Toid  arter\'  passes  behind 
the  carotid  just  above  the  omohyoid  muscle.  The  common  carotid  is  in 
relation  internally  with  the  trachea.  th\Toid  gland,  lar}-nx,  and  pharynx. 
To  the  outer  side  are  the  pneumogastric  nerve  (which  is  on  a  posterior  plane) 
and  the  internal  jugular  vein.  On  the  left  side,  low  down  in  the  neck,  the 
jugular  vein  often  lies  in  front,  or  partly  in  front,  of  the  arter}'. 


484  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Ligation  in  the  Triangle  of  Necessity. — In  this  operation  the  patient  is 
placed  supine,  with  the  shoulders  raised,  a  sand-pillow  under  the  neck,  and 
the  head  turned  to  the  opposite  side,  with  the  chin  raised.  The  operator 
stands  upon  the  side  oj)erated  uj)on.  The  incision,  three  inches  long,  at 
a  slight  angle  to  the  arterial  line,  runs  from  the  level  of  the  cricoid  cartilage 
downward  and  inward  toward  the  sternoclavicular  joint,  following  the  inner 
border  of  the  sternocleidomastoid  muscle.  The  surgeon  opens  the  deep 
fascia,  draws  the  sternocleidomastoid  outward,  retracts  the  sternohyoid  and 
sternothyroid  muscles  inward,  and  feels  for  the  carotid  tubercle  of  Chas- 
saignac.  This  tubercle  is  the  costal  process  of  the  sixth  cervical  vertebra, 
and  lies  directly  under  the  artery.  The  tubercle  is  found  about  the  point 
at  which  the  omohyoid  crosses  the  carotid.  When  the  tubercle  is  found  we 
know  the  situation  of  the  artery,  and  that  the  triangle  of  necessity  is  below, 
and  the  triangle  of  election  above,  the  tubercle.  The  operator  draws  the 
omohyoid  muscle  upward,  opens  the  sheath  of  the  artery  on  its  inner  side, 
clears  the  vessel,  and  passes  the  needle  from  without  inward  to  avoid  the 
internal  jugular  vein,  remembering  that  the  pneumogastric  nerve  is  in  the 
same  sheath  as  the  artery  and  vein,  posterior  and  external  to  the  artery. 
In  this  operation  the  inferior  thyroid  veins  are  much  in  the  way,  the  anterior 
jugular  vein  crosses  low  down,  and  on  the  left  side,  at  the  root  of  the  neck, 
the  internal  jugular  vein  may  be  in  front  of  the  carotid  artery.  If  the  incision 
is  not  sufficiently  wide,  partially  divide  the  sternocleidomastoid  or  the  sterno- 
hyoid and  thyroid  muscles.  In  the  triangle  of  necessity  the  descendens  noni 
nerve  does  not  serve  as  a  guide  to  the  sheath  of  the  vessels.     (See  PI.  4, 

Fig.  4-) 

Ligation  in  the  Triangle  of  Election  (Fig.  225). — The  position  of  the  patient 
for  this  operation  is  the  same  as  in  the  preceding  one.  An  incision,  three 
inches  in  length,  is  made  along  the  anterior  edge  of  the  sternocleidomastoid 
muscle  in  the  line  of  the  artery,  the  middle  of  this  incision  being  opposite  the 
cricoid  cartilage  (Fig.  225).  In  cutting  the  .superficial  fa.scia,  the  surgeon  avoids 
the  external  jugular  vein,  the  course  of  which  should  be  outlined  before  making 
the  incision.  The  line  of  the  external  jugular  is  from  the  angle  of  the  jaw  to 
the  middle  of  the  clavicle.  The  operator  opens  the  deep  fascia,  retracts  the 
sternocleidomastoid  muscle  outward,  feels  for  the  carotid  tubercle,  draws 
the  omohyoid  muscle  downward,  finds  the  descendens  noni  nerve  upon  the 
sheath,  opens  the  sheath  at  its  inner  side,  and  passes  the  needle  from  without 
inward.  This  incision  permits  ligation  of  either  the  superior  thyroid  or  the 
external,  internal,  or  common  carotid,  and  if  it  be  extended  up  a  little  there 
can  be  tied  through  it  the  lingual,  and  even  the  facial  and  occipital,  arteries 
(See  PI.  4,  Fig.  4.) 

Results. — In  from  20  to  25  per  cent,  of  cases  after  ligation  of  the  common 
carotid  artery  there  is  cerebral  softening  or  some  other  intracranial  com- 
plication. Crile  states  that  of  the  cases  that  develop  cerebral  trouble,  one- 
half  die.     The  operative  mortality,  according  to  Crile,  is  only  3  per  cent. 

External  Carotid  Artery. — Burke  ligated  the  external  carotid  in 
1827  (Treves,  from  Chelius).  The  line  of  the  external  carotid  artery  is  the 
upper  portion  of  the  common  carotid  line. 

Anatomy  (PI.  4,  Fig.  3). — The  external  carotid  artery,  which  is  one  of 
the  terminal  branches  of  the  common  carotid,  arises  on  a  level  with  the  upper 


Internal  Carotid  Artery  485 

border  of  the  thyroid  cartilage  and  runs  to  the  level  of  the  neck  of  the  condyle 
of  the  lower  jaw.  At  its  point  of  origin  it  is  covered  only  by  skin,  platysma, 
and  fascia,  and  the  edge  of  the  sternomastoid,  but  as  it  ascends  it  passes  be- 
neath the  digastric  and  stylohyoid  muscles  and  into  the  parotid  gland.  The 
glossopharyngeal  nerve,  styloid  process,  and  stylopharyngeus  muscle  lie  be- 
tween the  external  and  internal  carotid  arteries.  The  hypoglossal  nerve 
crosses  the  vessel  just  below  the  digastric  muscle,  and  the  facial  and  lingual 
veins  cross  it  a  little  below  the  nerve.  The  first  branch  is  the  superior  thyroid, 
which  arises  from  the  very  beginning  of  the  trunk.  The  lingual  arises  on  a 
level  with  the  greater  cornu  of  the  hyoid  bone.  The  facial  and  occipital  take 
origin  above  the  lingual.  Each  of  them  can  be  ligated  through  the  incision 
made  for  ligation  of  the  external  carotid. 

Operation. — Place  the  patient  in  the  same  position  as  for  ligation  of  the 
common  carotid.  The  point  of  election  is  between  the  superior  thyroid  and 
the  lingual  arteries.  Make  an  incision  three  inches  in  length  at  a  slight  angle 
to  the  arterial  line,  from  near  the  angle  of  the  jaw  to  opposite  the  middle  of 
the  thyroid  cartilage.  Cut  through  the  skin,  superficial  fascia,  platysma, 
and  deep  fascia,  and  retract  the  sternocleidomastoid  muscle  outward.  Watch 
for  the  digastric  muscle,  find  the  hypoglossal  nerve,  and  feel  for  the  greater 
cornu  of  the  hyoid  bone.  Open  the  sheath  a  httle  below  the  hyoid  cornu  and 
pass  the  needle  from  without  inward.  Ligation  of  the  external  carotid  has 
been  neglected  because  ligation  of  the  common  carotid  is  easier. 

Results. — Crile  believes  the  operative  mortahty  to  be  2  per  cent. 

Internal  Carotid  Artery.— The  internal  carotid  was  tied  by  Keith, 
of  Aberdeen,  in  1851  (Ashhurst's  "International  Encyclopedia  of  Surgery"). 
The  line  of  the  internal  carotid  is  parallel  with  and  half  an  inch  external  to 
the  line  of  the  external  carotid. 

Anatomy  (PI.  4,  Fig.  3). — The  internal  carotid  artery,  the  other  terminal 
branch  of  the  common  carotid,  arises  on  a  level  with  the  upper  border  of  the 
thyroid  cartilage  and  enters  the  carotid  canal.  The  first  inch  of  the  artery 
is  the  only  point  where  a  ligature  is  ever  applied,  this  point  being  covered 
only  by  skin,  platysma,  fascia,  and  the  sternocleidomastoid  muscle;  higher  up 
it  is  more  deeply  placed.  It  rests  upon  the  vertebras  and  the  rectus  capitis 
anticus  major  muscle.  The  internal  jugular  vein  is  in  the  same  sheath  and 
external  to  the  artery;  the  pneumogastric  is  in  the  same  sheath,  between  the 
artery  and  the  vein,  but  posterior  to  both.  The  superior  cervical  ganglion 
of  the  sympathetic  hes  behind  the  origin  of  the  internal  carotid,  and  between 
the  ganglion  and  the  artery  is  the  superior  laryngeal  nerve. 

Operation. — In  this  operation  the  position  of  the  patient  is  the  same  as 
for  ligation  of  the  external  carotid.  The  incision  is  of  the  same  length  and 
direction  as  that  for  ligation  of  the  external  carotid,  and  is  half  an  inch 
external.  The  sternocleidomastoid  muscle  is  drawn  outward,  the  external 
carotid  artery  is  found  and  drawn  inward,  the  internal  carotid  is  found  and 
cleared,  and  the  needle  is  passed  from  without  inward.  The  internal  carotid 
is  known  by  its  more  external  position  and  by  the  fact  that  it  gives  ofif  no 
branches. 

Results. — There  is  the  same  danger  of  cerebral  complications  after  this 
operation  as  after  ligation  of  the  common  carotid.  The  operative  mortality 
is  probably  as  great. 


486  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Superior  Thyroid  Artery  (PI.  4,  Fig.  3). — This  branches  off  from 
the  external  carotid  below  the  level  of  the  greater  cornu  of  the  hyoid  bone,  in 
the  triangle  of  election.  It  is  primarily  superficial,  runs  first  upward  and 
inward,  next  downward  and  forward,  passes  underneath  the  omohyoid, 
sternohyoid,  and  sternothyroid  muscles,  and  reaches  the  thyroid  gland. 

Ligation. — The  position  of  the  patient  and  of  the  surgeon  is  the  same  as 
for  ligation  of  the  carotid.  The  artery  may  be  reached  through  the  incision 
employed  for  ligation  of  the  external  carotid.  Gross  made  an  incision  be- 
ginning at  the  edge  of  the  hyoid  bone,  and  running  downward  and  outward 
to  the  sternomastoid  muscle.  The  skin  and  superficial  and  deep  fasciae  are 
divided,  and  the  artery  is  found  deeply  placed  in  the  triangle  of  election  be- 
tween the  carotid  sheath  and  the  thyroid  gland. 

Lingual  Artery. — Charles  Bell  ligated  the  first  part  of  the  lingual 
artery  in  1814.  The  operation  beneath  the  hyoglossus  muscle  was  devised 
by  Pirogoff  in  1836.     (See  Treves's  "Manual  of  Operative  Surgery.") 

Anatomy  (PI.  4,  Fig.  3). — The  lingual  artery  arises  from  the  external 
carotid  opposite  the  greater  cornu  of  the  hyoid  bone,  passes  beneath  the  di- 
gastric and  stylohyoid  muscles,  reaches  the  margin  of  the  hyoglossus  muscle, 
passes  under  that  muscle,  and  emerges  from  beneath  it  to  run  along  the  under 
surface  of  the  tongue.  The  place  of  election  for  Hgation  is  where  the  artery 
is  beneath  the  hyoglossus  muscle.  Its  guide  is  the  hypoglossal  nerve,  which 
lies  upon  the  muscle,  but  at  a  slightly  higher  level  than  the  artery. 

Operation. — In  this  operation  the  patient  is  placed  recumbent  with  the 
shoulders  raised  and  the  face  turned  away  from  the  side  to  be  operated  upon. 
The  surgeon  stands  upon  the  affected  side.  A  curved  incision  is  made  from 
a  httle  external  to  the  symphysis  of  the  lower  jaw,  downward  and  outward, 
to  just  above  the  greater  cornu  of  the  hyoid  bone,  and  upward  and  outward 
to  just  in  front  of  the  facial  artery  at  the  lower  edge  of  the  lower  jaw.  The 
skin,  the  superficial  fascia  and  platysma,  and  the  deep  fascia  are  incised. 
The  submaxillary  gland  is  cleared  and  retracted  well  upward.  The  fascia 
below  the  gland  is  divided  by  a  transverse  incision.  The  posterior  edge  of 
the  mylohyoid  muscle  and  the  belhes  of  the  digastric  muscle  are  sought  for 
and  identified.  One  of  the  digastric  tendons  is  retracted  down  and  out 
(Treves).  The  hyoglossus  muscle  is  cleared  with  a  dissector;  the  hypo- 
glossal nerve  and  ranine  vein  are  found  and  drawn  a  little  upward.  The 
hyoglossus  muscle  is  divided  transversely  a  httle  above  the  hyoid  bone  and 
below  the  level  of  the  hypoglossal  nerve.  The  artery  is  found  under  the 
muscle  and  the  needle  is  passed  from  above  downward. 

Facial  Artery.— Anatomy  (PI.  4,  Fig.  3).— Arises  from  the  external 
carotid  a  little  above  the  lingual,  runs  upward  and  forward  beneath  the  body 
of  the  inferior  maxillary  bone,  passes  along  a  groove  in  the  posterior  and  upper 
surface  of  the  submaxillary  gland,  crosses  the  body  of  the  lower  jaw  at  the 
lower  anterior  edge  of  the  masseter  muscle,  and  passes  forward  and  upward 
to  the  angle  of  the  mouth  and  side  of  the  nose. 

Ligation  (PL  4,  Fig.  4).— The  facial  artery  is  rarely  ligated  in  the  cervical 
portion,  but  may  be  reached  through  the  incision  employed  for  ligation  of 
the  external  carotid.  The  vessel  may  be  tied  before  it  crosses  the  submax- 
illary gland,  the  stylohyoid  and  digastric  muscles  being  drawn  aside.  The 
vessel  is  reached  in  the  facial  portion  of  its  course  by  a  one-inch  cut  at  the 


Occipital  Artery 


487 


anterior  edge  of  the  masseter  muscle  (Fig.  225).  Branches  of  the  facial 
nerve  are  j)ushed  aside.  The  needle  is  i)assed  from  behind  forward  to  avoid 
the  vein  (Jacobson). 

Temporal  Artery. — The  line  of  the  temporal  artery  passes  "  upw^ard 
over  the  root  of  the  zygoma,  midway  between  the  condyle  of  the  jaw  and  the 
tragus"  (Jacobson). 

Anatomy. — The  temporal  artery  arises  from  the  external  candid  behind 
the  condyle  of  the  jaw  and  in  the  parotid  gland,  passes  over  the  zygoma,  and 
divides  into  two  terminal  branches. 

Ligation. — The  patient  is  placed  recumbent  and  the  head  is  turned  to 
the  opposite  side.     An  incision  an  inch  in  length  is  made   (Fig.  225),  the 


Fig.  225. — Position  of  the  lines  of  incision  of  temporal,  facial,  lingual,  common  carotid 
(above  the  omohyoid),  subclavian,  axillary  (first  portion),  and  internal  mammary  arteries 
(MacCormac). 


superficial  structures  and  dense  fascia  are  divided,  the  vein  is  retracted  back- 
ward, and  the  needle  is  passed  from  behind  forward. 

Occipital  Artery. — Takes  origin  from  the  posterior  surface  of  the 
external  carotid,  below  the  digastric  muscle  and  opposite  the  point  of  origin 
of  the  facial  artery.  It  ascends  beneath  the  digastric  and  stylohyoid  muscles 
and  parotid  gland;  the  hypoglossal  nerve  hooks  around  it  from  behind  for- 
ward. It  crosses  the  internal  carotid  artery,  the  internal  jugular  vein,  the 
pneumogastric  and  spinal  accessory  nerves ;  passes  between  the  mastoid  process 
of  the  temporal  bone  and  the  atlas;  grooves  the  temporal  bones;  penetrates 
the  trapezius  muscle,  and  ascends  over  the  occiput. 

Ligation. — This  vessel  can  be  ligated  near  its  origin  through  the  same 
incision  as  is  employed  to  reach  the  external  carotid.  The  hypoglossal  nerve 
is  avoided.  To  tie  back  of  the  mastoid  process,  place  the  patient  in  the  same 
position  as  for  ligation  of  the  carotid.     Carry  an  incision  from  the  tip  of  the 


488  Diseases  and  Injuries  of  the  Heart  and  Vessels 

mastoid  upward  and  backward,  reaching  a  point  midway  between  the  mastoid 
and  the  occipital  protuberance  (Jacobson).  Cut  the  skin,  the  fascia,  the 
sternocleidomastoid,  the  splenius  capitis,  and  possibly  a  portion  of  the  trachelo- 
mastoid  muscles.  Bring  the  head  toward  the  operator  in  order  to  relax  the 
structures,  retract  the  edges  of  the  wound,  and  clear  the  artery  where  it  lies 
between  the  mastoid  process  and  the  transverse  process  of  the  atlas  (Jacob- 
son).  An  electric  forehead  light  is  of  great  assistance  in  finding  the  vessel. 
Pass  the  needle  away  from  the  vein  or  veins  (there  are  often  several). 

Dorsalis  Pedis  Artery.— The  line  of  the  dorsalis  pedis  artery  is 
from  the  middle  of  the  front  of  the  ankle-joint  to  the  middle  of  the  base  of  the 
first  interosseous  space. 

Anatomy  (PL  5,  Fig.  i). — The  dorsalis  pedis  is  a  continuation  of  the 
anterior  tibial  artery,  and  it  runs  from  the  bend  of  the  ankle  to  the  proximal 
extremity  of  the  first  interosseous  space,  where  it  divides  into  the  dorsalis 
hallucis  and  the  communicating  arteries.  The  artery  rests,  from  above  down- 
ward, upon  the  astragalus,  scaphoid,  and  internal  cuneiform  bones,  and  at 
its  point  of  bifurcation  lies  between  the  heads  of  the  first  dorsal  interosseous 
muscle.  It  may  lie  in  some  persons  a  little  external  to  this  course.  It  is  held 
upon  the  bones  by  a  distinct  layer  derived  from  the  deep  fascia.  This  artery 
is  covered  by  skin,  by  superficial  and  deep  fascia,  and  by  the  annular  ligament 
above,  and  is  sometimes  partly  overlaid  by  the  extensor  proprius  pollicis 
muscle,  and  is  crossed,  just  before  its  bifurcation,  by  the  innermost  tendon 
of  the  extensor  brevis  muscle.  The  inner  tendon  of  the  extensor  communis 
digitorum  is  to  the  outer  side  of  the  vessel;  the  tendon  of  the  extensor  proprius 
pollicis  is  to  the  inner  side,  and  is  a  guide.  The  artery  is  hgated  in  the  dorsal 
triangle  of  the  foot — a  space  which  is  bounded  above  by  the  lower  edge  of  the 
annular  ligament,  externally  by  the  inner  tendon  of  the  extensor  brevis,  and 
internally  by  the  tendon  of  the  extensor  proprius  pollicis.  The  artery  has 
venae  comites;  the  anterior  tibial  nerve  lies,  as  a  rule,  to  its  inner  side,  but  may 
be  found  upon  the  artery  or  to  its  outer  side,  and  the  inner  division  of  the 
musculocutaneous  nerve  is  external  to  the  vessel  in  the  superficial  parts. 

Operation  (PI.  5,  Fig.  2). — In  this  operation  the  patient  is  placed  supine 
with  the  leg  and  foot  extended.  Heath  flexes  the  leg  partly  and  rests  the  sole 
of  the  foot  directly  upon  the  table.  The  surgeon  stands  below  the  extremity, 
and  cuts  from  above  downward.  Make  an  incision  two  inches  in  length 
along  the  arterial  line,  beginning  opposite  the  lower  edge  of  the  annular  liga- 
ment and  running  along  by  the  tendon  of  the  extensor  proprius  pollicis;  cut 
through  the  skin  and  superficial  and  deep  fascia;  have  the  toes  extended;  re- 
tract the  tendon  of  the  extensor  proprius  pollicis  inward,  and  the  tendon  of 
the  extensor  communis  digitorum  outward;  clear  the  artery,  find  the  nerve, 
try  to  separate  the  venae  comites,  and  pass  the  needle  from  the  nerve. 

Anterior  Tibial  Artery. —  To  locate  the  line  of  the  anterior  tibial 
mark  a  point  midway  between  the  head  of  the  fibula  and  the  tuberosity  of  the 
tibia,  drop  one  inch,  and  draw  a  hne  from  the  second  point  to  the  middle  of 
the  front  of  the  ankle-joint. 

Anatomy. — The  anterior  tibial  artery  is  one  of  the  terminal  branches 
of  the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  forward  between  the  two  heads  of  the  posterior  tibial  muscle,  comes 
to  the  front  of  the  leg  through  an  opening  in  the  interosseous  membrane,  and 


Anterior  Tibial  Artery  489 

runs  down  to  the  middle  of  the  front  of  the  ankle-joint.  In  the  upper  two- 
thirds  of  its  course  it  rests  upon  the  interosseous  membrane,  to  which  it  is 
fastened  by  firm  fascia;  in  the  lower  third  it  lies  first  upon  the  front  of  the 
tibia  and  then  upon  the  anterior  ligament  of  the  ankle-joint.  For  its  upper 
two-thirds  the  artery  has  the  tibialis  anticus  muscle  just  external  to  it;  at  the 
junction  of  the  middle  and  lower  thirds  the  e.xtensor  proprius  pollicis  comes 
from  the  outside  and  lies  either  upon  the  artery  or  to  its  inner  side  for  the 
rest  of  its  course.  Externally  in  its  upper  third  is  the  extensor  communis 
digitorum;  in  the  middle  third  is  the  extensor  proprius  pollicis;  in  the  lower 
third,  the  proprius  pollicis  having  crossed  to  the  inner  side,  the  extensor 
communis  digitorum  again  becomes  the  outer  boundary.  The  artery  is 
covered  by  skin  and  by  superficial  and  deep  fascia.  In  its  upper  third  it  is 
deeply  placed  between  the  muscles;  in  its  middle  third  it  is  less  overlaid  by 
muscle;  in  its  lower  third  it  is  superficial  except  where  it  is  crossed  by  the 
extensor  proprius  and  where  it  is  covered  by  the  annular  ligament.  The 
artery  has  venae  comites.  In  the  lower  three-fourths  of  its  course  it  is  accom- 
panied by  the  anterior  tibial  nerve,  which  in  its  course  in  the  upper  third  of 
the  leg  is  external  to  the  artery;  in  the  middle  third  it  is  external  and  a  little 
in  front  of  the  arterv;  and  in  the  lower  third  it  is  external  to  or  upon  the  artery 
(PI.  4,  Fig.  5). 

Operations. — The  ligations  of  the  anterior  tibial  (PI.  4,  Fig.  6)  are  (i)  of 
the  lower  third;  (2)  of  the  middle  third;  and  (3)  of  the  upper  third.  In  all 
these  ligations  the  patient  is  placed  recumbent  with  the  leg  extended,  and  the 
surgeon  stands  to  the  outer  side  of  the  extremity,  cutting  from  above  down- 
ward on  the  right  side  and  from  below  upward  on  the  left  side. 

Ligation  of  the  Lower  Third. — Make  an  incision  three  inches  long  in  the 
line  of  the  artery  and  over  the  annular  ligament.  This  incision  is  external 
to  the  tibialis  anticus  muscle  and  half  an  inch  from  the  outer  border  of  the 
tibia  (Barker).  Divide  the  skin  and  fascia,  retract  the  tendon  of  the  tibialis 
anticus  inward,  and  the  tendon  of  the  extensor  proprius  pollicis  outward,  along 
with  the  tendons  of  the  extensor  communis.  Flex  the  ankle-joint  to  relax 
the  tendons,  and  clear  the  artery.  Draw  the  nerve  external  and  pass  the 
ligature  from  without  inward.  In  order  to  recognize  the  muscles  in  this  as 
in  other  ligations,  rely  largely  upon  the  finger  while  the  muscles  are  being 
moved. 

Ligation  of  the  Middle  Third. — In  this  operation  the  procedure  is  similar 
to  the  above.  Remember  that  the  nerve  lies  in  front  of  the  vessel  and  that 
the  extensor  proprius  pollicis  muscle  is  external.  The  nerve  is  retracted 
outward  and  the  needle  is  passed  from  the  nerve.  A  good  rule  for  detecting 
the  artery  is  to  find  the  outer  edge  of  the  tibia  and  by  this  locate  the  inter- 
osseous membrane,  and  then,  by  passing  out  along  this  membrane,  discover 
the  artery. 

Ligation  of  the  Upper  Third. — Make  an  incision  three  inches  long  in  the 
arterial  line.  On  opening  the  deep  fascia,  do  not  rely  on  the  eye  for  finding 
the  muscular  interspace,  as  often  the  latter  cannot  be  seen,  and  neither  a  white 
nor  a  yellow  line  is  reliable.  Place  the  index-finger  deep  in  the  wound  and 
have  the  tibiahs  anticus  and  extensor  communis  digitorum  muscles  successively 
rendered  tense  by  an  assistant.  In  opening  the  interspace  use  the  handle 
of  the  knife.     Relax  the  muscles,  retract  the  tibialis  anticus  inward  and  draw 


49°  Diseases  and  Injuries  of  the  Heart  and  Vessels 

the  extensor  cummunis  digitorum  outward.  Find  the  interosseous  membrane 
where  it  is  attached  to  the  edge  of  the  tibia,  and  the  artery  will  be  found  upon 
this  membrane,  between  the  tibia  and  the  nerve.  Clear  the  vessel  and  pass 
the  Hgature  from  without  inward  to  avoid  the  nerve. 

Posterior  Tibial  Artery. — The  line  of  the  posterior  tibial  is  from 
the  middle  of  the  popliteal  space  to  a  point  midway  between  the  tip  of  the 
inner  malleolus  and  the  point  of  the  heel  (PL  5,  Figs.  5,  6). 

Anatomy. — The  posterior  tibial  is  the  larger  of  the  two  terminal  branches 
of  the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  down  between  the  deep  and  superficial  l^exor .  muscles  to  midway 
between  the  tip  of  the  malleolus  and  the  point  of  the  heel,  and  divides  into  the 
external  and  internal  plantar  vessels.  In  the  upper  third  of  its  course  it  is 
very  deeply  placed  midway  between  the  tibia  and  fibula;  in  its  middle  third 
it  is  less  deep,  having  passed  inward;  and  in  its  lower  third  it  is  superficial. 
At  the  ankle  the  artery  is  beneath  the  annular  ligament.  From  above  down- 
ward the  posterior  tibial  artery  rests  upon  the  posterior  tibial  muscle,  the 
flexor  longus  digitorum  muscle,  the  posterior  surface  of  the  tibia,  and  the 
internal  lateral  ligament  of  the  ankle-joint.  For  the  first  inch  or  two  of  the 
course  of  the  artery  the  posterior  tibial  nerve  is  to  the  inner  side;  the  nerve 
then  crosses  to  the  outer  side,  and  remains  in  that  relative  position  throughout 
the  rest  of  the  course  of  the  artery.  When  the  knee  is  partly  flexed  and  the 
leg  is  laid  upon  its  outer  surface  the  artery  is  between  the  operator  and  the 
nerve,  and  the  nerve  is  between  the  artery  and  the  table.  Back  of  the  malleo- 
lus, in  the  first  compartment,  lies  the  posterior  tibial  muscle;  in  the  next  com- 
partment is  the  flexor  longus  digitorum  muscle;  in  the  next  compartment 
are  the  artery  and  nerve;  and  in  the  most  posterior  is  the  flexor  longus  pollicis 
muscle. 

Operations. — Ligation  Back  oj  the  Malleolus. — In  this  operation  the 
patient  is  placed  recumbent  with  the  thigh  abducted  and  the  leg  flexed  and 
resting  upon  its  outer  surface.  The  surgeon  stands  to  the  outer  side.  Make 
a  two-inch  semilunar  incision  corresponding  in  its  curve  to  the  malleolus  and 
half  an  inch  posterior  to  its  margin  (Fig.  228).  Cut  down  to  the  annular  liga- 
ment, incise  the  ligament,  and  find  the  artery  and  venae  comites.  Clear  the 
vessel  and  pass  the  needle  from  behind  forward  (to  avoid  the  nerve,  which  is 
here  posterior  and  external).  Do  not  make  the  preliminary  incision  nearer  the 
malleolus  than  half  an  inch,  as  the  sheath  of  the  tibialis  posticus  muscle  will 
then  surely  be  opened.  In  closing  the  wound,  suture  the  ligament  by  buried 
sutures  of  catgut  before  closing  the  superficial  parts  (PI.  5,  Fig.  6). 

Ligation  in  the  Middle  of  the  Leg. — In  this  operation  the  patient  is  placed 
in  the  same  position  as  for  the  hgation  back  of  the  malleolus.  Feel  for  the 
inner  border  of  the  tibia,  and  make  an  incision  four  inches  long  one  inch 
behind  the  osseous  border,  parallel  with  it,  and  extending  through  skin  and 
superficial  and  deep  fascia  (Fig.  228).  Draw  the  gastrocnemius  muscle  out- 
ward. Incise  the  soleus  muscle,  but  not  the  fascia  beneath  the  soleus;  cut  this 
fascia,  after  dropping  the  handle  of  the  knife  so  that  the  blade  is  at  right 
angles  with  the  plane  of  the  tibia.  Clear  the  artery;  pass  the  needle  from 
without  inward  (PL  5,  Fig.  6). 

The  popliteal  artery  is  almost  never  ligated  in  continuity.  It  can  be 
tied  at  the  upper  portion  of  the  popliteal  space,  at  the  lower  portion  of  the 
popliteal  space,  or  at  the  inner  side  of  the  thigh. 


LIGATIONS. 


Plate  5. 


Popliteal  Artery 


491 


Anatomy  (Fig.  226). — The  popliteal  artery  is  the  continuation  of  the 
femoral,  and  runs  from  the  opening  in  the  adductor  magnus  muscle  to  the 
lower  margin  of  the  popliteus  muscle.  This  vessel  runs  downward  and  out- 
ward behind  the  knee-joint  and  in  the  popliteal  space.  The  ham,  or  popliteal 
space,  is  a  lozenge-shaped  space,  which  above  the  joint  is  bounded  on  the 
outer  side  by  the  bicei)s  muscle,  and  on  the  inner  side  by  th^  semitendinosus, 
semimembranosus,  gracilis,  and  sartorius  muscles,  while  below  the  joint  it 
is  bounded  e.xternally  by  the  plantaris  and  outer  head  of  the  gastrocnemius 


Fig.  226.— Anatomy  of  popliteal  artery-  (Bernard 
and  Huette). 


Fig.  227. — Ligation  of   popliteal    artery  in    its 
upper  third  (Bernard  and  Huette). 


muscles,  and  internally  by  the  inner  head  of  the  gastrocnemius  muscle.  The 
floor  of  this  space  is  formed  by  the  surface  of  the  femur,  the  posterior  ligament 
of  the  knee-joint,  the  end  of  the  .tibia,  and  the  popliteus  fascia.  The  internal 
popliteal  nerve  passes  down  the  middle  of  the  popliteal  space;  it  is  superficial 
to  the  vessels  in  the  upper  half  of  the  space,  and  is  external  to  them ;  it  is  inter- 
nal to  the  vessels  in  the  lower  half  of  the  space.  The  external  popliteal 
nerve  is  in  the  outer  side  of  the  space.  The  popliteal  vein  is  between  the 
nerve  and  the  artery.  Above  the  knee-joint  it  is  to  the  outer  side  of  the 
artery,  but  below  the  knee-joint  it  is  to  the  inner  side.  The  artery  lies  deeply 
in  the  space. 

Ligation  in  Upper  Third. — Place  the  patient  prone.  The  surgeon  stands 
to  the  outer  side  of  the  limb  and  makes  a  vertical  incision  three  inches  in  length 
along  the  outer  margin  of  the  semimembranosus  muscle,  exposes  the  popliteal 
nerve,  retracts  the  muscle  inward  and  the  nerve  outward,  exposes  the  artery, 
separates  it  from  the  other  structures,  and  passes  the  needle  from  without 
inward  (Fig.  227). 

Ligation  in  Lower  Third. — Make  a  three-inch  vertical  incision  between 
the  heads  of  the  gastrocnemius  muscle.     Avoid  the  external  saphenous  vein 


492  Diseases  and  Injuries  of  the  Heart  and  Vessels 

and  nerve,  and  retract  them  with  the  popliteal  nerve.  Separate  the  artery 
from  the  vein  and  pass  the  needle  from  within  outward. 

Femoral  Artery.— The  line  of  the  femoral  artery  is  from  midway 
between  the  anterior  superior  spine  of  the  ilium  and  the  symphysis  pubis  to 
the  adductor  tubercle  on  the  inner  condyle  of  the  femur,  the  thigh  being 
abducted  and  resting  upon  its  outer  surface  (PI.  5,  Fig.  3). 

Anatomy. — The  femoral  artery  is  the  continuation  of  the  external  iliac 
trunk;  it  extends  from  the  lower  border  of  Poupart's  ligament  to  the  opening 
in  the  adductor  magnus  muscle,  and  hence  occupies  the  upper  two-thirds  of 
the  thigh.  The  artery  for  its  first  five  inches  is  superficial,  lying  in  Scarpa's 
triangle,  a  space  which  is  bounded  externally  by  the  sartorius  muscle  and 
internally  by  the  adductor  longus,  its  base  being  Poupart's  ligament  and  its 
floor  being  composed  of  the  psoas,  iliacus,  pectineus,  and  adductor  longus 
muscles,  and  often  the  adductor  brevis.  The  artery  enters  the  triangle  as 
the  common  femoral,  but  after  *a  two-inch  course  it  divides  into  the  profunda 
(which  passes  deeply)  and  the  superficial  femoral.  The  latter  vessel  is  the 
one  alluded  to  in  this  section. 

At  the  base  of  Scarpa's  triangle  the  vein  is  internal,  the  artery  is  between, 
and  the  nerve  is  external  (v.  A.  N.).  At  the  apex  of  the  triangle  the  vein  is 
internal  and  a  little  posterior.  At  the  apex  of  the  triangle  the  superficial 
femoral  passes  under  the  sartorius  muscle  and  enters  into  Hunter's  canal, 
which  occupies  the  middle  third  of  the  thigh  and  which  terminates  at  an 
opening  in  the  adductor  magnus  muscle.  Hunter's  canal  is  bounded  ex- 
ternally by  the  vastus  internus  muscle,  internally  by  the  adductors  longus 
and  magnus,  and  its  roof  is  fascia  which  stretches  from  the  adductor  longus 
to  the  vastus  internus.  In  Hunter's  canal  the  vein  is  behind  the  artery  in  the 
upper  part,  but  external  to  it  in  the  lower  part,  and  is  firmly  attached  to  the 
artery.  There  may  be  two  veins.  Inside  Hunter's  canal,  but  outside  the 
femoral  sheath,  is  the  long  saphenous  nerve,  which  crosses  the  artery  from 
without  inward. 

A  way  to  remember  the  relation  of  the  femoral  vein  to  the  femoral  artery 
is  to  recall  the  fact  that  the  relation  of  the  vein  to  the  artery  is  always  con- 
trary to  the  relation  of  the  sartorius  muscle  to  the  artery:  when  the  sartorius 
muscle  is  external  to  the  artery,  the  vein  is  internal,  as  at  the  base  of  Scarpa's 
triangle;  when  the  sartorius  muscle  is  crossing  in  front  toward  the  inside  of 
the  artery,  the  vein  is  passing  at  the  back  to  the  outside,  as  at  the  apex  of 
Scarpa's  triangle;  when  the  muscle  is  over  the  artery,  the  vein  is  back  of  it, 
as  in  the  upper  third  of  Hunter's  canal;  and  when  the  muscle  is  to  the  inside 
of  the  artery,  the  vein  is  to  the  outside,  as  in  the  lower  two-thirds  of  Hunter's 
canal.  In  a  ligation  at  the  apex  of  Scarpa's  triangle  the  inner  edge  of  the 
sartorius  is  the  guide.  In  a  ligation  in  Hunter's  canal  the  long  saphenous 
nerve  is  the  guide. 

Operations. — Ligation  oj  the  Superficial  Femoral  at  the  Apex  oj  Scarpa's 
Triangle. — In  this  operation  the  position  of  the  patient  is  supine  with  the 
thigh  and  leg  partly  flexed,  and  the  thigh  abducted,  everted,  and  rested  upon 
its  outer  surface  on  a  pillow.  The  operator  stands  to  the  outer  side  of  the 
extremity.  From  a  point  corresponding  to  the  middle  of  Scarpa's  triangle, 
and  two  and  a  half  inches  below  Poupart's  ligament,  make  a  three-inch  inci- 
sion in  the  arterial  line  (Fig.  228).     Cut  the  skin  and  superficial  fascia.     The 


Iliac  Arteries 


493 


saphenous  vein  will  not  be  seen  unless  the  incision  is  internal  to  the  arterial 
line;  if  this  vein  is  seen,  draw  it  inward.  Open  the  fascia  lata,  firid  the  inner 
border  of  the  sartorius  muscle,  and  draw  it  outward.  The  fibers  of  this 
muscle  run  downward  and  inward,  thus  distinguishing  it  from  the  adductor 
longus,  whose  fibers  run  downward  and  outward.  Open  the  common  sheath 
for  the  artery  and  vein,  and  then  incise  the  individual  arterial  sheath.  Clear 
the  artery  and  pass  the  ligature  from  within  outward  (PI.  5,  Fig.  4). 

Ligation  oj  the  Superficial  Femoral  in  Hunter's  Canal. — This  operation 
was  lirst  performed  for  aneurysm  by  John  Hunter  in  1785.     In  this  operation 


Fig.  228. — The  lines  indicate  the  incision  to  be  made  for  the  ligature  of  the  common  femoral,  of 
the  femoral  in  Scarpa's  triangle  and  in  Hunter's  canal,  and  of  the  posterior  tibial  in  the  calf  and 
behind  the  malleolus  (MacCormac). 


the  position  of  the  patient  is  the  same  as  in  the  ligation  at  the  apex  of  Scai-pa's 
triangle.  Make  a  three-inch  incision  in  the  middle  third  of  the  thigh, 
parallel  with  the  arterial  line  and  half  an  inch  internal  to  it  (Barker) 
(Fig.  228).  Incise  the  skin  and  superficial  fascia,  look  out  for  the  internal 
saphenous  vein,  open  the  fascia  lata,  find  the  sartorius  muscle,  and  retract  it 
inward,  thus  exposing  the  roof  of  Hunter's  canal,  which  is  to  be  opened  for  an 
inch  or  more.  Within  the  canal  is  seen  the  long  saphenous  nerve,  usually 
upon  the  sheath.  Open  the  sheath  of  the  artery,  clear  the  vessel,  and  pass  the 
needle  from  without  inward. 

Results. — Ligation  at  the  apex  of  Scarpa's  triangle  is  a  method  for 
treating  popliteal  aneurysm.  It  is  a  very  successful  procedure.  I  have  per- 
formed it  three  times  with  success  and  have  assisted  other  operators  in  3 
successful  cases.  Syme  successfully  ligated  the  femoral  about  its  middle 
twenty-three  consecutive  times,  and  in  Guy's  hospital  the  same  operation  was 
done  twenty-four  times  with  i  death  ("Practice  of  Surgery,"  by  Thomas  D. 
Bryant) . 

Iliac  Arteries. — The  line  of  the  common  and  external  iliac  arteries  is 
from  a  point  half  an  inch  below  and  half  an  inch  to  the  left  of  the  umbilicus 


494  Diseases  and  Injuries  of  the  Heart  and  Vessels 

to  midway  between  the  anterior  superior  spine  of  the  ilium  and  the  pubic 
symphysis.  The  upper  third  of  this  hne  represents  the  common  ihac,  and 
the  lower  two-thirds  the  external  iliac  (PI.  2,  Fig.  4). 

Anatomy. — The  common  iliac  arteries  arise  from  the  aorta  opposite  the 
left  side  and  lower  border  of  the  fourth  lumbar  vertebra,  and  extend  to  the 
upper  margin  of  the  right  and  left  sacro-iliac  joints,  where  they  each  bifurcate 
into  an  external  and  an  internal  iliac.  The  common  iliac  arteries  he  upon 
the  fifth  lumbar  vertebra,  are  covered  with  peritoneum,  and  are  crossed  by 
the  ureters.  In  women  the  ovarian  arteries  cross  the  common  iliacs.  Each 
common  iliac  vein  lies  to  the  right  side  of  its  associated  artery.  The  right 
common  iliac  artery  has  in  front  of  it,  besides  the  peritoneum  and  ureter  (in 
women  also  the  ovarian  artery),  the  ileum,  branches  of  the  superior  mesenteric 
artery,  and  branches  of  the  sympathetic  nerve.  The  left  common  iliac  artery 
has  in  front  of  it,  in  addition  to  structures  common  to  both  sides  (ureter, 
ovarian  artery,  sympathetic  branches),  branches  of  the  inferior  mesenteric 
artery  and  the  sigmoid  flexure  with  its  mesocolon.  The  internal  iliac  artery 
runs  from  the  sacro-iliac  joint  to  the  upper  margin  of  the  great  sacrosciatic 
foramen.  It  is  very  rarely  ligated  (only  for  gluteal  aneurysm,  for  uncontrol- 
lable hemorrhage  from  the  gluteal  or  sciatic  arteries,  or  to  produce  atrophy 
of  the  prostate  gland).  The  external  iliac  artery  runs  from  the  sacro-ihac 
joint  along  the  pelvic  brim,  upon  the  inner  edge  of  the  psoas  muscle,  to 
Poupart's  ligament.  The  external  iliac  vein  is  internal  to  the  artery.  On 
the  right  side,  high  up,  it  passes  behind  the  artery.  The  external  iliac  artery 
has  in  front  of  it  peritoneum  and  subserous  tissue  (Abernethy's  fascia).  The 
ileum  crosses  the  right,  and  the  sigmoid  flexure  crosses  the  left,  external  iliac 
artery.  The  genital  branch  of  the  genitocrural  nerve  crosses  the  artery  low 
down,  and  the  circumflex  iliac  vein  crosses  it  just  before  it  terminates  in  the 
femoral.  The  spermatic  vessels  and  the  vas  deferens  in  the  male,  and  the 
ovarian  vessels  in  the  female,  lie  upon  the  artery  near  its  termination.  Some- 
times the  ureter  crosses  the  vessel  near  its  point  of  origin. 

Ligation  oj  the  Iliac  Arteries  after  Abdominal  Section. — The  best  method 
for  ligating  the  common,  the  external,  or  the  internal  iliac  is  by  abdominal 
section.  The  patient  is  placed  in  the  Trendelenburg  position.  The  abdomen 
is  opened  in  the  midline  below  the  umbilicus  or  in  the  semilunar  line  of  the 
diseased  side.  The  intestines  are  lifted  toward  the  diaphragm,  and  are  held 
up  by  gauze  pads.  The  edges  of  the  incision  are  retracted.  The  vessel  to 
be  tied  is  located  and  the  point  for  ligation  is  selected.  The  posterior  layer 
of  the  peritoneum  is  opened  over  the  selected  point,  the  vessel  is  cleared,  and 
the  threaded  Dupuytren's  aneurysm  needle  is  passed  in  a  direction  away 
from  the  vein.  In  ligating  either  common  iliac,  pass  the  needle  from  right  to 
left.  In  ligating  the  external  iliac,  pass  the  ligature  from  within  outward. 
It  is  not  necessary  to  suture  the  posterior  layer  of  peritoneum.  The  abdo- 
men is  closed  without  a  drain.  In  these  operations  be  sure  to  push  the  ureter 
out  of  the  way.  This  method  of  operating  is  indorsed  by  Dennis,  Hearn. 
Marmaduke  Shield,  Mitchell  Banks,  and  others  who  have  employed  it. 

Results:  Bryant  ("Operative  Surgery")  alludes  to  5  reported  cases  of 
transperitoneal  ligation  of  the  common  iliac  artery  with  i  death. 

Ligation  oj  the  Common  Iliac  Artery  by  the  Extraperitoneal  Method. — The 
common  iliac  artery  was  tied  unsuccessfully  by  Dr.  Wm.  Gibson  in  181 2.     It 


Iliac  Arteries  495 

was  first  successfully  ligated  by  Valentine  Mott  in  1827.  The  patient  is  placed 
recumbent  or  in  the  Trendelenburg  position.  The  body  is  then  turned  a  little 
to  the  opposite  side  and  the  thighs  are  partly  flexed.  Bryant  says  there  are 
two  linear  guides  for  this  artery.  Crampton's  line  is  drawn  from  "the  apex 
of  the  cartilage  of  the  last  rib  downward  and  a  little  forward  nearly  to  the 
crest  of  the  ilium,  then  carried  forward  parallel  with  it  to  a  little  below  the 
anterior  superior  spine"  ("Operative  Surgery,"  by  Joseph  D.  Bryant). 
McKees'  line  is  "  drawn  from  the  tip  of  the  cartilage  of  the  eleventh  rib  to  a 
point  an  inch  and  a  half  within  the  anterior  superior  spine,  then  curved  down- 
ward, forward,  and  inward,  and  terminating  abruptly  above  the  internal 
abdominal  ring"  ("Operative  Surgery,"  by  Joseph  D.  Bryant). 

The  incision  can  be  begun  just  external  to  the  internal  abdominal  ring 
and  be  curved  upward  and  outward  as  in  ligation  of  the  external  iliac,  but 
Crampton's  incision  gives  more  room.  The  superficial  tissues  are  divided 
down  to  the  transversalis  fascia,  this  structure  is  nicked  and  divided,  and  the 
exposed  and  unopened  peritoneum  is  rolled  upward  and  inward.  The 
muscular  guide  is  the  inner  border  of  the  psoas  magnus  muscle.  By  its  side 
an  artery  is  felt.  If  the  sacrovertebral  prominence  is  above  the  vessel  touched, 
the  artery  is  the  external  iliac;  otherwise  it  is  the  common  iliac.  If  the  ex- 
ternal iliac  is  the  vessel  first  exposed,  follow  it  up  to  find  the  common  trunk. 
When  the  common  iliac  is  found,  separate  the  fatty  tissue  about  it  and  pass 
the  ligature  from  the  right  toward  the  left  in  order  to  avoid  the  associated 
vein. 

Results:  Jos.  D.  Bryant  tells  us  that  this  vessel  has  been  ligated  by  the 
extraperitoneal  method  sixty-nine  times  with  only  16  recoveries,  but  it  is  to 
be  remembered  that  many  of  these  operations  were  in  preantiseptic  days. 
The  artery  has  been  tied  80  times  with  56  deaths  (70  per  cent.). 

Twenty-one  of  these  operations  were  done  since  1880;  there  were  10  deaths 
(mortality  of  nearly  48  per  cent.).  In  these  21  cases  gangrene  occurred  7 
times.     (See  Wm.  J.  Gillette  in  "Annals  of  Surgery,  July,  1908). 

Ligation  of  the  Internal  Iliac  Artery. — This  operation  was  first  performed 
by  Stevens,  of  Vera  Cruz,  in  1812  ("Practice  of  Surgery,"  by  Thomas  Bry- 
ant) .  The  incision  and  the  method  of  exposing  the  vessel  are  identical  with 
like  steps  in  the  ligation  of  the  common  iliac. 

Results:  Of  26  ligations  of  this  vessel  recorded,  18  were  fatal,  but  only 
a  few  of  the  cases  were  done  antiseptically  (Joseph  D.  Bryant's  "  Operative 
Surgery"). 

Ligation  of  the  External  Iliac  by  Abernethy s  Extraperitoneal  Method  (PI. 
2,  Fig.  4). — The  external  iliac  artery  was  first  ligated  by  Abernethy  in  1796. 
The  operation  failed,  but  he  did  the  first  successful  operation  in  1806.  The 
patient  is  placed  recumbent  with  the  thighs  extended  during  the  first  incisions; 
but  in  the  later  stages  of  the  operation  the  thighs  are  flexed  a  little,  to  relax 
the  abdominal  structures.  The  operator  stands  to  the  outer  side.  The 
surgeon  will  find  the  artery  by  the  side  of  the  psoas  muscle.  Mark  a  pomt 
one  inch  above  and  one  inch  external  to  the  middle  of  Poupart's  Hgament, 
and  another  point  one  inch  above  aAd  one  inch  internal  to  the  anterior  superior 
iliac  spine  (Barker).  Join  these  two  points  by  a  curved  incision  four  inches 
long  and  convex  downward.  Cut  the  skin,  the  fat,  the  two  oblique  muscles,  and 
the  transversalis  muscle;  open  the  transversalis  fascia,  separate  the  peritoneum 


496 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


toward  the  vessels,  and  draw  it  inward  by  a  broad  retractor,  and  look  for  the 
artery  along  the  pelvic  brim.  The  anterior  crural  nerve  is  seen  to  the  outer 
side  of  the  artery,  the  external  iliac  vein  is  to  the  inner  side  of  the  artery,  and 
the  genitocrural  nerve  is  upon  the  artery.  Clear  the  artery  near  its  middle 
and  pass  the  ligature  from  within  outward.     In  Sir  Astley  Cooper's  method 


Fig.  22g.—A,  Nephrotomy:  a,  last  dorsal  n. ;  i^,  latissimus  dorsal  m. ;  c,  serratus  post,  inferior 
m. ;  d,  middle  layer  of  lumbar  fascia  ;  e,  outer  layer  ;  /,  ext.  oblique  m. ;  £-,  int.  oblique  m.  ;  h,  peri- 
nephritic  (extraperitoneal)  fat ;  z,  quadratus  lumborum  m.  ;  j\  erector  spinae  m.  £,  Nephrotomy  :  a, 
first  lumbar  n.  ;  b,  kidney  ;  c,  transversalis  fascia.  C,  Ligature  of  the  sciatic  and  internal  pudic 
arteries,  and  exposure  of  the  great  sciatic,  small  sciatic,  and  internal  pudic  nerves:  a,  glutseus  maxi- 
mus  m. ;  6,  inf.  gluteal  n.  ;  c,  sciatic  a. ;  d,  int.  pudic  a.  and  n.  ;  e,  great  sciatic  n.  ;  /,  small  sciatic  n.  ; 
g-,  pyriformis  m.  D,  Ligature  of  the  gluteal  artery  and  exposure  of  the  superior  gluteal  nerve :  a, 
glutaeus  maximus  m. ;  6,  gluteal  a. ;  c,  superior  gluteal  n.  ;  d,  pyriformis  m. ;  <?,  glutseus  medius  m. 
(Kocher). 


of  hgation  the  inguinal  canal  is  opened;  in  Abernethy's  method  the  inguinal 
canal  is  not  opened. 

The  Gluteal  Artery.— This  vessel  is  a  continuation  of  the  posterior 
division  of  the  internal  iliac.  It  emerges  from  the  great  sacrosciatic  foramen 
at  the  upper  border  of  the  pyriformis  muscle.  It  rests  upon  the  glutaeus 
minimus,  divides  into  three  branches,  and  is  covered  by  the  glutaeus  maximus 
muscle.     The  superior  gluteal  nerve  lies  inferior  to  the  artery  (Fig.  229). 


Sciatic  Artery 


497 


Ligation. — The  patient  should  be  prone.  The  surgeon  stands  to  the  outer 
side.  The  incision  corresponds  to  a  Hne  drawn  from  the  posterior  superior 
iliac  spine  to  the  upper  border  of  the  great  trochanter  (Fig.  230).  Divide  the 
skin,  fascia,  glutasus  maximus  muscle,  and  the  fascia  over  the  gluteus  medius 
muscle,  and  retract  the  glutaeus  medius  upward.  Feel  for  the  great  sacro- 
sciatic  foramen,  and  at  this 
point  the  artery  is  found 
above  the  pyriformis  mus- 
cle. Clear  the  vessel  and 
pass  the  needle  from  below 
upward  (see  Kocher's  "  Op- 
erative Surgery").  There 
is  practically  no  mortality 
from  this  operation. 

The  Sciatic  Artery. 
■ — This  artery  is  the  larger 
of  the  terminal  branches  of 
the  anterior  division  of  the 
internal  iliac  artery.  It 
passes  to  the  lower  portion 
of  the  great  sacrosciatic 
foramen,  lying  back  of  the 
internal  pudic  artery,  and 
resting  upon  the  sacral 
plexus  of  nerves  and  pyri- 
formis muscle  (Gray).  It 
leaves  the  pelvis  between 
the  pyriformis  and  coccy- 
geus  muscles,  and  passes 
downward  between  the 
ischial  tuberosity  and  great 
trochanter.  It .  is  covered 
by  the  gluteus  maximus 
muscle,  rests  upon  the 
gemelli,  internal  obturator 
and  quadratus  femoris 
muscles,  has  the  great 
sciatic  nerve  external  to  it, 
and  the  small  sciatic  nerve 
external  and  posterior  (Fig. 
229). 

Ligation. — The  patient 
lies  prone.  The  surgeon 
stands  to  the  outer  side.  The  incision  "corresponds  to  the  middle  two- 
thirds  of  a  line  extending  from  the  posterior  inferior  iliac  spine  to  the  base 
of  the  great  trochanter."*  MacCormac  advises  the  incision  shown  in 
Fig,  230).  Divide  the  skin,  fat,  fascia,  and  the  glutaeus  maximus  muscle. 
Find  the  artery  at  the  lower  border  of  the  pyriformis  muscle  and  trace  it  to 
*  Kocher's  "  Operative  Surgery,"  by  Stiles. 
32 


Fig.  230.— Position  and  direction  of  the  superficial  incisions 
which  must  be  made  in  order  to  secure  the  gluteal  artery  and 
the  sciatic  and  pudic  arteries  :  A ,  Posterior  superior  iliac  spine ; 
£,  great  trochanter;  C,  tuberosity  of  the  ischium  ;  £>,  anterior 
superior  iliac  spine;  A  £,  iliotrochanteric  line,  divided  into 
thirds.  This  line  corresponds  in  direction  with  the  fibers  of 
the  glutaeus  maximus  muscle.  The  incision  to  reach  the  glu- 
teal artery  is  indicated  by  the  darker  portion  of  the  line.  Its 
center  is  at  the  junction  of  the  upper  and  middle  thirds  of  the 
iliotrochanteric  line,  and  exactly  corresponds  with  the  point 
of  emergence  of  the  gluteal  artery  from  the  great  sciatic  notch. 
A  C,  ilio-ischiatic  line.  The  incision  to  reach  the  sciatic 
artery  and  internal  pudic  is  indicated  by  the  lower  dark  line. 
It  is  also  to  be  made  in  the  direction  of  the  fibers  of  the  glu- 
tasus  maximus  muscle.  The  center  of  the  wound  corresponds 
to  the  junction  of  the  lower  with  the  middle  third  of  the  ilio- 
ischiatic  line  (MacCormac). 


498  Diseases  and  Injuries  of  the  Heart  and  Vessels 

its   point   of  emergence   from   the   pelvis.     Pass   the   ligature   from   without 
inward.     There  is  practically  no  mortality  from  this  operation. 

Internal  Pudic  Artery.— This  artery  is  one  of  the  terminal  branches 
of  the  anterior  trunk  of  the  internal  ihac.  It  passes  to  the  lower  margin  of 
the  great  sacrosciatic  foramen,  and  leaves  the  pelvis  between  the  pyriformis 
and  coccygeus  muscles,  crosses  the  ischial  spine,  and  again  enters  the  pelvis 
by  the  lesser  sacrosciatic  foramen.  The  vessel  is  accompanied  by  the  internal 
pudic  nerve  (Fig.  229). 

Ligation. — The  position  of  the  patient  and  the  incision  are  the  same  as 
for  ligation  of  the  sciatic  artery  (Fig.  230).  ■  The  artery  is  found  below  the 
ischial  spine.  Pass  the  needle  from  below  upward  to  avoid  the  nerve.  There 
is  practically  no  mortality  from  this  operation. 

Ligation  of  the  Abdominal  Aorta. — This  operation  was  first  per- 
formed by  Sir  Astley  Cooper  in  181 7.  The  patient  hved  but  a  few  hours. 
Fifteen  cases  of  ligation  of  the  aorta  have  been  published,  and  there  were  15 
deaths,  but  only  4  of  these  cases  were  aseptic  operations.  The  patient  of 
Monteiro,  of  Rio  Janeiro,  lived  for  ten  days.  The  circulation  was  entirely 
restored  in  the  limbs,  and  the  man  died  from  hemorrhage  resulting  from  the 
ulceration  produced  b}-  a  septic  ligature.  Keen's  case  hved  for  forty-eight 
days  after  ligation  just  below  the  diaphragm.  The  urinary  secretion  was 
plentiful  and  the  circulation  in  the  lower  extremities  was  restored,  death 
resulting  from  cutting  through  of  the  hgature.  Robt.  T.  ^Morris  performed 
distal  ligation  below  an  aneurysm.  He  encircled  the  aorta  with  a  soft-rubber 
catheter  and  clamped  it  with  forceps.  Twenty-two  hours  after  operation 
the  aneurysm  began  to  shrink,  and  in  three  hours  more  had  apparently  dis- 
appeared. Twenty-seven  hours  after  operation  the  clamp  and  catheter  were 
removed.  The  patient  died  of  septicemia  fifty-three  hours  after  operation. 
The  necropsy  disclosed  gangrene  of  a  bit  of  intestine  which  had  been  in  con- 
tact with  the  forceps,  but  the  dissecting  aneurysm  was  filled  with  solid  clot, 
the  aorta  was  patent,  and  the  circulation  in  the  extremities  was  re-estabhshed 
("  Amer.  Jour,  of  Med.  Sciences,"  Sept.,  1900).  These  cases  prove  that  under 
certain  circumstances  the  operation  is  feasible,  and  in  desperate  cases  it  must 
be  considered  as  a  possible  means  of  treatment. 

Murray  Operation. — This  procedure  aims  to  avoid  opening  the  peritoneum. 
An  incision  is  made  from  just  below  the  tip  of  the  tenth  rib  to  a  point  one  inch 
internal  to  the  anterior  superior  ihac  spine.  The  peritoneum  is  separated 
from  the  abdominal  w^all  until  the  vessel  is  reached.  Cooper's  operation  by 
abdominal  section  is  the  preferable  procedure. 

Operation  by  Abdominal  Section  {Cooper's  Operation);  Instruments  Re- 
quired.— Those  used  in  any  ligation,  with  the  addition  of  an  aneurysm  needle 
with  a  large  curve  and  a  very  long  handle.  With  an  ordinary  instrument  it 
is  extremely  difficult  to  pass  the  hgature.  It  would  be  a  great  advantage  to 
use  an  instrument  which,  after  being  passed  under  the  vessel,  could  have  a 
central  eyed  shaft  projected,  as  is  the  center  shaft  of  a  Bellocq  cannula.  Floss 
silk  is  probably  the  best  hgature  material. 

If  the  patient  is  much  exhausted,  an  assistant  should  infuse  salt  solution 
in  a  vein  during  the  operation.  In  Keen's  case  there  was  profound  shock, 
but  the  moment  the  ligature  was  tightened  it  passed  away. 

Operation. — The  patient  should  be  placed  upon  his  back.     The  surgeon 


Ligation  of  the  Abdominal  Aorta  499 

stands  to  the  right  of  the  patient  and  opens  the  abdomen  in  the  median  line, 
a  httle  above  the  level  of  the  aneurysm.  The  intestines  are  packed  aside, 
the  posterior  layer  of  the  peritoneum  is  divided,  the  surface  of  the  aorta  over 
a  small  area  is  cleared  of  nerves,  the  plexuses  being  separated  with  a  blunt 
dissector. 

The  needle  is  passed  from  right  to  left.  A  double  ligature  of  floss  silk 
should  be  passed  and  the  ends  should  be  tied  with  a  stay-knot.  The  wound  is 
closed  and  dressed. 

It  has  been  suggested— I  think  b\-  Wyeth — that  it  might  be  wise  to  only 
partially  tighten  the  ligature  at  tirst,  completing  the  occlusion  of  the  artery 
after  a  day  or  two.  Such  a  procedure  would  certainly  give  a  better  chance 
for  the  collaterals  to  dilate,  and  restore  circulation  in  the  legs. 

Unfortunately,  in  an  aneurysm,  the  vessel  will  usually  be  extensively 
diseased,  and  ligation  will  be  out  of  the  question.  If,  however,  a  normal 
region  is  found,  the  chance  of  success  in  a  case  of  aneurysm  will  be  greater 
than  in  a  case  of  hemorrhage  from  a  branch  of  the  aorta,  because,  in  a  case 
of  aneurysm,  the  probabilities  are  that  the  collaterals  are  somewhat  distended 
before  a  ligature  is  appUed. 


500  Diseases  and  Injuries  of  Bones  and  Joints 


XIX.  DISEASES  AND  INJURIES  OF  BONES  AND  JOINTS. 

Diseases  of  the  Bones. 

Atrophy  of  bone  is  a  diminution  in  the  amount  of  bony  matter  without 
change  in  osseous  structure.  It  arises  from  want  of  use  (as  seen  in  the  wasting 
of  the  bone  of  a  stump)  or  from  pressure  (as  seen  in  the  destruction  of  the 
sternum  by  an  aneurysm  of  the  aorta).  Eccentric  atrophy  is  the  thinning 
of  a  long  bone  from  within,  the  outer  surface  being  unchanged.  It  is  usually 
a  senile  change.  Concentric  atrophy  means  a  thinning  of  the  outer  surface 
of  the  shaft,  causing  a  lessened  diameter.  It  is  usually  linked  with  eccentric 
atrophy. 

Hypertrophy  of  bone  may  be  due  to  increased  blood-supply  (as  is 
seen  in  chronic  epiphyseal  inflammation),  the  bone  growing  much  more  than 
does  its  fellow.  It  may  arise  from  excessive  use  or  from  strain,  as  is  seen  in 
the  increased  size  of  the  fibula  when  the  tibia  is  congenitally  absent. 

Tumors  of  Bone. — Bones  give  origin  to  both  innocent  and  malignant 
tumors.  Myeloid  sarcoma  takes  origin  in  the  endosteum  and  expands  the 
bone.  The  fasciculated  sarcoma  is  a  periosteal  growth.  Besides  these 
growths  there  may  develop  an  osteoma,  a  chondroma,  and  secondary  deposits 
of  cancer  and  sarcoma.  There  is  no  such  thing  as  primary  cancer  of  bone. 
A  bone  may  become  cystic,  and  occasionally  the  cysts  are  due  to  hydatids. 
Gummata  are  frequently  met  with. 

Cysts  and  Cystomata  of  Bone. — One  variety  of  cyst  is  found  in  the 
jaws  (dentigerous  cysts,  page  355).  The  other  variety  occurs  usually  in  the 
medullary  canal  of  long  bones  and  very  seldom  in  short  bones  and  flat 
bones.  "It  differs  from  the  dentigerous  cyst  in  the  absence  of  a  connective- 
tissue  capsule.  The  fluid  is  usually  hemorrhagic.  Islands  of  cartilage  may 
be  found  in  the  bone  capsule"  (Bloodgood,  in  "Progressive  Medicine,"  Dec. 
I,  1907). 

A  bone-cyst  slowly  expands  and  thins  the  shaft  of  the  bone,  and  in  some 
cases  fracture  of  the  bone  is  the  first  evidence  of  the  trouble.  Union  takes 
place  after  fracture,  but  the  enlargement  remains.  The  x-ray  picture  does 
not  enable  us  to  make  the  diagnosis,  because  it  exactly  resembles  the  picture 
of  any  medullary  growth  possessed  of  a  bony  capsule  and  producing  osseous 
absorption. 

The  diagnosis  is  proved  by  exploratory  incision  and  the  condition  is  treated 
by  curettement  and  drainage. 

Many  bone-cysts  are  produced  by  softening  of  sohd  neoplasms  (sarcoma, 
myxoma,  medullary  fibroma,  chondroma) .  Occasionally  cysts  form  in  osteo- 
malacia and  osteitis  deformans,  the  condition  arising  from  softening.  Hydatid 
cysts  and  dermoid  cysts  are  sometimes  encountered.  A  true  cystoma  of  bone, 
except  in  one  of  the  jaws,  is  a  surgical  rarity.  In  the  jaws  cystomata  are  not 
very  uncommon. 

Syphilis  of  bone  (see  page  322), 

Actinomycosis  of  bone  is  most  usual  in  the  jaw,  but  may  attack  the 
orbit,  ribs,  sternum,  or  Hmbs  (see  page  309).     Actinomycosis  of  bone  may 


Osteitis,  Periostitis,  and  Osteoperiostitis  501 

arise  secondarily  after  infection  of  superficial  parts  with  the  ray-fungus.  In  the 
jaw  the  fungus  obtains  entrance  to  the  interior  of  the  bone  through  a  tooth 
socket.  In  some  cases  of  bone  actinomycosis  the  fungus  reaches  the  bone  by 
the  blood.  Actinomycosis  leads  to  the  production  of  granulation  tissue,  the 
bone  is  expanded  and  becomes  carious,  and  a  quandty  of  new  bone  is  some- 
times produced.  In  vertebral  actinomycosis,  although  the  condition  resembles 
tuberculosis,  angular  deformity  does  not  occur. 

Tuberculosis  of  bone  {tuberculous  osteomyelitis)  tends  especially  to 
appear  in  the  cancellous  ends  of  long  bones.  In  about  one-fifth  of  the  cases  it 
is  primary,  that  is,  only  one  focus  can  be  found.  In  such  cases  the  point  of 
entry  shows  no  lesion,  or  the  lesion  at  that  point  may  have  healed.  In  some 
cases  the  bacilli  enters  through  the  tissue.  Trauma  may  be  an  excidng  cause. 
Long  after  apparent  healing  the  disease  process  may  awaken  into  activity  and 
trauma  is  often  the  cause  of  the  awakening  (Konig) .  In  one  of  Konig's  cases 
trouble  began  anew  after  sixty  years.  The  disease  is  especially  apt  to  attack" 
the  epiphysis  and  spread  to  the  joint,  although  in  some  cases  it  spreads  to  the 
shaft.  Primary  tuberculosis  is  rare  in  the  shafts  of  long  bones,  but  is  not  un- 
common in  the  shafts  of  short  bones.  A  bone  focus  leads  to  the  formation  of  a 
bone  cavity  which  may  contain  tuberculous  granuladons  or  bone  sequestra. 
The  sequestra  in  tuberculous  osteomyelitis  are  not  completely  loose,  but  are 
still  attached  at  some  point.  The  bone  may  sclerose  or  may  undergo  altera- 
tions of  an  osteoporotic  nature,  making  it  soft.  Sclerotic  bone  means  a  healing 
process.  Softened  bone  means  a  spreading  process.  A  sequestrum  in  tuber- 
culous osteomyelitis  is  usually  wedge-shaped,  the  base  being  toward  the  joint. 
A  sequestrum  is  due,  Konig  thinks,  to  the  obstruction  of  a  terminal  artery  by  a 
tuberculous  embolus  or  by  the  intra-arterial  growth  of  bacilli  (''Die  Tubercu- 
lose  der  Menschlichen  Gelenke,  swiel  der  Brustwand  und  des  Schaedels"). 
In  a  certain  number  of  cases  tuberculosis  infiltrates  a  spongy  bone  with  great 
rapidity  because  of  rapid  caseation.  This  condition  is  known  as  infiltrating 
progressive  bone  tuberculosis  (see  page  252). 

Osteitis,  Periostitis,  and  Osteoperiostitis.— Osteitis,  or  inflam- 
mation of  bone,  may  be  due  to  traumatism,  to  a  constitutional  malady 
or  diathesis,  to  the  extension  of  inflammation  from  some  other  structure,  to 
certain  fevers,  to  cold,  to  phosphorus  or  mercury,  to  infection,  or  to  working  in 
pearl  button  factories.  In  inflammation  of  bone  the  exudate  and  leukocytes 
pass  into  the  Haversian  canals,  spaces,  and  canaliculi.  The  bone  corpuscles 
proliferate  and  the  bone  undergoes  thinning  (rarefaction) ,  not  because  of  pres- 
sure, but  because  of  absorption  by  voracious  leukocytes  and  osteoclasts.  This 
process  of  rarefaction  enlarges  all  the  bony  spaces,  and  by  destroying  septa 
throws  many  of  the  spaces  into  one.  If  the  surface  of  a  bone  inflames,  the 
periosteum  will  be  separated  more  or  less  by  exudation,  and  the  bone  will  be 
covered  with  little  pits  or  erosions  made  by  the  leukocytes.  Inflamed  bone 
is  so  soft  that  it  can  readily  be  cut  with  a  knife. 

Pearl  ivorkers^  osteitis  occurs  particularly  in  youths  before  fusion  of  the 
epiphyses.  It  arises  in  the  diaphysis  by  the  epiphysis.  The  bones  of  the 
limbs  are  most  apt  to  suffer, but  the  bones  of  the  faceor  chest  maybe  attacked. 
The  attack  begins  with  pain  and  moderately  elevated  temperature  and  the 
fever  may  persist  for  several  weeks.     The  condition  may  apparently  get  well 


502  Diseases  and  Injuries  of  Bones  and  Joints 

and  yet  begin  again  when  the  patient  returns  to  work.  The  lesions  are  often 
symmetric  and  always  multiple  (Broca).  It  is  a  condensing  osteitis  and 
undergoes  spontaneous  cure  if  the  patient  gives  up  the  occupation  (Deturk,  in 
"Archives  Generales  de  Chirurgie,"  Nov.,  1908). 

Osteitis  may  terminate  in  resolution  or  it  may  terminate  in  sclerosis,  the 
mass  of  prohferating  cells  being  converted  first  into  fibrous  tissue  and  next 
into  dense  bone  which  contains  a  very  few  small  cancellous  spaces.  If  the 
exudation  is  under  the  periosteum,  the  bone  will  be  thickened  at  this  point, 
bone  stalactites  marking  the  points  of  passage  of  the  vessels.  Osteitis  may 
terminate  in  suppuration,  this  condition  being  often  called  caries.  In  tuber- 
culous osteitis  caseation  of  the  inflammatory  products  is  very  apt  to  arise  {tuber- 
culous caries,  the  strumous  caries  of  our  predecessors).  Acute  osteitis  may 
terminate  in  necrosis,  the  inflammatory  exudate  compressing  the  vessels  in 
their  bony  canals,  a  portion  of  the  bone  being,  in  consequence,  deprived  of 
nutritive  material.  The  portion  cut  off  from  nutritive  fluid  dies  en  masse 
(necrosis).  Osteitis  is  usually  associated  with  more  or  less  periostitis.  A 
simple  acute  periostitis  without  involvement  of  the  bone  may  arise  from 
traumatism  or  strain;  but  in  all  severe  cases  of  periostitis,  in  all  chronic 
cases,  in  all  cases  due  to  sj^hilis,  rheumatism,  measles,  scarlatina,  or  enteric 
fever  the  bone  is  involved  at  the  same  time  or  subsequently.  In  syphilitic 
states  gummatous  degeneration  frequently  ensues. 

Symptoms  of  Osteitis  and  Osteoperiostitis. — As  a  chronic  process, 
osteitis  is  most  commonly  found  in  the  femur..  Its  history  usually  exhibits 
a  record  of  an  antecedent  injury  or  chilling  of  the  body.  Pain  is  severe, 
boring  or  aching  in  character,  deep-seated,  worse  at  night,  and  aggravated 
by  a  dependent  position  of  the  part.  The  symptoms  closely  resemble  those 
of  periostitis,  with  which  disease  it  is  almost  sure  to  be  linked.  Tenderness 
exists  on  percussion,  and  sometimes  on  pressure.  Subperiosteal  swelling, 
fusiform  in  shape,  is  noted;  cutaneous  edema  and  discoloration  are  observed 
if  a  superficial  bone  is  inflamed.  In  s}'philis,  atrophic  osteitis  may  attack  the 
cranial  bones  and  produce  softening  or  even  perforation,  or  osteophytic 
osteitis  may  arise,  exostoses  being  formed.  Osteoperiostitis  may  be  acute 
or  chronic,  circumscribed,  or  diffused,  and  may  terminate  in  resolution, 
organization,  or  suppuration.  It  arises  from  cold,  blows,  wounds,  strains, 
the  spread  of  adjacent  inflammation,  specific  febrile  maladies,  pyogenic 
infection,  S3^philis,  rheumatism,  or  tuberculosis.  The  symptoms  are  pain 
(which  is  worse  at  night  and  which  is  aggravated  by  motion,  pressure,  or  a 
dependent  position),  swelling,  edema,  and  discoloration  of  the  soft  parts. 
Pain  in  the  syphilitic  form  is  not  so  severe  as  in  other  varieties.  Acute  necrosis 
or  diffuse  periostitis,  a  pyogenic  inflammation  of  bone  and  periosteum,  is  com- 
monest in  boys  about  the  age  of  puberty.  It  is  usually  due  to  cold,  a  specific 
fever,  or  injury,  and  most  often  affects  the  tibia  or  femur;  the  symptoms 
locally  are  redness,  swelling,  and  severe  pain;  constitutionally  there  are  rigors, 
fever,  and  sometimes  convulsions.  Necrosis  is  apt  to  result.  Pyemia  is 
common.  In  simple  acute  periostitis  a  swelling  is  felt  upon  the  osseous  sur- 
face. The  swelling  is  firmly  fixed  and  is  very  tender,  but  the  bone  itself  is 
not  enlarged.  There  is  some  local  heat,  discoloration,  often  fever,  and  the 
patient  complains  of  an  aching  pain,  which  is  worse  at  m'ght. 


Osteoplastic  Periostitis  503 

Periostitis  due  to  strain  demands  some  special  attention.  Sir  James  Paget, 
years  ago,  pointed  out  that  muscular  exertion  might  cause  periostitis.  C.  T. 
Dent  has  written  a  valuable  article  upon  this  subject.* 

It  is  common  to  hear  footI)all  players  complain  of  some  swelling  of  the 
knee-joint.  E.xamination  finds  tenderness  over  the  tubercle  of  the  tibia  with 
slight  swelling  of  the  joint.  Dent  points  out  that  pain  is  felt  on  straightening 
the  leg,  not  on  rotating  it.  The  same  observer  states  that  omnibus  drivers 
suffer  from  periostitis  of  the  fibula,  due  to  pressing  forcibly  against  the  foot- 
board; those  who  ride  may  develop  periostitis  of  the  adductor  insertion 
(riders'  bone) ;  the  victims  of  fiat-foot  may  labor  under  periostitis  of  the  inner 
tuberosity  of  the  os  calcis;  bar-keepers,  from  working  a  beer-pump,  may  get 
periostitis  of  the  scapula,  pain  being  marked  on  contracting  the  biceps;  a 
housemaid  may  develop  periostitis  at  the  points  of  bony  origin  of  the 
great  pectoral  from  the  chest,  the  condition  being  due  to  sweeping  and 
scrubbing.! 

Treatment  of  Osteitis  and  Osteoperiostitis. — In  syphilitic  forms  the 
local  treatment  consists  in  rest,  elevation  of  the  part,  the  application  of  iodin 
and  mercurial  ointment,  and  bandaging.  Specific  treatment  is  by  the  stom- 
ach or  hypodermatically.  Operation  is  rarely  justifiable.  In  other  forms, 
if  the  case  be  recent  and  severe,  put  the  patient  to  bed,  place  the  limb 
in  a  splint  and  elevate  it,  employ  cold,  apply  a  bandage,  and  give  salines 
and  iodid  of  potassium  internally.  Later  use  ichthyol  inunctions  locally 
and  apply  a  hot  water-bag.  Morphin  is  administered  for  pain.  If  these 
means  fail,  order  counterirritation  by  iodin  and  blue  ointment  or  blisters, 
and  apply  heat  locally.  In  severe  cases  take  a  tenotome  and  slit  the  perios- 
teum subcutaneously  to  relieve  tension;  this  procedure  often  quickly  relieves 
the  pain.  Some  cases  demand  a  longitudinal  osteotomy,  which  is  performed 
by  taking  Hey's  saw  and  dividing  the  bone  longitudinally  into  the  medullary 
canal.     If  pus  forms,  drain  at  once. 

Diffuse  osteoperiostitis  requires  early  and  free  incisions,  antiseptic  irri- 
gation, drainage,  rest  and  elevation  of  the  limb,  and  strong  supporting  and 
stimulating  treatment.  Amputation  is  sometimes  demanded,  as  when  the 
patient  grows  weaker  and  weaker  even  after  incision,  and  when  a  joint  is 
seriously  involved.  If  the  necrosis  affects  the  entire  shaft,  which  separates 
from  its  epiphyses,  and  new  bone  has  not  yet  formed  from  the  periosteum, 
make  a  subperiosteal  resection  of  the  shaft. 

Chronic  periostitis  is  usually  syphilitic.  A  node  is  a  chronic  inflamma- 
tion of  the  deep  periosteal  layers.  Nodes  occurring  early  in  the  secondary 
stage  remain  soft  and  soon  pass  away  under  treatment,  but  those  occurring 
two  years  or  more  after  infection  are  apt  to  cause  a  bony  deposit.  A  node 
may  soften,  leaving  a  sinus,  at  the  bottom  of  which  is  a  piece  of  dead  bone. 
Gumma  of  the  periosteum  is  one  form  of  node  which  is  apt  to  produce  caries 
or  necrosis. 

Osteoplastic   periostitis   accompanies   chronic   osteitis   and   causes   the 

deposit  of  new  bone,  which  undergoes  sclerosis.     The  chief  symptom  is  aching 

pain,  which  is  worse  when  the  patient  is  warm  in  bed,  and  is  aggravated  by 

damp  and  wet.     A  swelling  is  found  at  the  seat  of  pain  (often  over  the  tibia 

*  Practitioner,  Oct.,  1897.  flbid. 


504 


Diseases  and  Injuries  of  Bones  and  Joints 


ulna,  clavicle,  or  sternum).     The  soft  parts  are  uninflamed  and  move  freely 
unless  softening  or  suppuration  has  occurred.     Tenderness  is  manifest. 

Treatment  of  Chronic  Periostitis  and  Osteoplastic  Periostitis. — For  the 
nodes  of  early  syphilis  administer  mercury  by  the  plan  usually  followed  in 
secondary  syphilis;  for  the  nodes  of  late  syphihs  give  mercury  and  large 
advancing  doses  of  iodid  of  potassium.  Blisters,  blue  ointment,  and  iodin 
are  applied  to  the  skin  over  the  area  of  periostitis  in  both  forms,  and  sub- 
cutaneous division  of  the  periosteum  is  of  value.  If  suppuration  occurs,  in- 
cise antiseptically. 

Chronic  Abscess  of  Bone,  or  Brodie's  Abscess.— This  condition 
is  sometimes  due  primarily  to  tuberculous  infection,  symptoms  being  absent  for 
a  longer  or  shorter  time  and  arising  because  of  secondar}'  infection  with  staphy- 
lococci. It  is  always  chronic,  never  acute.  A  very  acute  inflammation,  such 
as  is  induced  by  virulent  pyogenic  organisms,  causes  acute  necrosis  rather  than 
an  acute  abscess.  After  typhoid  fever  an  area  of  suppuration  may  slowly  form 
in  the  head  of  a  long  bone,  due  to  the  action  of  t}TDhoid  bacilli.  Non-virulent 
staphylococci  may  be  responsible,  and  the  condition  may  follow  long  after  a 

staphylococcus  osteomyelitis,  and  in  84 
per  cent,  of  cases  of  Brodie's  abscess  this 
is  the  history  (Alexis  Thomson).  The 
same  author  says  the  latest  period  between 
the  osteomyelitis  and  the  abscess  varies 
from  one  to  fifty-seven  years.  Chronic 
abscess  of  bone  was  first  described  by  Sir 
Benjamin  Brodie,  and  is  often  called 
Brodie's  abscess.  It  occurs  in  the  cancel- 
lous structure  of  the  ends  of  bones — 
usually  in  the  head  of  the  tibia,  sometimes 
in  the  femur  (Fig.  231)  or  humerus.  It 
seldom  occurs  in  the  shaft  of  a  long 
bone.  A  tuberculous  abscess  of  bone 
may  follow  a  slight  injury,  which  consti- 
tutes a  point  of  least  resistance.  Bacteria 
lodge  and  multiply;  bone  rarefaction  leads 
to  the  formation  of  a  cavity,  the  inflam- 
matory products  caseate,  sometimes  sup- 
puration arises,  and  the  surrounding  bone  thickens  and  hardens  because  of 
growth  from  the  periosteum.  The  abscess  is  apt  to  break  and  often  breaks 
into  a  joint,  as  the  joint-surface  is  not  covered  by  periosteum  and  no  barrier 
of  bone  is  there  formed.     Brodie's  abscess  may  induce  necrosis. 

Alexis  Thomson  thus  describes  Brodie's  abscess  ("Edinburg  Med.  Jour.," 
April,  igo6). 

In  the  first  or  quiescent  stage  there  is  a  cavity  filled  with  serum  and  lined 
with  a  membrane  like  the  periosteum  of  young  bones.  The  outer  layer  of  the 
membrane  is  forming  new  bone  of  a  spongy  nature,"further  away  the  old  bone 
is  sclerosed  and  the  medullary  canal  obliterated." 

When  the  mature  stage  or  abscess  stage  arises  the  lining  membrane  is 
converted  into  granulation-tissue,  and  the  cavity  becomes  filled  with  staphy- 
lococcus pus.  The  outer  layer  of  granulations  erodes  the  bone  and  the  abscess 
progressively  enlarges.     As  the  bone  is  eroded  within,  new  bone  is  formed 


Fig.  231. — Chronic  abscess  in  the  great 
trochanter  ("American  Text-Book  of 
Surgery"). 


Caries  505 

by  the  periosteum  and  the  bone  enlarges.  If  pus  formation  is  more  rapid  than 
bone  erosion  there  is  tension  and  i)ain,  but  if  bone  erosion  is  sufficiently  rapid 
to  prevent  tension  there  is  little  or  no  pain.  Finally  the  abscess  perforates 
the  bony  shell  "on  the  periosteal  surface  or  into  an  adjacent  joint." 

Symptoms. — There  are  attacks  of  boring  pain,  worse  at  night  and  aggra- 
vated by  motion  and  pressure,  and  a  dependent  position.  The  pain  is  in- 
termittent and  may  be  absent,  for  many  days  at  a  time.  These  pains  are  fre- 
quently thought  to  be  rheumatic.  The  tenderness  is  marked,  even  when 
pain  is  absent,  and  is  not  in  the  joint,  as  the  patient  beheved  the  pain  was,  but 
is  over  the  abscess.  If  the  head  of  the  tibia  or  the  great  trochanter  is  the 
seat  of  disease  percussion  over  that  region  develops  pain  most  certainly.  At 
times  pain  in  the  bone  becomes  excruciating  and  tenderness  acute.  There 
is  more  or  less  loss  of  function  in  the  limb  and  in  far  advanced  cases  the  bone  is 
enlarged.  There  may  be  thickening  of  the  bone  and  soft  parts,  edema  and 
discoloration  of  the  skin  over  the  seat  of  trouble,  and  attack  after  attack  of 
synovitis  in  the  nearest  joint.  Irregular  fever  and  sweats  are  usually  noted 
but  there  may  be  no  fever.  The  harrassing  pain  causes  sleeplessness,  ex- 
haustion, and  emaciation.  WTien  the  pus  breaks  through  the  bone  abscess 
develops  in  the  soft  part,  and  if  this  bursts  or  is  opened  pain  ceases  (Thomson). 
In  many  cases  the  .v-rays  aid  in  making  the  diagnosis. 

Treatment. — In  treating  bone-abscess,  trephine  the  bone  at  the  point  of 
greatest  tenderness,  and  if  the  abscess  is  missed,  follow  the  advice  of  Holmes 
and  perforate  the  wall  of  bone  with  the  trephine,  opening  in  several  directions 
to  discover  the  tuberculous  matter  or  pus.  It  is  often  easy  to  open  into  the 
abscess  with  a  chisel  or  gouge.  After  opening  the  cavity  scrape  its  walls, 
remove  dead  bone,  thoroughly  dry  with  gauze,  touch  with  pure  carbolic  acid, 
and  pack  with  iodoform  gauze.  If  the  abscess  opens  into  a  joint,  trephine  the 
bone  and  open,  irrigate,  and  drain  the  joint. 

Caries  was  a  term  once  used  universally  to  signify  suppuration  or  molecular 
death  of  bone.  In  some  cases  caries  means  suppurative  osteitis;  in  others, 
tuberculous  osteitis;  in  still  others,  gummatous  osteitis.  Typhoid  fever  is 
occasionally  followed  by  a  carious  condition  of  bone.  Osteitis  is  apt  to 
become  purulent  when  the  bone  is  exposed  to  the  air,  when  rest  is  not  secured, 
when  the  health  of  the  individual  is  below  normal,  when  a  foreign  body  such 
as  a  bullet  is  in  the  bone,  or  when  tubercle  or  syphilis  exists.  The  term  is 
seldom  used  to-day  except  loosely,  and  then  usually  to  signify  tuberculous  dis- 
ease of  bone.  WTien  caries  arises,  the  softened  and  granulating  bone  breaks 
down  and  is  discharged  through  a  sinus.  After  drainage  is  secured  organiza- 
tion, sclerosis,  and  heahng  may  result.  In  these  cases  new  bone  may  form 
and  a  cure  follow. 

Tuberculous  or  strumous  caries  (caseous  osteitis),  a  condition  produced  by 
the  caseation  of  the  products  of  a  tuberculous  osteitis,  shows  no  tendency  to 
self-cure,  no  organization  or  sclerosis  take  place,  and  new  bone  seldom  forms 
unless  an  operation  is  performed.  The  interior  of  bones,  especially  of  the  car- 
pus and  tarsus,  is  entirely  softened  and  destroyed  and  thin  shells  only  are  left. 

Caries  necrotica  is  a  condition  in  which  small  but  visible  portions  of  soft 
and  dead  bone  are  cast  off;  caries  sicca  is  molecular  death  of  bone  without 
liquefaction  or  suppuration. 

The   caseating    masses   in    tuberculous   caries   contain    tubercle    bacilli. 


5o6  Diseases  and  Injuries  of  Bones  and  Joints 

If  a  tuberculous  collection  is  evacuated  and  infection  with  pus  organisms 
occurs,  genuine  su])[)uration  takes  place,  and  constitutional  infection  causes 
sepdc  fever  and  may  cause  death.  Pyogenic  osteitis  may  affect  any  part  of 
any  bone;  but  caseous  osteitis  (tuberculous  caries)  tends  to  arise  especially 
in  cancellous  structures  (heads  of  long  bones,  vertebral  bodies,  ribs  and 
sternum,  and  bones  of  the  carpus  and  tarsus).  Tuberculous  osteitis  of  the 
shaft  of  a  long  bone  occasionally,  but  rarely,  arises.  Tuberculous  osteitis  is 
apt  to  cause  tuberculous  disease  in  an  adjacent  joint.  Tuberculous  osteitis 
may  be  followed  by  the  formation  of  a  cold  abscess. 

Symptoms. — In  the  beginning  the  evidences  of  caries  are  usually  those 
of  osteitis,  but  the  first  sign  noted  may  be  a  fluctuating  swelling  due  to  pus 
or  to  caseated  tubercle.  After  a  time,  at  any  rate,  a  fluctuating  swelling  is 
discovered.  If  not  opened,  the  softened  mass  breaks  externally,  voids  its 
contents,  and  leaves  a  sinus  from  which  flows  caseated  matter  which  after 
a  time  becomes  thin,  reddish,  and  irritating  to  the  skin,  contains  small  por- 
tions of  gritty  bone,  and  has  a  foul  smell.  The  opening  of  the  sinus  fills  up 
with  edematous  granulations.  A  probe  carried  to  the  bottom  of  the  sinus 
finds  bone  which  is  sieve-like  (worm-eaten),  and  which  on  being  struck  gives 
a  muffled  note  rather  than  the  clear,  sharp  note  of  necrosis;  the  bone  is  rough, 
is  bared,  and  is  so  soft  that  the  probe  can  usually  be  stuck  into  it.  In  old 
cases  of  caries  amyloid  disease  may  arise. 

Treatment. — If  syphilis  exists,  give  iodid  of  potassium  in  advancing  doses 
and  a  mild  mercurial  course.  If  tuberculosis  exists,  give  iodid  of  iron, 
arsenic,  cod-liver  oil,  and  nourishing  foods,  and  recommend  ocean  air  and 
living  in  the  open  air.  Locally,  in  all  cases,  insist  on  rest  and  at  once  secure 
drainage,  enlarging  the  opening,  if  necessary,  and  inserting  a  tube,  and  even 
making  additional  openings;  syringe  often  with  antiseptic  fluids  and  dress  anti- 
septically.  If  the  case  is  seen  before  spontaneous  evacuation  has  occurred, 
open  under  strict  antiseptic  precautions.  When  a  chronic  sinus  exists  there 
arises  the  question  of  operation.  Incomplete  operations  are  worse  than  useless, 
for  they  may  be  followed  by  diffuse  tuberculosis  or  pyemia.  If  the  gouge  is 
used,  try  to  remove  all  carious  bone.  The  diseased  bone  is  white,  crumbles, 
and  does  not  bleed;  the  non-carious  bone  is  pink  and  vascular.  Scrape  away 
all  granulations,  swab  the  cavity  with  pure  carbolic  acid,  and  pack  it  with 
iodoform  gauze.  Instead  of  gouging  away  bone,  there  may  be  used  the  actual 
cautery,  sulphuric  acid,  or  hydrochloric  acid.  In  severe  cases  excision  is  re- 
quired, and  in  some  rare  cases  amputation  may  be  necessary.  Caries  of  the 
spine  is  considered  under  Diseases  of  the  Spine. 

Necrosis  is  the  death  of  visible  portions  of  bone  from  circulatory  im- 
pediment or  the  direct  action  of  bacterial  toxins.  It  is  analogous 
to  gangrene.  One  cause  of  necrosis  is  traumatism  (such  as  the  tear- 
ing off  of  periosteum)  which  deprives  the  bone  of  blood.  Inflamma- 
tion of  the  periosteum  further  lessens  the  nutrition.  Acute  inflammation 
in  bone  causes  necrosis,  the  excessive  exudation  in  the  canals  and 
spaces  occluding  the  blood-vessels  by  pressure.  The  occlusion  of  vessels 
by  bacterial  thrombi  or  emboli  may  lead  to  necrosis,  or  the  direct  action  of  tox- 
ins may  first  inflame  and  finally  destroy  a  pordon  of  the  bone.  A  thin  shell  of 
bone  only  may  necrose  from  periosteal  separation,  or  an  entire  shaft  may  die 
from  acute  pyogenic  osteomyelitis  or  diffuse  infective  periostitis.  Osteomye- 
litis is  the  most  usual  cause  of  necrosis.    Necrosis  is  most  frequently  met  vdth  in 


Symptoms  of  Necrosis 


507 


the  diaphyscs  of  the  long  bones,  caries  in  the  cancellous  tissue  of  bones.  The 
ril)s  may  become  carious,  but  verj-  rarely  become  necrotic.  A  sequestrum 
may,  but  does  not  often,  form  in  a  vertebral  body  in  the  cancellous  head  of  a 
long  bone,  in  the  carpus,  or  in  the  tarsus.  If  a  sequestrum  arises  from  tuber- 
culous osteomyelitis  it  is  seldom  completely  detached,  but  still  retains  some  vas- 
cular connection.  In  tuberculous  osteomyelitis  of  a  long  bone  the  sequestrum 
is  wedge-shaped  with  its  base  toward  the  joint,  and  is  due  to  infarction  of  ter- 
minal arteries.  A  fragment  of  dead  bone  is  a  foreign  body;  the  healthy  bone 
adjacent  to  it  inflames  and  softens;  granulations  form,  and  this  line  of  granu- 
lation, like  the  line  of  demarcation  of  gangrene,  tends  to  separate  the  dead  part 
from  the  living,  the  white  dead  bone  being  surrounded  by  the  red  zone  of 
granulation  tissue.  A  bit  of  dead  bone  is  called  a  '^sequestrum  "  and  Nature 
tries  to  cast  it  o£f.     A  superficial  sequestrum  is  known  as  an  '^  exfoliation.'" 

Nature's  method  of  casting  off  a  sequestrum  is  as  follows:  suppuration 
takes  place  at  the  line  of  demarcation,  osteitis  extends  for  a  considerable 
distance  around  this  line,  the  periosteum  shares  in  the  inflammation,  and 
new  bone  forms.  A  cavity  is  thus  made  within  by  suppuration,  and  a  box 
or  case  forms  without  by  ossification,  the  now  entirely  loosened  sequestrum 
being  so  encased  that  it  cannot  escape.  The  pus  finds  its  way  through  the 
new    bone,   and    there    is 

presented  the  condition  so  ■- — — " 

often  seen  by  the  surgeon— 
namely,  a  case  of  new  bone 
known  as  the  "  invohi- 
cnun,"  a  cavity  containing 
pus  and  the  dead  fragment 
or  sequestrum,  and  a  dis- 
charging sinus  or  "cloaca" 
(Fig.  232).  Nature  may 
eventually  cast  off  the  frag- 
ment, but  the  surgeon 
should  not  wait  for  the  com- 
pletion of  this  slow  process. 

^^^len  a  portion  of  the  bone  surrounding  the  medullary  canal  dies,  the 
condition  is  called  "central  necrosis."  In  some  rare  cases  necrosis  occurs 
without  apparent  suppuration,  a  painless  swelHng  of  bone  simulating  sarcoma. 
This  condition  is  known  as  quiet  necrosis,  and  has  been  described  by  Sir  James 
Paget  and  Mr.  Morrant  Baker.  Mercury  is  an  occasional  cause  of  necrosis. 
The  fumes  of  phosphorus  may  cause  necrosis  of  the  lower  jaw  in  those  with 
decayed  teeth.  Necrosis  may  be  produced  also  by  frost-bites  and  burns. 
Many  fevers  (measles,  t}-phoid,  scarlet  fever,  etc.)  are  occasionally  followed 
by  necrosis.     Syphihs  and  tuberculosis  are  occasional  causes. 

Symptoms. — The  s}Tnptoms  of  necrosis  are  at  first  those  of  osteitis  or 
osteomyelitis.  The  abscess,  when  formed,  opens  of  itself  or  is  opened  by  the 
surgeon,  and  a  sinus  or  sinuses  form  in  the  soft  parts  as  happens  in  caries. 
A  probe  introduced  into  the  sinus  strikes  upon  hard  bone  with  a  clear,  ringing 
note,  and  often  finds  a  sinus  or  sinuses  in  the  bone.  In  superficial  necrosis 
the  discharge  is  sHght  and  the  probe  shows  the  Umitations  of  the  disease. 
In  extensive  necrosis  the  discharge  is  profuse,  much  new  bone  forms,  several 
sinuses  appear  far  apart,  and  the  probe  must  pass  through  a  considerable 


Fig.  232.— Diagram  illustrating  the  formation  of  a  se- 
questrum: Ay  Sound  bone;  B,  new  bone;  C,  granulations 
lining  involucrum  ;  D,  cloaca  ;  E,  sequestrum. 


5o8  Diseases  and  Injuries  of  Bones  and  Joints 

thickness  of  new  bone  before  it  finds  the. bit  of  dead  bone.  The  surgeon 
should  not  operate  until  the  dead  bone  is  separated  from  the  living  by  a  line 
of  demarcation,  and  until  the  sequestrum  is  loose.  In  youth  dead  bone 
loosens  quickly,  but  in  old  age  slowly.  An  exfoliation  becomes  loose  sooner 
than  the  sequestrum  of  central  necrosis.  In  diffuse  periostitis  the  necrosed 
shaft  loosens  quickly.  Necrosed  portions  of  the  upper  extremity  loosen 
more  rapidly  than  those  of  the  lower.  In  a  young  adult  two  or  three  months 
will  be  required  to  loosen  a  necrosed  fragment  in  the  lower  extremity  and 
from  six  weeks  to  two  months  in  the  upper.  A  loose  sequestrum  may  be 
moved  by  the  probe,  and  when  struck  gives  a  hollow  note.  In  protracted 
cases  of  necrosis  there  is  always  danger  that  amyloid  disease  may  arise. 

Quiei  necrosis  is  a  rare  condition  which  has  led  to  some  deplorable  but 
pardonable  mistakes,  because  it  resembles  ossifying  sarcoma.  It  follows 
injury,  particularly  fracture.  The  bone  enlarges  greatly.  There  is  little 
or  no  pain  and  no  fever.  The  diagnosis  can  only  be  made  by  exploratory 
incision,  and  it  may  even  be  necessary  to  remove  portions  for  microscopic 
study  before  a  conclusion  can  be  reached. 

Postfebrile  necrosis  is  most  usually  met  with  after  typhoid  fever.  The  bacilli 
of  typhoid  cause  chronic  osteomyelitis,  and  this  is  followed  by  necrosis.  Scarlet 
fever,  measles,  and  other  febrile  processes  may  also  induce  necrosis.  It  is 
certain  that  bacilli  accumulate  in  the  bones  during  tv'phoid  fever.  They  may 
promptly  induce  disease;  they  may  remain  for  long  periods  apparently  inactive 
and  finally  pass  away;  or  after  a  shght  strain  or  injury  these  organisms 
may  induce  bone  disease  months  or  even  years  after  the  primary  infection. 
Typhoid  bone  disease  is  often  multiple,  many  bones  being  involved  succes- 
sively.* Not  unusually  after  typhoid  fever  muscle  strain  causes  periostitis 
and  osteitis,  and  at  such  a  point  necrosis  may  occur.  Either  exfoliation  or 
central  necrosis  may  follow  typhoid  fever.  The  tibia  is  involved  more  often 
than  other  bones. 

Treatment. — An  exfoliation  should  be  removed  as  soon  as  it  becomes 
loose,  the  seat  of  trouble  should  be  touched  with  pure  carbohc  acid,  and  pack- 
ing of  iodoform  gauze  should  be  inserted.  The  treatment  of  central  necrosis 
comprises  free  incisions  for  drainage,  antiseptic  dressing,  frec^uent  cleansing,  rest, 
nourishing  food,  stimulants,  and  tonics.  When  the  sequestrum  becomes  loose 
the  operation  of  sequestrectomy  or  necrotomy  is  performed,  the  extremity  is 
drained  of  blood,  an  Esmarch  band  is  applied,  the  bone  is  exposed  by  a  longi- 
tudinal incision,  the  periosteum  is  reflected  on  each  side,  and  the  involucrum 
is  broken  through  and  the  opening  is  enlarged  with  the  chisel,  gouge,  and  ron- 
geur. The  dead  bone  should  be  removed  by  sequestrum  forceps,  the  ca\'ity 
scraped  by  a  sharp  spoon,  the  lateral  edges  of  the  involucrum  cut  down  until  tlie 
cavity  which  formerly  contained  the  sequestrum  is  very  shallow,  the  wound  is 
irrigated  with  hot  salt  solution,  dried,  painted  \ntli  pure  carbohc  acid  and  then 
with  alcohol,  again  irrigated  ^vith  salt  solution,  and  firmly  packed  with  iodo- 
form gauze.  Remove  the  Esmarch  band,  tie  the  vessels  in  the  soft  parts, 
suture  the  wound,  and  apply  dressings.  The  simple  removal  of  a  sequestrum 
— /.  e.,  the  operation  of  sequestrectomy — often  fails  to  effect  a  cure,  and  even 
in  the  most  satisfactory  cases  healing  requires  a  very  long  time.     "The  in- 

*  Keen's  "Surgical  Complications  of  Typhoid  Fever." 


Treatment  of  Necrosis  509 

volucrum  always  contains  pyogenic  germs  that  may  live  in  its  small  foramina 
and  crevices  almost  indefinitely.  For  this  reason,  and  on  account  of  the 
denseness  of  bony  structure,  it  is  well-nigh  impossible  to  disinfect  it"  (Dr. 
J.  Shelton  Horsley,  in  the  "Medical  Record,"  Oct.  20,  1900).  Because  of  the 
difficulty  of  curing  a  case  when  an  involucrum  has  formed.  Dr.  Gushing,  of 
Baltimore,  has  warmly  advocated  early  operation  in  osteomyelitis;  that  is, 
operation  before  an  involucrum  has  formed,  and  when  the  osteoblasts  of  the 
periosteum  are  extremely  active.  He  points  out  that  if  an  involucrum  has 
formed,  the  sequestrum  and  involucrum  should  be  removed  after  stripping  the 
periosteum  from  this  region.  If  the  periosteum  is  found  not  to  be  infected, 
it  may  be  stitched  together  at  the  gap  where  the  bone  has  been  removed,  so 
that  a  periosteal  cord  exists  between  the  two  ends  of  the  bone;  and  the  soft 
parts  above  this  may  be  closed.  If  the  periosteum  is  found  to  be  infected,  we 
agree  with  Gushing  that  the  ca\'ity  should  be  packed  \Mith  gauze.  The  ca\'ity 
that  is  left  by  the  removal  of  a  sequestrum  and  the  chiseling  of  the  walls  of  the 
involucrum,  if  large,  may  be  filled  by  various  methods  more  or  less  satis- 
facton,'.  In  some  cases  of  widespread  necrosis  due  to  diffuse  infective  osteo- 
periostitis or  to  osteomyelitis,  extensive  resection,  or  even  amputation,  may  be 
necessar}'. 

Treatment  of  Bone  Cavities. — Schede  does  not  pack  the  bone-cavity  but 
allows  it  to  fill  up  with  blood-clot  after  the  wound  in  the  soft  parts  has  been 
closed  with  sutures.  The  blood-clot  obliterates  the  dead  space  in  the  bone, 
acts  as  a  support  for  granulations  from  the  margin,  and  is  slowly  eaten  up. 
Unfortunately  it  is  an  excellent  culture-medium  and  it  often  fails  of  its  purpose. 
The  surgeon  may  try  to  fill  the  cavity  by  taking  flaps  of  skin  from  the  sides  of 
the  wound,  separating  them  freely  from  the  fascia  beneath  and  holding  them 
■within  the  bone  cavity  by  inversion  sutures  or  fastening  them  to  the  bottom 
with  nails  (Xeiiber''s  operation).  Another  operation  consists  in  breaking 
the  edges  of  the  involucrum  and  turning  them  in.  Some  surgeons  insert 
decalcified  bone-chips.  Bone-chips  are  prepared  as  described  on  page  78, 
and  they  are  applied  as  is  directed  below.  The  cavity  in  the  bone  is  made 
sterile  and  is  well  dusted  with  iodoform,  the  bone-chips  are  dried  and  in- 
serted into  the  cavity,  a  capillar}-  drain  is  employed,  the  periosteum  is  stitched 
over  the  opening,  and  the  soft  parts  are  sutured;  but  if  this  cannot  be  done, 
iodoform  packing  is  used  to  keep  the  chips  in  place.  This  method  we  owe 
to  the  genius  of  Senn.  Senn's  method  often  fails  because  of  the  impossi- 
bility of  completely  sterilizing  the  walls  of  the  bone-cavity.  Attempts 
have  been  made  to  fill  bone-cavities  as  a  dentist  fills  teeth — with  gutta- 
percha, plaster-of-Paris,  copper  amalgam,  etc.,  but  each  of  these  materials 
acts  as  a  foreign  body  in  the  bone  (James  E.  Moore,  on  "the  Treatment 
of  Bone-cavities,"  "Jour.  Am.  Med.  Assoc,"  !May  20,  1905).  Schleich 
uses  formalin-gelatin  to  fill  bone-cavities.  The  difficulty  in  every  case  is  the 
impossibility  of  completely  sterilizing  the  walls  of  the  cavity.  Dressman 
has  advised  for  this  purpose  the  use  of  boihng  oil,  but  it  is  apt  to  cause  super- 
ficial necrosis.  In  some  cases  the  cavity  has  been  healed  by  the  insertion  of  a 
Thiersch  skin-graft.  This  method  has  been  advocated  by  J.  P.  Lord  ("Jour. 
Am.  Med.  Assoc,"  May  31,  1902).  \'on  Mosetig-Moorhof's  method  is 
one  of  the  best  (Zeitschrift  fiir  Ghirurgie,"  Ixxi,  No.  5).  He  pours  into  the 
cavitv'  a  melted  material  which  completely  fills  the  ca\-ity,  which  v,-iU  not 


5IO  Diseases  and  Injuries  of  Bones  and  Joints 

act  as  a  culture-medium  or  as  a  foreign  body,  which  is  gradually  absorbed, 
and  which  "possesses  the  inhibitory  and  medicinal  properties  of  iodoform 
without  causing  iodoform  intoxication"  (James  E.  Moore,  on  "The  Treat- 
ment of  Bone-cavities,"  "Jour.  Am.  Med.  Assoc,"  May  20,  1905).  Mose- 
tig's  material  consists  of  60  parts  of  iodoform,  40  parts  of  spermaceti,  and 
40  parts  of  oil  of  sesame.  These  materials  are  mixed  by  heating  gradu- 
ally up  to  100°  C.  On  cooling,  a  solid  mass  is  formed.  When  the  surgeon 
wishes  to  use  it  he  heats  it  up  to  50°  C.  and  stirs  it  while  headng  (Moore), 
and  pours  it  into  the  cavity  in  the  bone.  On  entering  the  cavity  it  at  once 
solidifies.  A  capillary  drain  is  introduced,  the  periosteum  is  sutured  with 
catgut,  and  the  skin  is  sutured  with  silkworm-gut.  Many  attempts  have 
been  made  to  fill  the  defect  by  hone-grajting.  The  first  case  of  satisfactory  trans- 
plantation from  one  of  the  lower  animals  with  the  retention  of  a  vascular  attach- 
ment was  reported  by  A.  W.  Morton  in  "American  Medicine,"  July  12,  1902. 
The  patient  suffered  from  a  compound  comminuted  fracture  of  both  bones 
of  the  right  leg.  The  fracture  in  the  fibula  united,  but  the  tibia  underwent 
necrosis,  and  it  was  necessary  to  remove  five  inches  of  the  lower  end  of  the 
bone.  Some  days  later,  the  periosteum  was  raised  from  the  ends  of  the  bone 
and  these  ends  were  freshened.  The  left  leg  of  a  dog  was  amputated  just 
above  the  tarsus,  the  bones  being  sawed  so  that  the  ulna  was  one  inch  longer 
than  the  radius.  The  lower  end  was  partly  bared  of  periosteum,  and  the  ulna 
of  the  dog  was  forced  into  the  cavity  of  the  tibia  of  the  man,  and  wired  to 
that  bone  with  silver  wire.  The  incision  in  the  man's  leg  was  then  sutured, 
and  powerful  tendons  in  each  leg  of  the  dog  were  divided.  Each  of  the  dog's 
other  legs  was  wrapped  separately  in  a  plaster-of-Paris  bandage,  and  the 
entire  animal  and  the  leg  of  the  man  were  then  put  up  in  a  plaster-of-Paris 
dressing.  Five  weeks  later  the  cast  was  removed,  and  the  bones  were  sawed 
and  placed  in  contact  with  the  astragalus.  Union  took  place,  and  the  man 
was  fortunate  enough  to  obtain  a  useful  leg.  In  some  cases  a  bone  defect 
may  be  supplied  by  transference  of  another  bone.  Nichols  reported  1 1  cases 
and  insisted  on  the  necessity  of  preserving  the  periosteum  ("Jour.  Am.  Med. 
Assoc,"  Feb.  3,  1904).  Huntington  has  reported  a  case  similar  to  case  No.  2  in 
Nichols'  Ust.  The  padent  was  a  boy  of  seven.  A  large  piece  of  the  entire 
thickness  of  the  tibia  was  lost  as  a  result  of  acute  osteomyelitis.  There  was 
a  gap  of  5  inches  between  the  ends  of  the  bone,  and  the  leg  was  a  mere  flail. 
Eight  months  after  the  beginning  of  the  osteomyelitis  the  fibula  was  sawed 
opposite  the  lower  end  of  the  upper  fragment  of  the  tibia  and  the  upper  end 
of  the  lower  fragment  of  the  fibula  was  fixed  in  a  cup-shaped  depression  in 
the  lower  end  of  the  upper  fragment  of  the  dbia.  Six  months  later  union  was 
solid,  but  in  order  to  improve  the  weight-bearing  power  of  the  limb,  nine 
months  after  the  first  operation,  the  lower  end  of  the  upper  fragment  of  fibula 
was  fastened  to  the  upper  end  of  the  lower  fragment  of  tibia.  The  result 
was  excellent.  The  shortening  is  only  three-fourths  of  an  inch  ("Annals  of 
Surgery,"  Feb.,  1905). 

Acute  pyogenic  osteomyelitis  is  an  acute  and  diffuse  inflammation  of  the 
bone-marrow  due  to  pyogenic  organisms.  Infection  from  staphylococci  may  be 
limited  to  a  portion  of  one  bone.  Streptococcus  infection  causes  widespread 
involvement  of  a  bone  or  of  several  bones.     Acute  osteomyelitis  may  be  due  to- 


Acute  Osteomyelitis  511 

mixed  infection  with  bacilli  of  t}'}Dhoid  and  pyogenic  organisms,  or  bacilli  of 
tubercle  and  pyogenic  organisms,  a  tjphoid  process  or  a  tuberculous  process 
serving  to  establish  a  point  of  least  resistance.  The  gonococcus  and  the 
pneumococcus  occasionally  produce  acute  osteomyelitis.  In  a  case  of  gonor- 
rheal arthritis  in  which  I  resected  the  wrist-joint  cultures  of  gonococci  were 
obtained  from  the  interior  of  the  bone  removed. 

It  was  at  one  time  believed  that  osteomyelitis  was  due  to  a  specific  organism, 
but  Pasteur  proved  that  micrococci  are  the  cause,  and  Ogston  demonstrated 
pyogenic  bacteria  in  pus  obtained  from  cases  of  osteomyelitis.  In  some  cases 
there  is  pure  staphylococcus  infection  (aureus  or  albus) ,  both  aureus  and  albus 
may  be  present,  there  may  be  mixed  infection  with  streptococci  and  staphylo- 
cocci, streptococci  and  several  sorts  of  bacilli,  or  staphylococci  and  bacilli. 
Mixed  infections  with  streptococci  are  more  malignant  than  staphylococcus 
infections.  Most  cases  of  osteomyelitis  are  due  to  staphylococci.  Ullman 
was  unable  to  experimentally  induce  osteomyelitis  without  first  creating  by 
bone  injury  a  period  of  least  resistance.  When  he  applied  a  ligature  to  a 
rabbit's  leg  for  fourteen  hours  distinct  changes  were  found  to  occur  in  the 
marrow  of  the  bones.  These  changes  consisted  chiefly  in  extravasation  and 
localized  hemorrhages.  When  the  marrow  was  in  this  condition,  if  virus 
were  injected  into  the  animal,  osteomyelitis  resulted,  because  the  bones 
presented  points  of  least  resistance,  vulnerable  points  in  which  pus  cocci 
lodged  and  multiphed. 

The  pyogenic  organisms  may  gain  entrance  directly  by  way  of  a  wound 
(a  gunshot- wound,  a  compound  fracture,  an  amputation).  The  eausative 
organisms  may  reach  the  bone  by  way  of  the  blood,  having  entered  the  blood 
originally  through  the  h-mphatic  system  or  from  a  focus  of  suppuration  in 
the  skin,  the  subcutaneous  tissue,  or  a  deeper  part. 

Pus  organisms  may  pass  into  the  blood  from  the  tonsils  or  respiratory 
organs  (Kraske);  the  intestinal  canal  (Kocher) ;  the  genito-urinary  tract;  or 
from  excoriations,  bruises,  or  small  wounds  in  the  skin  (Warren).  Certain 
fevers  strongly  predispose  to  the  disease  by  preparing  the  soil  as  it  were  for 
the  growth  of  pyogenic  bacteria.  Typhus  fever,  smallpox,  malarial  fever, 
scarlet  fever,  measles,  and  diphtheria  lessen  the  vital  resistance  of  bone- 
marrow.  Typhoid  fever  is  not  unusually  followed  by  a  chronic  osteomyeHtis, 
due  solely  to  typhoid  baciUi.  If  mixed  infection  with  pus  organisms  occurs, 
acute  osteomyeHtis  arises.  Vital  resistance  of  marrow  is  lessened  by  exhausting 
diseases,  overexertion,  unhealthy  and  especially  putrid  food.  We  know  that 
various  infections  produce  various  reactions  in  marrow,  and  in  this  changed 
marrow  vital  resistance  is  probably  lessened  or  even  seriously  impaired. 
Longcope  made  a  study  of  the  marrow  in  26  fatal  cases  of  enteric  fever,  and 
he  invariably  found  numerous  lymphoid  cells,  phagocytes  of  large  size,  and 
multiple  foci  of  distinct  necrosis.  The  cells  whose  function  is  to  form  blood 
were  noted  to  be  undergoing  hyperplasia.  In  those  dead  of  perforation  and 
general  peritonitis  there  were  numerous  foci  of  necrosis,  and  also  widespread 
degenerative  changes  in  the  blood-making  cells  and  pronounced  edema  and 
congestion  of  the  marrow  ("A  Text-Book  of  Pathology,"  by  Alfred  Stengel). 
W^hen  organisms  gain  entrance  directly  by  a  wound  (as  in  a  compound  frac- 
ture), the  endosteum,  the  medulla,  and  the  cancellous  tissue  inflame  and 


512  Diseases  and  Injuries  of  Bones  and  Joints 

suppurate,  and  the  entire  length  and  thickness  of  the  bone  may  be  involved. 
The  periosteum  becomes  infiltrated,  detached  from  the  bone,  and  retracted 
from  the  edges  of  the  wound  in  the  bone.  The  soft  tissues  around  the  bone 
may  inflame,  suppurate,  or  slough.     More  or  less  necrosis  inevital)ly  occurs. 

Acute  osteomyelitis  v^^ithout  a  wound  is  often  called  acute  epiphysitis  or 
acute  injantile  arthritis.  This  condition  is  most  common  in  infants  or  children 
of  one  or  two  years  of  age,  but  occasionally  arises  in  older  children  (from  ten 
to  fourteen  years)  or  even  in  adults.  It  is  most  common  during  the  period 
of  active  growth  of  bone.  It  is  frequently  preceded  by  one  of  the  predis- 
posing causes  before  mentioned.  In  many  cases  a  strain  or  bruise  is  followed 
by  pyogenic  infection,  because  the  damaged  tissue  extends  a  hospitable 
welcome  to  micro-organisms  which  are  traveling  in  the  body-fluids  and  pass 
through  the  injured  area.  In  some  cases  chilling  of  the  surface  of  the  body 
is  a  predisposing  cause.     In  others  no  predisposing  cause  is  discoverable. 

The  compact  bone  suffers  secondarily,  but  is  never  attacked  primarily. 
New  tissue  is  more  susceptible  to  infection  than  old  tissue,  and  the  disease, 
as  a  rule,  begins  near  the  epiphyseal  Hne,  where  new  bone  is  being  formed. 
This  point  was  spoken  of  by  Oilier  as  "  the  zone  of  election  of  pathological 
processes."  Warren  points  out  that  in  a  growing  bone  near  the  epiphyseal 
cartilage  there  exists  a  newly  formed  spongy  tissue,  very  vascular  and  con- 
nected with  the  cartilage  by  a  spongy  layer  of  tissue,  which  is  not  yet  bone, 
but  which  does  not  possess  a  cartilaginous  structure.  It  is  in  this  portion 
of  the  skeleton  that  the  most  active  changes  take  place  during  the  period  of 
growth.  •  The  medullary  substance  is  very  vascular  at  this  point;  it  is  red  and 
without  fatty  tissue.  It  communicates  with  the  medullary  canal  and  with 
the  periosteum  by  a  number  of  vascular  channels.  The  epiphyseal  cartilage 
itself  is  intimately  blended  with  the  periosteum.  The  diaphyseal  side  of  the 
cartilage  produces  much  more  bone  than  is  found  in  the  epiphyseal  margin. 
There  is  also  an  active  growth  of  bone  in  the  periosteum,  and  it  is  in  these 
regions  and  in  the  medullary  canal  that  the  inflammatory  process  originates.* 
The  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  are  the  regions 
most  commonly  attacked;  but  the  upper  end  of  the  femur  and  the  lower  end 
of  the  tibia  may  suffer,  and  other  bones  may  be  attacked,  especially  the 
humerus,  radius,  ulna,  and  inferior  maxilla.  The  adjacent  joint  not  unusu- 
ally becomes  involved.  Though  the  inflammation  begins  in  the  spongy 
tissue  or  medulla,  it  passes  to  the  canals  and  spaces  of  the  compact  bone. 
The  inflammatory  exudate  in  the  canals  compresses  the  vessels  and  cuts  off 
nutrition  from  certain  areas.  Suppuration  begins,  clots  form  in  the  medulla 
from  thrombophlebitis,  and  the  clots  in  the  vessels  of  the  Haversian  canals 
become  septic.  A  small  sequestrum  forms  at  the  seat  of  origin  of  the  disease, 
and  the  pus  about  the  sequestrum  is  apt  to  empty  into  the  medullary  canal, 
causing  diffuse  osteomyelitis,  or  into  the  adjacent  joint,  causing  suppurative 
inflammation  of  the  articulation. 

Marked  constitutional  symptoms  arise  from  absorption  of  toxins  (sup- 
purative fever),  and  sometimes  true  septic  infection  or  even  pyemia  arises. 

Very  extensive  necrosis  may  follow  osteomyelitis  if  the  patient  recovers. 

Symptoms. — Osteomyelitis  secondary  to  a  wound  may  occur  in  a  person 

*  Warren's  "  Surgical  Pathology." 


Treatment  of  Acute  Osteomyelitis  513 

of  any  age.  If  a  wound  exists, — for  instance,  a  compound  fracture,— the 
diagnosis  is  evident.  The  constitutional  symptoms  of  septic  absorption  are 
positive:  there  is  a  profuse,  offensive,  purulent  discharge  containing  bone- 
fragments  and  tissue-sloughs;  the  periosteum  is  red,  thick,  and  separated; 
there  are  swelling  over  the  bone,  great  tenderness,  and  violent  boring,  gnawing, 
or  aching  pain.  Osteomyelitis  occurring  without  a  wound,  the  condition 
known  as  acute  epiphysitis,  occurs  in  the  young,  and  particularly  in  children 
under  three  years  of  age. 

The  symptoms  of  acute  epiphysitis  usually  come  on  suddenly  and  espe- 
cially at  night,  and  the  attack  may  be  so  acute  as  to  cause  death  by  systemic 
poisoning  before  a  diagnosis  is  arrived  at.  The  disease  is  generally  ushered 
in  by  a  chill,  which  is  followed  by  septic  febrile  temperature.  The  history  will 
sometimes  contain  the  statement  that  a  blow  had  been  received,  that  a  febrile 
process  had  existed,  or  that  the  patient  had  been  suddenly  chilled  after  having 
been  overheated  (sitting  in  a  draft  or  in  a  cellar  on  a  hot  day,  possibly  swimming 
when  very  warm,  etc.).  There  is  violent  aching  pain  in  the  bone  and  acute 
tenderness  near  the  joint;  the  soft  parts,  which  at  first  are  healthy  in  appear- 
ance, after  a  time  discolor,  swell,  and  present  distended  veins,  and  may  become 
glossy  and  edematous  because  pus  is  gathered  below.  An  abscess  sometimes 
reaches  the  surface  and  may  break  spontaneously.  The  neighboring  joint 
swells,  and  may  become  filled  with  pus;  the  periosteum  and  the  shaft  are 
involved  for  a  considerable  distance;  each  epiphysis  may  become  affected, 
the  shaft  between  being  comparatively  uninvolved,  and  the  epiphyses  may 
separate,  displacement  and  shortening  taking  place.  This  disease  is  often 
mistaken  for  rheumatism  because  of  the  joint-swelling,  occasionally  for 
typhoid  fever  because  of  the  fever,  and  in  some  cases  for  erysipelas  because 
of  the  redness  of  the  skin.  It  gives  a  very  grave  prognosis.  Sometimes  an 
epiphysitis  shows  milder  symptoms  and  is  slower  in  progress  (subacute). 
These  cases  are  very  often  mistaken  for  rheumatism.  But  in  rheumatism 
the  joint  is  the  part  involved  from  the  beginning,  while  in  epiphysitis  the  joint 
is  involved  secondarily  after  obvious  evidence  of  inflammation  well  clear  of 
the  articulation.  Further,  the  symptoms  of  rheumatism  will  be  rapidly 
improved  by  the  use  of  the  alkalies  or  the  salicylates. 

Treatment. — If  a  wound  exists,  apply  a  tourniquet,  sterilize  the  parts, 
enlarge  the  wound,  expose  and  curet  the  medullary  cavity,  remove  loose 
fragments  of  bone,  irrigate  the  medullary  cavity  with  a  hot  solution  of  corro- 
sive sublimate  or  hot  salt  solution,  scrape  it  with  bits  of  gauze  held  in  the 
bite  of  a  forceps,  paint  with  pure  carbolic  acid,  pack  lightly  with  iodoform 
gauze,  dress  with  hot  antiseptic  fomentations,  and  secure  rest  for  the  parts 
by  splints  and  bandages.  The  constitutional  treatment  is  the  same  as  that 
for  septicemia.  Acute  osteomyelitis  without  a  wound  is  a  most  serious  con- 
dition, rapidly  progressive,  apt  to  be  quickly  fatal,  and  requiring  prompt  and 
radical  treatment.  In  treating  it  do  not  wait  for  fluctuation,  but  incise  at 
once;  break  through  the  bone  at  one  or  more  points  with  a  gouge  or  chisel; 
chisel  away  the  diseased  bone,  and  if  necessary  curet  the  medullary  canal; 
irrigate  with  hot  corrosive  subHmate  solutions  or  hot  salt  solution;  swab  with 
pure  carbolic  acid;  use  iodoform  plentifully;  pack  with  iodoform  gauze; 
dress  with  hot  antiseptic  fomentations;  drain  the  joint  if  it  is  involved;  employ 
33 


514  Diseases  and  Injuries  of  Bones  and  Joints 

rest,  anod>Ties,  strong  supporting  treatment,  and  other  remedies  advised  in 
septicemia.  Remove  dead  bone  subsequently  when  it  becomes  loose.  Am- 
putation may  be  required  in  either  form  of  the  disease. 

Chronic  osteomyelitis  is  usually  linked  with  osteitis.  It  may 
eventuate  in  osteosclerosis  with  filling  up  of  the  medullar}-  canal,  in  limited 
suppuration,  in  caseation  of  the  cancellous  tissue  (Brodie's  abscess),  or  in 
necrosis.  A  tuberculous  inflammation  is  one  form  of  chronic  osteomyelitis 
(page  252).  Syphihs,  typhoid  fever,  etc.,  may  cause  it,  and  it  can  be  caused 
by  glanders,  leprosy,  and  actinomycosis. 

The  typhoid  bacillus  under  certain  conditions  is  pyogenic.  Frankel 
taught  this  some  years  ago,  and  Keen  seems  to  prove  it  in  his  work  on  the 
Surgery  of  Typhoid  Fever.  Osteomyelitis  due  purely  to  typhoid  bacilli  is 
chronic.  When  the  medulla  contains  typhoid  bacilli  pus  infection  is  apt  to  take 
place,  and  if  such  a  mixed  infection  arises  acute  osteomyelitis  develops. 

In  chronic  osteomyelitis  there  are  pain,  tenderness,  and  swelling,  but  no 
marked  constitutional  symptoms.  In  some  cases  the  real  trouble  is  not 
identified  until  an  abscess  forms  (see  Necrosis). 

Treatment. — If  an  abscess  exists,  at  once  evacuate  it  by  incising  the  soft 
parts  and  chiseling  the  bone.  Do  not  wait  for  an  involucrum  to  form,  but 
promptly  incise,  disinfect  and  drain.  If  dead  bone  is  present  it  must  be 
removed. 

Osteomalacia,  or  Mollities  Ossium.— In  this  disease  the  bones 
are  partly  decalcified,  and  consequently  soften  and  bend.  Masses  of  new 
uncalcified  bone-tissue  are  formed.  Many  bones  are  usually  involved,  but 
bones  of  the  head  are  not  obviously  aflfected.  It  is  commoner  beyond  than  before 
middle  age,  though  it  may  occur  in  infancy,  and  a  case  has  been  reported  in 
which  the  disease  arose  at  the  age  of  seventy.  It  is  more  frequently  met  with 
in  women  than  in  men,  and  pregnancy  seems  to  bear  more  than  a  casual 
relation  to  its  production.  In  osteomalacia  the  medulla  increases  in  bulk 
and  becomes  more  fatty,  and  the  osseous  matter  is  absorbed  gradually,  first 
from  the  cancellous  tissue  and  then  from  the  compact  tissue.  Some  obsen-ers 
beHeve  that  this  curious  condition  is  due  to  lactic  acid  in  the  blood,  an  abnor- 
mal amount  of  acid  haAing  been  produced  and  absorbed  because  of  disorder 
of  the  primar}'  assimilation.  Volkmann  maintained  that  some  inflammatory 
condition  disturbs  the  blood-supply  of  the  medulla,  and  von  Reckhnghausen 
asserts  that  arterial  h^-peremia  is  responsible.  Honnicke  suggests  that  the 
disease  is  due  to  hypersecretion  of  the  th}Toid  gland. 

Fehling,  influenced  by  finding  that  improvement  may  follow  removal  of 
the  ovaries,  set  forth  the  view  that  the  disease  is  due  to  overaction  of  the 
ovaries,  causing  reflex  dilatation  of  the  blood-vessels  of  bone.  This  explana- 
tion fails  entirely  to  account  for  the  disease  in  men.  Some  have  thought  that 
the  disease  is  of  bacterial  origin.  It  is  most  common  in  those  who  dwell  in 
damp  or  dark  habitations.  It  may  arise  after  a  soaking  and  "taking  cold." 
It  is  a  rare  disease  in  England  and  America,  but  is  much  more  common  in 
Germany. 

Sjrmptoms. — The  symptoms  of  osteomalacia  are  as  follows:  many  points 
of  pain  which  are  often  thought  to  be  due  to  rheumatism;  deformities  from 
twisting  and  bending  of  bone;  sometimes  lactic  acid  and  occasionally  an  excess 


Osteitis  Deformans  515 

of  calcium  salts  in  the  urine.  There  is  no  fever  early  in  the  case,  but  later  there 
may  be  a  hectic  fever.  When  the  disease  comes  on  after  childbirth  the  iliac 
bones  suffer  first.  Severe  pain  arises  in  the  pelvis  and  back  and  the  pain 
radiates  into  the  thighs,  the  pain  is  worse  at  night,  and  is  greatly  aggravated  by 
pressure  or  movements.  Finally,  standing  and  walking  become  unbearably 
painful.  Fractures  occur  from  very  sHght  force.  In  the  majority  of  cases  the 
disease  is  not  cured,  but  grows  progressively  worse  until  the  patient  dies,  after 
many  years,  from  exhaustion.  In  some  cases  the  process  is  arrested  and  the 
osteoid  tissue  is  calcified. 

Treatment. — In  treating  osteomalacia  in  women  insist  that  pregnancy 
must  not  occur.  In  all  cases  put  braces  and  supports  upon  distorted  hmbs 
to  prevent  further  bending  and  fracture.  Advise  hygienic  surroundings  and 
nourishing  food,  and  insist  on  the  value  of  fresh  air.  Among  the  medicines 
that  can  be  used  may  be  mentioned  cod-Hver  oil,  lime  salts,  preparations  of 
phosphorus,  and  bone-marrow.  In  women  the  removal  of  the  ovaries  some- 
times produces  great  improvement.  It  has  been  asserted  that  the  production 
of  anesthesia  by  means  of  chloroform  may  be  of  benefit. 

Acromegaly. — This  is  a  disease  which  causes  progressive  and  often 
great  enlargement  of  both  the  bones  and  soft  parts  of  the  extremides,  which 
enlargement  is  symmetrical.  The  cranium  becomes  triangular  in  shape,  v^n'th 
the  base  below  at  the  lower  jaw.  The  lower  jaw  projects  in  advance  of  the 
upper  jaw,  the  nose  becomes  prominent  and  thick,  the  supra-orbital  ridges 
are  accentuated,  and  the  costal  cartilages  and  inner  ends  of  the  clavicles 
become  protuberant.  Later  the  larynx,  ribs,  shoulder-blades,  and  vertebra? 
become  involved,  and  the  back  becomes  markedly  humped  (cervicodorsal 
hump).  The  hands  and  feet  are  effected  in  advanced  cases.  As  a  rule,  the 
thyroid  gland  is  enlarged,  and  a  post-mortem  examination  may  detect  an 
enlarged  pituitary  gland.  Severe  and  uncontrollable  headache  is  sometimes 
a  distressing  feature  of  the  disease.  In  some  cases  there  is  marked  somno- 
lence. A  fireman  who  suffered  from  acromegaly  would  go  to  sleep  almost  the 
moment  he  sat  down.  The  disease  slowly  but  surely  causes  death.  Medical 
treatment  is  fudle.  If  there  are  evidences  of  tumor  of  the  hypophysis  it  is 
justifiable  to  undertake  its  removal  by  operation.  This  has  been  accomplished 
successfully  by  Hochenegg,  Von  Eiselsberg,  Brochardt,  Gushing,  Sir  Victor 
Horsley,  and  others.  In  the  cases  of  Hochenegg  and  Gushing  not  only  were 
pressure  symptoms  reheved,  but  acromegalic  conditions  were  greatly  bene- 
fited. 

Leontiasis  Ossium  (Virchow's  Disease). — This  is  a  symmetrical 
hypertrophy  limited  to  the  facial  and  cranial  bones,  and  which  begins,  as 
a  rule,  in  the  superior  maxillae.  The  hypertrophy  progressively  increases, 
causes  difficulty  of  mastication,  and  is  accompanied  by  headache.  It  produces 
distinct  deformity  of  the  jaw  like  a  tumor,  whereas  acromegaly  enlarges  all 
of  the  proportions  of  a  bone  (Fig.  233).  It  may  produce  blindness,  new  bone 
pressing  upon  the  optic  nerves.  Treatment  is  not  sadsfactory,  as  a  rule. 
Recently  Horsley  has  obtained  amelioradon  by  operating  and  removing  masses 
of  bone. 

Osteitis  Deformans  (Paget's  Disease)  .—This  disease  was  first  de- 
scribed by  Paget  in  1877,  and  about  100  cases  have  been  reported.    Packard 


5i6 


Diseases  and  Injuries  of  Bones  and  Joints 


and  Steele  ("  Amer.  Jour,  of  Med.  Sciences,"  Nov.,  1901)  point  out  that  many 
of  the  reported  cases  are  not  genuine  instances  of  the  disease,  some  being  ordi- 
nary osseous  tumors,  others  being  cases  of  enlargement  after  fracture,  and  still 
others  being  instances  of  mollities  ossium.  They  think  that  67  of  the  reported 
cases  are  genuine  instances  of  the  disease.     In  this  disease  great  quantities 


Fig.  233. — Leontiasis  ossium. 

of  new  bone  are  formed,  but  calcification  does  not  occur.  The  material 
undergoes  absorption,  and  the  medullary  substance  of  the  bone  becomes 
extremely  vascular  and  filled  with  white  blood-cells,  and  also  with  giant- 
cells.  The  fact  that  the  new  bone  does  not  calcify  leads  to  various 
deformities  of  the  long  bones,  on  account  of  the  weight  of  the  body,  but 
fracture  is  not  particularly  apt  to  occur.  Numbers  of  bones  may  be 
decidedly  thickened.  The  underlying  cause  of  this  curious  condition  is  en- 
tirely unknown,  but  it  is  assumed  to  be  trophic.  It  is  claimed  that  it  has 
occasionally  arisen  after  an  injury  to  a  long  bone,  and  has  been  e.xcited  into 
activity  by  heat  and  cold.  It  is  extremely  rare  before  the  age  of  forty,  and 
usually  begins  between  forty  and  fifty.  The  enlargement  of  the  bones  may 
be  first  detected  in  the  cranium,  but  is  more  often  first  seen  in  some  other  bone 
— for  instance,  the  cla\'icle,  the  tibia,  the  spine,  or  the  radius.  The  tibia  in 
most  cases  suffers  first,  and  other  bones  become  involved  later.  In  fact,  in  some 
cases  the  bones  of  the  head  do  not  enlarge  at  all;  but,  taking  all  the  reported 
cases,  the  skull  is  affected  more  frequently  than  any  of  the  other  bones.  In 
some  cases  the  enlargement  of  the  bones  seems  to  be  symmetrical;  in  others 
it  is  not.  In  the  disease  known  as  leontiasis  ossium  the  chief  enlargement 
is  manifested  in  the  face;   in  Paget's  disease  there  is  no  enlargement  of  the 


Varieties  of  Fractures 


517 


bones  of  the  face,  or  else  these  bones  are  trivially  involved.  Packard  and 
Steele  point  out  that  the  diagnosis  is  extremely  difficult  when  but  a  single  bone 
is  involved;  but  that  if  two  or  more  bones  are  involved,  we  should  think  of 
Paget's  disease  as  the  condition,  especially  if  we  are  able  to  exclude  syphilis, 
cancer,  and  sarcoma.  In  mollities  ossium  the  head  is  not  involved  at  all; 
and  there  is  not  nearly  so  much  thickening  of  the  bone.  The  two  authors 
before  quoted  show  that  in  acromegaly  the  cranium  is  a  triangle  with  its 
base  below  at  the  lower  jaw,  the  orbital  arches  being  chiefly  involved;  but  that 
in  Paget's  disease  the  involvement  is  chiefly  of  the  calvarium.  In  this  curious 
malady  there  may  or  may  not  be  pain.  The  patient  actually  diminishes  in 
height.  The  chest  becomes  deformed.  There  is  angular  curvature  in  the 
dorsocervical  region.  The  lower  extremities  are  usually  bent;  and  the  pelvis, 
as  a  general  thing,  is  broadened.  In  the  67  cases  collected  by  Packard  and 
Steele,  3  sufi'ered  with  cancer  and  5  with  sarcoma. 

Treatment. — Treatment  is  practically  useless.  No  known  remedy 
diminishes  the  size  of  the  bones,  although  iodid  of  potassium  is  said  occa- 
sionally to  mitigate  the  pain,  if  pain  exists. 


Fractures. 
Definition. — A  fracture  is  a  solution,  by  sudden  force,  of  the  continuity 
of  a  bone  or  of  a  cartilage.     Clinically,  under  this  head  are  placed  epiphyseal 
separations  and  the  tearing  apart  of  ribs  and  their  cartilages. 

Varieties  of  Fractures. — The  varieties  of  fractures  are  as  follows: 
Simple  fracture  is  a  subcutaneous  fracture,  or  one  in  which  there  is  no 


Fig.  234. — Compound  comminuted  fracture  of  the  tibia. 


wound  extending  from  the  surface  to  the  seat  of  bone-injury.     This  corre- 
sponds to  a  contusion  of  the  soft  parts. 

Compound  jradtire  (Fig.  234)  is  an  open  fracture,  or  one  in  which  an 
open  wound  extends  from  the  surface  to  the  seat  of  bone-injury  or  in  which  a 
wound  opens  up  a  passage  from  the  fracture  to  the  surface.  This  corresponds 
to  a  contused  or  lacerated  wound  of  the  soft  parts.  The  opening  may  be  through 
the  skin ;  through  a  mucous  membrane,  as  in  some  fractures  of  the  base  of  the 
skull  and  pelvis;  through  the  drum  of  the  ear,  as  in  some  fractures  of  the 
middle  fossa  of  the  base  of  the  skull;  through  the  lung,  as  when  a  broken  rib 


5i8 


Diseases  and  Injuries  of  Bones  and  Joints 


penetrates  that  organ;  or  through  the  bowel  or  bladder,  as  in  some  fractures 
of  the  pelvis. 

A  primary  compound  fracture  is  one  in  which  the  breach  in  the  soft  parts 


a  b  C  d 

Fig.  235 — Complete  fractures  :  a,  Transverse  ;  b,  spiral ;  c,  dentated  ;  d,  oblique  or  multiple. 


is  produced  at  the  time  of  the  accident,  either  by  the  direct  violence  of  the 
injury  or  by  the  forcing  of  a  bone  or  bones  through  the  tissues. 

A  secondary  compound  fracture  is  one  in  which  the  breach  in  the  soft  parts 
occurs  after  the  accident,  either  from  sloughing  of  damaged  tissues,  from 
ulceration  because  of  the  pressure  of  ill-adjusted 
fragments,  or  from  the  forcing  of  a  bone  or  bones 
through  the  soft  parts  because  of  rough  handling, 
neglect,  or  the  tossing  of  delirium. 

Complicated  fracture  is  a  fracture  plus  the  com- 
plication of  a  joint-injury,  arterial  or  venous  damage, 
or  injury  to  the  nerves  or  soft  parts.  When  a  frac- 
tured rib  injures  the  lung  or  when  a  broken  vertebra 
damages  the  cord  a  complicated  fracture  exists.  The 
term  is  unfortunate,  as  it  conveys  no  definite  meaning, 
and  its  use  is  no  more  justifiable  than  it  would  be  to 
speak  of  "complicated  pneumonia"  or  "complicated 
typhoid,"  for  the  complication  should  be  named  in 
any  case.  It  must  be  remembered  that  damage  to 
the  soft  parts  not  sufficiently  severe  to  produce  a 
wound  reaching  from  the  surface  to  the  seat  of  frac- 
ture does  not  make  the  case  a  compound  fracture, 
but  rather  complicates  a  simple  fracture.  Remember 
also  that  even  superficial  areas  of  tissue-destruction 
must  be  treated  antiseptically,  otherwise  absorption 
of  pyogenic  bacteria  and  their  deposition  at  the  seat  of  injury  may  cause 
diffuse  osteomyelitis. 

Complete  fracture  is  that  which  extends  through  the  whole  thickness  of 
a  bone  or  entirely  across  it  (Fig.  235). 

Incomplete  fracture  is  that  which  extends  only  partially  through  the  thick- 
ness of  a  bone  or  only  partially  across  it. 


Fig.  236. — Longitudinal 
and  oblique  fracture. 


Varieties  of  Fractures 


519 


A  linear,  hair,  capillary,  or  fissured  fracture,  or  a  fissure,  is  a  crack  in  a  bone 
with  very  little  separation  of  the  edges.  This  is  an  incom- 
plete fracture,  but  may  be  associated  with  a  complete  break. 
A  green-stick,  hickory-stick,  willow,  or  bent  fracture  is  a 
true  incomplete  break  (Fig.  237).  The  bones  most  frequently 
broken  are  the  radius,  ulna,  clavicle,  and  ribs.  It  arises  from 
indirect  force,  and  it  is  very  rare  after  the  age  of  sixteen.  In 
rickets  green-stick  fractures  are  very  common.  It  is  called 
"  green-stick  "  because  the  bone  breaks  like  a  green  stick  when 
forced  across  the  knee,  first  bending  and  then  breaking  on  its 
convex  surface.  The  bone,  being  compressed  between  two 
forces,  bends,  and  the  fibers  on  the  outer  side  of  the  curve  are 
pulled  apart,  while  those  on  the  concavity  are  not  broken,  but 
are  compressed.  In  correcting  the  deformity  such  fractures 
are  often  made  complete.  The  permanent  bending  of  a  bone 
without  a  break  may  possibly  occur  in  youth.  In  children  a 
portion  of  a  bone  of  the  skull  may  be  bent  inward,  causing 
depression.  In  some  cases  such  a  depression  is  permanent; 
in  others  it  is  temporary,  the  bone  returning  to  its  proper 
level. 

Depression-jracture  occurs  when  a  portion  of  the  thickness 
of  a  bone  is  driven  in  by  crushing.     Fracture  by  depression  is 
a  result  of  the  bending  in  of  a  bone  (as  the  parietal),  a  frag- 
ment   breaking    off    from    the    side 
toward  which  the  bone  is  bending. 
A  depressed  jracture  is  complete,  not 
incomplete,    and    by    this    terra    is 
meant  an  injury  in  which  a  fragment  of  the  entire 
thickness  of  the   bone  is  driven   below  the  level  of 
the  surrounding  surface. 

Splinter-  and  Strain-fracture.  —  The  breaking 
off  of  a  splinter  of  bone  (splinter-fracture)  or  of 
an  apophysis  constitutes  a  form  of  incomplete  frac- 
ture. A  strain  upon  a  ligament  or  a  tendon  may 
tear  off  a  shell  of  bone,  and  this  injury  is  the  "  strain- 
fracture"  or  "sprain-fracture"  of  Callender. 

Longitudinal  fracture  is  a  fracture  whose  line  is 
for  a  considerable  distance  parallel,  or  nearly  so,  with 
the  long  axis  of  the  bone.  Such  fractures  are  com- 
mon in  gunshot-injuries  (Fig.  236). 

Oblique  fracture  is  a  fracture  the  direction  of 
which  is  positively  oblique  to  the  long  axis  of  the 
bone.  Most  fractures  from  indirect  force  are  obhque 
(Fig.^235,  d). 

Transverse  fracture  is  a  fracture  the  direction  of 
which  is  nearly  transverse  to  the  long  axis  of  the  bone  (no  fracture  is  math- 
ematically transverse)  (Fig.  235,  a).  The  cause  is  often,  but  not  invari- 
ably, direct  force.     The   '^fracture  en  rave"   (radish-fracture,  so  called  be- 


V^ 


Fig.  237.— Green 
stick  fracture. 


Fig.  238. — Appearances  of 
the  ends  of  fragments. 


520 


Diseases  and  Injuries  of  Bones  and  Joints 


cause  the  bone  breaks  as  does  a  radish)  is  transverse  at  the  surface,  but  not 
within. 

Toothed  or  dentate  fracture  is  a  form  of  fracture  in  which  the  end  of  each 
fragment  is  irregularly  serrated  and  the  fragments  are  commonly  locked  to- 
gether; hence  it  is  difficult  to  correct  the  deformity  (Fig.  235,  c,  and  Fig. 
238).     Most  simple  fractures  from  direct  force  are  serrated. 


Fig.  239. — Impacted  fracture  of  the 
neck  of  the  femur. 


Fig.  240.— Impacted  fracture  of  the 
neck  of  the  femur. 


Wedge-shaped,  V-shaped,  cuneated,  or  cuneijonn  fracture  ("  fracture  oblique 
spiroide,"  "  fracture  en  V"  of  Gosselin,  "fracture  en  coin")  is  one  the  lines  of 
which  take  the  shape  of  a  V,  which  may  be  entire  or  may  lack  the  point.  It 
occurs  at  the  articular  extremity  of  a  long  bone,  and  a  fissure  usually  arises  from 
its  point  and  enters  the  joint.     If  complete,  it  is  a  "comminuted  fracture." 

T-shaped  jracture  is  a  fracture  which  presents 
a  transverse  or  oblique  line  and  also  a  longitudinal 
or  vertical  line.  It  occurs  at  the  lower  end  of 
either  the  humerus  or  femur,  the  transverse  line 
being  above,  and  the  vertical  line  (intercondyioid) 
between,  the  condyles.  If  complete,  it  is  in  reality 
a  form  of  comminuted  fracture. 

Multiple  or  composite  fracture  is  a  condition 
in  which  a  bone  is 
broken  into  more 
than  two  pieces,  the 
lines  of  fracture  not 
inter  communicating, 
or  a  condition  in 
which  two  or  more' 
bones  are  broken.  Multiple  fractures  of  one  bone 
are  divided  into  double,  treble,  quadruple,  etc. 
Muldple  fractures  involving  more  than  one  bone 
are  seldom  seen,  and  represent  less  than  2  per 
cent,  of  fracture  cases.  The  reason  of  their 
rarity  in  hospitals  is  that  they  result  from  severe  force  and  many  of  the  victims 
die  before  they  can  be  brought  to  an  institution.  The  mortaHty  in  cases  which 
reach  the  hospital  is  large,  over  27  per  cent.  (Astley  P.  C.  Ashhurst,  in  "Annals 
of  Surgery,"  Augue^t,  1907). 


Fig.  241. — Comminuted  frac- 
ture of  the  lower  extremity  of 
radius. 


Fig.  242 


Comminuted  fracture  of 
the  upper  part  of  femur. 


Varieties  of  Fracture  521 

Commiuuted fracture  is  a  condition  in  which  a  bone  is  broken  into  more  than 
two  pieces,  the  lines  of  fracture  intercommunicating  (Figs.  241  and  242J. 

The  bone  may  be  broken  into  many  small  fragments,  there  may  be  much 
splintering,  or  the  osseous  matter  may  actually  be  ground  up. 

Impacted  fracture  is  one  in  which  one  fragment  is  driven  into  the  other 
and  solidly  wedged  (Figs.  239,  240,  and  243). 

Fracture  'ivith  crushing  or  penetration  is  a  fracture  in  which  one  bone  is 
driven  into  the  other,  the  encasing  bone  being  so  splintered  that  the  impacting 
bone  is  not  firmly  held. 

Pathological,  spontaneous,  or  secondary  fracture  is  one  occurring  from  a 
very  insignificant  force  acting  on  a  bone  rendered  brittle  by  disease. 

Ununited  fracture  is  a  fracture  in  which  bony  union  is  absent  after  the 
passage  of  the  period  normally  necessar\'  for  its  occurrence. 

Direct  fracture  is  one  occurring  at  the  point  at  which  the  force  was  pri- 
marily applied. 

Indirect  fracture  is  one  occurring  at  a  point  distant  from  the  area  of 
primar}'  application  of  force. 

Stellate  or  starred  fracture  (fracture  par  irradiation)  is  one  in  which 
several  fissures  radiate  from  a  center.  If  the  fractures  be  complete,  the 
condition  is  in  realitv  a  form  of  comminuted  fracture. 


Fig.  243.— Impacted  fracture  of  neck  of  femur  (Conner). 

HelicoidaL  spiral,  or  torsion  fracture  is  a  fracture  resulting  in  a  long  bone 
from  tnisting. 

Fracture  by  contrecoup  is  a  fracture  of  the  skull  which  is  on  the  opposite 
side  of  the  head  to  that  which  was  the  recipient  of  the  force. 

Epiphyseal  Separation  or  Diastasis. — This  injur}-  occurs  only  before  the 
age  of  t\\enty-five.  In  order  of  frequency,  the  bones  chiefly  subject  to  epiphy- 
seal separation  are:  the  upper  end  of  the  humerus,  the  lower  end  of  the 
radius,  the  lower  end  of  the  femur,  and  the  lower  end  of  the  tibia   (John 


522  Diseases  and  Injuries  of  Bones  and  Joints 

Poland,  in  the  "Practitioner,"  Sept.,  igoi).  This  injury  induces  defonnity, 
which  is  often  difficult  to  reduce,  and  by  damaging  the  cartilage  mav  retard 
or  inhibit  a  further  lengthening  of  the  limb  by  growth.  Occasionally,  after 
damage  to  an  epiphysis  suppuration  will  occur,  sometimes  thickening  takes 
place.  Non-union  is  ver}'  rare.  After  a  sprain  of  an  epiphysis  tubercu- 
lous disease  sometimes  develops,  but  very  rarely  after  a  separation. 

Intra-uterine  fractures  are  usually  due  to  injuries  of  the  mother's  abdomen 
sustained  toward  the  end  of  pregnancy.  Some  hold  that  they  can  arise  as 
a  consequence  of  the  force  of  violent  uterine  contractions.  Many  so-called 
"intra -uterine"  fractures  are  wrongly  named,  as  they  result  from  injury 
during  deUvery.  In  sporadic  cretinism  the  bones  are  fragile  and  ill-ossified, 
and  many  fractures  may  occur  in  utero. 

Designation  According  to  Seat  oj  Fracture. — A  fracture  may  be  desig- 
nated according  to  its  anatomical  seat;  for  instance,  fracture  of  the  upper 
third  of  the  shaft  of  the  femur,  fracture  of  the  olecranon  process  of  the  ulna, 
fracture  of  the  middle  third  of  the  clavicle,  and  fracture  of  the  bodv  of  the 
lower  jaw.  Intra-articular  fracture  is  one  extending  into  a  joint;  intracapsular 
fracture  is  one  within  the  capsule  of  either  the  shoulder-  or  hip-joint;  and 
extracapsular  fracture  is  one  just  without  the  capsule  of  either  the  shoulder- 
or  hip-joint. 

Causes  of  Fracture.— The  causes  of  fracture  are  (i)  exciting,  imme- 
diate or  direct,  and  (2)  predisposing  or  indirect. 

Exciting  causes  are  (a)  external  violence  and  (b)  muscular  action. 

External  violence  is  the  most  usual  exciting  cause.  Two  forms  are  noted: 
(i)  direct  violence  and  (2)  indirect  force. 

Fractures  from  direct  violence  occur  at  the  point  struck,  as  when  the  nasal 
bones  are  broken  with  the  fist.  In  such  fractures  the  soft  parts  are  injured; 
they  may  be  destroyed  at  once  in  part,  they  may  be  damaged  so  severely 
that  a  portion  sloughs,  or  they  may  be  damaged  so  slightly  that  they  do  not 
lose  vitality;  hence  fractures  by  direct  violence  may  be  compound  from  the 
start,  may  become  so,  or  may  remain  simple.  In  fractures  by  direct  force 
discoloration,  due  to  effused  blood,  usually  appears  at  the  point  struck  soon 
after  the  accident.  In  compound  fractures  by  direct  violence  the  soft-part 
injury  is  so  great  that  primary  tissue-union  cannot  occur. 

Fractures  from  indirect  force  do  not  occur  at  the  point  of  application  of 
the  force,  but  at  a  distance  from  it,  the  force  being  transmitted  through  a 
bone  or  a  chain  of  bones,  as  when  the  clavicle  is  broken  by  a  fall  upon  the 
extended  hand.  Such  fractures  tend  to  occur  in  regions  of  special  predi- 
lection. If  they  are  not  compound,  there  is  no  injury  of  the  surface  over 
the  fracture.  If  they  become  compound  by  projection  of  fragments,  primary 
union  may  still  occur.  Discoloration  over  the  seat  of  fracture  is  usually 
not  present  soon  after  the  accident,  but  may  occur  later.  Discoloration 
rapidly  appears  in  soft  parts  at  the  point  where  the  force  was  first  applied. 

Muscular  action  is  rather  an  unusual  cause.  Fractures  thus  produced 
result  from  sudden  or  violent  muscular  contraction.  Bones  so  broken  are 
usually  diseased.  Violent  coughing  may  fracture  the  ribs;  attempting  to 
kick  may  fracture  the  femur;  saving  one's  self  from  falling  backward  may 
fracture  the  patella;  throwing  a  stone  may  fracture  the  humerus;  and  sudden 
extension  of  the  forearm  may  fracture  the  olecranon  process  of  the  ulna. 


Predisposing  Causes  of  Fracture  523 

Predisposing  Causes. — There  are  two  classes  of  i)redisposing  causes, 
namely:  (i)  physiological,  natural  or  normal,  and  (2)  pathological  or  abnor- 
mal. 

Natural  Predisposing^  Causes. — Under  this  head  is  considered  the  liability 
to  fracture  possessed  by  individual  bones  because  of  their  shape,  structure, 
function,  or  position.  Those  predispositions  occasioned  by  special  ages  are 
also  considered.  In  youth  epiphyseal  separation  is  commoner  than  fracture 
and  a  fracture  is  apt  to  be  incomplete.  Fractures  are  commonest  between 
the  ages  of  twenty-five  and  sixty.  From  two  to  four  years  of  age  a  child 
is  more  liable  to  fracture  than  later,  because  he  is  then  learning  to  walk 
(Malgaigne).  The  bones  of  the  old  are  easily  broken,  but  the  normal  lack 
of  activity  of  the  aged  saves  them  from  more  frequent  injury.  Thus  the 
predispositions  of  age  are  in  part  due  to  habits  and  in  part  to  bony  structure. 
The  bones  of  the  young,  being  elastic,  bend  considerably  before  they  break; 
the  bones  of  the  old,  being  brittle  and  inelastic,  break  easily,  but  do  not 
bend.  In  old  age  the  bones  become  lighter  and  more  porous,  though  they 
do  not  diminish  in  size.  Absorption  takes  place  from  the  interior  of  a 
bone,  particularly  at  its  articular  head,  the  medullary  canal  increases  in 
size,  the  cancellous  spaces  become  notably  larger,  and  portions  of  the  re- 
maining bone  of  the  interior  show  a  fatty  change.  There  is  no  increase  in 
the  amount  of  mineral  salts  present,  as  was  long  taught.  These  alterations 
occur  earlier  in  women  than  in  men.*  The  change  of  age  is  a  diminution 
in  the  amount  of  bone  present,  and  sometimes  a  fatty  change  in  a  portion 
of  what  remains.  If  the  atrophy  of  bone  is  other  than  that  normal  to  senility, 
it  constitutes  a  pathological  predisposing  cause  of  fracture.  Normal  predis- 
posing causes  include  the  person's  weight  (which  determines  the  force  of 
a  fall),  muscular  development,  habits,  sex,  occupation,  and  the  season  of  the 
year. 

Pathological  Predisposing  Causes. — Hereditary  jragility,  a  form  of  fragili- 
ias  ossium,  is  a  condition  commonest  among  women,  often  existing  in  genera- 
tion after  generation,  and  in  this  condition  fractures  occur  from  a  very  slight 
force.  There  exists  in  these  cases  bony  rarefaction — in  fact,  a  premature 
senility.  Fragilitas  ossimn  {osteopsa-thyrosis)  may  be  congenital  or  may  come 
on  later  in  life.  It  may  result  from  seniUty,  wasting  diseases,  scurvy,  scarla- 
tina, bone-cyst,  malignant  disease  of  the  bone,  certain  nervous  disorders, 
rickets,  osteomalacia,  and  atrophy  due  to  disuse. 

Nervous  Diseases. — Bony  nutrition  is  dependent  on  the  spinal  cord,  and 
the  trophic  influence  is  probably  exerted  through  the  posterior  nerve-roots 
{Gowers).  In  diseases  of  the  anterior  cornua  bony  growth  is  much  interfered 
with;  in  diseases  of  the  posterior  columns,  as  in  locomotor  ataxia,  a  true 
bony  atrophy  bespeaks  trophic  disorder.  Syringomyelia  causes  brittleness 
of  the  osseous  structures,  and  in  paralysis  agitans  bones  are  thought  to  break 
easily.  Trophic  changes  may  occur  in  the  bones  of  the  insane,  most  com- 
monly when  insanity  is  linked  to  organic  disease.  About  one-quarter  of 
paretic  dements  show  undue  brittleness  or  unnatural  softness  of  bones-t 
The  bones  of  maniacs  are  frequently  fragile.  Fractures  among  the  insane 
are  not  necessarily  an  indication  of  abuse. 

T^/cy^e/^.— Rickets  predisposes  to  fracture  because  of  altered  bone-structure 
and  the  great  liability  to  falls. 

*  Humphrey  on  "  Old  Age."  t  "Manual  of  Insanity,"  by  Spitzka. 


524  Diseases  and  Injuries  of  Bones  and  Joints 

Osteomalacia  predisposes  to  fracture  of  the  long  bones,  sternum  and  ribs. 

Atrophy  of  Bone. — This  condition,  as  has  been  stated  (page  500J,  is  nor- 
mal in  senility.  It  may  arise  from  want  of  use,  as  is  observed  in  the  bedfast 
in  the  wasted  femur  of  hip-joint  disease,  and  in  the  bones  of  a  stump.  It 
may  arise  from  pressure,  as  when  an  aneurysm  compresses  the  ribs,  sternum, 
or  vertebrae.  Among  other  of  the  pathological  predisposing  causes  are  to  be 
mentioned  cancer,  sarcoma,  hydatid  and  solitary  cysts  of  bone,  caries,  necrosis, 
gout,  scrofula,  syphilis,  mollities  ossium,  and  scurvy. 

Symptoms  of  Fracture. — History  0;  an  Injury. — In  spontaneous 
fracture  there  may  be  no  record  of  violence;  for  instance,  a  bone  may  break 
while  an  individual  is  turning  in  bed.  In  investigating  the  histon.',  not  only 
seek  for  a  record  or  for  evidences  of  violence,  but  try  to  determine  exactly 
how  the  accident  happened. 

A  sound  oj  cracking  is  occasionally  audible  to  a  bystander  at  the  time 
of  the  injury.  The  patient  may  have  heard  it,  but  ver}-  rarely  does.  A 
rupture  of  a  tendon  or  a  ligament  produces  a  similar  sound. 

Pain  is  usually,  but  not  invariably,  present  (absent  often  in  rickets). 
Malgaigne  says  that  in  some  fractures  the  pain  is  slight  or  absent,  in  others 
it  is  torturing,  and  in  most  it  is  severe  for  a  time  after  the  injury,  but  gradually 
abates  unless  reinduced  by  movement.  Pain  developed  at  the  time  of  the 
accident  is  far  less  important  as  a  symptom  than  that  which  can  subsequently 
be  produced  by  movement.  In  indirect  fracture  there  is  an  area  of  pain 
at  the  point  of  apphcation  of  the  force,  and  another  at  the  seat  of  fracture. 
Pain  at  the  seat  of  fracture  can  be  greatly  aggravated  by  pressure  or  movement 
and  is  rather  narrowly  localized. 

Deformity  or  alteration  in  length  or  outline  is  due  in  part  to  swelling  and 
in  part  to  a  change  in  the  mutual  relation  of  the  fragments  (displacement). 
The  deformity  due  to  swelling  is  no  aid  to  diagnosis,  as  the  same  condition 
occurs  in  contusion,  and  often  hides  some  positive  symptomatic  distortion. 
The  swelling  is  due  first  to  blood  and  next  to  inflammatory  products  and 
pressure-edema,  and  is  ver}'  great  in  joint-fractures.  Swelling  due  to  bleeding 
is  early  and  rapid.  Swelling  due  to  inflammatory  exudation  is  later  and  grad- 
ual. SwelHng  due  to  pressure-edema  may  be  rapid.  The  greater  part  of  the 
swelling  is  due  to  hemorrhage  and  exudation  from  the  damaged  soft  parts,  a 
porrion  of  it  is  due  to  hemorrhage  and  exudarion  from  the  bone.  The 
swelling  is  usually  in  direct  ratio  to  the  mobility,  the  greater  the  mobihty  the 
greater  the  swelling.  "The  swelling  in  fractures  of  the  skull  is  inconsider- 
able, notwithstanding  that  the  total  area  of  bone  surface  involved  is  commonly 
more  than  in  fractures  of  the  leg  or  arm,  and  the  vascularit}-  greater.  The 
reason  for  this  is  the  natural  immobiUty  of  fractures  of  the  skull"  (James  P. 
Warbasse,  in  ''Jour.  Am.  Med.  Assoc,"  March  13,  1909).  The  deformit}'  of 
displacement  may  be  produced  by  the  violence  of  the  injury  (as  is  the  depres- 
sion in  a  skull-fracture),  by  the  weight  of  an  extremitv^  (as  is  the  falling  of 
the  shoulder  in  a  fracture  of  the  claxicle),  or  by  muscular  action  (as  is  the 
pulling  upward  oi  the  fragment  oi  a  fractured  olecranon  process). 

The  varieties  of  displacement  are  d)  transverse  or  lateral,  where 
one  fragment  goes  to  the  side,  front,  or  back,  but  does  not  overlap  the  other; 
(2)  angular,  the  bony  axis  at  the  point  of  fracture  being  altered  and  the 
fragments  forming  \\\\.h.  each  other  an  angle;  (3)  rotary,  one  fragment  rotating 


Symptoms  of  Fracture  525 

in  the  bony  circumference,  the  other  remaining  stationary.  As  a  rule,  it  is 
the  lower  fragment  which  turns  on  its  long  axis,  the  limb  below  the  level 
of  the  break  rotating  with  it;  (4)  overlapping  or  overriding,  when  the  upper 
level  of  one  fragment  is  above  the  lower  level  of  the  other  fragment.  It  is 
usually  the  lower  fragment  which  is  drawn  by  the  muscles  above  the  upper, 
but  in  a  fracture  of  the  lower  extremity  the  body-weight  and  sliding  down 
in  bed  may  push  the  upper  below  the  lower  fragment.  In  overriding  the 
ends  are  near  together  and  the  bones  are  usually  in  contact  at  their  periphery. 
It  is  obvious  that  overlapping  is  associated  with  transverse  displacement,  as 
one  fragment  must  go  front,  back,  or  to  the  side;  (5)  penetration  or  impaction 
when  one  fragment  is  driven  into  the  other,  thus  producing  shortening; 
(6)  separation  of  the  two  fragments  occurs  in  fracture  of  the  patella,  olecranon, 
OS  calcis,  certain  articulations,  and  in  some  breaks  of  the  humerus  when  the 
arm  is  not  supported. 

It  is  important  to  remember  that  a  dislocation  as  well  as  a  fracture  may 
produce  displacement,  but  these  two  conditions  may  be  differentiated  by 
the  observation  that  the  di.^placement  of  fracture  tends  to  reappear  even 
after  complete  reduction,  while  the  displacement  of  dislocation  does  not 
reappear  after  correction.  A  displacement  is  difficult  of  detection  in  a  flat 
bone  and  when  one  of  two  parallel  bones  is  broken. 

Loss  of  function  may  be  shown  by  inability  to  move  the  limb  because 
of  the  break,  but  it  is  not  always  markedly  present,  though  some  degree 
invariably  exists.  It  is  slight  in  "green-stick"  and  impacted  fractures  (unless 
the  loss  of  power  arises  from  pain  or  nerve-injury).  A  person  can  walk 
when  the  fibula  alone  is  broken,  and  likewise  in  some  cases  of  intracapsular 
fracture  of  the  femur,  and  can  often  put  the  hand  on  the  head  in  fractured 
clavicle  (Malgaigne).  The  pain  of  any  injury  or  the  loss  of  power  from 
nerve-traumatism  may  cause  loss  of  mo\"ement  in  the  limb.  This  symptom 
is  of  slight  diagnostic  value  in  most  fractures. 

Extravasation  oj  Blood. — A  contusion  of  the  surface  accompanied  by  skin- 
abrasion  indicates  merely  the  point  of  application  of  direct  external  violence. 
If  contusion  is  extensive  over  a  superficial  bone,  as  the  tibia  or  parietal, 
after  a  few  hours  it  often  simulates  fracture  by  presenting  a  soft,  compressible 
center  surrounded  by  a  ring  of  hard,  condensed  tissues  and  coagulated  blood. 
Direct  external  violence  may  merely  occasion  ecchymosis,  and  in  fracture 
from  indirect  force  ecchymosis  may  occur  throughout  a  considerable  area. 
In  regard  to  this  symptom,  note  that  even  great  external  violence  may  occasion 
no  evident  contusion  or  ecchymosis,  and  in  any  fracture  this  symptom  may 
be  present  or  absent.  In  old  people,  anemic  subjects,  alcoholics  and  opium- 
eaters,  extravasation  of  blood  is  frequently  marked  and  persistent.  By  sug- 
gillation  is  meant  an  extravasation  of  blood  which  slowly  invades  wide  areas 
of  tissue  and  which  appears  at  the  surface  only  after  some  time,  and  then 
usually  as  a  yellowish  discoloration,  red  hemoglobin  having  been  changed 
to  yellow  hematoidin.  Linear  ecchymosis  has  been  esteemed  by  some  as  a 
sign  of  fissure,  and  it  is  often  noted  after  fracture  of  the  fibula.  Linear 
ecchymosis  over  the  line  of  the  posterior  auricular  artery  was  shown  by 
Battle  to  be  a  valuable  sign  of  fracture  of  the  posterior  fossa  of  the  base  of 
the  cranium. 

Preternatural  mobility  is  a  most  important  symptom,  which  is  pathogno- 


526  Diseases  and  Injuries  of  Bones  and  Joints 

monic  when  surely  found.  The  unbroken  bone  is  nowhere  mobile  in  con- 
tinuity. By  preternatural  mobility  is  meant  that  a  bone  is  mobile  in  con- 
tinuity or  that  there  is  abnormality  in  the  direction  or  extent  of  joint-mobility. 
In  some  fractures  this  symptom  does  not  exist  (impacted,  green-stick,  and 
locked  serrated  fractures) ;  in  others  it  cannot  be  found  (fractures  of  tarsus, 
carpus,  vertebral  bodies) ;  in  others  it  is  difficult  to  obtain,  but  at  times  can; 
be  developed  (fractures  near  or  into  many  joints).  To  develop  this  symptom, 
try,  when  the  case  admits,  to  grasp  the  fragments  and  to  move  them 
in  opposite  directions.  In  a  fracture  of  the  shaft  of  the  femur  or  humerus 
fix  the  upper  fragment  and  carry  the  knee  or  elbow  in  various  directions 
to  develop  bending  at  the  point  of  fracture.  In  fracture  of  the  clavicle  push 
the  shoulder  downward  and  inward.  In  fractures  of  either  bone  of  the  fore- 
arm grasp  the  parallel  bone  with  four  fingers  of  each  hand  and  make  pressure- 
on  the  suspected  bone  alternately  with  either  thumb,  and  the  same  procedure 
can  be  used  in  fractures  of  the  leg.  In  fracture  of  the  neck  of  the  femur 
the  altered  rotation-arc  of  the  great  trochanter  demonstrates  preternatural 
mobility  (Desault).  In  fracture  of  the  lower  end  of  the  radius  bend  the 
hand  back,  and  in  a  break  of  the  lower  end  of  the  fibula  evert  the  foot 
(Maisonneuve).  In  seeking  preternatural  mobility,  remember  that  the  elas- 
tic ribs  when  forced  in  give  a  sense  of  bending,  and  that  the  fibula  at  its 
middle  is  "normally  flexible"  (Dupuytren).  Some  rachitic  bones  may  be 
bent. 

Crepitus  or  crepitation  is  both  a  sensation  and  a  sound,  which  indicates 
the  grating  together  of  the  two  rough  surfaces  of  a  broken  bone.  This  symp- 
tom is  of  great  value,  but  it  is  not  always  present.  It  is  absent  in  locked 
serrated  fractures,  in  impacted  fractures,  in  cases  where  the  broken  ends 
cannot  be  approximated  (as  in  overlapping),  is  rare  when  a  fractured  surface 
is  against  the  side,  and  not  the  broken  face,  of  the  other  fragment,  and  is 
unusual  in  incomplete  fractures.  Crepitus  is  often  absent  in  epiphyseal 
separation,  in  softened  bones,  and  in  fractures  in  or  near  joints,  and  it  may 
be  prevented  from  occurring  by  blood-clot,  fascia,  synovial  membrane,  perios- 
teum, or  muscle  between  the  broken  surfaces.  The  grating  found  in  teno- 
synovitis must  not  be  mistaken  for  the  crepitus  of  fracture:  the  former  is 
diffuse,  large,  soft,  and  moist;  the  latter  is  limited,  small,  harsh,  and  dry. 
The  clicking  of  an  inflamed  or  eroded  joint  and  the  crackling  of  emphysema 
must  also  be  separated  from  bony  crepitus.  Crepitus  of  fracture  may  be 
present  at  one  moment,  but  absent  the  next.  It  is  often  not  detected  during 
the  time  swelling  is  marked,  and  cannAt  be  discovered  after  organization 
of  the  callus  begins.  In  but  few  fractures  is  it  needful  to  try  to  hear  crepitus 
with  the  unaided  ear  or  with  a  stethoscope  upon  the  part,  but  in  doubt- 
ful cases  of  fractures  of  ribs  and  joints  this  evidence  should  be  sought  for. 

The  above-named  symptoms  are  known  as  "direct."  There  are  other 
symptoms  known  as  "circumstantial,"  such  as  the  flow  of  blood  and  cere- 
brospinal fluid  from  the  ear  after  some  fractures  of  the  middle  fossa  of  the 
skull;  emphysema  of  the  face  and  epistaxis  after  fracture  of  the  nasal  bones;, 
hemoptysis  and  emphysema  after  crushes  of  the  chest;  discoloration  following 
the  hne  of  the  posterior  auricular  artery  after  fracture  of  the  posterior  fossa 
of  the  skull;  and  subconjunctival  ecchymosis  after  fracture  of  the  anterior 
fossa  of  the  skull. 


Diagnosis  of  Fracture  527 

Diagnosis. — Examine  as  soon  as  practicable  after  the  injury — before 
the  onset  of  swelling,  if  possible.  Expose  the  part  completely,  taking  off 
the  clothing,  if  necessary,  by  clipping  it  along  the  seams.  Attentively  scru- 
tinize the  part  and  compare  it  with  the  corresponding  part  on  the  oj)posite 
side.  If  any  deformity  be  present,  it  must  be  ascertained  that  it  did  not 
exist  before  the  accident.  If  the  nature  of  the  injury  be  uncertain,  if  the 
patient  be  very  nervous,  or  if  the  part  be  acutely  painful,  it  is  better  to  give 
ether  to  diagnosticate,  set,  and  dress.  In  injuries  of  the  elbow- joint  anesthe- 
tize before  examination,  unless  an  .r-ray  apparatus  is  accessible  to  settle 
the  diagnosis,  and  even  then  it  is  usually  well  to  anesthetize  in  order  to  facili- 
tate reduction  and  dressing.  In  every  case  of  suspected  fracture  get  an  x-ray 
picture  if  possible.  A  correct  diagnosis  is  of  the  first  importance  and  on  a  cor- 
rect diagnosis  proper  treatment  primarily  depends. 

A  fracture  is  distinguished  from  a  dislocation  by  its  preternatural  mobility, 
its  easily  reduced  but  recurring  displacement,  and  its  crepitus,  as  contrasted 
with  the  preternatural  rigidity,  the  deformity,  difficult  to  reduce  but  remaining 
reduced,  and  the  absence  of  crepitus  of  a  dislocation.  Further,  in  dislocation 
the  bone,  when  rotated,  moves  as  one  piece,  whereas  in  fracture  it  does  not 
so  move;  in  dislocation  the  bony  processes  are  felt  occupying  their  proper 
relations  to  the  rest  of  the  same  bone,  while  in  fracture  some  of  them  present 
altered  relations.  In  dislocation  the  head  of  the  bone  is  found  out  of  its 
socket,  but  in  fracture  it  is  felt  in  place.  It  is  important  to  remember, 
moreover,  that  a  fracture  and  a  dislocation  may  occur  together,  and  that 
the  rubbing  of  a  dislocated  bone  against  an  articular  edge,  when  the  joint  has 
been  roughened  by  inflammation,  simulates  crepitus. 

Great  contusion,  by  inducing  extreme  tumefaction,  may  mask  charac- 
teristic deformity  and  obscure  crepitus.  When  only  a  contusion  exists, 
pain  is  apt  to  be  widespread;  but  if  a  fracture  has  occurred,  the  pain  is 
accentuated  at  some  narrow  spot.  In  many  cases,  before  he  can  give  a  certain 
opinion,  the  surgeon  must  wait  some  days  until  the  swelling  has  largely 
subsided.  In  such  a  case  it  is  best  to  assume  in  our  treatment  that  a  fracture 
exists  until  the  contrary  is  known.  Combat  swelling  by  rest,  the  use  of 
evaporating  lotions,  and  moderate  compression. 

In  impaction  the  diagnosis  is  difficult.  The  moderate  deformity  is  con- 
cealed by  swelling;  crepitus  and  preternatural  mobility  do  not  exist  unless 
the  fragments  are  pulled  apart,  and  there  is  not  necessarily  much  loss  of 
function.  A  conclusion  is  reached  largely  by  considering  the  nature,  direction, 
and  extent  of  the  violence,  the  seat  of  the  pain,  and  by  a  careful  study  of 
the  most  minute  deformity.  It  is  difficult  to  recognize  fissures.  They 
rarely  present  any  evidence  of  their  existence  except  a  localized  pain,  and 
possibly  a  linear  ecchymosis  appearing  after  a  few  days. 

In  green-stick  fractures  the  age,  the  deformity,  and  possibly  crepitus 
during  reduction  help  in  the  diagnosis,  although  in  many  cases  no  crepitus 
is  obtained.  Epiphyseal  separations  are  diagnosticated  by  the  age,  the 
preternatural  mobility,  the  pain,  the  swelHng,  the  ecchymosis,  the  deformity, 
the  situation  of  the  injury,  and  the  absence  of  crepitus  or  the  presence  only 
of  a  soft  crepitus.  It  is  important,  however,  to  remember  that  an  epiphyseal 
separation  is  sometimes  incomplete,  and  even  when  it  is  complete  there 
may  be  no  displacement.     In  cases  without  displacement  the  .T-rays  will 


528  Diseases  and  Injuries  of  Bones  and  Joints 

not  enable  us  to  make  a  diagnosis.  In  many  cases  of  complete  separation 
soft  crepitus  is  obtainable;  but  in  not  a  few  cases  it  is  not  to  be  found.  In 
incomplete  separation  crepitus  is  absent.  If  absent  in  complete  separation, 
probably  some  tissue  is  between  the  lines.  Fractures  are  often  difficult  to 
recognize  when  occurring  in  a  group  of  bones  (which  are  firmly  joined  by 
dense  ligaments)  like  those  of  the  carpus  and  tarsus,  or  in  one  of  two  parallel 
bones.  There  is  not  always  a  certainty  that  a  fracture  exists,  and  when, 
after  a  careful  examination,  there  is  still  an  uncertainty,  do  not  prolong 
the  efforts  or  use  great  force,  but  treat  the  case  as  a  fracture  until  a  cure 
ensues  or  the  diagnosis  becomes  apparent. 

In  a  child  the  diagnosis  of  fracture  is  sometimes  difficult.  Pain  may  be 
trivaal.  Children  are  liable  to  a  form  of  fracture  in  which  the  periosteum 
is  but  slightly  torn  or  is  not  torn  at  all,  the  disability  and  pain  are  often  slight, 
and  the  fracture  may  be  easily  overlooked  (Cotton  and  Vose). 

We  have  recentlv  had  added  to  our  resources  a  method  of  incalculable 
value  in  diagnosticating  fracture;  that  is,  the  use  of  the  force  known  as  the 
.v-ray  or  the  Rontgen  ray.  We  can  look  through  a  part  with  a  fluoroscope 
and  see  the  bones  as  shadows,  or  we  can  take  a  negative  of  the  shadows 
and  print  skiagraphs  from  it.  This  method  is  applicable  even  when  the 
parts  are  swollen,  and  even  when  a  limb  is  clothed  or  wrapped  in  dressings. 
It  is  possible  to  obtain  a  picture  of  a  fractured  skull  after  long  exposure; 
fractured  ribs  and  vertebrae  can  be  detected;  and  the  process  is  of  the  greatest 
use  in  detecting  fractures  of  the  Hmbs.  It  is  not  infallible.  An  epiphyseal 
separation  may  not  be  detected,  and  a  slight  angling  of  the  plate  may  give 
a  deceptive  appearance  of  distortion.  An  .v-ray  picture,  to  be  useful,  must 
be  taken  by  an  expert  and  should  be  interpreted  by  a  surgeon.  It  is  imperative 
to  employ  this  method  in  doubtful  cases,  if  an  .v-ray  apparatus  is  accessible. 
It  is  advisable  to  use  it  in  all  recognized  cases  and  in  all  suspected  cases. 

Complications  and  Consequences.— Some  of  the  consequences  and 
complications  of  fractures  are— sloughing  of  the  soft  parts,  thus  making 
the  fracture  compound;  extravasation  of  blood,  causing  swelling  or  even  gan- 
grene; rupture  of  the  main  artery  or  vein  of  the  limb;  dislocation;  edema 
from  pressure  of  extravasated  blood,  from  inflammatory  exudation,  from 
tight  bandaging,  from  thrombosis,  or,  later,  from  the  pressure  of  callus; 
stiffness  of  joints  from  synovitis  with  adhesion,  from  displaced  fragments, 
or  from  intra-articular  callus;  stiffness  of  tendons  from  adhesive  thecitis  or 
from  the  pressure  of  callus;  paralysis  from  traumatic  neuritis,  the  pressure 
of  callus  upon  nerve-trunks,  or  from  division  of  a  nerve;  muscular  spasm; 
painful  callus;  exuberant  callus;  embolism;  fat-embolism;  pulmonary  con- 
gestion; gangrene;  shock;  septicemia;  pyemia;  tetanus;  delirium  tremens; 
urinary  retention;  extensive  laceration  of  the  soft  parts;  rupture  of  large 
nerves:  and  involvement  of  joints.  A  fracture  may  fail  to  unite,  fibrous 
union  or  cartilaginous  union  only  being  obtained.  An  epiphyseal  separation 
may  arrest  the  future  growth  of  the  limb. 

Repair  of  Fractures.— Simple  Fracture.— In  a  simple  fracture  the 
bone  iy  broken,  the  medullary  contents  are  lacerated,  the  periosteum  is  torn, 
and  the  overlying  soft  parts  are  damaged  to  a  considerable  degree.  The 
periosteum  is  stripped  more  or  less  from  each  fragment,  but  it  is  rarely  com- 
pletely torn  through,  an  untorn  portion  known  as  the  periosteal  bridge  re- 


Repair  of  Fractures  529 

maining.  The  amount  of  blood  effused  is  usually  considerable,  and  it  forms 
a  decided  prominence  at  the  seat  of  fracture;  it  gradually  gathers  because 
of  oozing,  and  soon  clots.  This  clot  lies  in  the  medullary  canal,  between  the 
fragments,  under  the  periosteum  at  the  ends  of  the  fragments,  and  in  the 
tissues  outside  of  the  periosteum.  Very  rapidly  after  the  accident  the  dam- 
aged parts  inflame  (bone,  endosteum,  periosteum,  and  the  torn  periosseous 
structures).  The  inflammatory  exudate  enters  into  the  blood-clot  and  the 
leukocytes  eat  up  and  destroy  the  clot.  The  clot  is  simply  dead  material 
and  in  no  way  contributes  to  repair.  The  cells  of  the  damaged  tissue  pro- 
liferate and  the  young  prohferating  cells  (fibroblasts)  enter  into  the  spaces 
in  the  blood  and  clot  eaten  out  by  the  leukocytes.  Finally  the  entire  clot  is 
replaced  by  fibroblasts  and  much  of  this  cellular  mass  quickly  becomes  vas- 
cularized (granulation  tissue). 

The  osteoblasts,  which  exist  in  the  deeper  layers  of  the  periosteum  and 
in  the  tissue  of  the  medulla  itself,  begin  to  prohferate  actively  soon  after 
the  fracture  has  taken  place.  The  fibroblasts  have  been  formed  by  the 
proliferation  of  the  ordinary  connective-tissue  cells,  and  the  proliferating 
osteoblasts  soon  enter  into  and  become  widely  distributed  through  this  mass 
of  fibroblasts.     Some  maintain  that  the  fibroblasts  themselves  are  directly 


Fig.  244. — Ununited  compound  fracture. 

transformed  into  bone;  other  observers  deny  this,  and  think  that  all  bone- 
formation  comes  from  the  osteoblasts.  Osteoblasts  may  form  bone  directly, 
or  may  form  cartilage  first  and  then  bone.  When  a  fracture  takes  place, 
a  bridge  of  periosteum  is  usually  left  untorn;  and  this  bridge  holds  the  frag- 
ments in  contact  at  some  point,  just  as  a  strap  nailed  to  a  trunk  and  also 
to  its  fid  might  hold  these  two  objects  in  contact  at  some  point.  The  new 
tissue  about  the  periosteal  bridge  always  becomes  cartilaginous  for  a  time; 
but  the  rest  of  the  callus  rarely  shows  the  development  of  cartilage,  and 
passes  directly  into  bone.  If,  however,  osteoblasts  fail  to  proliferate  with 
sufl&cient  activity,  the  mass  of  granulation  tissue  becomes  fibrous  tissue; 
bone  is  not  formed  at  all,  or  is  very  scantily  formed;  and  fibrous  union  occurs. 
If  the  osteoblasts  lack  activity,  but  are  more  active  than  in  the  case  just 
cited,  they  form  cartilage  extensively — but  cartilage  only;  consequently, 
caj-tilaginous  union  occurs.  During  the  process  of  the  repair  of  a  fracture 
the  ends  of  the  bony  fragments  are  always  softened,  and  some  of  the  bone 
is  absorbed  by  the  osteoclasts.  The  osteoclasts  are  really  large  osteoblasts 
that  have  lost  the  power  of  producing  bone  and  that  furnish  a  secretion  to 
34 


530 


Diseases  and  Injuries  of  Bones  and  Joints 


absorb  bone  (the  elder  Senn).  After  bony  union  has  been  accompHshed  the 
osteoclasts  absorb  the  superfluous  callus.  The  mass  of  new  tissue  around 
and  between  the  bone-ends  is  called  callus.  It  will  be  observed  that  the 
name  is  apphed  successively  to  fibroblastic  tissue,  granulation  tissue,  fibrous 
tissue,  and  bone.  Warren  tells  us  that  callus  has  no  well-defined  outline, 
and  "involves  not  only  the  bone  and  periosteum  but  also  the  connecdve 
tissue  and  some  of  the  surrounding  muscular  tissue."  Within  a  few  days 
after  the  injury  the  inflammatory  mass  is  much  firmer  than  follows  inflam- 
mation involving  other  structures,  and 
the  bone-ends  are  deeply  imbedded  in  a 
dense  mass. 

During  the  second  week  the  callus  is 
greatly  strengthened  by  the  formation  of 
dense  fibrous  tissue  in  and  below  the 
periosteum,  of  less  dense  fibrous  tissue 
outside  the  periosteum,  and  of  cartilage 
from  the  periosteal  bridge.  The  newly 
formed  tissue  contracts  decidedly.  Dur- 
ing the  third  week  ossification  begins  at 
the  points  farthest  from  the  fracture,  and 
in  the  course  of  a  short  time  (from  three 
to  six  weeks)  is  complete.  The  mass  of 
ossified  callus,  or  new  bone,  is  spindle- 
shaped  and  spongy. 

The  term  intermediate,  definitive,  or 
permanent  callus  is  used  to  describe  the 
material  which  forms  between  the  ends 
of  the  broken  bone.  The  name  provis- 
ional or  temporary  callus  is  given  to  the 
material  within  the  canal  (central  callus) 
and  external  to  the  bone  (ensheathing 
callus).  The  amount  of  provisional  cal- 
lus depends  directly  on  the  extent  of 
separation  and  the  amount  of  motion 
between  the  fragments.  It  is  Nature's 
splint,  and  when  the  break  is  not  well 
immt)bilized  a  large  amount  is  formed. 
The  greater  the  amount  of  motion,  short 
of  a  degree  sufficient  to  cause  non-union,  the  larger  the  amount  of  provisional 
callus. 

The  ensheathing  callus  is  after  a  time  largely  absorbed,  and  the  central 
callus  in  the  course  of  a  long  time  may  also  be  absorbed,  with  the  restoration 
of  the  medullary  canal,  although  this  latter  result  is  rare.  An  excessive 
amount  of  provisional  callus  may  ossify  nearby  tendons,  may  unite  two 
parallel  bones  (radius  to  ulna,  tibia  to  fibula,  a  rib  to  its  neighbors),  may 
l)lock  a  joint  just  as  a  stone  in  the  crack  of  a  door  will  block  a  door,  or  may 
absolutely  abolish  a  joint.  Fragments,  even  if  entirely  detached,  often  unite, 
but  they  may  be  surrounded  by  provisional  callus;  sometimes  they  do  not 
cause  trouble,  but  sometimes  suppuration  takes  place.     It  takes  about  one 


245 


-Ununited  fracture  of  humerus; 
unsuccessful  wiring. 


Xon-union  of  Fractures  531 

year  for  Nature  to  remove  the  temporary  callus.  The  definitive  or  permanent 
callus  after  a  time  ceases  to  be  porous  and  becomes  very  dense  bone. 

Compound  fractures  without  much  destruction  or  bruising  of  soft  parts, 
if  treated  antiseptically,  become  at  once  simple  fractures  and  unite  as  such. 
If  the  wound  is  not  drained  and  asepticized  and  septic  inflammation  occurs, 
pus  forms,  and  union  by  granulation  is  the  best  that  can  be  obtained.  Com- 
pound fractures  by  direct  violence  will  not  heal  by  first  intention  because 
of  the  loss  of  vitality  of  a  large  area  of  the  soft  parts. 

Delayed  union  is  usually  due  to  imperfect  approximation  of  the  frag- 
ments. This  imperfect  approximation  may  result  from  failure  to  reduce 
the  fracture  (muscle,  ligament,  or  synovial  membrane  being  caught  between 
the  ends  of  the  bone) ;  the  use  of  unsuitable  sphnts ;  too  tight  application  of 
bandages;  and  general  causes  of  ill  health,  for  instance  anemia,  scurvy, 
Bright's  disease,  rickets,  S}'phihs,  and  pregnancy.  In  delayed  union  there  is 
pain  on  passive  motion;  in  non-union  there  is  not.  In  delayed  union  there 
is  loss  of  voluntary  motion;  in  non-union  there  is  power  of  voluntary  motion 
(A.  H.  Tubby,  in  "Brit,  Med.  Jour.,"  Dec.  7,  1901).  Delayed  union  is 
not  non-union,  but  may  eventuate  in  non-union. 

Vicious  or  faulty  union  is  union  with  great  deformity.  This  occurs 
when  no  treatment  has  been  employed,  or  when  immobilization  has  been  im- 
perfect, or  when  deformity  has  not  been  reduced.  It  may  arise  because  re- 
tentive dressings  have  been  removed  by  the  patient  at  too  early  a  period,  the 
callus  yielding.  In  many  cases  it  is  slight  and  produces  httle  or  no  pain  or 
impairment  of  usefulness.  In  other  cases  it  is  pronounced  and  produces 
functional  impairment  or  disastrous  pressure  on  nerves  or  vessels.  Vicious 
union  near  a  joint  always  impairs  function.  If  there  is  pronounced  \'icious 
union  the  bone  should  be  rebroken  and  set  as  a  fresh  fracture.  In  some  recent 
cases  the  bone  is  broken  by  manual  force,  and  for  several  weeks  after  a  fracture 
this  can  be  easily  accompHshed.    In  older  cases  osteotomy  should  be  performed. 

Non=union  of  Fractures. — An  ununited  fracture  is  a  fracture  in  which 
union  is  not  effected  at  all  or  in  which  it  is  not  brought  about  by  bone.  Non- 
union is  especially  common  in  fractures  of  the  upper  third  of  the  femur  and 
of  the  middle  third  of  the  humerus.  The  causes  are  local  and  constitutional. 
The  local  causes  are:  (i)  Want  of  approximation  of  fragments;  a  frequent  cause 
of  want  of  approximation  is  interposition  of  soft  tissues — viz.,  muscle,  fascia, 
or  periosteum;  this  is  the  great  cause  of  non-union,  the  cause  responsible 
for  an  enormous  majority  of  the  cases;  if  soft  tissues  are  interposed  between 
bone  fragments  non-union  is  almost  inevitable;  (2)  want  of  rest;  (3)  want  of 
blood-supply  (as  seen  in  the  heads  of  the  humerus  and  femur,  or  when  a 
nutrient  arterj-  is  torn,  or  when  a  thrombus  forms  in  a  vein  near  the  fracture) : 
(4)  defective  inner\-ation ;  (5)  bone-disease;  (6)  the  use  of  unsuitable  splints; 
(7)  tight  bandaging.  The  constiiutional  causes  are  debilit}',  scuny,  Bright's 
disease,  syphilis,  etc.  Sometimes  union  fails  to  occur  for  no  appreciable  rea- 
son. In  an  ununited  fracture  the  broken  ends  of  the  bone  round  off  and  the 
medullan,'  canal  of  each  fragment  becomes  closed  by  bone.  The  fragments 
may  not  be  held  together  by  any  material,  or  they  may  be  held  by  verj-  thin 
and  much-stretched  fibrous , tissue  {membranous  union),  or  by  strong,  thick, 
fibrous  tissue  {ligamentous  or  fibrous  union) .  When  the  ends  of  the  bones 
come  together,  are  held  by  a  fibrous  capsule,  and  move  on  each  other,  there 
exists  a  false  joint  or  pseudo-arthrosis.     Such  a  joint  may  after  a  time  secrete 


532 


Diseases  and  Injuries  of  Bones  and  Joints 


serous  fluid  for  lubrication.  In  very  rare  cases  a  fracture  once  apparently 
soundly  united  may  at  a  later  period  be  obviously  ununited,  callus  having 
been  absorbed  or  broken. 

Treatment  of  Fracture. — If  a  man  is  found  in  the  street  with  a 
fracture,  further  injury  must  be  prevented  by  applying,  after  cutdng  oflf  the 
clothing  over  the  fracture,  some  temporary  support.  If  an  ambulance  or 
patrol-wagon  cannot  be  obtained,  move  the  patient  by  hand.  If  the  lower 
extremity  be  involved,  an  improvised  stretcher  (a  board  or  a  shutter)  is 
placed  on  the  ground  beside  the  patient,  who  is  laid  on  the  stretcher,  the 
surgeon  lifting  the  injured  limb,  and  the  patient  is  then  carried  to  the  hospital 


Fig.  246. — Vicious  union  of  frac- 
tured bones  of  the  leg.  View  from 
inner  side  of  limb  (Horwitz). 


Ununited  fracture  of  the  femur. 


and  carefully  transferred  to  a  fracture-bed,  of,  if  taken  home,  to  a  small  or- 
dinary bed,  several  boards  being  placed  transversely  beneath  a  rather  hard 
but  even  mattress.  The  temporary  appliances  are  now  removed  and  a  diag- 
nosis is  made  by  the  methods  before  given.  After  determining  the  nature 
of  the  injury  the  fragments  must  be  adjusted.  This  should,  if  possible,  be 
done  at  once,  because  a  fracture  remaining  unreduced  may  become  com- 
pound, the  fragments  may  injure  important  structures,  and  they  are  sure  to 
cause  intense  pain.  Reduction  is  easily  effected  during  shock,  as  the  mus- 
cles are  in  a  state  of  relaxation.  Early  reduction  and  fixation  largely  prevent 
swelling.  If  there  is  ver}^  great  swelling,  reduction  may  be  impossible,  and 
the  part  must  then  be  supported,  moderate  cold,  sorbefacients,  and  gentle 


Treatment  of  Fracture  533 

pressure  being  used,  ice  and  tight  bandaging,  which  predispose  to  gangrene, 
not  being  employed.  In  most  cases  we  can  reduce  displacement  in  spite  of 
swelling  and  cure  swelling  by  the  reduction.  Set  the  fracture  at  the  first 
possible  moment.  Velpeau's  axiom  was  to  reduce  fractures  at  once,  regardless 
of  pain,  spasm,  or  inflammation,  as  reduction  is  their  cure.  The  longer  we  wait 
to  reduce  a  fracture,  the  greater  the  amount  of  force  necessary  to  accomplish 
it  because  of  progressive  infiltration  of  the  soft  parts  with  inflammatory  exu- 
date and  blood,  a  process  which  lessens  and  finally  destroys  tissue  elasticity. 

If  the  patient  is  very  nervous,  if  the  pain  is  severe,  or  if  rigid  muscles 
antagonize  the  efforts  of  the  surgeon,  reduce  the  fracture  under  anesthesia.  In 
some  fractures  (as  those  of  the  clavicle)  adjustment  is  effected  by  altering 
the  position,  and  in  others  (as  those  of  the  femur)  by  extension  and  counter-exten- 
sion; in  some  by  tenotomy,  and  in  some  by  kneading,  bending,  and  coaptation. 
When  extension  is  employed,  always  endeavor  to  get  a  point  of  counterextension. 
The  extension  is  to  be  made  on  the  broken  bone  (if  possible,  in  the  axis  of  the 
bone),  is  to  be  steady,  and  neither  jerky  nor  \iolent.  In  some  cases  complete 
reduction  is  impossible.  This  may  be  due  to  spasm,  to  swelling,  to  the  catching 
of  soft  parts  between  the  fragments,  to  the  existence  of  a  loose  fragment,  to  lock- 
ing, or  to  impaction.  An  impaction  by  rotation  can  generally  be  released,  but 
it  is  sometimes  undesirable  to  unlock  it.  If  the  fragments  cannot  be  adjusted 
without  violence,  retain  them  in  the  best  attainable  position,  combat  the  an- 
tagonistic cause,  and  set  them  properly  as  soon  as  possible  or  else  operate. 

After  adjusting  the  fragments  maintain  them  in  position  by  some  apparatus. 
All  sorts  of  material  are  used  for  splints,  among  them  may  be  mentioned  wood, 
felt,  pasteboard,  plaster  of  Paris,  silicate  of  sodium,  tin  (Le\-is),  and  aluminium 
(Elsberg).  Avoid  pressure  over  joints  or  bony  prominences  and  particu- 
larly guard  against  tight  or  improper  bandaging.  In  fracture  of  a  bone  of 
a  limb  the  circulation  in  the  fingers  or  toes  must  be  observed  as  an  index  of  cir- 
culation in  the  limb;  hence  leave  those  digits  exposed.  A  retentive  apparatus 
should  prevent  the  redevelopment  of  deformity,  and  not  be  itself  productive  of 
pain  or  harm.  For  the  first  few  days  of  treatment  of  a  simple  fracture  the  dressing 
is  removed  every  day,  to  make  sure  that  deformity  has  not  recurred,  and  if  it 
does  recur  the  fragments  must  at  once  be  reset.  The  spHnts  should  be  padded 
thoroughly,  especially  when  over  joints  or  bony  prominences,  and  they  should, 
if  possible,  fix  the  joints  immediately  above  and  below^  the  break.  A  priman,- 
roller  should  not  be  used  unless  plaster  is  to  be  employed.  By  a  primary  roller 
is  meant  a  bandage  applied  to  the  extremit}'  before  sphnts  are  placed  upon  it. 

Some  surgeons  at  once  apply  an  immovable  dressing.  This  proceeding  is 
safe  in  simple  fractures  without  much  displacement  or  soft-part  injury.  This 
dressing  is  valuable  in  military  practice,  for  the  old  and  feeble  whom  we  fear 
to  put  to  bed,  for  the  young  who  are  ver\'  restless,  and  for  the  insane  or  the 
delirious.  If,  how-ever,  there  is  great  deformity,  much  soft-part  injury,  or 
marked  swelling,  immovable  dressings  may  induce  sloughing,  edema,  gangrene, 
or  faulty  union.  In  the  above-named  cases  use  sphnts  for  the  first  few  days: 
then,  if  it  is  desirable,  the  immovable  dressing  can  be  apphed.  Plaster-of- 
Paris  bandages  are  unsafe  in  very  young  children,  and  gangrene  may  occasion- 
ally result  from  their  appHcation.  It  is  dangerous  to  keep  old  or  feeble  persons 
long  in  bed,  as  they  are  prone  to  develop  bed-sores  and  hypostatic  pulmonary 
congestion.  The  period  for  the  artificial  retention  of  the  fracture  varies  with 
the  seat  of  the  fracture  and  the  age  and  condition  of  the  patient.     Passive 


534 


Diseases  and  Injuries  of  Bones  and  Joints 


motion  is  to  be  made  in  most  fractures  in  from  two  to  three  weeks,  though  it  is 
sometimes  made  earUer  to  prevent  ankylosis  and  sometimes  later  because  of 
risk  of  non-union.  Landerer  strongly  advocates  massage,  beheving  that  it 
hastens  union  and  prevents  wasting.  He  appHes  it  as  soon  as  there  is  no 
danger  of  the  callus  bending  (in  from  eight  to  fourteen  days).  Massage 
should  not  be  used  when  great  edema  points  to  the  possibility  of  venous  throm- 
bosis. The  movements  might  break  up  a  clot  and  cause  fatal  embolism.*  Very 
early  massage  may  cause  fat-embolism.  In  fracture  of  the  patella,  Barker  and 
many  others  believe  in  wiring,  and  some  surgeons  advocate  the  same  procedure 


Fig.  248.— Ambulatory  dressing  of  plaster-of-Paris 
for  fracture  of  the  bones  of  the  leg  (Pilcher). 


Fig.  249. — Ambulatory  dressing  apparatus  for 
fracture  of  thigh  (Harting). 


in  fracture  of  the  clavicle,  fracture  of  the  tibia,  and  fracture  of  the  upper 
third  of  the  femur.  If  fragments  cannot  be  approximated  or  retained  by 
ordinary  methods,  an  incision  should  be  made,  approximation  effected,  and 
the  fragments  retained  by  wire,  a  clamp,  or  a  bone  ferrule. 

The  plan  known  as  the  ambulatory  treatment  of  fractures  of  the  lower 
extremities  has  had  warm  advocates.  The  ambulatory  spHnt  is  an  apparatus 
which  enables  a  man  to  walk  about  a  few  days  after  receiving  a  fracture  of  the 
leg  or  thigh.  It  was  devised  by  Hessing,  a  carpenter  dwelling  in  a  village  near 
Augsburg.  Its  aim  is  not  only  to  get  the  patient  about  on  crutches,  but  al.'io 
to  cause  him  to  use  the  Hmb.  It  is  held  that  this  plan  of  treatment  greatly 
lessens  the  patient's  sufferings  and  actually  favors  union  by  the  stimulation  of 
walking.  Bardeleben,  in  his  report  to  the  German  Surgical  Congress,  gave  the 
*  Cerne's  case,  in  "  Normandie  med."  ;  Bull,  med.,  1895,  No.  44. 


Treatment  of  Fracture  535 

records  of  iii  fractures  of  the  lower  extremity  thus  treated  (77  simple  and 
12  compound  fractures  of  the  leg;  17  simple  and  5  compound  fractures  of 
the  thigh).  The  patients  were  gotten  about  a  few  days  after  the  accident, 
were  able  to  attend  to  business,  had  excellent  appetites,  digested  their  food 
perfectly,  slept  well,  and  were  saved  from  muscular  atrophy.  Pilcher  has 
warmly'  advocated  the  method.  It  can  be  used  in  fractures  as  high  up  as 
the  middle  of  the  femur.  The  apparatus  which  we  should  employ  in  the 
ambulatory  treatment  reaches  below  the  sole  of  the  foot,  and  is  supported 
firmly  above  the  seat  of  fracture,  the  weight  of  the  body  being  transferred  from 
above  the  fracture  to  the  firm  pad  below  the  sole  of  the  foot  on  which  the  patient 
walks  (Figs.  248  and  249) .  This  appliance  in  a  fractured  thigh  is  put  on  about 
one  week  after  the  infliction  of  the  injury.  While  the  patient  sits  on  the  ischial 
tuberosities  extension  is  made  upon  the  leg.  The  seat  of  fracture  is  encircled 
with  a  thin  plaster  cast.  The  sole  of  the  other  foot  is  raised  by  a  cork  sole. 
Albers,  when  he  treats  a  fractured  thigh,  uses  plaster-of-ParLs  strengthened  by 
bits  of  wood,  running  from  below  the  sole  of  the  foot  to  the  iliac  crest. 
Krause  says  in  fracture  of  the  ankle  carr\-  the  dressing  to  the  head  of  the  tibia; 
in  fracture'  of  the  leg  carry  it  to  the  middle  of  the  thigh;  in  fracture  of  the  lower 
end  of  the  femur  carry  it  to  the  pehis.*  Bradford  warmly  advocates  the  use  of 
Thomas's  splint  often  combined  with  plaster  of  Paris.  During  the  last  few  years 
surgeons  have  come  to  recognize  that  ambulator}'  treatment  must  not  be  used 
for  all  fractures  of  the  lower  extremity  and  is  only  suited  to  selected  cases. 

Prevention  and  Treatment  of  Complications.— In  ever)-  case  of  frac- 
ture of  an  extremity  feel  for  the  pulse  between  the  periphery  and  the  seat  of 
injury  in  order  to  be  sure  the  artery  is  not  ruptured.  If  the  soft  parts  are  badly 
contused,  try  to  prevent  sloughing  by  employing  rest  and  relaxation,  and  by 
applying  heat.  If  superficial  sloughing  occur,  treat  antiseptically,  remember- 
ing that  even  a  superficial  excoriation  can  admit  bacteria  which,  carried  by  the 
blood  or  lymph,  may  infect  the  bones.  If  a  slough  leads  down  to  the  fracture, 
treat  the  case  as  a  compound  fracture.  If  there  be  great  blood-extravasation 
the  danger  is  gangrene,  and  after  fracture  of  the  lower  extremity  the  foot  of  the 
bed  may  be  elevated,  or,  better,  after  fracture  of  the  upper  or  lower  limb  the 
extremity,  to  which  splints  and  bandages  are  to  be  loosely  applied,  is  to  be 
raised  and  surrounded  with  hot  bottles.  If  a  bleb  forms,  it  is  to  be  opened 
with  a  clean  needle  and  dressed  antiseptically.  If  gangrene  occurs,  treat  by 
the  usual  rules.  Frequently  after  fracture  of  a  bone  blebs  containing  reddish 
serum  form  on  the  skin.  The  appearance  of  hlehs  when  the  circulation  is  good 
does  not  mean  gan.grene,  and  is  not  of  any  particular  consequence.  If  blebs 
are  due  to  gangrene,  there  are  distinct  s}-mptom5  of  circulatory  impairment.^ 
Edema  may  be  due  to  tight  bandaging.  If  it  is  due  to  phlebitis,  there  is 
danger  of  pulmonar}-  or  cerebral  embolism.  In  phlebitis  elevate  the  Hmb, 
remove  all  constriction,  and  employ  locally  ichthyol  ointment;  do  not  use  mas- 
sage, and  give  stimulants  by  the  mouth.  In  edema  due  to  weak  circulation  or 
venous  relaxation  v&t  daily  frictions  and  firm  bandaging.  If  the  fracture  m- 
volves  a  joint,  carefully  adjust  the  fragments,  make  passive  motion  early,  and 
inform  the  patient  that  he  will  probably  have  a  stiff  joint. 

A  dislocation  occurring  unth  a  fracture  is  reduced  at  once  if  possible.     To 
do  this,  splint  the  Hmb  and  give  ether,  and  tn-  to  reduce  while  the  hmb  is  man- 
aged with  the  spHnt  as  a  handle.     Allis  is  often  able  to  reduce  a  dislocation 
*  Centralbl.  f.  Chir.,  vol.  .xxii,  1895. 


536 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  250.— Fracture-hook  (McBurney  and  Dowd). 


accompanied  by  a  fracture.  He  uses  the  untorn  portion  of  periosteum  as  a 
hinge,  pulls  upon  the  lower  fragment,  and  thus  draws  down  the  upper  frag- 
ment and  pushes  it  in  place 
by  manipulation.  If  this 
fails,  it  is  best  to  incise  and 
pull  the  separated  end  in 
place  by  the  hook  of  Mc- 
Burney and  Dowd  (Figs. 
250-252);  but  some  sur- 
geons say,  get  the  bones  in 
the  best  possible  position, 
set  them,  await  union,  and 
then  treat  the  unreduced 
dislocation.  A  rupture  of 
the  main  artery  of  the  limb  presents  the  symptoms  of  absent  pulse  below  the 
rupture,  a  tumor  which  may  pulsate,  and  possibly  a  whirring  sound  or  an 
aneurysmal  thrill  and  bruit.  This  condition  demands  that  the  surgeon  should 
apply  an  Esmarch  bandage,  cut  down  upon  the  tumor,  turn  out  the  clot,  and 
ligate  each  end  of  the  vessel.  Rupture  0}  the  main  vein  of  a  limb  causes  intense 
edema  and  calls  for  sutures, 
lateral  ligatures,  or  complete 
ligation.  If  these  measures 
fail  after  injury  of  vein  or  ar- 
tery, or  it  gangrene  appears, 
amputate  at  once  above  the 
seat  of  the  fracture. 

Inflammation  is  to  be 
treated  by  compression,  rest, 
moderate  cold,  and  later  by 
a  50  per  cent,  ichthyol  oint- 
ment. Muscular  spasm  re- 
quires morphin  internally,  firm  bandaging,  or  even  tenotomy.  Fat-embolism 
is  treated  by  stimulants  and  inhalation  of  oxygen,  and  possibly  artificial 
respiration.  Shock,  delirium  tremens,  urinary  retention,  etc.,  are  treated 
according  to  the  ordinary  rules  of  surgery. 

Treatment  of  Compound  Fractures. — It  must  first  be  decided,  in  a  case 
of  compound  fracture  of  a  limb,  if  amputation  is  necessary,  and  the  :x:-rays  are 
of  great  value  in  determining  the  condition  of  the  bones  in  a  crushed  part. 

Amputation  is  demanded 
when  the  limb  is  completely 
crushed  or  pulpified  through 
its  entire  thickness ;  when  ex- 
tensive pieces  of  skin  are  torn 
off;  when  the  main  artery, 
vein,  and  nerve  are  torn 
through;  and  sometimes 
when  there  is  violent  hemor- 
rhage from  a  deep-seated 
What  is  to  be  done  is  to  some 
In  a  healthy  young 


251  — Fracture-hook  applied  at  base  of  acromion  process 
(McBurney  and  Dowd). 


Fig.  252.— Fracture-hook    inserted    in    displaced    fragment 
(McBurney  and  Dowd). 

vessel  or  when  an  important  joint  is  splintered. 

extent  determined  by  the  patient's  age  and  general  health 


Treatment  of  Fracture 


537 


person,  if  in  doubt,  give  the  limb  the  benefit  of  the  doubt  and  try  to  save  it;  if 
the  artery  alone  is  ruptured,  cut  down  upon  it  and  tie  both  ends;  if  the  vein 
alone  is  torn,  suture  it,  apply  a  lateral  ligature,  or  tie  both  ends;  if  the 
nerve  is  severed,  suture  it;  if  a  joint  is  opened,  drain  and  asepticize.  If  an 
attempt  is  made  to  save  the  limb,  be  ready  at  any  time  to  amputate  for  gan- 
grene, secondary  hemorrhage  (if  re-hgation  at  original  point  and  compression 
high  up  fail),  extensive  celluHtis,  and  profuse  and  prolonged  suppuration.* 
When  it  is  determined  to  try  to  save  the  limb,  the  part  must  be  cleansed  thor- 
oughly by  the  antiseptic  method  (in  no  injuries  is  this  more  important).  If  a 
small  portion  of  bone  protrudes,  cleanse  the  skin  of  the  extremity  and  the  pro- 
truding bone,  push  the  spicule  out  a  little  more  and  cut  it  off.  If  a  large  piece 
of  bone  is  protruded,  it  must  not  be  cut  away,  but  should  be  thoroughly  dis- 
infected, and 
after  the  skin 
wound  has 
been  enlarged 
should  be  re- 
turned into 
place.  Hemor- 
rhage requires 
a  free  incision 
to  permit  of  li- 
gation of  bleed- 
ing points.  In 
comminuted 
fractures,  frag- 
ments which 
are  completely 
broken  off 
should  be  re- 
moved, but  those  which  are  only  partially  separated  should  be  retained. 
In  all  cases  a  drainage-tube  must  be  carried  down  to  the  seat  of  fracture,  and 
in  some  cases  a  counter-opening  must  be  made  and  the  tube  be  pulled  through 
the  limb  (Fig.  253). 

After  inserting  the  tube  the  wound  is  sutured,  a  plentiful  antiseptic  dressing 
is  applied,  and  the  extremity  is  dressed  with  plaster.  The  plaster  can  be  ap- 
plied over  a  narrow  strip  of  wood,  trap-doors  or  fenestra  being  cut  in  the  plas- 
ter before  it  sets  (the  fenestrated  splint)  (Fig.  253).  The  wound  is  then  covered 
with  gauze  and  a  bandage. 

The  bracketed  splint  is  a  better  dressing  than  the  one  just  described.  After 
the  wound  has  been  dressed  with  gauze,  plaster  is  at  once  applied  over  the  ends 
of  brackets  (Fig.  254;.  The  above  methods  not  only  immobilize  the  fractured 
bones,  but  keep  the  parts  aseptic  and  afford  easy  access  to  the  wound.  The 
drainage-tubes  are  usually  removed,  if  suppuration  does  not  occur,  in  from 
forty-eight  to  seventy-two  hours.  The  wound  is  treated  as  any  other  wound. 
In  some  compound  fractures  there  is  difificulty  in  retaining  the  fragments  in 
apposition  (lower  end  of  femur,  upper  third  of  femur).  In  such  cases  the  ends 
of  the  bone  should  be  resected  and  the  bones  should  be  fastened  together  as  in 
*See  Howard  Marsh  on  "Fractures,"  in  Heath's  Dictionary  of  Practical  Surgery. 


Fig.  253.— Fenestrated  plaster-of-Paris  dressing. 

limb. 


Drainage  tube  pulled  through 


538 


Diseases  and  Injuries  of  Bones  and  Joints 


a  case  of  united  fracture,  with  silver  wire,  aluminum  wire,  chromicized  catgut, 
or  kangaroo-tendon.  In  a  compound  jradiire  of  the  patella  after  free  incision 
and  disinfection,  investigate  to  determine  the  gravity  of  the  injury.  In  an 
ordinary  case  in  which  there  are  two  or  three  fragments,  open  the  joint,  irrigate 
with  saline  fluid,  drill  the  fragments,  and  fasten  them  with  silver  wire.  Very 
small  fragments  should  be  removed.  A  tube  is  carried  into  the  joint,  the 
wound  is  sutured  and  dressed,  and  the  limb  is  immobilized  in  extension. 
In  a  case  of  severe  compound  comminuted  fracture  of  the  patella,  after  disin- 
fection, the  loose  piece  should  be  removed  and  "the  remaining  portions 
made  smooth  with  bone  forceps  and  the  sharp  spoon."  *  The  wound  is  only 
partially  sutured,  is  drained  and  dressed,  and  the  limb  is  placed  on  a  straight 

posterior  splint.  If 
a  fracture  of  a  rib  is 
compound  irtternally, 
resect  the  rib;  if  it 
is  compound  exter- 
nally, dress  antisep- 
tically. 

Compound    frac- 


Fig.  254.— Bracketed  plaster-of-Paris  dressing. 


tures  may  be  followed 
by  gangrene,  slough- 
ing, periostitis,  septicemia,  pyemia,  osteomyelitis,  necrosis,  etc. 

Operative  Treatment  of  Recent  Fractures. — In  some  fractures  reduction 
and  fixation  are  only  possible  by  operation.  The  operative  treatment  grows 
in  popularit)'  and  should  be  employed  oftener  than  it  is.  In  most  cases  an 
incision  is  made,  the  bone  is  inspected,  tissue  intervening  between  the  frag- 
ments is  removed,  and  the  fragments  are  coaptated  and  fixed  by  screws  and 
a  perforated  plate,  by  silver  wire  sutures,  by  nails,  or  by  some  form  of  clamp. 
Treatment  of  Delayed  Union  and  Ununited  Fracture. — WTien  delayed  union 
exists,  seek  for  a  cause  and  remove  it,  treating  constitutionally  if  required,  and 
thoroughly  immobilizing  the  parts  by  plaster.  Orthopedic  splints  may  be  of 
value.  Use  of  the  limb  while  splinted,  percussion  over  the  fracture,  and  rub- 
bing the  fragments  together,  thus  in  each  case  producing  irritation,  have  all 
been  recommended.  Blistering  the  skin  with  iodin  or  firing  it  has  been  em- 
ployed. If  the  union  be  very  long  delayed,  forcibly  separate  the  fragments  and 
put  up  the  limb  in  plaster  as  we  would  a  fresh  break.     If  these  means  fail,  irri- 


Fig-  255.— Parkhill's  clamp  for  ununited  fracture. 


tate  by  subcutaneous  drilling  or  scraping,  or,  better,  by  laying  open  the  parts 
and  then  driUing  and  scraping  at  many  places.  Buechner  advocates  the  induc- 
tion of  hyperemia  by  a  constricting  band,  just  as  Bier  induces  congestive 
hyperemia  in  treating  tuberculous  areas.  At  first  the  constriction  is  per- 
mitted to  remain  but  a  short  time,  but  the  period  is  lengthened  every  day, 
^Lilicnthal's  "  Imperative  Surgery." 


Fractures  of  Nasal  Bones  539 

until  in  a  few  days  it  remains  almost  continuously  day  and  night.  He  claims 
that  ten  days  of  almost  continuous  application  cures  most  cases.  Helferich 
devised  this  method  in  1887.  In  several  cases  I  have  thought  that  it  did 
good,  and  I  also  administered  thyroid  extract  to  these  patients.  Lanne- 
longue  and  Menard  inject  a  i  :  10  solution  of  zinc  chlorid  between  the 
fragments.  Leaving  acupuncture  needles  in  for  days  is  approved  by  some,  and 
electropuncture  is  advocated  by  others.  Cases  of  ununited  fracture  must  be 
treated  by  excision  of  the  bony  ends  and  fibrous  tissue,  securing  the  fragments 
together  by  periosteal  sutures,  by  pins,  by  screws  and  plates,  by  ivory  pegs,  by 
screws,  by  silver  or  aluminum  bronze  wire,  by  kangaroo-tendon,  by  Senn's 
bone-rings  or  bone-ferrules,  or  by  chromicized  catgut.  Delorme  makes  an  in- 
cision, removes  bone-splinters  and  fibrous  tissue,  smooths  off  one  end,  forces  this 
into  the  bored-out  medullary  canal  of  the  other  fragment,  and  sutures  the  peri- 
osteum. Gussenbauer's  clamp  will  often  give  a  good  result,  and  was  used  for 
years  by  Billroth.  This  is  a  metal  bar  with  two  nails  set  at  right  angles  to  the 
bar.  One  nail  is  driven  into  each  fragment.  Langenbeck  fixed  a  screw  into 
each  fragment  and  connected  the  screws  by  a  piece  of  iron.  Parkhill's  clamp 
(Fig.  255),  which  is  an  improvement  on  Langenbeck's  instrument,  secures 
absolute  immobility  and  is  a  very  useful  instrument  (see  Osteotomy  for  Un- 
united Fracture).  In  some  fractures  a  very  small  incision  is  made  in  the 
skin  and  the  fragments  are  nailed  together  (transcutaneous  fixation  Roberts 
calls  it).  I  believe  that  the  following  closed  fractures  should  be  treated  by 
operation : 

Fractures  of  the  clavicle  with  sharp  ends  which  are  liable  to  punch 
through  the  skin  or  damage  important  structures. 

Some  fractures  of  the  mandible. 

Fractures  of  the  zygoma. 

Some  fractures  of  the  metacarpus. 

Some  fractures  of  the  bones  of  the  forearm. 

Some  fractures  about  the  elbow-joint. 

All  fractures  of  the  olecranon. 

Most  fractures  of  the  patella. 

Many  fractures  of  the  surgical  neck  of  the  humerus. 

Pott's  fracture. 

Fracture  of  the  upper  third  of  the  femur. 

Some  fractures  of  the  neck  of  the  femur  in  the  young  and  middle  aged. 

Fractures  of  the  os  calcis. 

Treatment  of  Vicious  Union. — If  angular  deformity  results  from  faulty 
union,  it  can  be  corrected  by  moulding  the  part  into  shape  while  the  callus  is 
soft.  If  the  callus  has  become  hard,  the  bone  can  be  refractured.  If  faulty 
union  occurs  with  overriding,  an  osteotomy  can  be  performed. 

Special  Fractures. — Nasal  Bones. — The  nasal  bones,  because  of  their 
situation,  are  often  broken.  The  commonest  seat  of  fracture  is  through  the 
lower  third,  where  the  bones  are  thin  and  lack  support.  The  fracture  is  usually 
compound  externally  or  through  the  mucous  membrane  internally.  The 
cause  is  direct  violence.  Displacement  may  not  occur  at  all,  but  when  present 
it  arises  purely  from  force,  and  never  from  muscular  action,  no  muscle  being 
attached  to  these  bones.  If  the  force  is  from  the  front,  the  nose  is  flattened ; 
if  from  the  side,  it  is  deflected.  Displacement  is  soon  masked  by  sweUing. 
Crepitus  can  sometimes  be  elicited  by  lightly  grasping  the  upper  part  of  the 


540 


Diseases  and  Injuries  of  Bones  and  Joints 


nose  with  the  fingers  of  one  hand  and  moving  it  gently  below  from  side  to  side 
with  the  fingers  of  the  other  hand.  Preternatural  mobility  is  valueless  as  a 
sign,  because  of  the  natural  mobility  of  the  cartilages.  Nose-breathing  is  diffi- 
cult because  of  blocking  of  the  nostrils  by  blood-clot.  Diagnosis  may  be 
almost  impossible  when  deformity  is  absent. 

The  complications  that  may  be  noted  are  cerebral  concussion,  brain-symp- 
toms from  implication  of  the  frontal  bone  or  cribriform  plate  of  the  ethmoid 
bone,  and  extension  of  the  fracture  to  the  superior  maxillary  or  lachrymal  bones. 
Emphysema  of  the  root  of  the  nose,  the  eyelids,  and  the  cheeks  is  common,  and 
means  either  a  rent  in  the  mucous  membrane  of  Schneider  or  a  crack  in  the 
frontal  sinus.  There  may  be  much  discoloration  because  of  subcutaneous 
hemorrhage.  Epistaxis  is  usual,  and  is  recognized  from  the  epistaxis  pro- 
duced by  fracture  of  the  base  of  the  skull  by  the  facts  that  the  bleeding  in  the 
first  condition  is  profuse,  is,  as  a  rule,  soon  checked,  and  is  not  followed  by 
oozing  of  cerebrospinal  fluid,  whereas  in  the  second  condition  it  is  profuse,  con- 
tinued, and  followed  by  a  flow  of  cerebrospinal  fluid.  Fracture  of  the  bony 
septum  occasionally  complicates  nasal  fractures,  and  deviation  of  the  cartila- 
ginous septum  often  takes  place.  Suppuration  may  occur  and  necrosis  of  bone 
or  cartilage  may  follow.     The  prognosis  is  usually  good. 

Treatment. — After  cocainizing  the  nares  a  careful  inspection  should  be 
made  by  means  of  a  mirror  and  a  light  to  determine  if  there  is  any  injury  of  the 
septum.  This  point  must  be  determined  in  order  that  the  deformity  of  the 
septum  may  be  corrected  at  the  same  time  as  is  the  deformity  of  the  nasal  bones. 
When  there  is  no  displacement,  or  when  a  displacement  does  not  tend  to  be  re- 
produced after  reduction,  employ  no  retentive  apparatus  of  any  kind.  Order 
the  patient  not  to  blow  his  nose  for  ten  days  and  syringe  it  daily  with  a  solu- 
tion of  bicarbonate  of  sodium.  If  deformity  be  noted,  correct  it  at  once,  as  the 
bones  soon  unite  in  deformity.  If  the  attempts  at  reduction  are  very  painful, 
or  if  the  subject  be  a  child,  a  woman,  or  a  nervous  man,  give  ether  to  obtain 
primary  anesthesia.  Reduction  is  effected  by  a  grooved  director  or  steel 
knitting-needle  wrapped  in  iodoform  gauze  and  passed  into  the  nostril;  the 
fragments  are  Hfted  with  this  instrument,  and  the  fingers  externally  mould 
them  into  place.  A  rubber  dilator  can  be  used  in  reduction.  This  is  pushed 
into  the  nose  and  inflated  by  air  or  water.  If  the  septum  is  deviated  and  can- 
not be  pushed  in  place  by  a  metal  sound,  it  must 
be  twisted  into  place  by  means  of  septum  for- 
ceps. If  bleeding  is  moderate,  check  it  with 
cold  ;  if  severe,  by  plugging.  "For  fractures 
high  up  with  displacement,  gauze  packing  car- 
ried well  up  will  be  required  to  retain  the  elevated 
bones.  For  lower  deviations  the  Asch  tube  will 
be  needed"  (Scudder,  on  "The  Treatment  of 
Fractures").  A  hollow  vulcanite  plug  is  inserted 
in  each  nostril  and  the  nose  is  moulded  into  cor- 
rect shape  over  the  plug.  The  patient  breathes 
through  the  hollow  plug.  A  thread  runs  from 
each  plug  and  is  fastened  to  the  cheek  by  adhe- 
sive plaster.  Once  or  twice  a  day  the  plugs  are 
removed,  cleaned,  and  greased  with  iodoform  ointment.  The  nose  is  cleared, 
and  the  plugs  are  reinserted.     If  flattening  tends  to  recur,  pass  a  Mason  pin 


Fig.  256 — Mason's  pin. 


Fractures  of  the  Superior  Maxillary  Bones  541 

(Fig.  256)  just  beneath  the  fragments,  through  the  Hncof  fracture  and  out  the 
opposite  side.  Steady  the  fragments  by  a  piece  of  rubber  externally  caught 
on  each  end  of  the  pin,  or  with  tigure-of-eight  turns  around  the  ends  with 
silk.  Leave  the  pin  in  place  for  five  days.  The  instrument  of  Mason  is  a 
sharp,  strong,  nickel-plated  j)in,  with  a  triangular  point. 

If  lateral  deformity  tends  to  recur,  hold  a  compress  over  the  fracture  or 
fix  a  moulded-rubber  splint  over  the  nose  by  a  piece  of  rubber  plaster  one  and  a 
half  inches  broad  and  long  enough  to  reach  well  across  the  face,  and  use  com- 
pression for  ten  days.  In  neither  of  the  above 
cases  is  the  nose  to  be  blown,  and  in  both  cases 
it  is  to  be  syringed  once  or  twice  a  day.  In 
fractures  rendered  compound  by  tears  in  the 
mucous  membrane  irrigate  with  normal  salt  so- 
lution   or     boracic-acid    solution,    holding    the  Fig.  257.— Jones's  nasal  splint. 

head  so  that  the   solution  will    not    run    into 

the  mouth;  plug  with  iodoform  gauze  around  a  small  rubber  catheter,  which 
instrument  permits  nose-breathing;  carefully  remove  the  gauze  daily  and 
svTinge.  In  fractures  compound  externally  cleanse  anti.septically  externally, 
and  dress  with  a  film  of  cotton  soaked  in  iodoform  collodion  or  compound  tinc- 
ture of  benzoin,  or  apply  sterile  gauze.  Fractures  of  the  bony  septum,  if  show- 
ing a  tendency  to  reproduction  of  deformity,  require  packing  as  above  explained 
or  the  use  of  a  special  splint  within  the  nostrils  (Fig.  257),  or  the  application 
of  viilcanite  plugs,  so  made  that  the  patient  can  breathe  through  them,  and  that 
threads  can  be  attached  to  them.  Fractures  of  the  nasal  cartilages  are  to  be 
pinned  in  place.  Fractures  of  the  nose  are  entirely  united  in  from  ten  to 
twelve  days. 

Fractures  of  the  Lachrymal  Bone. — The  lachrymal  bone  may  be  broken 
when  the  nasal  bones,  a  superior  maxillary  bone,  or  the  lateral  plate  of  the 
ethmoid  are  fractured,  and  union  is  solid  in  from  three  to  four  weeks.  The 
question  of  how  much  deformity  is  to  be  expected  is  always  uncertain,  and  in 
not  a  few  cases  obstruction  of  the  nose  follows  fracture  because  of  damage  to 
the  septum. 

Treatment. — Treat  the  chief  injury,  which  is  the  fracture  of  the  other  bone 
or  bones.  Maintain  the  patency  of  the  lachrymal  duct  by  frequently  pass- 
ing a  clean  probe. 

Fractures  of  the  Superior  Maxillary  Bone. — Although  a  fragile  bone, 
the  superior  maxillary  is  rarely  broken  except  through  the  alveolar  border. 
It  may  be  broken  by  transmitted  force  from  blows  on  the  chin,  or  on  the  head 
w'hen  the  chin  is  fixed;  but  direct  violence  is  the  usual  cause.  The  wall  of  the 
antrum  may  be  crushed  in.  Comminution  is  the  rule,  and  the  injury  is  often 
compound.  These  fractures  induce  great  swelling,  pain,  and  inability  to 
chew.  Mobility  and  crepitus  may  be  detected.  Deformity  is  due  to  the  break- 
ing force,  and  not  to  the  action  of  any  muscle.  \\'hen  a  portion  of  the  alveolar 
arch  is  fractured,  as  may  occur  in  pulling  teeth,  the  small  fragment  is  de- 
pressed backward,  and  there  exist  irregularity  of  the  teeth  (some  of  which 
may  be  loosened)  and  inability  to  chew  food.  Fracture  of  the  nasal  process 
is  apt  to  injure  the  lachrymal  duct.  When  the  antrum  is  broken  in  there 
are  great  sinking  over  the  fracture,  depression  of  the  malar  bone,  and  emphy- 
sema.    Transverse  fracture  of  the  upper  part  of  the  body  of  the  bone  may 


542 


Diseases  and  Injuries  of  Bones  and  Joints 


cause  no  deformity.  The  force  required  to  break  the  superior  maxillary 
bone  is  so  great  that  fractures  of  other  bones  almost  certainly  occur,  and  con- 
cussion of  the  brain  not  infrequently  exists.  Injury  of  the  infra-orbital 
nerve  is  not  unusual,  causing  pain,  numbness,  or  an  area  of  anesthesia  in- 
volving one-half  of  the  upper  lip,  the  ala  of  the  nose,  and  a  triangle  whose 
base  is  one-half  the  upper  lip  and  whose  apex  is  the  infra-orbital  foramen. 
There  is  also  loss  of  sensation  in  the  gums  and  upper  teeth  of  the  injured  side. 
Fractures  of  the  superior  maxillary  bone  occasionally  induce  fierce  hemor- 
rhage from  branches  of  the  internal  maxillary  artery;  and  if  this  occurs, 
watch  for  secondary  hemorrhage  (these  vessels  being  in  firm  canals). 

Treatment . — If  the  fracture  does  not  implicate  the  alveolus,  or  if  no  deform- 
ity exists,  apply  no  apparatus,  but  feed  the  patient  on  Hquid  food  for  four 
weeks.  Reduce  deformity,  if  it  exists,  by  inserting  a  finger  in  the  mouth. 
If  the  antrum  is  broken  in,  put  the  thumb  in  the  mouth  and  push  the  malar 
bone  up  and  back.  In  certain  cases  of  deformity  make  an  incision  at  the 
anterior  border  of  the  masseter  muscle,  insert  a  tenaculum  or  aneurysm 
needle,  and  pull  the  bone  into  place  (Hamilton).     If  the  malar  bone  or  malar 


Fig.  258. — Hard-rubber  splint ;  wire  arms  and  chin-piece  held  together  by  metal  rods  and  nuts. 

process  is  driven  into  the  antrum,  \\'eir  tells  us  to  incise  the  mucous  membrane 
above  and  external  to  the  canine  tooth  of  the  upper  jaw,  break  into  the  antrum 
with  a  bone-gouge,  insert  a  steel  sound,  lift  out  the  malar  bone,  and  pack  the 
antrum  with  gauze.  Loose  teeth  are  not  to  be  removed;  they  are  pushed 
back  into  place  and  held  by  wiring  them  to  their  firmer  neighbors.  Hem- 
orrhage is  arrested  by  cold  and  pressure.  If  hemorrhage  is  dangerously 
profuse  or  prolonged,  tie  the  external  carotid. 

If  the  Hne  of  the  teeth,  notwithstanding  the  wiring,  is  not  regular,  mould  on 
an  interdental  splint.  The  usual  splint  for  the  upper  jaw  is  the  lower  jaw  held 
firmlv  against  it  by  the  Gibson,  the  Barton,  or  the  four-tailed  bandage.  There 
is  a  great  amount  of  dribbling  ot  saliva  during  the  treatment,  and  a  dressing 
must  be  used  to  catch  this  fluid.  Every  day  remove  the  bandage  and  dressing, 
and  wash  the  face  with  ethereal  soap.  The  patient,  who  is  ordered  not  to  talk, 
is  to  live  on  liquid  food  administered  by  a  nasal  tube  or  by  pouring  it  into 
the  mouth  back  of  the  last  molar  tooth  by  means  of  a  tube  or  a  feeding- 
cup.     Never  pull  a  tooth  to  obtain  a  space;  but  if  a  tooth  is  lost,  utiHze  the 


Fractures  of  the  Malar  Bone 


543 


vacant  space  for  this  purpose.  After  every  meal  wash  out  the  mouth  with 
peroxid  of  hydrogen  followed  by  chlorate  of  ])otassium,  boracic-acid  or  nor- 
mal salt  solution,  and  thus  prevent  foulness  and  the  digestive  disorders  it 
may  induce.  Dispense  with  the  dressings  in  six  weeks,  anfl  let  the  patient 
gradually  return  to  ordinary  diet. 

In  fractures  compound  externally  do  not  remove  fragments,  antisepticize, 
arrest  bleeding  as  far  as  possible  by  ligature,  by  pressure,  or  by  plugging,  wire 
the  fragments  if  feasible,  dress  with  gauze,  and  wash  the  mouth  with  great 


Fig.  259. — Front  view  of  splint  (Fig.  258),  with  mouth  closed  (Moriarty). 

frequency.  Fractures  compound  internally  are  treated  as  simple  fractures, 
except  that  the  mouth  is  washed  more  frequently. 

The  malar  bone  is  rarely  broken  alone.  Hamilton  says  no  uncompli- 
cated  case  is  on  record.  The  malar  is  a  strong  bone  resting  on  a  fragile 
support,  and  hence  it  may  become  a  wedge  to  break  other  bones  and  yet  itself 
be  unfractured.  The  cause  of  fracture  is  violent  direct  force.  A  fracture  of 
the  orbital  surface  of  this  bone  causes  subconjunctival  hemorrhage  like  that 
encountered  in  fracture  at  the  base  of  the  skull,  and  may  produce  irritation 
of  the  infra-orbital  nerve.  Protrusion  of  the  eye  may  result  either  from  hem- 
orrhage or  from  crushing  in  of  the  malar  bone.  There  is  a  hollow  below  and 
to  the  inner  side  of  the  orbit.  Occasionally  the  line  of  fracture  is  detectable, 
but  mobility  and  crepitus  are  very  rarely  discoverable.  Chewing  is  apt  to 
cause  pain,  and  often  the  motions  of  the  lower  jaw  are  limited,  the  coronoid 
process  being  pressed  upon  by  a  depressed  malar  bone,  an  a.s.sociated  fracture 
of  the  zygoma,  a  blood-clot  or  swollen  tissue.  (See  Scudder,  on  "The  Treat- 
ment of  Fractures.") 

Treatment. — If  no  deformity  exists,  there  is  practically  nothing  to  be  done. 
If  deformity  exists,  try  to  correct  it  as  in  fractures  of  the  superior  maxillary 


544 


Diseases  and  Injuries  of  Bones  and  Joints 


bone.  If  correction  is  impossible  by  ordinary  methods  and  the  movements 
of  the  lower  jaw  are  impeded  by  the  displaced  bone,  make  a  small  incision 
and  through  this  insert  an  instrument  and  endeavor  to  lift  the  bone  into 
place.  As  these  cases  are  almost  invariably  complicated  by  fracture  of  the 
upper  jaw,  they  are  treated  in  the  same  manner  as  the  latter  injury.  The 
union  is  complete  in  three  weeks. 

Fractures  of  the  zygomatic  arch  are  very  rare.  The  causes  are  (i) 
direct  violence;  (2)  indirect  force  (from  depression  of  the  malar);  and  (3) 
forcing  foreign  bodies  through  the  mouth.  Direct  violence  is  the  usual 
cause.  Direct  violence  causes  inward  di.splacement,  and  indirect  force  may 
cause  outward  displacement.  The  usual  seat  of  fracture  is  at  the  smallest 
portion  of  the  process — that  is,  on  the  temporal  side  of  the  temporomalar 
suture  (Matas).  The  symptoms  are  pain,  ecchymosis,  swelling,  displacement, 
and  difficulty  in  moving  the  jaw  (because  of  injury  to  the  masseter  muscle). 

Treatment. — In  simple  fracture  give  ether  and  try  to  push  the  arch  in 
place.  Many  surgeons  do  not  make  an  incision,  as  depression  will  do  no 
harm  and  the  functions  of  the  jaw  will  be  restored.  Simply  dress  with  a  com- 
press, adhesive  strips,  and  the  crossed  bandage  of  the  angle  of  the  jaw.  Union 
will  take  place  in  three  weeks.  Matas*  advises  operation.  An  anesthetic 
is  administered,  and  the  parts  are  asepticized.  A  long  semicircular  Hagedorn 
needle  is  threaded  with  silk,  is  entered  one  inch  above  the  middle  of  the  dis- 
placed fragment,  is  passed  well  into  the  temporal  fossa,   and    is   made  to 


Fig.  260.  — Hard-rubber  splint  in  position,  upper  teeth  resting  upon  it  (Moriarty). 

emerge  half  an  inch  below  the  arch.  The  silk  is  used  to  pull  a  silver  wire 
around  the  fracture,  and  this  wire  is  employed  to  pull  the  bone  into  position. 
A  firm  pad  is  applied  externally  and  the  wire  is  twisted  over  the  pad.     Anti- 

*  New  Orleans  Med.  and  Surg.  Jour.,  Sept.,  1896. 


Fractures  of  the  Inferior  Maxillary  Bone 


545 


septic  dressings  are  applied,  und  on  the  ninth  or  tenth  day  the  wire,  splint, 
and  dressings  are  removed  permanently.  I  have  employed  this  plan  in  two 
cases  with  ])erfect  satisfaction. 

Fractures  of  the  inferior  maxillary  bone  may,  and  most  usually  do, 
affect  the  body,  although  they  occasionally  occur  in  the  rami.  Any  part  of 
the  body  may  be  fractured,  the  most  usual  seat  being  near  the  canine  tooth 
or  a  little  external  to  the  symphysis  (Pick).  A  portion  of  alveolus  may  be 
broken  off.  In  fractures  of  the  ramus  either  the  angle,  the  condyloid  neck, 
or  the  coronoid  process  may  be  broken.  In  fractures  of  the  body  the  posterior 
fragment  generally  overrides  the  anterior.  Fractures  of  the  lower  jaw  are 
often  multiple  and  are  almost  always  compound,  because  the  oral  mucous 
membrane  and  alveolar  periosteum  are  torn.  The  cause  is  usually  direct  vio- 
lence. Indirect  violence  (lateral  pressure)  may  fracture  the  body  anteriorly. 
Fractures  near  the  angle  are  always  due  to  direct  violence.  Indirect 
violence  may  fracture  the  condyle  (falls  on  the  chin),  and  so  may  direct 
violence.  Fractures  of  the  coronoid  process  are  very  rare,  and  they  arise  from 
great  direct  violence  (usually  a  gunshot-wound  or  some  other  penetrating  force). 

Symptoms. — In  fracture  of  the  body  preternatural  mobility  and  crepitus 
generally  exist.  The  gum  over  the  fracture  swells  rapidly  and  decidedly. 
There  is  bleeding  because  of  laceration  of  the  gum;  saliva  dribbles  constantly; 
after  two  or  three  days  some  of  the  cervical  lymph-glands  enlarge;  when  the 
fracture  is  open  through  the  mucous  membrane  suppuration  is  usual ;  the  odor 
of  decomposition  soon  becomes  marked;  the  patient  supports  the  jaw  with 
the  hand ;  great  pain  exists  (possibly  from  injury  of  the  nerve) ;  and  deformity  is 
present,  shown  by  inequality  of  the  teeth  if  the  fracture  is  anterior  to  the  masseter, 
the  anterior  fragment  going  downward  and  backward  and  the  posterior  fragment 
going  upward  and  forward.  The  downward  displacement  is  due  to  muscular 
action  (action  of  the  digastric,  geniohyoid,  and  geniohyoglossus) .  The  back- 
ward displacement  is  due  to  the  violence.  The  temporal,  internal  pterygoid,  and 
masseter  muscles  draw  the  posterior  frag- 
ment upward  and  to  the  front.  In  fracture 
of  the  neck  of  the  condyle  the  jaw  is  drawn 
toward  the  injured  side,  and  the  condyle 
is  pulled  inward  and  forward  by  the  action 
of  the  external  pterygoid  muscle.  In  frac- 
ture of  the  coronoid  process  the  temporal 
muscle  pulls  the  small  fragment  upward. 

Complications. — The  complications 
are — digestive  disorders  and  diarrhea  from 
swallowing  foul  discharges;  loosening  of 
the  teeth ;  lodgment  of  loosened  teeth  be- 
tween the  fragments;  bleeding  (usually 
only  oozing  from  the  gum,  but  there  may 
be  hemorrhage  from  the  inferior  dental 
artery) ;  and  suppuration.  Necrosis  may 
follow  these  fractures,  an  abscess  of  the 
neck  may  develop,  or  a  sinus  may  form. 

Treatment. — Remove  a  tooth  if  it  Hes  between  the  fragments,  but  replace 
35 


Fig.  261, — Hamilton's  bandage. 


546 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  262.^Vulcanite  splint  with  boxes 
vulcanized  on  each  side.  If  the  jaw  is 
fractured  in  the  region  of  the  molars,  con- 
siderable pressure  is  required  to  get  the 
parts  in  position ;  therefore  it  is  best  to 
vulcanize  on  to  the  sides  of  the  vulcanite 
splint  boxes  into  which  wire  arms  can  be 
inserted  (Pilcher). 


it  in  its  socket  after  reducing  the  fracture.     Correct  deformity  with  great  care 
and  be  sure  to  bring  the  teeth  into  normal  alinement.     As  a  rule,  push  loose 

teeth  into  place  and  put  back  detached 
ones;  but  occasionally  a  tooth  obstinately 
prevents  perfect  approximation,  and  if  it 
does  it  must  be  removed.  Wash  the 
mouth  with  hot  water  to  clean  it  and  to 
check  bleeding.  If  bleeding  is  very  severe, 
compress  the  carotid  artery  for  a  time. 
The  fracture  can  be  dressed  with  a  pad 
of  lint  over  the  chin  and  Hamilton's  four- 
tailed  bandage  (Fig.  261,  A  common 
plan  is  to  take  a  splint  of  pasteboard,  felt, 
or  gutta-percha;  pad  it  lightly  with  cotton, 
mould  it  to  the  part,  and  hold  it  in  place 
with  a  Barton  or  a  Gibson  bandage.  If 
apposition  of  the  fragments  cannot  be 
maintained  by  the  above  methods,  fasten 
the  teeth  together  with  wire,  wire  the 
fragments  together,  or  have  a  dentist  apply  an  interdental  splint  (Figs. 
262,  263).  Fracture  of  the  lower  jaw  can  often  be  most  satisfactorily  treated 
by  Angle's  bands.  These  bands  are  of  great  value  in  complicated  cases, 
in  which  two  or  more  fractures  exist.  Each  band  consists  of  thin  metal  and 
a  screw  and  a  nut  to  fit  the  screw.  The  band  is  adjusted  around  a  firm  tooth 
and  a  nut  is  applied  so  as  to  hold  the  band  tightly.  Several  bands  are  placed 
upon  teeth  in  both  jaws.  Silver  wire  or  silk  is  thrown  around  the  pins  of  the 
bands  so  as  to  catch,  and  the  jaws  are  thus  held  firmly  together.  The  patient 
is  to  be  fed  on  liquid  food  (see  Fracture  of  the  Upper  Jaw),  the  mouth  is 
to  be  washed  frequently  with  peroxid 
of  hydrogen,  followed  by  boric  acid  solu- 
tion or  normal  salt  solution,  and  if  bandages 
were  used  they  should  be  changed  every 
second  day.  The  union  should  be  complete 
in  five  weeks.  The  best  plan  of  treatment 
in  all  of  these  cases  is  to  send  the  patient  to  a 
capable  dentist  and  have  him  apply  an  inter- 
dental splint  and  direct  the  treatment. 
Though  these  fractures  are  usually  com- 
pound, they  do  not  endanger  life. 

Fractures  of  the  Hyoid  Bone. — These 
fractures  are  uncommon  injuries,  and  are  caused  by  hanging,  by  throttHng,  and 
|jy  falls  in  which  the  neck  strikes  some  obstacle.     If  the  bone  breaks  by  throt- 
tling, it  is  its  body  which  fractures  (indirect  force).     Fractures  by  muscular 
action  are  most  unusual. 

Symptoms. — The  symptoms  are:  A  sensation  of  something  breaking; 
bleeding  from  the  mouth  if  the  mucous  membrane  be  lacerated;  pain,  which 
is  worse  on  opening  the  jaws  or  on  moving  the  head  or  tongue;  difficulty  in 
swallowing;  mufHed,  hoarse  voice  or  aphonia;  sweUing,  and  frequently  ecchy- 
mosis,  of  the  neck.     There  are  observed  occasionally,  though  rarely,  harsh 


Fig.  263. — Interdental  splint. 


Fractures  of  the  Ribs  547 

cough  and  dyspnea,  irregularity  of  bony  contour,  and  crepitus.  Ahvays  look 
into  the  mouth  and  see  if  there  can  be  detected  ecchymosis  or  laceration  of 
the  mucous  membrane  or  projection  of  a  bony  fragment.  The  displacement 
is  due  to  the  middle  constrictor  of  the  pharynx  contracting.  A  fracture  of 
the  hyoid  bone  may  destroy  life. 

Treatment. — For  dyspnea,  be  ready  to  perform  intubation  or  tracheotomy 
at  a  moment's  notice.  Edema  of  the  glottis  is  a  great  danger.  Try  to  restore 
the  fragments  with  one  hand  externally  and  with  a  finger  in  the  mouth. 
Put  the  patient  to  bed  and  have  him  lie  back  upon  a  firm  rest  so  that  his 
shoulders  are  elevated.  His  head  is  to  be  placed  between  extension  and 
flexion,  a  pasteboard  spHnt  or  collar  is  moulded  on  the  neck,  and  a  bandage 
is  applied  around  the  forehead,  neck,  and  shoulders  to  keep  the  head  immobile. 
The  patient  must  not  utter  a  word  for  a  week;  he  must  at  first  be  fed  by 
enemata,  and  then  for  some  time  on  liquid  diet,  which  is  given  through  a 
tube  early  in  the  case.  Endeavor  to  control  the  cough  by  opiates.  A  frac- 
tured hyoid  bone  requires  about  four  weeks  to  unite. 

Fractures  of  laryngeal  cartilages  are  caused  by  direct  violence,  as 
throttling,  blows,  or  kicks.  They  are  rare  in  young  persons,  and  are  com- 
monest when  the  cartilages  have  begun  to  ossify.  They  are  very  grave  in- 
juries, death  tending  to  occur  from  obstruction  to  the  entrance  of  air. 

Symptoms. — The  symptoms,  which  are  severe,  are  pain,  aggravated  by 
attempts  at  swallowing  or  speaking;  swelling,  ecchymosis  it  may  be,  and 
emphysema  of  the  neck;  cough;  aphonia;  intense  dyspnea;  and  bloody  ex- 
pectoration if  the  mucous  membrane  is  ruptured.  There  can  be  detected 
inequality  of  outline  (flattening  or  projection)  and  perhaps  moist  crepitus. 
The  usual  seat  of  the  injury  is  the  thyroid  cartilage. 

Treatment. — Cases  without  dyspnea  require  quiet,  avoidance  of  all  talking, 
feeding  with  a  stomach-tube,  the  application  of  compresses  and  adhesive 
strips  over  the  fracture,  and  the  use  of  remedies  to  quiet  cough.  The  surgeon 
must  be  ready  to  operate  at  any  moment.  In  most  cases  dyspnea  exists, 
due  to  projection  of  the  fragments  or  submucous  extravasation.  When  there 
is  dyspnea,  emphysema,  or  spitting  of  blood,  at  once  practise  intubation, 
or,  if  unable  to  do  this,  open  the  larynx  or  trachea  below  the  seat  of  fracture. 
If  laryngotomy  or  tracheotomy  is  performed,  try  to  restore  to  proper  position 
displaced  fragments.  If  the  fragments  will  not  remain  reduced,  introduce 
a  Trendelenburg  cannula  or  a  tracheotomy-tube,  and  pack  gauze  around 
it.  Take  out  the  packing  in  four  days,  and  remove  the  tube  as  soon 
as  the  patient  breathes  well,  when  the  opening  may  be  allowed  to  close. 
In  these  cases  feed  with  a  stomach-tube  and  keep  the  patient  absolutely 
quiet.     Union  takes  place  in  four  weeks. 

Fractures  of  the  Ribs. — The  ribs,  owing  to  their  shape,  elasticity,  and 
mode  of  attachment,  readily  bend  and  as  readily  recover  shape,  and  thus 
withstand  considerable  force  without  breaking.  Notwithstanding  these  facts, 
the  situation  of  the  ribs  so  exposes  them  that  in  16  per  cent,  of  all  cases  of 
fractures  noted  by  Gurlt  these  bones  were  involved.  In  children  fracture 
of  a  rib  seldom  occurs  and  is  usually  incomplete ;  it  is  common  in  adults  and 
the  aged,  and  in  them  is  generally  complete.  It  is  more  frequent  among 
men  than  among  women.  The  ribs  commonly  broken  are  from  the  fifth 
to  the  ninth,  the  seventh  being  the  one  that  most  frequently  suffers.     Fracture 


548  Diseases  and  Injuries  of  Bones  and  Joints 

of  the  first  rib  alone  is  an  excessively  rare  accident.  The  eleventh  and  twelfth 
ribs  are  seldom  broken.  A  rib  may  be  broken  in  several  places,  and  several 
ribs  are  often  broken  at  the  same  time.  Fracture  of  a  single  rib  is  not  nearly 
so  common  as  fracture  of  several  ribs.  These  fractures  may  be  compound 
either  through  the  skin  or  through  the  pleura,  a  damaged  lung  permitting 
pneumothorax.  Compound  fractures  are  very  rare,  however,  except  from 
bullet-wounds. 

Causes. — Direct  force,  as  buffer  accidents,  kicks,  blows  with  heavy  instru- 
ments, or  being  jumped  on  while  recumbent,  may  produce  these  injuries. 
A  fracture  from  direct  violence  occurs  at  the  point  struck,  and  the  ends, 
projecting  inward,  may  damage  a  viscus.  Indirect  force,  as  great  pressure 
or  blows  which  exaggerate  the  natural  bony  curves,  tends  to  produce  fractures 
near  the  middle  of  the  ribs  or  in  front  of  their  angles  and  to  force  the  ends 
outward.  A  number  of  ribs  are  apt  to  be  broken.  Muscular  action,  as  in 
coughing,  sneezing,  lifting,  or  parturidon,  occasionally,  but  very  rarely,  is  a 
cause. 

Symptoms. — In  connection  with  the  history  of  the  accident  the  symptoms 
are:  acute  localized  pain  (a  stitch)  on  breathing,  increased  by  pressure  over 
the  seat  of  pain,  pressure  backward  over  the  sternum,  cough,  and  forcible 
inspiration  or  expiration;  respiration  is  largely  diaphragmatic,  the  patient  en- 
deavoring to  immobilize  the  injured  side;  cough  is  frequent  and  is  sup- 
pressed because  of  pain.  Crepitus  is  often  but  not  invariably  found.  The 
surgeon  seeks  for  it,  first,  by  resting  the  palm  of  his  hand  over  the  seat  of 
pain  while  the  patient  takes  long  breaths;  second,  by  placing  a  thumb  before 
and  one  behind  the  seat  of  pain  and  making  alternate  pressure;  and  third, 
by  auscultation.  It  should  be  remembered  that  incomplete  fractures  are  the 
rule  in  children ;  hence  in  them  do  not  expect  crepitus.  Deformity  is  usually 
trivial  unless  several  ribs  are  broken,  because  shortening  cannot  occur  and  the 
intercostal  attachments  prevent  vertical  displacement.  Preternatural  mobility 
may  occasionally  be  elicited,  when  the  region  is  not  deeply  covered  with  mus- 
cles, by  pressing  on  one  side  of  the  supposed  break  and  observing  that  a  part 
of,  and  not  the  entire,  rib  moves.  If  air  gathers  in  the  subcutaneous  tissue 
and  there  is  no  wound  of  the  surface,  it  is  proof  of  rib  fracture  with  lung 
damage.  In  such  a  case  the  lung  has  been  penetrated  by  a  fragment,  and 
air  has  been  forced  out  into  the  tissues.  This  condition  is  recognized  by  great 
and  growing  swelling,  which  crackles  when  touched.  Such  a  collection  of 
air  is  known  as  cellular  emphysema.  Bloody  expectoration  suggests  lung 
injury;  bloody  expectoration  and  cellular  emphysema,  without  an  external 
wound,  prove  injury  of  the  lung.  ^A  simple,  uncomplicated  case  of  frac- 
ture of  a  rib  or  ribs  in  a  young  person  gives  a  good  prognosis. 

The  complications  are;  additional  injury,  making  the  fracture  externally 
or  internally  compound;  laceration  of  the  pleura,  pericardium,  heart,  lung, 
diaphragm,  liver,  spleen,  or  colon;  rupture  of  an  intercostal  artery;  hemo- 
thorax; cellular  emphysema;  pulmonary  emphysema;  pneumothorax;  pyo- 
thorax;  traumatic  pleurisy;  pneumonia;  bronchitis;  congestion  or  edema  of 
the  lungs. 

Treatment. — In  an  uncomphcated  case  the  patient  is  not  kept  in  bed,  as 
breathing  is  easier  when  erect  than  when  recumbent.  Angular  displacement 
outward  is  corrected  by  direct  pressure.     Displacement  inward  is  soon  cor- 


Fractures  of  the  Costal  Cartilages  549 

rected,  as  a  rule,  by  the  expansion  of  ordinary  respiratory  action;  but  if 
it  is  not  thus  corrected,  etherize,  the  deep  breathing  of  the  anesthetic  state 
almost  always  succeeding.  If  ether  fails,  and  dangerous  symptoms  come 
on,  incise  under  strict  antiseptic  precautions,  elevate,  and  drain,  or  some- 
times resect  a  portion  of  the  rib. 

After  correcting  any  existing  deformity  immobilize  the  injured  side. 
Direct  the  patient  to  raise  his  arms  above  his  head,  to  empty  his  chest  of  air 
by  a  forced  expiration,  and  to  keej)  it  empty  until  a  piece  of  rubber  plaster 
(tvi^o  inches  wide)  is  forcibly  applied  seven  or  eight  inches  below  the  fracture 
and  from  the  spine  to  the  sternum.  The  patient  is  now  allowed  to  take 
a  breath  and  is  directed  to  empty  the  chest  again,  another  piece  of  plaster 
being  applied,  covering  the  upper  two-thirds  of  the  width  of  the  first  strip. 
This  process  is  continued  until  the  side  is  strapped  well  above  and  well  below 
the  fracture  (PI.  6,  Fig.  13).  Over  the  plaster  Hght  turns  of  a  spiral  bandage 
of  muslin  are  carried,  or  a  figure-of-8  bandage  of  the  chest  is  applied,  the  turns 
crossing  over  the  seat  of  injury.  About  once  a  week  the  plaster  is  removed 
and  fresh  pieces  appHed  after  rubbing  the  chest  with  soap  liniment,  drying, 
and  anointing  excoriations  with  an  ointment  of  oxid  of  zinc.  The  dressing 
is  worn  for  three  or  four  weeks.  The  patient  avoids  cold,  damp,  and  draughts. 
The  diet  must  be  nutritious  but  non-stimulating,  and  any  cough  should 
be  treated  by  opiates  and  expectorants.  A  person  with  this  injury  who  has 
reached  the  age  of  sixty  must  take  stimulant  expectorants  (ammonii  carb., 
gr.  X,  in  infus.  senegae,  Sss,  /.  /.  d.)  or  employ  a  steam-tent  several  times  a 
day.  The  old  method  of  treatment,  in  which  the  chest  was  included  in  a 
forcibly  applied  broad  rib-roller,  is  not  to  be  used  except  as  a  temporary 
expedient;  it  compresses  the  entire  chest,  causes  pain  and  dyspnea,  and 
tends  to  loosen  and  slip. 

Fracture  of  the  ribs  complicated  with  visceral  injury  is  highly  dangerous, 
and  requires  confinement  to  bed.  The  treatment  is  that  of  the  visceral 
injury.  If  there  be  bloody  expectoration,  apply  adhesive  strips  as  above 
indicated,  put  the  patient  to  bed  reclining  on  a  bed-rest,  keep  him  quiet, 
subdue  the  circulation,  and  employ  opium,  diaphoretics,  and  expectorants 
(a  good  mixture  consists  of  squill  ipecac,  ammonium  acetate,  and  chloroform; 
opium  is  given  separately).  Inflammations  of  the  lung  or  the  pleura,  fortu- 
nately, are  apt  to  be  localized,  and  are  treated  as  are  ordinary  inflammations  of 
these  parts.  If  signs  of  pulmonary  injury  are  severe  from  the  start  or  become 
worse  under  medical  treatment,  incise,  resect  a  rib,  arrest  hemorrhage,  and 
drain  the  pleura.  In  laceration  of  an  intercostal  artery  incise  and  try  to 
hgate;  if  unable  to  ligate,  resect  a  rib  and  apply  a  ligature.  If  the  signs 
point  to  internal  bleeding,  resect  a  rib,  search  for  the  bleeding  point,  and 
ligate.  Emphysema  usually  soon  disappears;  but  if  it  does  not,  make  many 
small  incisions  in  the  cellular  tissue,  dress  antiseptically,  and  employ  pressure. 
When  there  arises  a  sudden  attack  of  dyspnea,  which  is  prone  to  happen 
in  these  cases,  and  in  which  the  face  becomes  blue,  the  heart  labors,  and 
suffocation  seems  imminent,  bleed  the  patient  almost  to  syncope. 

Fractures  of  the  costal  cartilages  are  not  common,  even  in  the  aged. 
Such  fractures  occur  either  through  the  cartilages  or  through  their  points  of 
junction  with  the  ribs.  These  injuries  generally  arise  from  direct  violence, 
the  cartilage  of  the  eighth  rib  being  most  prone  to  suffer.  Bennett,  of  Dublin, 
has  seen  over  25  specimens  of  fracture  of  the  first  costal  cartilage.     Indirect 


550  Diseases  and  Injuries  of  Bones  and  Joints 

force  (such  as  a  blow  upon  the  shoulder)  is  occasionally  the  cause,  but  when  it 
is  the  cause  some  other  injury  besides  the  fracture  of  the  cartilages  is  apt 
to  be  noticed.     Muscular  action  is  a  possible  cause. 

Symptoms. — Displacement  is  often  absent;  but  if  present,  it  is  forward  or 
backward  of  either  fragment,  and  is  due  chiefly  to  the  force  of  the  injur}-, 
but  partly,  it  may  be,  to  muscular  action.  When  displacement  is  absent, 
crepitus  will  not  often  be  found;  in  fact,  crepitus  is  usually  absent  in  these 
injuries.  Localized  pain,  swelling,  and  ecchymosis  are  noted.  Preternatural 
mobility  may  or  may  not  be  detected.     Union  by  bone  is  to  be  expected. 

Treatment. — If  displacement  exists,  try  to  reduce  it.  If  the  fragment  is 
displaced  backward,  reduce  by  deep  inspirations;  if  the  fragment  is  displaced 
forward,  reduce  by  pulling  back  the  shoulders.  In  this  attempt  failure  is 
the  rule,  and  the  surgeon  may  then  adopt  Malgaigne's  expedient  of  applying 
a  truss  over  the  projection  for  a  day  or  two.  Dress  and  treat  the  case  as 
if  a  rib  were  broken,  removing  the  dressings  in  four  weeks. 

Fractures  of  the  Sternum. — The  sternum  may  be  broken,  along  with 
the  ribs  and  spine,  from  great  violence.  Fractures  of  the  sternum  alone 
are  infrequent,  because  the  bone  rests  on  a  spring-bed  of  ribs.  Fractures 
of  the  sternum  may  be  simple  or  compound,  complete  or  incomplete,  single 
or  multiple.  The  most  usual  injury  is  a  simple  transverse  fracture  at  or 
near  the  gladiomanubrial  junction,  at  which  point  dislocation  may  also 
occur.  Both  fracture  and  separation  of  the  ensiform  cartilage  are  very  rare. 
The  sternum  may  be  broken  along  with  the  ribs  or  clavicle. 

Causes. — These  are:  direct  force,  as  by  a  fall  of  an  embankment  or  of  a 
wall,  by  a  car-crush,  or  by  the  passing  of  a  cart-wheel  over  the  body ;  indirect 
force,  as  by  a  fall  upon  the  head,  thus  driving  the  chin  against  the  chest;  by 
a  fall  upon  the  feet,  the  buttocks,  or  the  shoulder;  by  forced  flexion  or 
extension  of  the  body  over  an  edge  or  angle  (as  may  occur  during  labor- pains). 

Symptoms. — In  fracture  of  the  sternum  displacement  is  not  always  present, 
but  when  it  does  occur  the  lower  fragment  is  apt  to  pass  forward;  displace- 
ment may,  however,  be  transverse  or  angular,  or  there  may  be  overriding. 
The  posterior  periosteum,  which  rarely  tears,  limits  displacement,  but  some 
deformity  can,  as  a  rule,  be  detected.  The  history  of  the  nature  of  the  acci- 
dent has  a  valuable  bearing  upon  the  question  of  diagnosis.  The  position 
assumed  by  the  patient  is  with  the  head  and  body  bent  forward,  as  attempts 
to  straighten  up  cause  much  suffering.  There  is  fixed  and  locahzed  pain, 
increased  by  deep  respiratory  action,  by  body-movements,  or  by  cough. 
Crepitus  is  sought  for  by  auscultation  and  by  placing  the  hand  over  the 
injury  and  directing  the  patient  to  make  quick  respirations.  Mobility  may 
become  manifest  on  external  pressure,  during  respiration,  or  while  attempts 
are  being  made  to  bring  the  body  erect.  Respiration  in  these  cases  is  usually 
much  interfered  with.  It  is  not  important  to  separate  diagnostically  diastasis 
from  fracture. 

Complications. — Other  fractures  generally  complicate  fracture  of  the 
sternum,  and  laceration  of  the  pleura  or  pericardium  and  hemorrhage  into 
the  anterior  mediastinum  may  exist.  Abscess  of  the  mediastinum  and  necrosis 
of  the  sternum  may  appear  as  late  consequences.  The  prognosis  is  good  in 
uncomplicated  cases. 

Treatment. — The  deformity  attending  fracture  of  the  sternum  is  to  be 
corrected,  if  possible,  by  external  pressure.     If  overriding  is  found,  effect 


Fractures  of  the  False  Pelvis  551 

reduction  by  bending  the  body  back  over  a  firm  pillow  and  ordering  the 
patient  to  respire  deeply;  if  this  method  fails,  give  ether  and  then  bend  the 
body  backward.  The  deformity,  after  reduction,  tends  to  recur,  but  the 
bones  unite  well  even  in  deformity,  and  no  great  harm  results.  The  frag- 
ments need  not  be  cut  down  on  or  be  hooked  up  unless  there  be  internal 
injury.  After  reducing  the  deformity,  cover  the  front  of  the  chest  with 
adhesive  strips  extending  laterally  from  one  axillary  line  to  the  other,  and 
covering  a  region  from  above  the  fracture  down  to  the  ensiform  cartilage. 
Place  over  this  covering  an  anterior  figure-of-eight  bandage  of  the  chest. 
In  some  cases,  where  deformity  recurs  after  reduction,  a  circular  bandage 
of  the  chest  is  applied  and  the  shoulders  are  pulled  strongly  back  with  a 
posterior  figure-of-eight  bandage.  The  plaster  is  to  be  reapplied  once  a 
week.  Some  surgeons  treat  these  cases  by  means  of  a  large  compress  held 
by  adhesive  plaster  and  a  broad  tight  roller. 

The  patient  goes  promptly  to  bed,  and  reposes  erect,  or  semi-erect,  on 
a  bed-rest.  This  position  favors  easy  respiration  and  antagonizes  the  ten- 
dency to  displacement.  The  diet  should  be  light,  nutritious,  and  non-stimu- 
lating. Convalescence  is  established  in  four  weeks,  and  the  plaster  should  be 
permanently  removed  in  five  weeks.  When  the  ensiform  cartilage  is  so  bent 
in  as  to  cause  intense  pain  or  to  injure  the  stomach,  it  should  be  exposed 
by  incision  and  resected.  Edema  of  the  skin  and  fever,  if  they  appear,  in- 
dicate pus,  in  which  case  an  incision  should  be  made  at  the  edge  of  the 
sternum  and  the  pus-ca\'ity  should  be  irrigated  and  drained. 

Fractures  of  the  Pelvis. — In  some  of  the  indicated  fractures  serious 
injury  of  the  pelvic  contents  is  apt  to  be  found. 

Fractures  of  the  False  Pelvis. — Fractures  of  this  region  are  seldom 
dangerous  unless  comminuted.  There  may  be  fracture  of  the  iliac  crest 
or  of  the  anterior  superior  spine,  or  the  line  of  fracture  may  traverse  the 
entire  length  of  the  flanged-out  ilium,  or  the  bone  may  be  comminuted  with 
the  association  of  grave  \isceral  damage.  The  anterior  superior  and  posterior 
superior  spines  may  be  broken  off. 

Causes. — The  cause  of  fracture  of  the  false  pelvis  is  generally  violent 
direct  force,  as  the  passage  of  a  wagon-wheel,  the  fall  of  a  wall,  the  kick  of 
a  horse  or  mule,  or  the  force  of  car-crushes.  Violent  contraction  of  the 
rectus  femoris  muscle  may  tear  off  the  anterior  inferior  spine  of  the  ilium. 

Symptoms. — In  fracture  of  the  false  pelvis  the  history  of  violent  force 
is  noted.  The  patient  leans  toward  the  injured  side.  Pain  exists,  which 
is  aggravated  by  movements  (particularly  by  bending  forward),  by  coughing, 
or  by  straining  to  empty  the  bowels  or  the  bladder.  Ecchymosis  and  swelling 
are  manifest.  Crepitus  and  preternatural  mobility  are  detected  by  moving 
the  iliac  crest.  Deformity  is  ver\-  rarely  present.  Cases  uncomplicated  by 
visceral  injury  make  good  recoveries. 

Complications. — The  fracture  may  be,  but  rarely  is,  compound,  as  the 
parts  are  well  protected  \Aith  muscles.  The  colon  may  be  injured  when 
comminution  has  taken  place. 

Treatment. — If  there  are  symptoms  of  injur\-  of  the  colon,  perform  lapar- 
otomy, search  for  the  injured  region,  and  suture  it.  In  treating  an  ordinary 
fracture  of  the  false  pehis  put  the  patient  on  a  fracture-bed,  raise  the  shoul- 
ders, and  apply  a  canvas  binder  about  the  pelvis,  or  encase  the  pelvis  with 


552  Diseases  and  Injuries  of  Bones  and  Joints 

broad  pieces  of  rubl)er  plaster,  or  employ  the  belt  or  girdle.  The  pressure 
of  the  binder,  girdle,  or  plaster  must  not  be  so  great  as  to  force  the  fragment 
of  ilium  inward.  Place  the  knees  over  two  pillows  so  as  to  semitlex  the 
legs  and  thighs,  and  tie  the  knees  together.  To  restrain  thigh-movements  it 
may  be  necessary  to  encase  a  restless  patient  with  splints  or  bind  him  to  sand- 
bags. If  the  pelvic  binder  displaces  the  fragments  or  causes  pain,  abandon 
it  and  trust  to  position.  If  the  fragment  cannot  be  retained  in  place,  wire 
it.  The  dressings  can  be  removed  in  six  weeks,  and  the  patient  is  allowed 
to  get  up  in  eight  weeks.  In  simple,  uncomplicated  fracture  of  the  false 
pelvis  the  prognosis  is  good.  In  compound  fractures  of  the  false  pelvis 
asepticize,  drain  and  dress,  put  on  a  binder,  and  direct  the  same  position 
to  be  maintained  as  for  simple  fractures. 

Fractures  of  the  True  Pelvis. — The  most  usual  seat  of  these  fractures 
is  through  the  obturator  foramen,  the  ascending  ischial  and  horizontal  pubic 
rami  being  broken.  A  fracture  may  occur  near  the  symphysis  pubis,  the 
symphysis  may  be  separated,  a  line  of  fracture  may  run  near  to  or  into  the  sacro- 
iliac joint,  the  same  may  involve  each  side  of  the  body  of  the  pubis,  and  there 
may  be  muldple  fractures.  Fractures  of  the  acetabulum  and  of  the  tuber- 
osity of  the  ischium  may  occur.  Before  the  seventeenth  year  the  innominate 
bone  may  be  broken  into  its  three  anatomical  segments.  Fractures  of  the 
true  pelvis  are  highly  dangerous  because  of  the  damage  which  is  apt  to  be 
inflicted  on  the  pelvic  contents.  There  may  be  rupture  of  the  bladder  or 
membranous  urethra  and  injury  of  the  vagina,  the  rectum,  the  uterus,  or 
the  small  gut.  The  cause  of  pelvic  fracture  is  violent  force,  direct  or  in- 
direct. Front  force  tends  to  produce  direct,  and  side  force  indirect  frac- 
ture.    The  acetabulum  may  be  broken  by  falls  upon  the  feet. 

Symptoms. — In  pelvic  fracture  there  is  a  history  of  violent  force.  There 
are  great  shock,  ecchymosis  which  is  possibly  linear,  sweUing,  and  intense 
pain  increased  by  attempts  at  motion,  coughing,  and  straining.  There  is 
also  inability  to  sit  or  to  stand.  ^Mobility  becomes  obvious  on  grasping  an 
ihum  in  each  hand  and  moving  the  hands.  Crepitus  may  be  noticed  by 
this  maneuver  or  by  moving  an  ilium  with  one  hand,  a  finger  of  the  other 
hand  being  inserted  in  the  rectum  or  vagina.  In  making  movements  for 
diagnostic  purposes  be  very  gentle,  as  rough  manipulation  may  cause  injury 
by  sharp  fragments.  There  may  be  doubt  as  to  whether  crepitus  is  to  be 
referred  to  pelvic  fracture  or  to  fracture  of  the  neck  of  the  femur;  in  this 
case  follow  the  rule  of  John  Wood:  "The  surgeon  grasps  the  femur  with 
one  hand  and  places  the  other  firmly  upon  the  anterior  superior  iliac  spine 
or  crest  or  upon  the  pubes;  then,  on  moving  the  femur  and  abducting  it  freely, 
if  a  crepitus  be  detected,  it  will  be  felt  the  more  distinctly  by  that  hand  which 
rests  on  or  grasps  the  fractured  bone. " 

Rupture  of  the  bladder  is  made  manifest  by  pain  in  the  hypogastric 
region,  an  intense  desire  to  micturate,  an  inabihty  to  pass  urine  in  quantity 
although  a  few  drops  of  bloody  urine  may  be  voided,  great  shock,  sometimes 
dulness  on  percussion  in  the  loins,  and  evidences  of  extravasation  in  the 
prevesical  space.  The  condition  is  proved  to  exist  by  practising  the  maneu- 
vers suggested  under  Rupture  of  Bladder.  The  symptoms  of  ruptured 
urethra  are  set  forth  later.  Bleeding  from  vagina  or  rectum  points  to  lacera- 
tion of  the  part  by  a  fragment.  The  vagina  may  be  badly  lacerated  and  the 
bowels   may  emerge  from  the  laceration  (Maurice  H.  Richardson's  case). 


Fractures  of  the  Sacrum  553 

Intestinal  injury  is  apt  to  induce  septic  peritonitis.  Fracture  of  the  brim 
of  the  acetabulum  permits  dorsal  dislocation  of  the  femur  to  occur,  which 
dislocation  will  not  remain  reduced,  and  causes  shortening,  which  at  once  re- 
curs when  extension  is  abandoned — inversion  and  adduction,  although  the 
power  of  eversion  and  abduction  is  preserved  (Stokes).  There  is  crepitus, 
and  the  head  of  the  bone  goes  with  the  fragment  upward  and  backward 
(Stokes).  If  the  head  of  the  femur  be  driven  through  the  acetabulum  into 
the  pelvis,  the  injury  is  very  grave;  there  are  then  found  shortening,  adduc- 
tion, and  semiflexion  of  the  thigh,  absence  of  the  prominence  of  the  great 
trochanter,  and  more  capacity  for  movement  than  is  noted  in  dislocation. 
Fracture  of  the  ischium  rarely  occurs  alone. 

Treatment. — Examine  carefully  to  determine  if  the  bowel,  the  bladder,  the 
urethra,  or  the  vagina  is  injured.  If  such  an  injury  exists,  radical  operation 
is  of  course  demanded.  Always  use  a  catheter  to  see  if  the  urine  is  bloody. 
Bloody  urine  suggests,  but  does  not  prove,  the  existence  of  a  ruptured  bladder. 
It  may  be  due  to  simple  contusion  of  the  bladder  or  to  contusion  of  the  kidney. 
In  treating  a  pelvic  fracture  endeavor  to  restore  the  parts  to  a  normal  position, 
employing  external  manipulation  and  inserting  a  finger  in  the  rectum  or 
in  the  vagina.  If  reduction  is  difficult,  administer  ether.  The  pelvis  should 
be  encircled  with  a  canvas  binder  and  the  patient  should  be  placed  upon  a 
Bradford  frame.  If  this  is  done  he  can  be  cleaned  readily  and  the  bed-pan 
can  be  easily  used.  If  movements  of  the  thighs  distort  the  pelvic  bones,  each 
thigh  should  be  bound  to  the  frame.  In  fracture  with  separation  of  the  pubic 
bones,  the  bones  should  be  wired  together.  If  urinary  extravasation  occurs, 
perform  perineal  section.  If  there  are  signs  of  bowel  injury  or  intraperitoneal 
rupture  of  the  bladder,  perform  laparotomy;  and  if  the  bladder  is  found  to 
be  torn,  apply  sutures.  All  visceral  injuries  are  treated  by  general  rules. 
Remove  the  dressings  in  six  weeks  and  allow  the  patient  to  get  about  in 
twelve  weeks.  In  fracture  of  the  acetabulum,  if  the  limb  is  shortened, 
give  ether  and  reduce  by  extension  and  counterextension.  Treat  these 
fractures  in  the  same  way  as  intracapsular  fractures  of  the  femur.  Frac- 
tures of  the  ischium  are  best  treated  by  the  application  of  a  pad  and 
adhesive  plaster,  and  rest  in  bed. 

Fractures  of  the  Sacrum. — This  bone  may  be  broken  by  direct  force, 
such  as  a  kick,  but  the  injury  is  rare.  The  sacral  plexus  is  usually  injured, 
and  if  it  is  paralysis  is  observed  in  the  territory  of  its  branches. 

Symptoms. — The  symptoms  of  fracture  of  the  sacrum  are  pain,  frequently 
incontinence  of  feces  and  retention  of  urine,  irregularity  of  the  sacral  spines, 
ecchymosis,  and  crepitus.  Crepitus  may  be  sought  for  w-ith  one  hand  exter- 
nally and  a  finger  of  the  other  hand  in  the  rectum.  The  lower  fragment 
passes  forward  and  may  obstruct  or  may  tear  the  rectum.  Paralysis  may 
be  found  in  the  area  of  distribution  of  the  sacral  plexus. 

Treatment. — In  any  case  of  fracture  of  the  sacrum  if  there  are  evidences 
of  pressure  upon  nerves  by  displaced  bone,  incise  and  elevate  the  depressed 
bone.  If  the  rectum  is  lacerated  sutures  must  be  inserted.  In  many  cases 
of  fracture  of  the  sacrum  the  older  conservative  treatment  is  sufficient. 
The  conservative  treatment  is  as  follows:  Press  the  fragments  into  place 
with  a  hand  externally  and  a  finger  in  the  rectum.  Do  not  plug  the 
rectum.  Put  a  pad  over  the  upper  fragment,  hold  it  with  plaster  or  a  binder, 
place  the  patient  recumbent  on  a  fracture-bed,  and  insert  a  large  cushion 


554  Diseases  and  Injuries  of  Bones  and  Joints 

underneath  the  f)ad.  Some  surgeons  give  opium  to  induce  constipadon,  and 
allow  a  fecal  support  to  accumulate  in  the  rectum.  Use  a  clean  catheter 
regularly,  and  guard  against  bed-sores.  Union  occurs  in  about  four  weeks, 
when  the  dressing  can  be  removed.  The  patient  can  get  about  again  in 
six  weeks.  If  urinary  retention  persists  or  if  intractable  bed-sores  form  after 
eight  or  ten  weeks,  cut  down  on  the  seat  of  injury  and  elevate  or  remove 
the  portion  of  bone  causing  pressure. 

Fractures  of  the  Coccyx. — The  coccyx  may  be  broken  or  be  separated 
from  the  sacrum  by  a  fall,  a  blow,  a  kick,  or  the  straining  of  parturition. 
Its  mobility  is  so  great,  however,  that  it  does  not  often  break. 

Symptoms. — The  chief  symptom  of  fracture  of  the  coccyx  is  pain,  which 
is  much  aggravated  by  sitting,  walking,  or  straining  at  stool.  If  the  index 
finger  is  inserted  into  the  rectum,  the  displaced  bone  is  felt;  if  the  thumb  of 
the  same  hand  is  also  placed  externally,  a  rocking  motion  will  develop  crepitus 
and  preternatural  mobility. 

Treatment. — In  treating  fracture  of  the  coccyx  reduce  by  external  pressure 
and  by  the  manipulations  of  a  finger  in  the  rectum  and  put  the  patient  to 
bed.  In  four  weeks  the  fracture  should  be  united.  If  union  does  not  take 
place,  defecation  and  all  movements  of  the  coccvx  will  cause  excruciating 
pain  by  pressure  on  the  last  sacral  nerve.  This  condition,  known  as  "coccy- 
godynia, "  demands  a  subcutaneous  division  of  the  nerve  or  of  the  muscles 
which  move  the  coccyx,  or  a  resection  of  the  bone. 

Fractures  of  the  Vertebra.     (See  page  871.) 

Fractures  of  the  Skull.     (See  page  807.) 

Fractures  of  the  Clavicle. — The  clavicle  is  more  often  fractured  than 
any  other  bone.  The  fracture  may  occur  at  any  age,  but  is  commonest 
before  the  sixth  year  (Hulke  says  one-half  of  the  recorded  cases).  It  may 
be  simple,  multiple,  comminuted,  oblique,  transverse,  complete,  incomplete, 
or,  very  rarely,  compound.  Both  clavicles  may  be  broken.  Fractures  are 
most  apt  to  occur  just  external  to  the  middle,  at  the  point  where  the  inner 
or  large  curve  meets  the  outer  or  small  curve,  at  which  junction  the  bone 
is  at  its  smallest  diameter.  Fractures  of  the  acromial  end  are  more  frequent 
than  fractures  of  the  sternal  end,  and  less  frequent  than  fractures  of  the 
shaft.  The  causes  of  fracture  of  the  clavicle  are  direct  violence,  indirect 
violence,  and,  very  rarely,  the  contractions  of  "the  deltoid  and  clavicular 
fibers  of  the  great  pectoral"  (Treves,  from  Polaillon). 

Fractures  of  the  shaft  are  usually  due  to  indirect  violence,  as  falls  upon 
the  shoulder  or  upon  the  outstretched  hand.  In  the  latter  accident,  which 
is  the  usual  mode  of  origin,  the  concussion  of  the  fall  travels  up  and  the 
body-weight  travels  down,  and  these  two  forces  compress  the  bone,  which 
snaps  at  its  weakest  point.  Fractures  from  indirect  force  are  oblique,  and 
in  children  are  of  the  green-stick  form.  Fractures  from  direct  force  are 
usually  transverse,  and  are  occasionally  comminuted.  Fractures  from  mus- 
cular action  have  been  recorded  (Rubini  the  tenor,  recorded  by  Melay). 

Symptoms. — In  fracture  of  the  shaft  of  the  clavicle  the  attitude  of  the 
patient  is  peculiar.  He  supports  the  elbow  or  wrist  of  the  injured  side  with 
the  hand  of  the  sound  side,  and  also  pulls  the  extremity  against  the  chest; 
the  head  is  turned  down  toward  the  shoulder  of  the  damaged  side,  as  if 
trying  to  Usten  to  something  in  the  joint,  thus  relaxing  the  pull  of  the  sterno- 
cleidomastoid muscle  upon  the  inner  fragment.     The  shoulder  is  nearer  the 


PVactures  of  the  Shaft  of  the  Clavicle 


555 


sternum,  on  a  lower  level,  and  farther  front  than  that  of  the  sound  side. 
Loss  of  function  is  shown  by  inabilit}  to  abduct  the  arm,  and  in  many 
cases  by  inability  to  place  the  hand  on  the  top  of  the  erect  head.  Consider- 
able pain  exists,  which  is  increased  by  motion,  by  pressure,  and  by  hanging 
down  the  extremity  without  support. 

The  deformity  above  noted  is  described  by  stating  that  the  shoulder 
goes  downward,  inward,  and  forward  (d.  i.  f.).  The  downward  deformity 
is  chiefly  due  to  the  weight  of  the  extremity,  which  pulls  down  the  unsupported 
outer  fragment,  and  is  contributed  to  by  the  action  of  the  pectoraHs  minor 
muscle.  The  inward  deformity  is  chiefly  due  to  the  contraction  of  the  pec- 
torah's  minor  and  subclavius  muscles  assisted  by  the  action  of  the  pectoralis 
major.  The  forward  deformit}-  is  due  to  rotation  of  the  outer  fragment, 
which  is  brought  about  by  the  serratus  magnus  muscle  carrying  the  scapula 
forward.  In  this  deformity,  the  inner  end  of  the  outer  fragment  is  below 
and  behind  the  outer  end  of  the  inner  fragment,  which  overrides  it.  The 
inner  fragment,  though  pulled  on  by  the  sternocleidomastoid  muscle  and  rela- 
tively higher  than  the  outer  fragment,  is  really  but  little,  if  at  all,  elevated, 
marked  elevation  being  prevented  by  the  attachment  of  the  rhomboid  liga- 
ment. After  noting  the  deformity,  detect  with  the  finger  the  irregularity  of 
bony  contour.  Examine  for  preternatural  mobility  and  crepitus  by  raising 
and  throwing  back  the  shoulder.  In  looking  for  these  signs  in  children  it  is 
to  be  remembered  that  the  fracture  is  probably  incomplete.  The  prognosis 
is  good,  the  bone  uniting,  but  always  with  some  shortening  and  inequality. 

Complications. — Fractures  of  the  shaft  are  rarely  compound,  because  the 
sharp  end  of  the  outer  fragment  passes  backward  and  because  of  the  free 
play  the  skin  makes  over  the  bone  (Pickering  Pick).  Both  clavicles  may 
be  broken.  One  or  more  ribs  may  be  fractured  at  the  same  time.  In  frac- 
tures from  direct  force  deeper  structures  may  be  injured  by  fragments.  Thus, 
injury  of  the  brachial  plexus  will  induce  paralysis.  There  are  ii  recorded 
cases  of  simple  fracture  of  the  clavicle 
complicated  by  laceration  of  a  large 
vessel.  Eight  of  these  cases  died. 
The  vessel  ruptured  may  be  the  sub- 
clavian vein,  the  subclavian  artery, 
or  the  jugular  vein.  After  a  rupture 
a  huge  blood-clot  forms  (Gallois  and 
Piollet,  in  "Rev.  de  Chir.,"  July  and 
Aug.,  1901). 

Treatment. — In  treating  a  fracture 
of  the  shaft  of  the  clavicle  correct  the 
deformity  as  soon  as  possible  by  throw- 
ing the  shoulder  upw^ard,  outward,  and 
backward.  If  the  patient  is  a  girl,  it 
is  desirable  to  minimize  the  deformity. 
Place  her  upon  her  back  upon  a  hard 
bed,  with  a  small  pillow  under  her  head, 
a  firm  and  narrow  cushion  between  the 

shoulders,  a  bag  of  shot  resting  over  the  seat  of  fracture,  and  the  forearm 
lying  on  the  front  of  the  chest,  the  arm  being  held  to  the  side  by  a  sand- 
bag.    In   three  weeks   there   will   be   union,  practically  without  deformity. 


Fig.  264. -I- ox's  appavatus  for  fractured  clav- 
icle. 


:):)^ 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  265.— Sayre's  adhesive-plaster  dress- 
ing for  fracture  of  the  clavicle  (Stimson) :  A, 
First  piece  ;  B,  second  piece. 


In  a  child  with  an  incomplete  fracture  a  handkerchief  sling  for  the  fore- 
arm, worn  three  weeks,  is  all  that  is  needed.  In  a  fracture  of  the  collar- 
bone of  an  adult  the  Velpeau  bandage  is  efficient.  Before  applying  it, 
place  lint  around  the  chest  and  cotton  over  the  elbow.     Change  the  bandage 

every  day  for  the  first  week,  and  after 
that  period  every  third  day.  Each  time 
it  is  changed  rub  the  skin  with  alcohol, 
ethereal  soap,  or  soap  liniment,  dry 
carefully,  and  examine  for  excoriations ; 
if  any  are  found,  they  are  anointed 
with  zinc  ointment  before  the  dressing 
is  reapplied.  The  dressing  is  perma- 
nently removed  at  the  end  of  four 
weeks,  the  arm  being  carried  in  a  sling 
for  another  week.  The  classical  ap- 
paratus of  Desault  is  now  rarely  used. 
The  posterior  figure-of-eight  bandage 
associated  with  the  second  roller  of 
Desault,  some  turns  being  made  from 
the  elbow  of  the  injured  side  to  the  shoulder  of  the  sound  side,  can  be 
used  in  cases  in  which  the  forward  deformity  is  apt  to  return.  The  appa- 
ratus of  Fox,  which  is  very  useful,  consists  of  a  pad  for  the  axilla,  a  sling 
for  the  forearm,  and  a  ring  for  the  opposite  shoulder,  to  which  ring  are  tied 
the  tapes  from  both  the  pad  and  the  sling  (Fig.  264). 

The  dressing  of  Moore,  of  Rochester,  is  valuable  in  an  emergency.  It 
consists  of  a  piece  of  cotton  cloth,  two  yards  long,  and  folded  like  a  cravat 
until  it  is  eight  inches  in  width  at  the  middle.  The  center  of  the  bandage 
rests  upon  the  elbow,  the  posterior  tail  is  carried  across  the  front  of  the  shoulder 
of  the  injured  side.  The  forearm  is  at  an  acute  angle  with  the  arm,  and 
the  other  end  of  the  bandage  is  carried  across  the  forearm,  across  the  back 
over  the  opposite  shoulder,  and  around  the  axilla,  where  the  extremities 
are  stitched  together.  The  forearm  is  suspended  in  a  bandage  sling  (S.  D. 
Gross).  The  four-tailed  bandage  is  preferred  by  Pick.  Sa}Te's  dressing  has 
many  advocates  (Fig.  265),  For  this  there  are  required  two  pieces  of  rubber 
plaster,  each  piece  being  three  inches  wide  and  sufficiently  long  to  go 
around  the  chest  one  and  a  half  times.  The  end  of  one  piece  encircles 
the  arm  of  the  injured  side  just  below  the  arm-pit;  the  plaster  strip  is 
pulled  across  the  back  to  the  other  side,  to  the  front  of  the  chest,  and 
returns  again  to  the  middle  of  the  back.  This  procedure  pulls  the 
elbow  back  and  throws  the  shoulder  out.  The  hand  of  the  injured  side 
is  placed  on  the  breast  of  the  opposite  side,  cotton  being  interposed,  and 
the  second  strip  of  plaster  runs  from  the  elbow  of  the  injured  side  and 
the  opposite  shoulder,  front,  around,  and  back,  pressing  the  elbow  forward, 
upward,  and  inward.  In  children,  if  it  is  found  difficult  to  immobilize  the 
parts,  the  most  satisfactory  result  is  obtained  by  the  application  of  the 
Velpeau  bandage,  which  is  to  be  overlaid  by  a  thin  plaster-of-Paris  bandage. 
If  the  fragments  cannot  be  coaptated,  sterilize  the  parts,  administer  ether, 
incise,  clear  away  the  muscle  from  between  the  fragments,  saw  the  ends, 
bore  each  end  and  hold  them  in  contact  bv  means  of  kangaroo-tendon  or 


Fractures  of  the  Body  of  the  Scai)ula  557 

silver  wire.  The  same  procedure  should  be  pursued  when  a  fracture  is 
compound  or  threatens  to  become  so,  or  if  signs  indicate  pressure  upon 
vessels  or  nerves.  If  a  large  vessel  has  been  injured,  the  operation  is  impera- 
tively necessary.  If  a  patient  suffering  under  a  fracture  which  threatens  to 
become  compound  refuses  the  aid  of  operation,  keep  him  in  bed  and  hold 
the  arm  in  abduction.  In  five  cases  in  the  Jefferson  Medical  College  Hospital 
the  author  wired  the  fragments  with  excellent  results.  Year  by  year  I  become 
more  inclined  to  recommend  wiring  in  cases  of  fractured  collar  bone.  It 
secures  union  without  deformity,  saves  the  vessels  and  nerves,  and  obviates 
the  necessity  of  prolonged  and  very  uncomfortable  fixation  of  the  arm  and 
forearm. 

After  a  broken  collar-bone  has  united,  if  the  shoulder  is  found  to  be  stiflf, 
make  passive  movements  daily;  if  these  fail,  move  the  joint  forcibly,  first  giv- 
ing ether  or  nitrous  oxid. 

Fractures  of  the  acromial  end  of  the  clavicle  are  due  to  direct  force. 
If  the  fracture  is  between  the  two  coracoclavicular  ligaments,  deformity  is  very 
slight,  crepitus  is  elicited  by  manipulating  with  the  fingers,  and  pain  exists,  but 
loss  of  function  is  not  markedly  manifest  vmless  it  is  due  to  pain.  These  frac- 
tures are  treated  by  interposing  cotton  between  the  arm  and  the  side,  binding 
the  arm  to  the  side  with  the  second  roller  of  Desault,  and  hanging  the  hand  in  a 
sling.  In  fractures  external  to  the  ligaments  crepitus  is  manifest  on  moving 
the  shoulder,  the  outline  of  the  bone  is  irregular,  severe  pain  is  developed  by 
movement,  and  deformity  is  pronounced.  The  deformity  is  due  to  the  ser- 
ratus  magnus  muscle  rotating  the  scapula  forward,  the  inner  end  of  the  outer 
fragment  of  the  clavicle  often  coming  in  contact  with  the  anterior  surface  of  the 
outer  portion  of  the  inner  fragment.  Fracture  of  the  acromial  end  of  the 
clavicle  is  reduced  by  pulling  both  of  the  shoulders  strongly  backward,  and  it  is 
kept  reduced  by  the  use  of  a  posterior  figure-of-eight  bandage.  In  fracture 
external  to  the  ligaments  the  displacement  frequently  cannot  be  corrected  by 
position  and  manipulation.  Such  cases  demand  incision  and  wiring.  In 
either  variety  of  fracture  the  dressings  are  worn  for  four  weeks. 

Fractures  of  the  sternal  end  of  the  clavicle  are  very  rare.  They  are 
caused  by  either  direct  or  indirect  force.  In  such  a  fracture  there  are  found 
crepitus,  projection  at  the  seat  of  fracture,  rigidity  of  the  sternocleidomastoid 
muscle,  and  shortening  of  the  clavicle.  The  inner  end  of  the  outer  fragment 
always  passes  forward,  and  often  also  downward  and  inward.  Reduce  these 
fractures  by  pulling  the  shoulders  back,  and  treat  them  by  means  of  the  poste- 
rior figure-of-eight  bandage  worn  for  four  weeks.     Wiring  may  be  necessary. 

Fractures  of  the  Scapula. — This  bone  is  not  often  broken,  as  it  rests  upon 
thick  muscles  and  elastic  ribs;  it  is  freely  movable,  and  it  has  attached  to  it  a 
bone  which  easily  breaks. 

Fractures  of  the  Body  of  the  Scapula. — These  are  due  to  direct  violence. 
The  symptoms  are  pain  (which  becomes  agonizing  on  attempting  to  rotate  the 
shoulder-blade),  ecchymosis,  and  swelling.  Crepitus  is  sought  for  by  placing 
the  hand  over  the  bone  and  making  movements  of  the  arm ;  also  by  holding  the 
point  of  the  shoulder  and  lifting  up  the  lower  angle  of  the  bone.  The  latter 
plan  may  develop  mobility.  The  spine  of  the  scapula  is  uneven  only  when  it 
is  itself  fractured.  Examine  for  unevenness  of  the  vertebral  border  of  the 
shoulder-blade.     In  fractures  of  the  body  of  the  scapula  a  shoulder-cap  is  ap- 


55^  Diseases  and  Injuries  of  Bones  and  Joints 

plied,  a  gutta-percha  splint  is  molded  over  the  scapula,  the  arm  is  bound  to 
the  side,  and  the  hand  is  carried  in  a  sUng.  The  apparatus  is  worn  for  four 
weeks. 

Fractures  of  the  spine  of  the  scapula  are  treated  as  are  fractures  of  the 
body  of  the  bone,  and  for  the  same  time. 

Fractures  of  the  Neck  of  the  Scapula. — Fracture  of  the  anatomical  neck 
has  not  been  proved  to  exist.  Fracture  of  the  surgical  neck  is  exinced  by  flat- 
tening of  the  shoulder,  prominence  of  the  acromion,  and  the  presence  of  a 
lump  in  the  axilla,  crepitus  being  developed  by  pressing  the  axillar}-  promi- 
nence upward  and  backward.  The  coracoid  process  descends  with  the 
humerus.  The  deformity  is  reduced  with  ease,  but  it  at  once  recurs.  The 
condition  is  treated  by  placing  a  pad  in  the  axilla,  a  shoulder-cap  on  the 
shoulder,  applying  the  second  roller  of  Desault,  and  supporting  the  forearm 
and  elbow  in  a  sling.  A  \'elpeau  dressing  can  be  used,  associated  with  the 
application  of  a  folded  towel  in  the  axilla.  The  dressing  is  to  be  worn  for 
five  weeks. 

Fractures  of  the  glenoid  cavity  are  not  very  unusual,  and  may  occur 
with  or  without  dislocation.  Fracture  of  this  region  arises  from  direct  force 
applied  to  the  shoulder.  The  existence  of  this  fracture  is  determined  by  ex- 
cluding fractures  of  other  bones  and  by  detecting  crepitus  when  the  arm  is  at  a 
right  angle  to  the  body  and  the  humerus  is  pushed  against  the  glenoid  cavity, 
the  crepitus  not  being  found  when  the  arm  hangs  by  the  side. 

Treatment  is  b}'  the  second  roller  of  Desault  and  a  forearm  sling  worn 
for  four  weeks;  careful  passive  movements  limit  ankylosis.  If  ankylosis 
occiu-s,  adhesions  must  be  broken  up  while  the  patient  is  under  ether  or 
nitrous  oxid. 

Fractures  of  the  acromion  process  are  often  met  with  as  the  result 
of  direct  violence.  The  existence  of  fracture  of  the  acromion  is  indicated 
by  pain,  by  inability  to  abduct  the  arm,  by  flattening  of  the  shoulder,  by 
sudden  lowering  of  the  point  of  the  shoulder,  by  mobility,  and  by  crepitus. 
To  treat  a  case  of  this  kind,  put  a  large  pad  in  the  axilla  with  the  base  down, 
bind  the  arm  over  the  pad  with  the  second  roller  of  Desault,  lifting  the  elbow 
with  turns  of  the  roller  carried  over  it  and  the  opposite  shoulder,  thus  spHnting 
the  bone  in  place  by  the  head  of  the  humerus  pushing  against  the  coraco- 
acromial  ligaments.     The  dressing  is  to  be  worn  for  four  weeks. 

Fractures  of  the  coracoid  process  rarely  happen  alone,  and  may  arise 
from  direct  force  or  from  muscular  action.  But  little  displacement  is  found. 
Crepitus  and  mobility  are  usually  detected.  Inability  to  shrug  the  shoulder 
inward  was  pointed  out  as  a  symptom  by  Byers.  Such  a  case  is  well  treated 
by  a  Velpeau  bandage,  which  is  to  be  worn  for  four  weeks. 

Fractures  of  the  humerus  are  divided  into  (i)  fractures  of  the  upper 
extremity;  (2)  fractures  of  the  shaft;  and  (3)  fractures  of  the  lower  extremity. 
In  examining  any  fracture  of  the  humerus,  feel  at  once  for  the  pulse,  so  as 
to  ascertain  if  the  artery  has  been  torn;  in  any  fracture  near  the  head  of 
the  humerus  be  certain  that  dislocation  does  not  exist. 

Examination  of  the  Shoulder. — In  some  cases  ether  must  be  administered. 
Compare  the  injured  shoulder  with  the  sound  shoulder,  the  patient,  if  not 
anesthetized,  being  seated  in  a  chair  or  stool.  The  direction  of  the  axis 
of  the  arm  is  noted.     The  surgeon  grasps  the  fle.xed  elbow  with  one  hand 


SPLINTS. 


Plate  6. 


I.  Fracture-box.  2.  Double  Inclined  Plane  Fracture-box.  3.  Jaw-cup  (unfolded).  4.  Jaw-cup 
(folded).  5.  Anterior  Angular  Splint.  6.  Internal  Angular  Splint.  7.  Bond  Splint.  8.  Shoulder-cap. 
9.  Dupuytren  Splint  in  Pott's  Fracture.  10.  Agnew  Splint  for  Fracture  of  the  Metacarpus.  11.  Agnew 
Splint  for  Fracture  of  the  Patella.  12.  Agnew  Splint  applied.  13.  Strapping  the  Chest  in  Fractured 
Ribs.  14.  Extension  Apparatus  in  Fracture  of  the  Femur.  15,  16.  Adhesive  Strips  for  Extension 
Apparatus. 


Fractures  of  the  Anatomical  Neck  of  the  Humerus  559 

and  the  shoulder  with  the  other;  he  thus  can  move  the  extremity  and  f)ali)ate 
the  joint  and  adjacent  points.  The  shoulder  is  moved  gently  in  every  direc- 
tion, and  the  surgeon  notes  if  the  head  of  the  bone  moves  with  the  shaft. 
Examination  shows  if  the  head  of  the  bone  is  in  place  or  if  the  glenoid  cavity 
is  vacant — if  the  head  of  the  bone  is  in  an  abnormal  situation,  if  it  is  altered 
in  contour,  if  there  is  crei)itus  or  preternatural  mobility,  and  if  any  movement 
is  impaired.  The  acromion  process,  outer  end  of  the  clavicle,  coracoid  process 
of  the  scapula,  and  neck  of  the  scapula  are  also  investigated.  The  length 
of  the  arm  is  obtained  by  measuring  from  the  apex  of  the  acromion  process 
of  the  scapula  to  the  a[)ex  of  the  external  condyle  of  the  humerus,  and  it  is 
compared  with  the  length  of  the  sound  extremity. 

T.  Fractures  of  the  upper  extremity  of  the  humerus  include  (a)  frac- 
tures of  the  anatomical  neck;  (/;)  fractures  of  the  surgical  neck;  (c)  fractures 
of  the  head,  oblique  and  longitudinal;  and  (d)  separation  of  the  upper 
epiphysis. 

Fractures  of  the  Anatomical  Neck  of  the  Humerus. — The  anatomical 
neck  is  the  constricted  circumference  of  the  articular  surface,  and  fractures 
of  it,  though  rare,  do  occur,  especially  in  the  aged.  The  line  of  fracture  in 
some  cases  follows  the  insertion  of  the  capsule,  in  others  it  is  entirely  within 
the  capsule,  but  in  most  it  is  without  the  capsule  above  and  within  the  capsule 
below;  hence  the  term  "intracapsular"  is  rarely  correct  as  a  designation. 
Such  a  fracture  may  be  impacted.  The  cause  is  direct  violence  or  a  fall 
or  a  blow  upon  the  elbow  when  the  arm  is  abducted.  Polloson.  of  Lyons,* 
has  reported  a  case  due  to  muscular  action.  The  patient  died  in  eclampsia, 
and  at  the  necropsy  it  was  found  that  both  humeral  heads  were  fractured  and 
impacted.  The  fractures  must  have  been  produced  by  the  muscles  throwing 
the  heads  of  the  bones  violently  against  the  glenoid  cavities,  probably  by 
adduction. 

Symptoms. — The  symptoms  in  fracture  of  the  anatomical  neck  are  pain, 
swelling,  ecchymosis,  slight  irregularity  of  the  shoulder  (which  irregularity 
is  soon  hidden  by  tumefaction),  and  inabihty  to  actively  abduct  the  arm. 
Deformity,  as  a  rule,  is  slight  or  is  absent,  because  the  capsule  is  rarely 
entirely  torn  from  the  lower  fragment.  If  deformity  exists,  it  is  due  to  the 
muscles  inserted  on  the  bicipital  groove  and  to  the  coracobrachialis,  which 
pull  the  lower  fragment  inward  and  forward.  Treves  says  that  a  tear  of 
the  reflected  fibers  of  the  capsule  leads  to  subsequent  necrosis,  because 
this  joint  has  no  Hgamentum  teres.  In  unimpacted  cases  there  is  crepitus, 
and  mobility  of  the  shaft  can  be  detected  near  the  head  of  the  bone.  In 
some  cases  impaction  occurs,  the  upper  fragment  impacting  into  the  lower. 
In  this  condition  there  are  very  slight  shortening  and  trivial  shoulder-flattening, 
no  crepitus  unless  the  tuberosity  is  broken  off,  no  mobility,  and,  as  Erichsen 
says,  the  head  of  the  bone,  while  it  can  be  felt  through  the  axilla,  is  not  in 
the  axis  of  ihe  limb. 

The  prognosis  of  fracture  of  the  anatomical  neck  is  usually  good  for  bony 
union  (Hamilton,  Pick,  and  R.  W.  Smith),  but  a  stiff  joint  is  apt  to  result. 

Treatment. — Feel  the  pulse  to  be  sure  the  artery  is  untorn.  In  most 
cases  an  anesthetic  should  be  given  in  order  to  examine  with  ease  and  dress 

*  Rev.  de  Chir.,  vol.  viii,  1888. 


560 


Diseases  and  Injuries  of  Bones  and  Joints 


with  satisfaction.  Sometimes  the  fragments  are  readily  coaptated;  occasion- 
ally they  are  not.  In  a  case  reported  by  Carl  Beck  the  axes  of  the  fragments 
were  at  right  angles  and  they  could  only  be  kept  in  contact  by  holding  the 
arm  at  a  right  angle  to  the  body  ("New  York  Med.  Jour.,"  April  5,  1902). 
Some  surgeons  treat  this  fracture  by  simply  hanging  the  wrist  in  a  sling 
and  suspending  a  bag  of  shot  from  the  elbow  to  make  extension.  The  usual 
plan  of  treatment  is  as  follows:  flex  the  arm  to  a  right  angle  with  the  body, 
and  carry  up  from  the  base  of  the  lingers  to  above  the  elbow  the  turns  of 


I'ig.  266.— Fracture  at  upper  end  of  the 
humerus.  Note  hand,  forearm,  and  elbow  ban- 
daged ;  axillary  pad  and  strap,  plaster-of-Paris 
shoulder-cap,  sling  (Scudder). 


Fig.  267. -Fracture  at  upper  end  of  the 
humerus.  Arm  and  elbow  bandaged.  Axillary 
pad  and  shoulder-cap  in  position.  Application 
of  circular  bandage  to  trunk  and  shoulder. 
Sling  not  shown  (Scudder). 


a  spiral  reversed  bandage  made  of  flannel.  Interpose  lint  between  the  arm 
and  .the  side,  and  place  a  V-shaped  pad  with  the  apex  upward  in  the  axilla, 
tying  the  tapes  over  the  opposite  shoulder.  A  .shoulder-cap  made  of  paste- 
board (PI.  6,  Fig.  8)  or  plaster-of-Paris  (Fig.  266),  moulded  to  fit  and  well 
lined  with  cotton,  is  applied.  The  plaster-of-Paris  cap  is  the  most  satisfactory. 
It  is  appUed  "so  as  to  cover  the  whole  shoulder,  the  anterior  and  posterior  as- 
pects of  the  chest  and  the  outer  side  of  the  upper  arm  down  to  the  external  con- 
dyle of  the  humerus"  (Scudder,  on  ''The  Treatment  of  Fractures")  (Fig. 
266) .  The  arm  with  the  shoulder-cap  is  fixed  to  the  side  by  the  second  roller 
of  Desault,  and  the  wrist  is  hung  in  a  sling  (Fig.  267).  The  edges  of  the 
bandage  should  be  stitched  together.  This  apparatus  is  changed  daily  for 
the  first  few  days,  the  body  and  arm  being  rubbed  at  each  change  with  alco- 
hol, soap  liniment  or  ethereal  soap.  After  this  period  a  change  every  third 
or  fourth  day  is  often  enough.  Massage  is  begun  at  the  end  of  one  week, 
but   rotation   and    motion  of   the  joint  are    not  employed   until  after  three 


Fractures  of  the  Surgical  Neck  of  the  Humerus 


561 


Fig.  268.— Internal  angular  splint 
and  shoulder-cap  in  fracture  of  the 
surgical  neck  of  the  humerus. 


weeks.  The  dressings  are  removed  at  the  end  of  four  weeks,  the  fore- 
arm being  carried  in  a  sling  for  two  weeks  more.  In  impacted  fracture 
do  not  pull  apart  the  impaction,  do  not  use  a  pad,  but  apply  a  cap  to  the 
shoulder  and  fix  the  arm  to  the  side  for  five  weeks.  The  fracture  unites 
with  deformity. 

Fractures  of  the  Surgical  Neck  of  the  Humerus.— The  surgical  neck 
is  the  constricted  portion  of  bone  between  the  tuberosities  and  the  upper 
line  of  the  insertion  of  the  muscles  on  the 
bicipital  groove.  Fractures  in  this  region  are 
usually  transverse,  but  they  may  be  oblique. 
The  causes  are:  direct  force  almost  always; 
indirect  force  occasionally;  and  muscular  ac- 
tion in  rare  instances. 

Symptoms. — The  symptoms  in  fracture  of 
the  surgical  neck  are:  pain  running  into  the 
fingers  from  pressure  upon  the  brachial  plexus; 
crepitus  and  mobihty  on  extension;  and  flat- 
tening, which  differs  from  the  flattening  of  dis- 
location in  that  it  occurs  farther  below  the 
acromion  and  that  this  process  is  not  so 
prominent.  Shortening  to  the  extent  of  an  inch 
is  noted.  The  head  of  the  bone  can  be  feU 
in  the  glenoid  cavity,  but  it  does  not  move  on 
rotating  the  arm.  The  upper  end  of  the  lower  fragment  is  felt  and  moves  on  ro- 
tating the  arm.  The  displacement  is  pronounced.  The  lower  fragment  is  pulled 
upward  by  the  deltoid,  biceps,  coracobrachialis,  and  triceps;  inward  by  the 
muscles  of  the  bicipital  groove;  and  forward  by  the  great  pectoral;  thus,  the 
upper  end  of  the  lower  fragment  projects  into  the  axilla,  and  the  elbow  lies 
from  the  side  and  backward.  Pean  holds  that  the  violence  drives  the  lower 
fragment  forward.  The  upper  fragment  is  abducted  and  rotated  outward, 
which  position  is  due,  it  is  generally  taught,  to  the  action  of  the  supraspinatus, 
infraspinatus,  and  teres  minor  muscles.  In  some  cases  displacement  is  for- 
ward, and  in  other  cases  it  is  not  obvious.  The  lower  fragment  may  impact 
into  the  upper,  in  which  case  the  symptoms  are  obscure  and  the  diagnosis 
is  made  by  exclusion.  If  the  impaction  is  solid  and  complete,  there  are 
the  history  of  direct  force,  the  impaired  movements,  the  slight  deformity, 
and  the  absence  of  crepitus.  In  all  fractures  of  the  upper  end  of  the  humerus 
the  distinction  can  be  made  from  dislocation  by  feeling  the  head  of  the  bone 
under  the  acromion  and  by  noting  that  it  does  not  move  on  rotating  the 
arm. 

The  prognosis  of  fracture  of  the  surgical  neck  of  the  bone  is  good. 

Treatment. — Some  surgeons  treat  a  fracture  of  the  surgical  neck  in  exactly 
the  same  manner  as  a  fracture  of  the  anatomical  neck.  We  prefer  the  fol- 
lowing plan:  In  many  cases  give  ether  in  order  to  examine  and  dress.  Feel 
the  pulse  to  see  that  the  artery  has  not  been  damaged.  Reduce  by  traction 
and  manipulation;  if  there  is  an  impaction,  pull  it  apart.  Take  an  internal 
angular  splint  (PI.  6,  Fig.  6)  and  pad  it  well,  putting  on  extra  padding 
at  the  points  that  are  to  rest  against  the  palm,  the  inner  condyle,  and 
36 


562 


Diseases  and  Injuries  of  Bones  and  Joints 


the  axillary  folds.  Lay  the  arm  and  pronated  forearm  upon  the  splint. 
Apply  a  padded  shoulder-cap.  Fix  the  splint  and  cap  in  place  with  a  spiral 
reversed  bandage  terminating  as  a  spica  of  the  shoulder,  and  hang  the  hand 
or  forearm  in  a  sling  (Fig.  268)  The  dressing  is  to  be  worn  for  four  weeks, 
and  the  rules  to  be  followed  in  changing  it  are  the  same  as  in  fracture  of 
the  anatomical  neck.  Massage  is  used  after  one  week  and  passive  motion 
after  four  weeks  to  amend  stiffness.  In  rare  cases — those  with  strong  ante- 
rior projection  of  the  lower  end  of  the  upper  fragment — apply  an  anterior 
angular  splint.  In  some  cases  where  the  deformity  strongly  tends  to  recur 
support  by  a  plaster-of-Paris  trough  on  the  back  and  sides  of  the  arm  and 
shoulder  (Fig.  269),  or  maintain  extension  by  weights  and  pulleys,  the  padent 

being  kept  in  bed  (Sdmson) .  I  have 
reached  the  conclusion  that  many 
cases  of  fracture  of  the  surgical  neck 
are  best  treated  by  incision  and  fixa- 
tion. 

Longitudinal  and  Oblique 
Fractures  of  the  Head  of  the 
Hvunerus. — By  this  term  may  be 
designated  separadon  of  the  great 
tuberosity  or  separation  of  a  por- 
don  of  the  articular  surface,  together 
with  the  great  tuberosity,  from  the 
shaft  and  lesser  tuberosity  (Pickering 
Pick,  Guthrie,  and  Ogston).  The 
cause  is  usually  direct  violence  to  the 
front  of  the  shoulder,  but  the  greater 
tuberosity  may  be  torn  off  by  mus- 
cular action. 

Symptoms.  —  The  symptoms  in 
longitudinal  and  oblique  fracture  of 
the  head  are  broadening  and  flatten- 
ing of  the  shoulder  with  projection  of 
the  acromion.  The  upper  fragment  passes  upward  and  outward,  and  the  lower 
fragment  passes  upward  and  inward  to  rest  on  the  margin  of  the  glenoid 
cavity  below  the  coracoid  process.  The  elbow  is  drawn  from  the  side,  there 
is  some  shortening,  and  the  patient  cannot  abduct  his  arm.  If  the  surgeon 
grasps  the  patient's  elbow  and  holds  it  to  the  side  and  rotates  the  arm  while 
with  his  other  hand  he  grasps  the  upper  fragment,  crepitus  is  very  positive. 
Kxamination  develops  wide  separation  of  the  fragments.  The  deformity 
cannot  be  entirely  corrected,  because  the  biceps  tendon  usually  gets  between 
the  fragments  (Ogston),  but  a  useful  hmb  can  usually  be  obtained. 

Treatment. — The  plan  which  gives  the  best  result  in  treating  longitudinal 
and  obUque  fracture  of  the  head  of  the  bone  is  to  place  the  patient  on  his 
back  upon  a  hard  bed  with  a  small,  firm  pillow  under  his  head,  abduct  the 
arm  above  the  head,  rotate  it  outward  so  that  the  back  of  the  hand  rests 
on  the  bed,  and  hold  it  in  place  by  sand-bags.  This  position  should  be 
maintained  for  three  weeks,  at  the  end  of  which  period  the  fracture  can 


Fig.  269. — Apparatus  for  fracture  of  the  hume- 
rus at  any  point  above  the  condyles. 


Fractures  of  the  Shaft  of  the  Humerus  563 

be  treated  for  three  weeks  more  as  is  a  fracture  of  the  anatomical  neck.  If 
the  patient  refuses  to  go  to  bed,  treat  the  injury  as  a  fracture  of  the  ana^ 
tomical  neck,  padding  well  over  the  tuberosities.  The  dressings  should  be 
worn  for  five  weeks,  passive  motion  being  made  after  four  weeks.  In  the 
above  injury  feel  at  once  for  the  pulse,  to  see  if  the  artery  has  been  torn. 

Separation  of  the  Upper  Epiphysis  of  the  Humerus. — The  epiphysis 
is  united  during  the  twentieth  year.  Separation  is  a  rare  accident  and  is 
produced  by  direct  force. 

Sytnploms. — The  chief  symptom  in  separation  of  the  upper  epiphysis  is 
projection  of  the  upper  end  of  the  lower  fragment  inward,  forward,  and 
upward  beneath  the  coracoid,  and  consequently  a  projection  of  the  elbow 
backward  and  from  the  side.  If  the  lower  fragment  passes  forward  and 
not  inward,  the  elbow  simply  passes  back.  The  upper  end  of  the  lower 
fragment  is  smooth  and  convex.  Rotation  of  the  shaft  develops  soft  cr.epitus 
when  the  fragments  are  in  contact. 

The  prognosis  is  good  for  bony  union,  though  "the  future  growth  of  the 
limb  may  be  impaired. 

Treatment. — The  treatment  for  separation  of  the  upper  epiphysis  is  a 
pad  in  the  axilla,  a  shoulder-cap,  binding  the  arm  to  the  side,  and  hanging 
the  hand  in  a  sling.  Wear  the  dressing  for  four  weeks,  and  begin  pas- 
sive motion  as  directed  when  deahng  with  fracture  of  the  upper  end  of  the 
humerus. 

2.  Fractures  of  the  Shaft  of  the  Humerus. — Fracture  of  the  shaft 
of  the  humerus  is  a  very  common  accident.  The  cause  is  usually  direct 
violence,  such  as  a  blow.  The  fracture  may  arise  from  indirect  violence, 
such  as  a  fall  upon  the  elbow.  Muscular  action  is  not  rarely  also  a  cause, 
as  in  throwing  a  ball,  in  catching  a  tree-Hmb  while  falling,  or  in  turning 
another's  wrist  outward  as  a  test  of  strength  (Treves).  This  test  of  strength 
is  known  by  the  French  as  "le  tour  de  poignet." 

The  opponents  sit  opposite  to  each  other  and  each  rests  his  elbow  on  a  table. 
They  clasp  hands  and  each  one  strives  to  rotate  the  other's  hand  outward. 
Ashhurst  collected  57  cases  due  to  throwing  a  ball  and  23  cases  due  to  "le 
tour  de  poignet."  He  beheves  that  in  some  cases  the  humerus  is  broken  as  a 
stick  may  be  broken  by  holding  one  end  and  swinging  the  other  through  the  air 
and  that  in  other  cases  fracture  results  from  twisting  (Astley  P.  C.  Ashhurst, 
in  "University  of  Penn.  Med.  Bulletin,"  Feb.,  1906).  In  fracture  due  to 
muscular  action  the  break  is  nearly  always  below  the  deltoid  insertion  and  the 
Hne  of  fracture  approaches  the  transverse. 

The  symptoms  of  fracture  of  the  shaft  of  the  humerus  are  pain,  swelling, 
ecchymosis,  inability  to  move  the  arm,  mobility,  and  distinct  crepitus.  Short- 
ening to  the  extent  of  three-fourths  of  an  inch  occurs.  The  displacement 
varies  with  the  situation  of  the  fracture  and  the  direction  of  the  force.  If 
the  fracture  is  above  the  insertion  of  the  deltoid,  the  lower  fragment  is  pulled 
up  by  the  triceps,  biceps,  and  deltoid,  and  pulled  out  by  the  deltoid,  and 
the  upper  fragment  is  pulled  inward  by  the  arm-pit  muscle.  In  fracture 
below  the  deltoid  this  muscle  is  apt  to  pull  the  lower  end  of  the  upper  frag- 
ment outward,  while  the  lower  fragment  passes  inward  and  upward  because 
of  the  action  of  the  biceps  and  triceps.     Injury  of  the  musculospiral  nerve 


564 


Diseases  and  Injuries  of  Bones  and  Joints 


sometimes  occurs.     The  nerve  may  be  contused,  producing  pain  at  the  seat 
of  bruising,  and  tingling  and  numbness  in  the  region  supplied  by  the  nerve. 


Fig.  270. — Fracture  of  the  shaft  of  the  humerus.     Note  bandage  to  hand,  forearm,  and  elbow  ;  axillary 
pad  and  strap  ;  coaptation  splints  and  sling.    Bandage  does  not  cover  fracture  (Scudder). 


Fig.  271."— Fracture  of  the  shaft  of  the  humerus.    Note  bandage  to  hand,  forearm,  and  elbow  ;  adhesive- 
plaster  swathe  holding  arm  upon  axillary  pad  and  covering  coaptation  splints.     Sling  (Scudder). 


In  most  cases  the  symptoms  soon  pass  away,  but  sometimes  neuritis  ensues. 
A  severe  contusion  produces  not  only  pain,  but  paralysis  of  the  muscles 


Fractures  of  the  Shaft  of  the  Humerus  565 

supplied  by  the  nerve,  and  surface  anesthesia.  In  most  cases  this  condition 
is  recovered  from  in  a  few  weeks,  but  sometimes  it  hists  a  long  while  or  even 
permanently.  In  musculospiral  paralysis  the  patient  is  unable  to  extend 
the  wrist  and  fingers  or  to  supinate  the  forearm.  There  is  "  complete  loss 
or  impaired  sensation  in  the  lower  half  of  the  outer  and  anterior  aspect  of 
the  arm  and  in  the  middle  of  the  back  of  the  forearm  as  far  as  the  wrist" 
(Scudder,  in  "The  Treatment  of  Fractures").  The  nerve  may  be  divided 
by  a  sharp  fragment,  paralysis  of  motion  and  anesthesia  resulting  at  once. 
In  some  cases  the  nerve  is  caught  in  and  compressed  by  callus,  scar-tissue, 
or  fragments,  motor  and  sensory  disturbances  resulting. 

The  prognosis  is  good,  but  the  fact  should  always  be  remembered  that 
ununited  fractures  are  commoner  in  the  humerus  than  in  any  other  bone. 
Treves  believes  this  to  be  due  to  entanglement  of  muscle  between  the  frag- 
ments, lack  of  fixation  of  the  shoulder-joint,  and  imperfect  elbow-support. 
Hamilton  believes  that  it  is  due  to  the  facts  that  the  elbow  soon  becomes 
fixed  at  a  right  angle,  and  that  any  movement  of  the  forearm  moves  the  seat  of 
fracture  and  not  the  elbow. 

Treatment. — It  is  rarely  necessary  to  anesthetize  unless  the  patient  be  a 
nervous  woman  or  an  excitable  child.  Feel  the  pulse,  to  be  certain  the  artery 
has  not  been  lacerated.  Reduce  the  fracture  by 
extension,  counterextension,  and  manipulation. 
Apply  four  humeral  splints.  The  internal 
splint  reaches  from  the  axilla  to  just  above  the 
internal  condyle  of  the  humerus.  A  short 
straight  sphnt  is  appHed  front  and  another 
back,  each  being  the  length  of  the  arm.  A 
shoulder  cap  is  applied,  which  cap  "is  prolonged 
below  into  an  external  angular  sphnt  reaching 
as  far  down  as  the  lower  third  of  the  forearm" 
("Manual  of  Surgical  Treatment,"  by  Cheyne 
and  Burghard).  The  elbow  is  brought  to  a 
right  angle  with  the  arm  and  the  forearm  is 
placed  midway  between  pronation  and  supi- 
nation.    As  Cheyne  and  Burghard  say:     "It  is        Fig.272.— Preliminary  splinting 

, ,     ,  , ,  u       1  1  u  <_•      II       i     for  complete  dressing  as  shown  in 

necessary  that  the  arm  should  hang  vertically  at      .         '^ 
the  side  with  the  long  axis  of  the  forearm  parallel 

with  the  anteroposterior  diameter  of  the  trunk;  if  the  forearm  be  brought  at  all 
forward  across  the  chest,  rotation  of  the  lower  fragment  upon  its  vertical  axis  is 
apt  to  take  place."  Sphnts  are  to  be  worn  for  five  or  six  weeks,  and  after  the 
removal  of  the  sphnts  the  wrist  is  hung  in  a  sHng.  The  sHng  is  dispensed  with 
eight  weeks  after  the  infliction  of  the  injury.  Passive  movements  are  not  to  be 
made  until  the  fracture  is  well  united  (after  five  or  six  w-eeks),  for,  if  made  too 
soon,  they  predispose  to  non-union,  and,  as  no  joint  is  involved,  genuine  an- 
kylosis will  not  occur.  Many  surgeons  treat  these  fractures  by  applying  plaster 
of  Paris  to  the  forearm  and  the  arm  (the  elbow  being  flexed  to  a  right  angle), 
binding  the  arm  to  the  side,  and  hanging  the  WTist  in  a  shng.  Others  apply  a 
trough  to  the  arm  and  forearm  (Fig.  269).  Scudder  prefers  to  bandage  the 
hand,  forearm,  and  elbow,  and  apply  an  axillary  pad,  coaptation  splints,  a 
swathe  of  adhesive  plaster  holding  arm  to  the  side,  and  a  shng  (Figs,  270,  271). 
In  any  case  in  which  is  is  impossible  to  obtain  and  maintain  correct  apposition 


566  Diseases  and  Injuries  of  Bones  and  Joints 

of  the  fragments,  cut  down  upon  them,  and  apply  sutures.  If  the  nerve  is 
divided,  an  incision  must  be  made,  and  the  nerve  sutured  and  the  bone  wired. 
If  the  nerve  is  caught  in  the  callus,  after  repair  has  taken  place  the  nerve 
must  be  liberated  by  chiseling  the  callus  away.  Neuritis  is  treated  by  blisters 
over  the  nerve,  the  use  of  the  descending  galvanic  current,  and  the  administra- 
tion of  sahcylate  of  ammonium  and  the  bromids. 

3.  Fractures  of  the  Lower  Extremity  of  the  Humerus. — These  frac- 
tures are  spoken  of  as  fractures  in,  or  in  the  neighborhood  of,  the  elbow- 
joint,  and  they  include  (a)  fractures  of  the  external  condyle;  (b)  fractures  of 
the  internal  condyle;  (c)  fractures  of  the  internal  epicondyle;  (d)  fractures 
at  the  base  of  the  condyles;  (e)  T-  or  Y-shaped  fractures;  (/)  epiphyseal  sepa- 
ration; and  (g)  fractures  of  the  capitellum  and  trochlea.  There  may  be  more 
than  one  fracture,  or  there  may  be  also  a  dislocation  of  the  humerus,  of  the 
ulna,  or  of  both  bones.  Rarely  the  fracture  is  compound.  These  fractures 
are  frequent  injuries  in  childhood,  and  are  not  uncommon  in  adults. 

Method  0}  Examination. — A  fracture  of  the  elbow  is  rapidly  followed  by 
great  swelling,  and  the  diagnosis  is  often  very  difficult.  In  most  cases,  when 
possible,  the  .T-rays  should  be  used  in  arriving  at  a  diagnosis.  In  every  case 
in  which  the  x-rays  are  not  used,  and  in  most  cases  in  which  they  are,  the  sur- 
geon examines  the  parts  carefully  while  the  patient  is  under  ether.  If  swelling 
is  very  great,  it  is  necessary  to  abate  it  in  order  to  reach  any  conclusion  as  to  the 
condition.  We  can  bandage  the  arm,  rest  it  semiflexed  on  a  pillow,  and  apply 
evaporating  lotions  or  even  an  ice-bag  for  a  day  or  two,  or,  what  is  better,  tem- 
porarily diminish  the  swelling  by  Gerster's  plan,  which  is  as  follows:  Apply  an 
Esmarch  bandage  from  the  hand  to  well  above  the  seat  of  fracture ;  this  will 
drive  away  extra-articular  swelling  and  permit  of  thorough  examination.  It 
is  a  great  advantage  to  have  the  patient  anesthetized,  for  then  not  only  can 
we  make  an  accurate  diagnosis,  but  we  can  reduce  the  fracture  satisfactorily 
and  apply  a  careful  first  dressing. 

Compare  the  injured  with  the  sound  elbow.  Note  swelling  and  local 
ecchymosis.  Feel  the  radial  pulse.  Note  the  "carrying  angle  "  (Fig. 
274).  Measure  each  arm  from  the  tip  of  the  acromion  process  of 
the  scapula  to  the  tip  of  the  external  condyle  of  the  humerus.  Feel  each 
prominent  body-point  and  note  if  it  is  mobile  (condyles,  olecranon,  head 
of  ulna).  Feel  the  shaft  just  above  the  condyles.  Mark  with  ink  on  each 
elbow  the  tip  of  the  external  condyle,  the  tip  of  the  internal  condyle,  and 
the  tip  of  the  olecranon,  and  observe  the  relation  between  these  points  of 
each  elbow  in  flexion  and  in  extension.  In  an  uninjured  elbow  a  straight 
line  transverse  to  the  long  axis  of  the  limb  with  the  joint  in  extension  will 
pass  through  the  condyles  and  leave  the  tip  of  the  olecranon  just  a  shade 
above  it.  "  When  the  elbow  is  at  a  right  angle,  these  three  points  will  be 
found  in  the  same  plane  with  the  back  of  the  upper  arm"  (Scudder,  in  "The 
Treatment  of  Fractures").  Rotate  the  radius  while  a  thumb  is  held  against 
the  head  of  the  bone.  Make  flexion  and  extension  of  the  elbow  and  determine 
if  there  is  any  lateral  motion.  Test  for  mobility  just  above  the  condyles. 
The  above  maneuvers  will  determine  the  presence  or  absence  of  crepitus, 
preternatural  mobility,  deformity,  etc. 

Fractures  of  the  External  Condyle  of  the  Humerus.— A  fracture  of 
the  external  condyle  runs  into  the  joint  and  the  capitellum  is  usually  broken 


Fractures  of  the  Internal  Condyle  of  the  Humerus  567 

off.  Such  an  injury  occurs  oftenest  in  children,  being  due  to  falling  on 
the  hand;  but  it  may  occur  from  direct  force,  and  may  happen  to  adults. 

Symptoms. — The  symptoms  of  fracture  of  the  external  condyle  are  severe 
pain,  great  swelling,  and  crepitus  (found  on  pressing  or  moving  the  condyle 
and  on  rotating  the  radius).  MobiHty  may  also  be  discovered.  A  projection 
is  felt  on  the  outer  and  posterior  surface  of  the  elbow.  The  forearm  is  semi- 
flexed and  supinated.     The  i)atient  cannot  use  the  joint. 

Fractures  of  the  Inner  Epicondyle  of  the  Humerus.— The  inner 
epicondyle  is  an  epiphysis  which  unites  during  the  seventeenth  year.  It  not 
infrequently  breaks  from  muscular  action  or  from  direct  violence,  and  the 
fracture  does  not  involve  the  joint.  Cre[)itus  and  mobility  can  be  detected. 
Displacement  is  slight.     The  outer  epicondyle  is  never  fractured  alone. 

Fractures  of  the  Internal  Condyle  of  the  Humerus,— The  hne  of 
fracture  after  a  break  of  the  internal  condyle  runs  into  the  joint,  to  the  troch- 
lear surface  of  the  humerus.  The  cause  is  nearly  always  direct  violence.  Pack- 
ard, of  Philadelphia,  observed  a  case  in  which  the  condyle  had  been  torn  off 
while  Hfdng  a  tub. 

Symptoms. — In  fracture  of  the  internal  condyle  the  fragment,  accompanied 
by  the  ulna,  goes  upward  and  backward,  and  when  the  forearm  is  extended 


Fig.  273. — Loss  of  carrying  luiiLlioii  after  fracture  of  inner  condyle  of  the  humerus. 

the  ulna  projects  posteriorly,  the  lower  end  of  the  humerus  being  felt  in 
front.  The  fragment  forms  a  projection  back  of  the  elbow.  Crepitus  and 
preternatural  mobility  can  be  found  if  swelling  is  not  too  great.  Crepitus 
is  detected  by  flexing  and  extending  the  forearm.  The  space  between  the 
condyles  is  broader  than  normal,  and  the  forearm  takes  a  bend  toward  the 
ulnar  side,  the  "carrying  funcdon  "  of  the  forearm  being  lost  (Fig.  273). 
When  a  person  carries  a  heavy  object,  such  as  a  bucket,  he  instinctively  rests 


568 


Diseases  and  Injuries  of  Bones  and  Joints 


the  inner  condyle  upon  the  pelvis,  and  the  normal  deviation  of  the  forearm  out- 
ward keeps  the  bucket  from  striking  the  leg.  This  deviation  outward  when 
the  inner  condyle  rests  against  the  ilium  gives  us  the  carrying  function.  In 
fracture  of  the  inner  condyle  the  broken  condyle  ascends  and  the  '-carrying 
function"  is  lost  (Fig.  274). 

Fractures  at  the  Base  of  the  Condyles  of  the  Humerus. — A  fracture  in 
this  region  is  just  above  the  olecranon  and  is  on  a  higher  level  behind  than  in 
front.     The  cause  is  direct  force  acting  upon  the  olecranon. 

The  symptoms  are  loss  of  function  and  pain  from  injury  of  the  median  or 
ulnar  nerve.  Crepitus  and  mobility  are  readily  found.  The  lower  fragment  is 
drawn  backward  and  upward  by  the  action  of  the  triceps,  biceps,  and  brachiajis 
anticus  muscles.  The  lower  end  of  the  upper  fragment  projects  in  front  of 
the  joint.  This  lesion  may  be  mistaken  for  dislocation  of  the  bones  of  the 
forearm  backward.  In  fracture  the  limb  is  mobile;  in  dislocation  it  is  rigid. 
In  fracture  the  deformity  is  easily  reduced  and  strongly  tends  to  recur;  ir 


Fig.  274.— Diagram  to  exhibit  the  "  carrying  function  "  of  the  forearm,  and  the  loss  of  this  func- 
tion in  fracture  of  the  inner  condyle  of  the  humerus  :  a  and  b  show  the  normal  relation  of  the  parts 
when  carrying ;  c  shows  the  alteration  of  axis  of  the  forearm  when  the  inner  condyle  is  fractured, 
what  is  known  as  gunstock  deformity  resulting  (after  AUis). 

dislocation  the  deformity  is  reduced  with  difficulty  and  does  not  tend  to  recur. 
In  dislocation  there  is  shortening  of  the  forearm,  but  not  of  the  arm;  in  fracture 
there  is  shortening  of  the  arm  but  not  of  the  forearm.  In  dislocation  there 
is  a  smooth,  large  projection  below  the  crease  in  front  of  the  elbow;  in  fracture 
there  is  a  sharp  projection  above  the  crease.  In  fracture  there  is  crepitus; 
in  dislocation  there  is  no  crepitus. 

The  diagnosis  can  usually  be  settled  by  the  Rontgen  rays. 


Treatment  of  Fractures  In  or  Near  the  Elbow-joint  560 

T-fractures  of  the  Humerus. — A  T-fracture  consists  of  a  transverse 
fracture  above  the  condyles  [)lus  a  vertical  fracture  l)etween  them.  The 
cause  is  violent  direct  force  applied  posteriorly. 

Symptoms. — The  symptoms  are  increase  in  breadth  of  the  joint  (Fig. 
275),  preternatural  mobility,  crepitus,  pain  and  swelling,  mounting  up  of  the 
inner  condyle  back  of  the  elbow  on  the  inner  side,  and  of  the  outer  condyle 
back  of  the  elbow  on  the  outer  side.  The  forearm  is  semiflexed  and  supin- 
ated,  and  the  carrying  function  is  lost. 

Prognosis  of  Fractures  in  or  near  the  Elbow-joint. — In  many  fractures 
it  is  difficult  or  impossible  to  obtain  reduction,  and  in  some  it  is  impossible  to 
maintain  reduction.  Stimson  is  undoubtedly  right  when  he  says  that  "in 
intercondyloid  fracture  with  marked  separation  there  is  no  practicable  means 
merely  to  maintain  reduction."*  The  prognosis  for  complete  restoration  of 
function  is  bad,  and  in  most  of  these  fractures  some  deformity  and  considerable 
stiffness  are  inevitable.  Ankylosis  partial  or  complete  is  a  not  unusual  se- 
quence. Ankylosis  may  result  from  prolonged  immobilization,  the  muscles  con- 
tracting and  becoming  fibrous,  the  fascia  and  ligaments  about  the  joint  short- 
ening, the  capsule  shrinking  and  thickening,  some  of  the  cartilages  becoming 


Fig-  275.— Deformity  following  fracture  of  the  humerus  between  the  condyles. 

fibrous,  and  the  joint  being  partly  obliterated.  It  may  result  from  extravasa- 
tion of  blood  into  the  joint  and  tendon-sheaths  with  subsequent  formation  of 
fibrous  tissue.  It  may  arise  from  organization  of  inflammatory  exudate  within 
and  about  the  joint  and  in  the  sheaths  of  muscles  and  tendons.  It  may  arise 
from  the  formation  of  an  excess  of  callus.  Bruns  claims  that  in  fracture  in  the 
joint  excess  of  callus  rarely  forms,  and  that  masses  of  callus  form  chiefly  in  the 
line  of  fracture  near  but  not  in  a  joint. f  Excessive  callus-formation  is  sure  to 
take  place  if  reduction  is  not  thoroughly  accomplished  or  if  the  fragments  are 
not  well  immobilized  but  move  upon  each  other.  A  mass  of  callus  in  or  about 
a  joint  Hmits  or  prevents  motion. 

Treatment  of  Fractures  In  or  Near  the  Elbow-joint.— Thoroughly  set 

*  Transactions  American  Surgical  Association,  vol.  ix. 
fMax  Oberst,  in  Volkmann's  "  Sammlung  Vortrage." 


570  Diseases  and  Injuries  of  Bones  and  Joints 

the  fracture  while  the  patient  is  under  ether.  It  is  advisable,  when  it  can  be 
done  conveniently,  to  use  the  ^vr-rays  to  confirm  the  diagnosis  and  to  use  them 
again  after  dressings  have  been  applied,  to  be  sure  that  the  bones  remain  in 
good  position.  If  swelling  is  very  great,  it  may  be  necessary  to  delay  setting  for 
two  or  even  three  days,  the  arm  being  bandaged  and  laid  upon  a  pillow  or 
lightly  supported  on  an  anterior  angular  splint  during  the  waiting  period. 

In  all  cases  except  transverse  fracture  above  the  condyles  reduction  is  best 
effected  by  drawing  upon  the  forearm,  supinating  it,  extending  it,  and  then 
bending  it  slowly  into  a  position  of  acute  flexion,  the  degree  of  flexion  being  in 
inverse  ratio  to  the  amount  of  swelling. 

In  transverse  fracture  above  the  condyles  reduction  is  effected  by  drawing 
the  forearm  and  the  lower  fragment  downward  and  forward  and  at  the  same 
time  pushing  the  upper  fragment  back. 

Some  surgeons  advocate  dressing  the  fracture  on  an  anterior  angular  splint, 
the  forearm  being  fully  supinated.     The  advantage  claimed  for  this  sphnt  is 

that  if  ankylosis  occurs  the  joint  is  in  a 
position  to  be  useful,  which  it  is  not  if 
ankylosed  in  extension.  Some  deform- 
ity is  usually  apparent  after  treating  a 
case  with  this  splint;  the  deformity  fol- 
lowing fracture  of  the  inner  condyle  is 
not  corrected  by  it,  but  if  the  splint  is 
carefully  applied  the  result  is  usually  a 
useful  extremity  in  aU  cases  except 
fracture  of  the  inner  condyle.  In  trans- 
verse fracture  of  the  shaft  of  the  hu- 
merus above  the  condyles  the  anterior 
angular  sphnt  is  the  best  method  of 
Fig.  276.-.-\nterior  angular  spHnt  for  frac       treatment,  as  it  prevents  displacement. 

tures  in  or  near  the  elbow-joinl.  ^         ^   i  r    j       u 

The  sphnt  must  not  be  apphed  when 
there  is  great  swelling,  and  swelling  must  be  removed  by  resting  the  ex- 
tremity on  a  pillow,  the  elbow  being  semiflexed,  applying  evaporating 
lotions  or  even  an  ice-bag,  employing  massage,  and  gently  compressing 
by  bandaging.  In  some  cases  the  joint  should  be  aspirated.  In  order  to 
apply  this  dressing,  take  a  right-angled  splint  and  pad  its  outer  surface,  being 
careful  to  place  thick,  soft  pads  over  the  convexity  which  will  press  in  front  of 
the  elbow  and  over  each  end  of  the  sphnt.  Fasten  the  upper  end  to  the  arm, 
then  make  extension  of  the  forearm,  and  if  the  fracture  is  found  to  be  well  re- 
duced, fasten  the  hand  and  forearm  to  the  splint  (Fig.  276J.  If  the  hand  and 
forearm  are  first  fixed  to  the  sphnt,  there  will  be  no  extension  from  the  elbow 
and  deformity  will  result.  If  posterior  projection  exists,  a  pasteboard  cup  is 
moulded  over  the  elbow.  The  extremity  is  hung  in  a  triangular  sling.  At 
night  the  extremity  is  kept  in  the  sling  or  laid  on  a  pillow.  Every  third  or 
fourth  day,  while  the  extremity  is  carefully  steadied,  the  splint  is  removed,  the 
arm  and  forearm  well  rubbed  with  alcohol,  massaged,  and  the  aplint  reapplied. 
The  splint  is  worn  between  five  and  six  weeks.  At  the  end  of  the  third  week, 
after  removing  the  dressings,  slightly  flex,  slightly  extend,  and  slightly  pronate 
the  forearm,  and  reapply  the  splint.  At  the  end  of  the  fourth  week  repeat 
this  maneuver,  making  movements  of  greater  range.  In  the  middle  of  the 
fifth  week  and  at  the  end  of  the  fifth  week  do  it  again,  and  flex  and  extend 


Treatment  of  Fractures  In  or  Near  the  Elbow-joint 


571 


as  much  as  possible.  Very  early  and  very  frequent  passive  motion  is  objec- 
tionable, as  it  leads  to  overproduction  of  callus  and  ankylosis,  but  passive 
motion  as  above  described  is  imperatively  necessary.  Many  surgeons  at  the 
end  of  the  second  week  apply  a  Stromeyer  splint,  which  permits  the  patient 
and  the  surgeon  to  make  some  motion  by  means  of  the  screw  without  re- 
moving the  dressings.  In  very  stout  people  an  anterior  angular  splint  will  not 
stay  in  place.  In  such  a  case  the  forearm  may  be  placed  at  a  right  angle  to  the 
arm  and  plaster-of-Paris  be  used.  After  the  dressings  are  removed  employ 
passive  motion,  massage,  hot  and  cold  douches,  inunctions  of  ichthyol  or  mer- 
curial ointment,  iodin  locally,  corrosive  sublimate  and  iodid  of  potassium  in- 
ternally, and  direct  the  patient  to  systematically  use  the  arm.  If  in  any  case 
after  four  weeks  non-union  exists,  put  up  the  arm  in  a  plaster  splint  for  three 
or  four  weeks  more.  Some  surgeons  use  a 
posterior  right-angled  trough  instead  of  an  an- 
terior angular  spHnt  (Fig.  269). 

AUis  warmly  advocates  treatment  in  exten- 
sion. He  holds  that  the  extended  position  secures 
the  best  circulation,  and  if  either  condyle  is  un- 
broken secures  the  benefit  derivable  from  a 
natural  splint.  Furthermore,  in  fractures  of 
the  inner  condyle,  it  restores  the  carrving  func- 
tion, which  the  flexed  position  does  not  do.  For 
one  week  after  the  accident  the  patient  stays 
in  bed.  with  his  arm  extended  upon  a  pillow. 
After  swelling  subsides  the  limb  is  wrapped 
firmly  in  a  spiral  flannel  bandage  and  plaster 
is  rubbed  in  or  the  bandage  is  covered  with 
adhesive  plaster. 

Some  surgeons  extend  the  limb  and  apply  an 
ordinarv'  plaster  bandage,  and  in  about  three 
weeks  substitute  an  anterior  angular  sphnt. 
The  trouble  with  treatment  in  extension  is  that 
if  ankylosis  ensues  the  hmb  is  nearly  useless, 
extension  requires  confinement  to  bed. 

Jones,  of  Liverpool,  thinks  that  spHnts  and  bandages  are  largely  responsi- 
ble for  the  stiffness  which  so  commonly  ensues  upon  an  elbow  injury.  He  ad- 
vocates treatment  by  acute  flexion  in  all  elbow  injuries  except  fracture  of  the 
olecranon.  It  has  been  demonstrated  that  the  position  of  acute  flexion  forces 
the  fragments  into  place  and  holds  them  firmly  between  the  coronoid  process  of 
the  ulna,  the  trochlear  surface  of  the  ulna,  the  fascia,  and  the  triceps  tendon. 
The  surgeon  must  be  certain  that  the  radial  pulse  is  perceptible  ajter  the 
elbow  has  been  flexed.  Flexion  is  maintained  by  fastening  a  bandage  around 
the  wrist  and  neck.  The  bandage  around  the  neck  passes  through  a  rubber 
tube,  which  serves  to  protect  the  neck.  The  ball  of  the  thumb  should  rest 
against  the  neck.  The  bandage  is  fastened  to  a  leather  band  around  the 
wrist.  The  most  convenient  dressing  to  maintain  Jones's  position  was  de- 
vised by  Frazier;  it  is  shown  in  Fig.  277. 

After  the  dressing  has  been  appUed  certain  precautions  are  to  be  observed. 
For  the  first  week  or  ten  days  look  at  the  arm  daily.  If  the  swelhng  grows 
worse,  diminish  the  degree  of  flexion,  and  do  the  same  if  there  is  severe  pain. 


Fig.  277. — Frdzicr's  modifi- 
cation of  Jones's  dressing  for 
injuries  of  the  elbow-Joint. 

Furthermore,  treatment  by 


572  Diseases  and  Injuries  of  Bones  and  Joints 

If  the  radial  pulse  disappears,  diminish  the  flexion  until  free  circulation  is 
obtained.  This  posidon  is  maintained  from  three  to  six  weeks.*  Passive 
motion  and  massage  are  apjjlied  as  if  an  anterior  splint  were  being  used. 
The  author  has  treated  a  number  of  cases  by  Jones'  method,  and  now  prefers 
it  to  any  other  plan  in  all  fractures  of  the  elbow  except  fracture  of  the  olec- 
ranon, transverse  fracture  above  the  condyles,  fracture  of  the  inner  condyle 
near  the  line  of  the  ulnar  nerve,  and  fracture  between  the  condyles  in  which  the 
coronoid  process  gets  between  the  fragments  in  flexion.  The  first-mentioned 
injury  must  be  dressed  in  extension,  the  transverse  fracture  above  the  condyles 
requires  an  anterior  angular  splint,  and  the  other  two  injuries  should  be  treated 
in  extension.  If  a  fracture  near  the  line  of  the  ulnar  nerve  is  treated  in  acute 
flexion,  the  callus  poured  out  will  be  apt  to  entangle  and  press  upon  the  nerve. 

If  it  is  found  impossible  to  reduce  the  fragments  or  to  maintain  reduction 
we  should  follow  the  advice  of  John  B.  Roberts,  make  an  incision  and  nail  the 
fragments  in  place.     A  comminuted  fracture  requires  operation. 

In  young  children  the  anterior  angular  splint  must  not  be  used.  It  will 
become  loosened,  and  motion  will  inevitably  take  place  at  the  seat  of  fracture. 
Such  cases  can  be  treated  satisfactorily  in  Jones's  position  with  Frazier's  sling, 
or  we  can  treat  them  in  extension.  Bertomier's  plan  is  very  useful  in  young 
children.f  The  extremity  is  dressed  without  pressure  in  extension  and  supi- 
nation. This  can  be  effected  by  flannel  bandages.  In  from  four  to  eight  days 
a  silicate  of  sodium  bandage  is  applied  in  order  to  prevent  pronation.  About 
the  sixteenth  day  the  bandage  is  cut  so  as  to  form  two  troughs.  From  this 
period  every  third  day  the  splints  are  removed  and  gentle  passive  motion  is 
made.     The  splints  are  removed  permanently  at  the  end  of  four  weeks. 

If  false  ankylosis  follows  fracture  of  the  elbow,  the  adhesions  should  be 
broken  up  under  ether,  and  for  some  time  the  hot-air  apparatus  should  be 
used  daily  and  massage,  passive  motion,  and  the  hot  and  cold  douche  should 
be  employed.  In  true  ankylosis  an  operation  should  be  performed  and  the 
interlocking  callus  or  the  interposed  tissue  or  fragment  removed,  if  a  skia- 
graph shows  that  operation  promises  success.  If  gunstock  deformity  results 
and  produces  marked  disablement,  it  should  be  operated  upon.  An  osteot- 
omy is  performed  on  the  inner  condyle.  The  arm  is  set  in  the  extended  posi- 
tion, plaster-of-Paris  applied,  and  is  not  removed  for  six  weeks.  J 

Separation  of  the  lower  epiphysis  of  the  humerus  is  a  not  unusual 
accident.  The  inferior  extremity  of  the  humerus  may  be  separated,  or  the 
condyles  may  be  separated  from  each  other  and  from  the  shaft  of  the  bone. 

Symptoms. — The  symptoms  are  prominence  in  front  of  the  joint,  caused 
by  the  lower  end  of  the  shaft  of  the  humerus;  projection  backward  of  the 
olecranon;  the  forearm  rests  midway  between  pronation  and  supination. 
Epiphyseal  separation  may  retard  growth  and  produce  deformity. 

Treatment. — Jones's  position  or  an  anterior  splint  as  above  directed. 

Fractures  of  the  ulna  comprise  the  following  varieties:  (i)  fracture  of 
the  coronoid  process;  (2)  fracture  of  the  olecranon  process;  (3)  fracture  of 
the  shaft;   and  (4)  fracture  of  the  styloid  process. 

Fractures  of  the  coronoid  process  of  the  ulna  are  rarely  observed, 
and  practically  occur  only  as  a  complication  of  backward  dislocation  of  the 
ulna  or  in  association  with  other  fractures. 

*  Provincial  Medical  Jour.,  Dec,  1894,  and  Jan.,  1895. 

t  Revue  de  Chir.,  vol.  viii,  1888. 

t  G.  G.  Davis,  Phila.  Med.  Jour.,  May  13,  1889. 


Fractures  of  the  Olecranon  Process  of  the  Ulna 


573 


Symptoms. — When  fracture  of  the  coronoid  process  is  associated  with  a 
dislocation,  crepitus  is  appreciated  on  reduction,  and  it  is  found  that  the 
deformity  of  the  dislocation  promptly  returns  on  cessation  of  extension.  The 
upper  fragment  may  be  pulled  upward  by  the  brachialis  anticus  muscle,  and 
there  exists  an  inability  to  flex  the  forearm  completely.  The  position  is  one 
of  extension  with  posterior  projection  of  the  olecranon.  The  broken  piece 
is  felt  in  front  of  the  joint. 

Treatment.— The  treatment  is  by  an  anterior  splint  the  angle  of  which 
is  less  than  a  right  angle.  Jones's  position  may  be  used  in  treating  such  a 
case.     A  stifT  joint  may  follow. 

Fractures  of  the  olecranon  process  of  the  ulna  occur  not  uncommonly 
in  adults.  Hulke  states  that  such  a  fracture  never  occurs  before  the  age  of 
fifteen,  but  the  writer  has  seen  in  the 
Jefferson  Medical  College  Hospital  a 
girl  aged  fourteen  with  a  fractured 
olecranon.  The  canse  is  direct  violence 
or  muscular  action.  Only  a  small  frag- 
ment may  be  torn  away,  or  the  entire 
olecranon  may  be  broken  off,  and  the 
break  may  be  comminuted  or  may  even 
be  compound. 

Symptoms. — The  symptoms  of  frac- 
ture of  the  olecranon  are:  swelling; 
partial  flexion  of  the  forearm;  separa- 
tion of  the  fragments,  the  upper  piece 
being  pulled  up  from  half  an  inch  to 
two  inches  by  the  triceps;  the  space 
between  the  fragments  is  increased  by 
flexion  at  the  elbow,  and  lessened  by 
extension  at  the  elbow;  and  there  is  in- 
ability to  extend  the  arm.  Bulging  of 
the  triceps  above  the  fragments  and  crep- 
itus   on   approximating    the    fragments 

are  observed.  In  some  few  cases  there  is  no  separation,  the  periosteum  being 
untorn  or  the  fascial  expansions  from  the  triceps  holding  the  fragments  in 
apposition.  In  such  cases  crepitus  can  be  ehcited  by  rocking  the  upper  frag- 
ment from  side  to  side. 

When  treated  by  non-operative  methods  the  prognosis  is  usually  fair, 
fibrous  union  being  the  rule.  Some  joint-stiffness  usually  occurs,  and  much 
ankvlosis  may  be  unavoidable.  The  prospect  of  a  freely  movable  joint  is 
better  when  extra-articular  wiring  is  practised. 

Treatment. — Fracture  of  the  olecranon  is  usually  treated  with  a  well- 
padded  anterior  splint  almost,  but  not  quite,  straight.  A  perfectly  straight 
sphnt  is  uncomfortable,  and  by  opening  a  retiring  angle  between  the  fragments 
and  into  the  joint  favors  non-union  and  ankylosis.  The  splint  should  reach 
from  a  level  with  the  axillary  margin  to  below  the  fingers.  If  the  upper  frag- 
ment does  not  come  in  contact  with  the  lower,  pull  it  down  by  adhesive  plas- 
ter and  fasten  the  strips  to  the  splint.  The  author  in  one  case  employed  a 
glove  to  which  strings  from  the  adhesive  plaster  were  attached.  After  apply- 
ing the  spHnt  keep  the  patient  in  bed  for  three  weeks.     The  danger  of  anky- 


Fig.  278.— Fracture  between  the  condyles. 
Treated  by  Jones's  position.  Degree  of  volun- 
tary flexion  obtained. 


574 


Diseases  and  Injuries  of  Bones  and  Joints 


losis  in  this  fracture  is  very  great,  and,  in  case  it  occurs  in  the  position  of  exten- 
sion, an  almost  useless  arm  results.  Follow  the  rule  of  T.  Pickering  Pick, 
and  at  the  end  of  three  weeks  anesthetize  the  patient,  press  the  thumb  firmly 
down  upon  the  top  of  the  olecranon,  put  the  forearm  at  a  right  angle,  and 


Fig.  279. 


-Fracture  between  the  condyles.    Treated  by  Jones's  position.     Degree  of  voluntary  exten- 
sion obtained. 


apply  an  anterior  angular  splint  and  direct  it  to  be  worn  for  two  weeks.  When 
the  anterior  splint  has  been  applied,  passive  motion  should  be  made  every 
other  day,  or  every  third  day,  and  massage  should  be  used  at  the  same  time. 
When  the  splint  is  removed,  try  to  increase  the  range  of  motion  as  previously 
directed.     Surgeons  usually  incise  and  apply  wires  only  when  it  is  found 


Fig.  280.  -Fracture  of  coronoid  process. 


impossible  to  secure  apposition  of  the  fragments  after  fracture  of  the  ole- 
cranon. Such  a  course  is,  I  am  persuaded,  injudicious  conservatism.  I  do  not 
advise  that  the  rule  should  be  to  treat  fracture  of  the  olecranon  as  a  routine 
by  opening  and  wiring,  but  I  do  advise  that  we  should  treat  them  by  extra- 
articular operation  and  wiring  as  advocated  by  John  B.  Murphy  ("Jour. 


Fractures  of  the  Olecranon  Process  of  the  Ulna 


575 


Am.  Med.  Assoc,"  Jan.  27, 1906).  The  conser\''ative  non-operative  treatment 
often  fails.  Sometimes  the  fragments  cannot  be  approximated,  frequently 
they  cannot  be  maintained  in  approximation,  not  unusually  a  stiff  or  actually 
ankylosed  joint  results.  Murphy  thus  describes  the  operation  which  should 
be  done  ("Jour.  Am.  Med.  Assoc.,"  Jan.  27,  1906).  "  A  longitudinal  incision 
J  of  an  inch  long  was  made  on  the  external  aspect  of  the  ulna,  |  of 
an  inch    from   its   articular   surface,  and    tissues  were  divided  to  the  bone. 


/-K«| 

'M 

H 

m 

^H 

■^""^U^M 

J 

^^1 

^m 

J 

j 

H 

4 

A 

i 

i 

^^^B^'i  '*^^^^^^B 

i 
i 

% 

■■€ 

^ 

■i 

WB/h  A^^^^^B 

i 

Fig.  2S1.— Fracture  of  the  shaft  of  the  ulna  (case  in  the  Pennsy'ivania  Hospital ;  skiagraphed  by  Bv. 

Gaston  Torrance). 

A  smaller  incision  was  made  on  the  corresponding  inner  side.  I  perforated 
the  base  of  the  olecranon  with  an  eyelet  drill,  which  ran  transversely  from 
outward  inward.  I  threaded  the  drill  vdih  a  fine  aluminum-bronze  ^^ire, 
drawing  it  through  this  transverse  canal.  The  wire  was  carried  up- 
ward  under  the  skin  on  the  inner  smiace  of  the  elbow  and  then  drami  out 
through  another  small  incision,  ^  of  an  inch,  made  at  the  level  of  the  apex 
of  the  olecranon.  The  wive  was  then  reinserted  and  directed  transversely 
from  inward  outward,  passing  it  through  the  tendon  of  the  triceps  above 
the  olecranon,  and  then  dra\^-n  out  to  corresponding  outward  point  through 


576 


Diseases  and  Injuries  of  Bones  and  Joints 


a  very  small  incision  similar  to  that  made  on  the  inner  side.  The  wire  was 
again  reinserted  and  pushed  downward  under  the  skin  until  it  was  finally 
brought  out  through  the  initial  external  incision.  The  circle  once  com- 
pleted, traction  was  exerted  on  the  wire  until  I  was  sure  that  the  two  frag- 
ments were  in  perfect  coaptation,  the  latter  being  easily  and  satisfactorily 
accomplished.  The  ends  of  the  wire  were  twisted  several  times  and  then 
divided  by  scissors  close  to  the  bone.  By  this  procedure  the  skin  was  incised 
at  four  points,  the  largest  incision  being  ^-  inch  in  length."  The  extremity 
is  placed  in  flexion  upon  an  anterior  splint,  which  is  worn  for  four  weeks. 
Passive  motion  is  begun  on  the  third  day.     A  compound  fracture  and  a  com- 


-O- 


Fig.  282. — Murphy's  method  of  treating  fracture  of  the  olecranon  by  subcutaneous  exartic- 
ular  wiring.  Lateral  view  and  posterior  view.  Wiring  the  fragments  of  the  olecranon  to- 
gether: a.  Incision;  6,  twist  or  tie  of  wire;  c,  hole  drilled  in  bone  for  passage  of  wire;  d, 
fracture;  e,  passage  of  wire  through  tendon  of  triceps  (Murphy). 


minuted  fracture  always  require  an  operation,  in  which  the  joint  is  freely  opened. 
Non-union  requires  opening  of  the  joint  and  wiring  of  the  fragments. 

Fractures  of  the  shaft  of  the  ulna  alone  are  most  usual  near  the  middle 
of  the  bone,  are  always  due  to  direct  violence,  and  are  not  infrequently  com- 
pound.    An  injury  which  breaks  the  ulna  is  very  apt  to  break  the  radius  also. 

Symptoms.— Qy  running  the  finger  along  the  inner  surface  of  the  bone  there 
are  detected  inequality  and  depression;  crepitus  and  mobility  are  easily  devel- 
oped; there  are  pain  and  the  evidence  of  direct  violence.  The  long  axis  of  the 
hand  is  not  on  a  line  with  the  long  axis  of  the  forearm,  but  is  internal  to  it.  If 
deformity  exists,  it  is  due  to  the  lower  fragment  passing  into  the  interosseous 
space  because  of  the  action  of  the  pronator  quadratus ;  the  upper  fragment, 
acted  on  by  the  brachiaUs  anticus,  passes  a  little  forward  (Fig.  281).     The 


Fracture  of  the  Head  of  the  Radius  577 

forearm   at   and  below  the   seat  of  fracture  is  narrower  and  thicker  than 
normal. 

Treatment.-— In  treating  fracture  of  the  shaft  of  the  ulna  place  the  forearm 
midway  between  pronation  and  supination,  so  as  to  bring  the  fragments 
together  and  to  obtain  the  widest  possible  interosseous  space,  and  thus  limit 
the  danger  of  union  taking  place  between  the  radius  and  ulna.  The  po.sidon 
midway  between  pronation  and  supination  is  obtained  by  fiexing  the  forearm 
to  a  right  angle  with  the  arm  and  pointing  the  thumb  to  the  nose.  Take  two 
well-padded  straight  splints, 
one  long  enough  to  reach  from 
the  inner  condyle  to  below  the 
lingers,  the  other  from  the 
outer  condyle  to  below  the 
wrist;  place  a  long  pad  of  lint 
over  the  interosseous  space  on 
the  flexor  side  of  the  limb,  and 
another  on  the  extensor  side;     ^'^-  -'S3.--TW0  straight  splints  in   fracture  of  both 

bones  of  the  forearm. 

apply  the  sphnts  and  hang  the 

forearm  in  a  triangidar  sHng  (Fig.  283).  Passive  motion  is  to  be  made  in 
the  third  week,  and  the  splints  are  to  be  worn  for  four  weeks.  Fractures  of 
the  ulna  can  be  treated  very  etlliciently  with  plaster  of  Paris.  The  best  results 
are  secured  by  wiring. 

Fractures  of  the  styloid  process  of  the  ulna  are  due  to  direct  force. 
The  displacement  is  obvious. 

Treatment. — In  treating  fracture  of  the  styloid  process  push  the  fragment 
back  into  place  and  use  a  Bond  splint  with  a  compress  for  four  weeks,  or 
apply  a  plaster-of- Paris  dressing. 

Fractures  of  the  radius  include  the  following  variedes:  {a)  Fractures  of 
its  head;  {b)  fractures  of  its  neck;  (c)  fractures  of  its  shaft;  and  {d)  fractures 
of  its  lower  extremity. 

Fracture  of  the  head  of  the  radius  has  been  studied  by  Dr.  T.  Turner 
Thomas  ("University  of  Penn.  Med.  Bulletin,"  Oct.,  1905;  and  "Annals  of 
Surgery,"  August,  1907).  He  has  furnished  me  with  the  following  resume 
of  his  views,  with  which  I  entirely  agree: 

"Fracture  of  the  head  of  the  radius  is  not  infrequent  and  is  usually  the 
result  of  a  fall  on  the  hand,  with  the  elbow  in  extension  and  the  forearm  in 
pronation.  In  extension  of  the  elbow  the  capitellum  of  the  humerus  is  in 
contact  with  only  the  anterior  part  of  the  radial  head.  Since  the  carpus 
articulates  almost  entirely  with  the  radius,  the  force  of  the  usual  fall  on  the 
hand  is  transmitted  almost  entirely  through  this  bone,  and  at  the  elbow  is 
received  by  only  the  anterior  part  of  the  radial  head.  According  to  the  degree 
of  violence  apphed  more  or  less  damage  may  be  done  to  the  head,  or  head  and 
neck.  The  anterior  portion  of  the  rim  may  be  spht  off,  the  intact  ukia  pre- 
venting the  humerus  from  pursuing  the  detached  fragment  and  pushing  it  away 
from  its  fellow,  and  the  intact  orbicular  hgament  holding  the  two  in  close  apposi- 
tion. This  uncompHcated  fracture  is  the  most  common,  but  the  least  trouble- 
some. Union  with  ultimately  good  function  is  the  rule,  even  though  the  frac- 
ture go  unrecognized  and  untreated,  because  of  the  close  splinting  of  the 
37 


578  Diseases  and  Injuries  of  Bones  and  Joints 

untorn  orbicular  ligament.  Since  it  is  the  same  accident,  a  fall  on  the  out- 
stretched hand,  which  usually  produces  Colles'  fracture,  fracture  of  the  ex- 
ternal condyle  of  the  humerus,  fracture  of  the  neck  of  the  radius,  fracture  of  the 
coronoid  process,  and  posterior  dislocation  of  both  bones  of  the  forearm, 
any  one  or  several  of  these  injuries  may  compHcate  the  fracture  of  the  radial 
head.  When  the  anterior  part  of  the  head  breaks  off  the  bony  resistance  to  the 
descent  of  the  capitellum  by  the  radius  is  lost,  so  that  if  the  force  of  the  accident 
is  severe  enough,  lateral  bending  of  the  elbov^r  to  the  radial  side  with  further 
descent  of  the  capitellum  may  result  with  greater  separation  of  the  fragments, 
tearing  of  the  orbicular  ligament,  and  more  damage  to  the  head.  The  descent 
of  the  condyle  in  a  posterior  dislocation  may  carry  before  it  the  detached 
fragment  of  the  head,  and  this  fragment  be  left  buried  in  the  tissues  of  the  fore- 
arm several  inches  below  its  normal  position  after  the  dislocation  has  been 
reduced. 

"Prognosis. — In  the  vertical  or  oblique  fissured  fracture  of  the  head  with 
close  approximation  of  the  fragments,  after  union  takes  place,  Hmitadon  of  all 
movements  of  the  elbow  results  from  adhesions  and  slight  irregularities  in  the 
bone.  The  function  rapidly  returns  in  the  succeeding  weeks,  although  some 
limitation  of  extension  will  condnue  for  months.  More  marked  irregularity 
in  the  circumference  of  the  head  may  last  much  longer  and  may  produce 
permanent  limitation  of  rotation.  Bony  union  between  the  head  and  corre- 
sponding surface  of  the  ulna  will  prevent  all  rotation  of  the  forearm.  In 
either  case  flexion  and  extension  usually  return  almost  if  not  completely. 
Non-union  of  the  fragments  may  induce  pain  and  limitation  of  movement, 
especially  rotation;  but  vdth  close  approximation  of  the  fragments  and  an 
untorn  orbicular  hgament,  an  apparently  perfect  return  of  function  may  follow, 
the  fragments  moving  smoothly  as  one  piece  within  the  ligament.  The  prog- 
nosis will  depend  chiefly  upon  the  degree  of  damage  done  to  the  head  and  the 
separation  of  the  fragments. 

"Symptoms. — The  most  characteristic  feature  of  this  fracture  is  its  ob- 
scurity. The  thick  muscular  covering  of  the  radial  head,  except  posteriorly,  the 
splinting  effect  of  the  orbicular  ligament,  and  the  close  contact  of  the  head  vrith 
the  humerus  and  ulna,  make  the  diagnosis  of  the  small  intra-articular  fracture 
particularly  difficult.  In  the  uncomplicated  vertical  fracture  there  will  usually 
be  no  movements  of  the  fragments  on  each  other,  and,  therefore,  no  crepitus, 
and  there  will  be  no  deformity.  A  history  of  a  fall  on  the  hand;  some  swelling 
of  the  elbow,  particularly  on  the  radial  side;  severe  pain  and  limitation  in  all 
movements  of  the  elbow,  particularly  in  rotation;  pain  and  tenderness  dis- 
tinctly locahzed  to  the  head  of  the  radius;  and  the  exclusion  of  fracture  of  the 
humerus,  ulna,  and  the  shaft  of  the  radius,  will  point  strongly  to  a  fracture  of 
the  head  of  the  radius.  If  the  injury  is  treated  as  a  fracture,  and  two  or  three 
weeks  later,  when  fixation  is  removed,  there  is  marked  limitation  of  all  move- 
ments of  the  elbow,  the  diagnosis  will  be  more  than  reasonably  assured.  The 
rv-ray  may  be  misleading  unless  directed  in  the  line  of  the  fracture,  and  this  is 
not  easy  to  accomplish,  since  the  position  of  the  fragments  in  their  relation  to  the 
humerus  vary  vdth  every  change  in  rotation  of  the  forearm.  In  most  cases  an 
exposure  to  the  x-ray  in  the  transverse  plane  of  the  humeral  condyles,  with  the 
forearm  in  pronation,  will  give  a  successful  skiagraph  (see  Fig.  285).     If  the 


Fracture  of  the  Neck  of  the  Radius 


579 


.v-ray  is  directed  at  right  angles  to  the  line  of  fracture  the  skiagraph  will  usually 
be  negative.  If  the  fragments  are  freely  separated  and  if  crepitus  is  elicited, 
the  diagnosis  will  be  more  easily  determined. 

"  Treatuiejit. — In  the  uncomplicated  fracture  without  crepitus  or  deformity, 
Jones's  position  or  a  right-angled  splint  for  three  weeks  will  be  sufficient. 
The  resulting  fibrous  ankylosis  will  largely  disappear  from  forced  use  in  the  fol- 
lowing weeks,  but  several  months  will  be  necessary  before  extension  is  com- 
plete. If  crepitus  is  present,  four  or  five  weeks'  fixation  will  be  better,  and  in 
this  case  the  return  of  function  will  probably  take  longer.  As  a  rule,  if  union 
is  obtained  function  will  return.  If  pain  on  movement  persists  for  many 
months,  a  detached  fragment  or  the  whole  head  should  be  excised.  Marked 
limitation  of  movement  from  enlargement  of  the  head  or  bony  union  between 
it  and  the  ulna  calls  for  excision  of  the  head." 

Fracture  of  the  neck  of  the  radius  is  by  no  means  as  rare  an  accident  as 
was  thought  l)efore  the  discovery  of  the  .x'-rays.     It  seldom  occurs  alone  and  is 


Fig.  285.- 


Fig.  284. — Impacted  CoUes'  fracture. 


-Fracture  of  the  neck  of 
the  radius. 


usually  associated  with  fracture  of  the  radial  head.  These  fractures  are 
transverse  and  frequently  impacted.  The  cause  is  a  fall  upon  the  pronated 
hand. 

Symptoms. — In  this  fracture  the  forearm  is  pronated  and  the  patient  is 
found  to  have  lost  the  power  of  voluntary  pronation  and  supination.  Under 
forced  pronation  and  supination  it  will  be  noted  that  the  head  of  the  radius  does 
not  move  unless  there  is  impaction.  Crepitus  is  sometimes  absent  because  of 
impaction.     Thomas  points  out  that  there  is  angulation  of  the  neck  due  to 


58o 


Diseases  and  Injuries  of  Bones  and  Joints 


driving  of  the  radial  head  downward  and  forward  ("Annals  of  Surgery," 
August,  1907).     Reducdon  is  always  difi&cult  and  may  be  impossible. 

Treatment. — The  treatment  for  fracture  of  the  neck  of  the  radius  is  the 
same  as  for  fracture  of  the  elbow-joint — namely,  an  anterior  angular  splint  or 
Jones'  position. 

Fracture  of  the  shaft  of  the  radius  is  far  commoner  than  fracture  of  the 
shaft  of  the  ulna.     It  may  occur  above  or  below  the  insertion  of  the  pronator 


Figs.  286  and  287. — Fracture  of  both  bones  of  the  forearm. 


radii  teres  muscle.     It  may  arise  from  either  direct  or  indirect  force.     Fracture 
of  the  shaft  of  the  ulna  may  coexist  as  a  result  of  the  same  accident. 

Fracture  of  the  Shaft  of  the  Radius  Above  the  Insertion  of  the  Pro- 
nator Radii  Teres  Muscle. — Symptoms. — The  upper  fragment  is  drawn 
forward  by  the  biceps  and  is  fully  supinated  by  the  biceps  and  the  supinator 
brevis.  The  lower  fragment  is  fully  pronated  by  the  pronator  quadratus  and 
pronator  radii  teres,  and  its  upper  end  is  pulled  into  the  interosseous  space. 
There  are  crepitus,  mobility,  pain,  narrowing  and  thickening  of  the  forearm 
below  the  seat  of  fracture,  and  loss  of  the  power  of  pronation  and  supination. 


Fractures  of  the  Lower  Extremity  of  the  Radius  581 

The  head  of  the  hone  is  modonless  during  passive  pronadon  and  supinadon. 
The  hand  is  ])rone. 

Treatment. — In  treating  this  fracture  do  not  put  the  forearm  midway  be- 
tween pronation  and  supination,  as  this  position  will  not  bring  the  fragments 
into  contact,  the  upper  fragment  remaining  flexed  and  supinated.  To  bring 
the  lower  fragment  in  contact  with  the  upper,  flex  and  fully  supinate  the  fore- 
arm. Apply  an  anterior  angular  splint  to  the  extremity  for  four  weeks,  and 
make  passive  motion  in  the  third  week. 

Fracture  of  the  Shaft  of  the  Radius  below  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — In  this  variety  of  fracture  the  upper  frag- 
ment is  acted  on  by  the  biceps,  the  supinator  brevis,  and  the  pronator  radii 
teres,  and  it  remains  about  midway  between  pronation  and  supination,  pass- 
ing fonvard  and  also  into  the  interosseous  space.  The  lower  fragment  is  acted 
on  by  the  supinator  longus  and  the  pronator  quadratus,  the  latter  being  the 
more  powerful  of  the  two,  hence  the  lower  fragment  is  moderately  pronated, 
its  upper  extremity  being  drawn  into  the  interosseous  space.  Other  symp- 
toms are  identical  with  those  of  fracture  above  the  insertion  of  the  pronator 
radii  teres. 

Treatment. — In  treating  fracture  below  the  pronator  radii  teres  the  forearm 
is  flexed  and  is  placed  midway  between  pronation  and  supination;  two  inter- 
osseous pads  and  two  straight  spHnts  are  applied  as  for  fracture  of  the  ulna 
Fig.  283) .  The  splints  are  worn  for  four  weeks,  and  passive  motion  is  made 
in  the  third  week.  Plaster  of  Paris  is  a  most  satisfactory  dressing.  Loss  of 
function  is  best  obviated  in  this  fracture  by  incision  and  fixation. 

Fracture  of  the  shafts  of  both  bones  of  the  forearm  is  not  frequently 
seen.     It  is  caused  either  by  direct  or  indirect  force. 

Symptoms. — After  fracture  of  both  bones  of  the  forearm  the  hand  is  pro- 
nated and  the  two  lower  fragments  come  together  and  are  drawn  upward  and 
backward  or  upward  and  forward  by  the  combined  force  of  flexor  and  extensor 
muscles,  shortening  being  manifest  and  the  projection  of  the  lower  fragments 
being  detected  on  either  the  dorsal  or  the  flexor  surface  of  the  forearm.  The 
upper  fragment  of  the  ulna  is  somewhat  flexed  by  the  brachiahs  anticus;  the 
upper  fragment  of  the  radius  is  flexed  by  the  biceps  and  is  pronated  and  drawn 
toward  the  ulna  by  the  pronator  radii  teres.  The  forearm  is  narrower  than  it 
should  be  (the  ends  of  the  fragments  ha\ing  passed  into  the  interosseous  space) 
and  is  thicker  than  normal  from  front  to  back  (the  contents  of  the  interosseous 
space  having  been  forced  out).  Crepitus,  mobihty,  pain,  and  inequahty  exist, 
the  power  of  rotation  is  lost,  and  on  passive  rotation  the  head  of  the  radius  does 
not  move.     The  forearm  is  prone  and  semiflexed. 

Treatment. — The  treatment  usually  consists  in  the  application  of  two 
straight  splints  and  two  interosseous  pads,  the  forearm  being  flexed  to  a  right 
angle  and  placed  midway  between  pronation  and  supination  (Fig.  283).  The 
sj)lints  are  worn  for  four  weeks,  and  passive  motion  is  made  in  the  third  week. 
Instead  of  these  splints  a  plaster-of-Paris  dressing  can  be  used.  I  am  per- 
suaded that  pronation  and  supination  are  best  preserv'ed  by  incision  and 
fixation. 

Fractures  of  the  Lower  Extremity  of  the  Radius. — CoUes''  fracture  is  a 
transverse  or  nearlv  transverse  fracture  of  the  lower  end  of  the  radius,  between 


582 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  288. —Effect  upon  the  lower  end 
of  the  radius  of  the  cross-breaking  strain 
produced  bj-  extreme  backward  flexion 
of  the  hand  (Pilcher). 


the  limits  of  one-quarter  of  an  incii  and  one  and  a  half  inches  above  the  wrist- 
joint,  the  lower  fragment  sometimes  mounting  upon  the  dorsum  of  the  upper 

fragment.  An  oblique  fracture  beginning 
within  half  an  inch  of  the  joint  and  passing 
into  the  joint  is  known  as  Barton's  fracture. 
Colles's  fracture  was  first  recognized  as  a 
fracture  by  Colles,  of  Dublin,  in  18 14. 
Before  his  time  the  injury  was  called  back- 
ward dislocation  of  the  wrist.  It  is  a  very 
common  injury,  is  met  with  most  frequently 
in  those  beyond  the  age  of  forty,  and  oftener 
in  women  than  in  men.  It  is  due  to  trans- 
mitted force  (a  fall  upon  the  palm  of  the 
pronated  hand).  Some  think  that  the  force 
is  received  by  the  ball  of  the  thumb  and 
passes  to  the  carpal  bones  and  the  edge  of 
the  radius;  a  fracture  beginning  posteriorly 
rather  than  anteriorly  and  the  force  driv- 
ing the  lower  fragment  upon  the  dorsal 
surface  of  the  radius,  the  carpus  and  lower 
fragment  moving  upward  and  outward. 
It  is  much  more  likely  that  this  fracture  is  due  to  cross-strain  on  the  bone. 
There  is  sudden  traction  upon  the  anterior  hgaments,  which  drag  upon  the 
bone  and  break  it  at  a  point  where  the  cancellous  end  of  the  radius  joins 
the  compact  shaft  (Fig. 
288).  The  fragments  are 
not  unusually  impacted. 
In  the  author's  experience 
dislocation  of  the  lower 
end  of  the  ulna  is  a  not  un- 
usual complication,  which 
arises  from  a  fracture  of 
the  ulnar  styloid  or  tearing 
off  of  the  internal  lateral 
ligament  of  the  wrist. 

Symptoms. — In  Colles's 
fracture  the  hand  is  ab- 
ducted (drawn  to  the  radial 
side  of  the  forearm)  and 
pronated,  the  head  of  the 
ulna  is  prominent,  the  sty- 
loid process  of  the  radius  is 

raised,  and  the  lower  fragment  may  mount  on  the  back  of  the  lower 
end  of  the  upper  fragment,  causing  a  dorsal  projection,  termed  by 
Listen  the  "  silver- fork  deformity"  (Figs.  289  and  290).  The  lower  end 
of  the  upper  fragment  can  be  felt  beneath  the  flexor  tendons  above  the 
wrist.  The  position  in  deformity  is  produced  by  the  force.  Some  consider 
it  is  maintained  by  the  action  of  the  supinator  longus  and  the  flexor  and 
extensor  muscles,  but  particularly  by  the  extensors  of  the  thumb.     Pilcher 


Figs.  289,  29ct— Deformity  at  the  wrist  consequent  upon 
displacement  backward  of  the  lower  fragment  of  the  radius 
after  fracture  at  its  lower  extremity  (Levis). 


Fractures  of  the  Lower  Extremity  of  the  Radius 


583 


has  demonstrated  the  fact  that  in  this  fracture  a  portion  of  the  dorsal  perios- 
teum is  untorn,  and  this  untorn  jwrtion  acts  as  a  binding  band  to  hold  the 
fragments  in  deformity.  Pronation  and  supination  are  lost.  In  this  fracture 
the  hand  can  be  greatly  hyperextended  (Maisonneuve's  symptom).  Crepitus, 
which  is  best  obtained  by  alternate  hyperextension  and  flexion,  can  be  secured 
unless  swelling  is  great  or  impaction  exists.  Crepitus  on  side  movements  is 
rarely  obtainable.  Impaction  may  greatly  modify  the  deformity,  though  dis- 
placement generally  exists  to  some  extent,  and  the  fragments  do  not  ride 
easily  on  each  other.  The  styloid  process  of  the  ulna  may  be  broken,  or  the 
inferior  radio-ulnar  articulation  may  be  separated.  This  latter  complication, 
allows  the  lower  fragment  to  roll  freely  upon  the  upper,  and  the  characteristic 
silver-fork  deformity  does  not  appear.     If  the  stvloid  process  of  the  ulna  is 


Fig.  291.  — CoUes's  fracture  of  the  radius  (Pennsylvania  Hospital   case;   skiagraphed  by  Dr. 

Gaston  Torrance). 


broken,  pressure  over  it  causes  great  pain.  If  a  person  in  falling  strikes  the 
back  of  the  hand  and  a  fracture  of  the  radius  occurs,  the  lower  fragment  is 
driven  upon  the  front  surface  of  the  upper  fragment  and  is  felt  under  the  flexor 
tendons  at  the  wrist.  An  elaborate  study  of  fracture  of  the  radius  with  forward 
displacement  of  the  lower  fragment  has  been  published  by  John  B.  Roberts.* 
Treatment. — In  treating  CoUes's  fracture  reduce  the  deformity  by  hyper- 
extension to  unlock  the  fragments  and  relax  the  dorsal  periosteum,  and  follow 
by  longitudinal  traction  to  separate  the  fragments,  and  forced  flexion  to  force 
them  into  position.  This  formula  was  introduced  many  years  ago  by  the  late 
R.  J.  Levis.  It  is  of  the  first  importance  to  thoroughly  reduce  this  fracture, 
and  very  often  it  is  not  thoroughly  reduced.  Imperfect  reduction  means  perma- 
nent deformity,  stiffness  of  the  tendons  and  wrist,  and  possibly  an  almost  useless 
hand.  The  extremity  can  be  placed  upon  a  Levis  sphnt  (Fig.  292),  the  posi- 
tion maintaining  reduction  and  the  tense  extensor  tendons  giving  dorsal  sup- 
port. Some  surgeons  use  Gordon's  pistol-shaped  splint.  The  favorits  splint  in 
*  Am.  Jour.  Med.  Sci.,  Jan.,  1897, 


584 


Diseases  and  Injuries  of  Bones  and  Joints 


Philadelphia  practice  in  the  past  has  been  Bond's  (PI.  6,  Fig.  7).  It  places  the 
hand  in  a  natural  position  of  rest  (semiflexion  of  the  fingers,  semi-extension  of 
the  wrist,  and  deviation  of  the  hand  toward  the  ulna).  Two  pads  are  used: 
a  dorsal  pad  which  overlies  the  lower  fragment,  and  a  pad  for  the  flexor  surface 


Levis's  radius-splints,  riglit  and  left,  for  fracture  of  the  lower  end  of  the  radius. 


which  overlies  the  lower  end  of  the  upper  fragment.  A  bandage  is  applied, 
the  thumb  and  fingers  being  left  free  (Fig.  293).  Passive  motion  is  begun 
upon  the  fingers  in  three  or  four  days,  and  upon  the  wrist  during  the  second 
week.  The  splint  is  removed  in  three  weeks,  and  a  bandage  is  worn  for  a 
week  or  two  more  because  of  the  swelling.  In  applying  the  Bond  splint,  do 
not  pull  the  hand  too  much  up  on  the  block,  or  the  fracture  will  unite  with 
a  projection  upon  the  flexor  surface  of  the  extremity  and  the  tendons  of  the 
wrist  will  be  apt  to  be  caught  in  the  callus.  The  most  satisfactory  dressing 
is  the  straight  dorsal  splint  advised  by  Roberts  (Fig.  294).  I  use  it  almost 
invariably.     It  prevents  the  recurrence  of   deformity    and    is    mechanically 


Fig.  293.— Bond's  splint  in  Colles'  fracture. 

the  proper  mode  of  treatment.  It  should  be  worn  for  three  weeks.  Un- 
doubtedly more  or  less  stiffness  often  follows  Colles's  fracture,  and  some 
very  able  surgeons  have  been  so  impressed  with  the  frequency  of  its  oc- 
currence that  they  have  dispensed  with  the  use  of  a  splint.  Sir  Astley 
Cooper  long  ago  spoke  of  placing  the  arm  in  a  sling  as  proper  treatment 
for  fracture  of  the  radius.  Moore,  of  Rochester,  applied  a  cyHndrical  com- 
press over  the  ulna,  held  in  place  for  six  hours  with  adhesive  plaster,  then 
cut  the  plaster,  placed  the  forearm  in  a  sling,  and  let  the  hand  hang  over 
the  edge  of  the  shng.     Pilcher  appUes  a  band  of  adhesive  plaster  around  the 


Fractures  of  the  Carpus 


585 


wrist  and  supports  the  wrist  in  a  sling,  but,  as  Storp  says,  dispensary  patients 
are  apt  to  disarrange  this  dressing.  Storp  wraps  a  piece  of  rubber  plaster 
four  inches  wide  around  the  wrist,  and  places  a  second  piece  around  the  first  so 
arranged  as  to  form  a  fold  over  the  radius;  an  opening  is  made  through  the 
fold  for  the  passage  of  a  sHng.  In  ten  days  the  plaster  is  removed  and  the  fore- 
arm is  carried  in  a  sling.  If  a  stiff  joint  and  limited  tendon-motion  eventuate 
from  the  fracture,  use  massage,  frictions,  sorbefacient  ointments,  tincture  of 
iodin,  electricity,  hot  and  cold  douches,  and  the  hot-air  apparatus,  or  give  ether 
and  forcibly  break  up  adhesions.  If  reduction  was  not  thoroughly  effected  and 
too  great  a  length  of  time  has  not  elapsed,  and  the  hand  is  helpless  and  pain- 
ful, the  bone  should  be  refractured.  In  a  young  or  middle-aged  person, 
in  whom  a  useless  hand  has  followed  an  ill-reduced  fracture,  osteotomy  is 
justifiable. 

Fracture  of  both  the  Radius  and  Ulna  near  the  Wrist. — Colles's  frac- 
ture may  be  comphcated  by  a  fracture  of  the  ulna  other  than  of  its  styloid 
process. 

Symptoms. — In  fracture  of  the  radius  and  ulna  near  the  wrist  the  lower  ends 
of  the  upper  fragments  come  together,  the  upper  fragment  of  the  radius  is  pro- 


Spli  nt 


Fig.  294.- 


-Diagram  showing  the  arrangement  of  compresses  and  splint  best  adapted  to  retain  frag- 
ments in  proper  position  after  reduction  (Pilcher). 


nated,  and  the  lower  fragment  of  the  radius  is  drawn  up.  Pain,  crepitus, 
mobiUty,  shortening,  and  loss  of  function  exist. 

Treatment.— Yx?ici\xr:e  of  the  radius  and  ulna  near  the  wrist  should  be 
treated  with  the  straight  dorsal  sphnt,  as  in  Colles's  fracture. 

Separation  of  the  Lower  Radial  Epiphysis. — This  accident  occurs  in 
children  from  falhng  upon  the  palm  of  the  hand.  It  never  happens  after  the 
twentieth  year. 

Symptoms. — In  separation  of  the  lower  radial  epiphysis  the  lower  fragment 
mounts  upon  the  upper  and  produces  a  dorsal  projection  like  Colles's  fracture, 
but  the  hand  does  not  deviate  to  the  radial  side.  The  deformity  resembles  that 
of  a  backward  carpal  dislocation,  but  is  differentiated  from  dislocation  by  the 
unaltered  relation  in  the  fracture  between  the  styloid  processes  and  the  carpal 
bones. 

Treatment. — The  treatment  in  separation  of  the  lower  radial  epiphysis  is 
the  same  as  for  Colles's  fractiu"e. 

Fractures  of  the  carpus  were  until  recently  thought  to  be  infrequent,  but 
the  a--rays  have  taught  us  differently,  and  we  now  know  that  many  supposed 
sprains  of  the  wrist  are  in  reality  simple  fractures  of  the  carpus.     Codman 


586  Diseases  and  Injuries  of  Bones  and  Joints 

and  Chase  show  that  a  majority  of  carpal  injuries  "are  either  simple  fractures 
of  the  scaphoid  or  anterior  dislocations  of  the  semilunar  bone,"  the  two  inju- 
ries being  frequently  combined  ("The  Diagnosis  and  Treatment  of  Fracture 
of  the  Carpal  Scaphoid  and  Dislocation  of  the  Semilunar  Bone,"  Ernest 
Amor}'  Codman  and  Henry  ^Melville  Chase,  in  "Annals  of  Surgery,"  March 
and  June,  1905).  The  cause  of  carpal  fractures  may  be  violent  direct  force 
or  falls  upon  the  extended  palm. 

Symptoms. — Fractures  of  the  carpus  in  general  are  indicated  by  pain, 
swelling,  evidences  of  direct  force,  sometimes  crepitus,  loss  of  power  in  the 
hand,  and  a  very  httle  displacement. 

Treatment. — ]SIany  compound  comminuted  fractures  of  the  carpus  require 
amputation.  In  an  ordinary  compound  fracture  asepticize,  drain,  dress  mth 
antiseptic  gauze  and  a  plaster-of-Paris  bandage,  cutting  trap-doors  in  the 
plaster  over  the  ends  of  the  drainage-tube.  In  a  simple  fracture  dress  the 
hand  upon  a  well-padded  straight  palmar  spUnt  (PI.  6,  Fig.  10)  reaching 
from  beyond  the  fingers  to  the  middle  of  the  forearm,  and  place  the  hand 
and  forearm  in  a  sling.  The  splint  is  worn  for  four  weeks,  and  passive 
motion  of  the  wrist  is  begun  in  the  second  week. 

Fracture  of  the  carpal  scaphoid  (see  previously  quoted  article  by 
Codman  and  Chase)  usually  results  from  falls  upon  the  palm  of  the  extended 
hand  and  is  most  common  in  males  between  the  ages  of  twenty-five  and 
thirty-five.  It  is  rarely  recognized  at  the  time  of  the  accident;  the  patient  com- 
plains of  severe  pain,  tenderness,  and  disabihty  and  is  thought  to  have  a  sprain. 
According  to  Codman  and  Chase,  the  symptoms  improve  up  to  a  certain 
point  but  not  beyond  it  and  the  joint  remains  in  a  condition  of  irritation  and 
weakness.  After  months  or,  perhaps,  years,  the  diagnosis  is  made.  In  one 
case  of  my  owa,  a  locomotive  engineer,  the  injury  resulted  from  a  blow  on 
the  palm  with  the  reverse  lever.  He  came  to  me  three  years  after  the  injury 
when  I  recognized  the  condition  as  the  one  described  by  Codman  and  Chase. 
These  ■s\Titers  say  that  the  fingers  are  normally  flexible,  active  and  passive 
movements  of  the  ■oTist  are  restricted  to  one-half  or  more  of  the  normal  excur- 
sion, and  movements  of  flexion  or  extension  beyond  this  are  hmited  by  muscular 
spasm,  resembhng  the  spasm  occurring  in  a  tuberculous  joint.  Any  attempt 
to  forcibly  overcome  the  spasm  produces  violent  pain.  Crepitus  is  absent. 
The  radial  side  of  the  wTist-joint  exhibits  some  swelling,  which  obscures 
somewhat  the  flexor  tendons  of  the  thumb.  There  is  tenderness  on  pressiire 
over  the  scaphoid  and  it  is  most  acute  in  the  anatomical  snuff  box.  The 
x-xz.y  shows  a  transverse  fracture  of  the  scaphoid  bone  ("Annals  of  Surger)'," 
March  and  June,  1905).  Professor  Dwight  considers  the  above-described 
injury  to  be  due  to  the  two  portions  of  the  bone  (there  are  two  centers  of  ossi- 
fication) having  never  formed  a  bony  union  and  having  been  ^^Tenched  apart 
by  violence.  Codman  believes  the  injury  is  the  result  of  violence  acting  on 
a  normal  bone,  the  resulting  non-union  being  due  to  lack  of  fixation  and  the 
presence  of  synovial  fluid  between  the  fragments. 

The  fractiu-e  may  be  accompanied  by  forward  dislocation  of  the  semi- 
lunar bone.  If  for  several  weeks  after  an  accident  causing  fracture  of  the 
scaphoid  the  ^\Tist  is  immobihzed,  union  may  occur,  otherwise  non-union  ^\^']I 
surely  result. 

Treatment. — This  injun,'  should  be  thought  of  when  violence  has   been 


Fractures  of  the  Metacarpal  Bones 


587 


applied  to  the  carpus.  It  may  be  treated  by  a  straight  palmar  splint  if  the 
case  is  seen  early.  If  seen  when  there  is  non-union,  the  proximal  half  of  the 
scaphoid  should  be  excised  (the  incision  being  posterior  and  external  to  the 
extensor  communis  digitorum  tendons)  and  passive  motion  should  be  begun 
within  one  week  (Codman  and  Chase,  in  "Annals  of  Surgery,"  March  and 

June,  1905). 

Fractures  of  the  Metacarpal  Bones.— Fracture  of  the  metacarpus  is 
very  common.  One  or  more  bones  may  be  broken.  The  first  metacarpal 
bone  is  oftenest  broken;  the  third  is  seldom  broken  (Hulke).  The  ca2cse 
is  duect  or  indirect  force.  Fracture  at  the  base  of  the  first  metacarpal  bone 
was  described  by  E.  H.  Bennett  in  1881.  It  is  called  BenneWs  jradiire,  or, 
as  its  discoverer  named  it, 
"stave  0}  the  thumbs  The 
fracture  may  be  transverse  at 
the  neck  or  longitudinal,  "  the 
anterior  basal  projection  being 
broken  off"  (Raymond  Russ, 
in  "Jour.  Am.  Med.  A-ssoc," 
June  16,  1906).  This  injury 
results  from  violent  force  ap- 
pHed  to  the  distal  end  of  the 
metacarpal  (as  in  striking  with 
the  fist)  or  to  the  end  of  the 
extended  thumb,  and  Russ 
regards  it  as  the  most  com- 
mon metacarpal  fracture.  It 
is  usually  mistaken  for  a 
sprain  of  the  thumb  and  is 
sometimes  regarded  as  sub- 
luxation backward  of  the  first 
metacarpal. 

Symptoms.— T\^t  signs  of 
a  metacarpal  fracture  are — 
dorsal  projection  of  the  upper 
end  of  the  lower  fragment  or 
the  lower  end  of  the  upper 
fragment;  pain;  crepitus;  and 
often  evidences  of  direct  vio- 
lence. In  fracture  of  the  first  metacarpal  (Bennett's  fracture)  there  is  sweU- 
ing,  particularly  evident  in  the  flexor  tendon  sheaths  on  the  thenar  eminence 
(Russ),  disability,  pain,  tenderness  near  the  base  of  the  metacarpal,  and 
deform'ity,  apparent  shortening  of  thumb,  and  crepitus  on  reduction.  The 
x-ray  solves  a  doubtful  case. 

Treatment— To  treat  a  fracture  of  a  metacarpal  bone  reduce  by  extension; 
place  a  large  baU  of  oakum,  cotton,  or  hnt  in  the  palm  to  maintain  the  natural 
rotunditv,  and  apply  a  straight  pahnar  sphnt  like  that  used  for  fracture 
of  the  carpus.  It  may  be  necessary  to  apply  a  compress  over  the  dorsal 
projection.  The  duration  of  treatment  is  three  weeks,  and  passive  motion 
is   begun    after    two    weeks.      A   plaster-of-Paris    dressing    is    often    used. 


Fig.  295 Coaptation-traction  splint  of  Russ. 


588  Diseases  and  Injuries  of  Bones  and  Joints 

Raymond  Russ  ("Jour.  Am.  Med.  Assoc,"  June  16,  1906)  describes  the  fol- 
lowing splint  as  successfully  used  in  a  case  of  Bennett's  fracture.  I  have 
used  it  in  a  case  with  much  satisfaction.  "The  thumb  was  put  in  strong 
abduction  and  three  wooden  skewers — butcher's — neatly  padded  were  placed 
about  the  metacarpal,  one  posteriorly  in  the  interosseous  space,  one  along  the 
outer  border,  and  the  third  over  the  thenar  eminence.  These  extended  from 
well  above  the  metacarpal  bone  to  the  first  phalangeal  joint.  They  were 
fastened  tightly  in  place  by  two  strips  of  adhesive  plaster.  Traction  was 
then  exerted  on  the  thumb  and  maintained  by  strips  of  adhesive  plaster  pass- 
ing about  the  first  phalanx  and  the  projecting  ends  of  the  three  skewers. 
This  dressing  was  reinforced  by  a  rectangular  cardboard  splint.  Accurate 
coaptation  and  sufficient  traction  to  overcome  the  deformity  and  muscular 
action  are  most  necessary  in  the  treatment  of  this  fracture.  Slate  pencils 
or  small  lead  pencils  can  be  used  in  place  of  the  wooden  skewers.  The 
soapstone  slate  pencils  are  less  brittle  than  the  ordinary  kind. " 

Fractures  of  the  Phalanges. — The  phalanges  are  often  broken.  The 
fracture  may  be  compound.     The  cause  usually  is  direct  force. 

Symptoms.- — Fracture  of  a  phalangeal  bone  is  indicated  by  pain,  bruising, 
crepitus,  and  mobility,  with  very  little  or  no  displacement. 

Treatment. — If  the  middle  or  distal  phalanx  is  broken,  mould  on  a  trough- 
like splint  of  gutta-percha  or  of  pasteboard,  which  splint  need  not  reach 
into  the  palm.  If  the  proximal  phalanx  is  broken,  carry  the  splint  into 
the  palm  of  the  hand.  Make  the  splint  of  gutta-percha,  pasteboard,  wood, 
or  leather.  The  splint  is  worn  three  weeks.  A  sHng  must  be  worn,  otherwise 
the  finger  will  constantly  be  knocked  and  hurt.  Some  cases  require  a  dorsal 
as  well  as  a  palmar  splint.  These  cases  are  dressed  most  satisfactorily  with 
a  sihcate  of  sodium  or  plaster-of-Paris  bandage. 

Fracture  of  the  femur  is  a  very  common  injury.  The  divisions  of  the 
femur  are  (i)  the  upper  extremity;  (2)  the  shaft;  and  (3)  the  lower  extremity. 

I.  Fractures  of  the  upper  extremity  of  the  femur  are  divided  into: 
{a)  intracapsular;  (b)  extracapsular;  (c)  of  the  great  trochanter;  and  (d) 
epiphyseal  separation  (either  of  the  great  trochanter  or  the  head). 

Examination  of  the  Hip. — It  is  sometimes  tlwugh  seldom  necessary  to  give 
ether.  Remove  all  the  patient's  clothing  and  place  him  recumbent  upon  a 
table.  Note  the  position  of  the  extremity.  Feel  with  care  the  great  trochan- 
ter and  femoral  neck.  Very  gradually  and  gently  make  movements  to  deter- 
mine if  there  is  impairment,  undue  mobility,  or  crepitus.  Never  make  sud- 
den or  violent  movements  in  looking  for  crepitus.  The  diagnosis  can  be 
made  even  if  crepitus  is  not  obtained,  and  rapid  or  violent  movements  may 
tear  apart  an  impaction.  Measure  the  sound  extremity  and  the  injured 
extremity.  The  measurement  is  made  from  the  anterior  superior  spine  of 
the  ilium  to  the  inner  malleolus.  Other  symptoms  to  be  looked  for  are  set 
forth  on  pages  590  and  591. 

Intracapsular  Fracture  of  the  Femur. — Intracapsular  fracture  of  the 
neck  of  the  femur  is  transverse  or  only  slightly  obhque  (Fig.  296),  and  is  not 
unusually  impacted  (Figs.  239,  240,  243).  Stokes  follows  Gordon,  of  Belfast, 
in  classifying  fractures  of  the  femoral  neck.  He  divides  them  into  intracapsular 
and  extracapsular,  and  subdivides  intracapsular  fractures  into  fracture  with 
penetration  of  the  cervix  into  the  head;   fracture  with  reciprocal  penetration; 


Intracapsular  Fracture  of  the  Femur 


589 


intraperiosteal  fracture  at  the  junction  of  the  cervix  and  head;  intraperiosteal 
fracture  of  the  center  of  the  cervix;  extraperiosteal  fracture,  with  laceration 
of  the  cervical  ligaments.  The  last-named  fracture  is  the  most  common. 
The  first  four  forms  may  unite  by  bone,  the  fifth  form  will  not  because  of 
non-apposition,  lack  of  nutrition,  effusion  of  blood,  synovitis,  or  interstitial 
absorption.*  Stokes  claims  that  we  may  have  penetration,  but  not  im- 
paction. The  cause  is  often  slight  indirect  force,  of  the  nature  of  a  twist,  acting 
upon  a  person  of  advanced  years  (more  often  a  woman  than  a  man),  but  not 
unusually  a  fall  upon  the  great  trochanter  is  the  cause.     A  fall  upon  the  knees, 


Fig.  296.— Intracapsular  fracture  of  the  hip  (Pennsylvania  Hospital  case  ;  skiagraphed  by  Dr.  Gaston 

Torrance). 

a  trip,  or  an  attempt  to  prevent  a  fall  may  produce  this  fracture.  It  often 
happens  that  the  fall  is  due  to  the  fracture  rather  than  that  the  fracture 
arises  from  the  fall.  Intracapsular  fracture  is  never  caused  by  direct  force 
unless  it  is  due  to  gunshot  violence.  The  aged  are  more  Hable  to  intra- 
capsular fracture  than  the  young  or  the  middle-aged,  because,  first,  the  angle 
which  the  neck  forms  with  the  axis  of  the  femur  becomes  less  obtuse  with 
advancing  years,  and  may  even  become  a  right  angle;  this  change  is  more 
pronounced  in  women  than  in  men;  secondly,  the  compact  tissue  becomes 
thinned  by  absorption,  the  cancelH  diminish,  the  spaces  between  them  en- 
large, the  bony  portions  of  the  cancellous  structure  are  thinned  and  destroyed, 
*  Stokes,  in  Brit.  Med.  Jour.,  Oct.  12,  1895. 


590  Diseases  and  Injuries  of  Bones  and  Joints 

and  the  cancellous  structure  becomes  fatty  and  degenerated.  The  injury  is  not, 
however,  limited  to  the  aged.  It  has  been  positively  shown  that  this  fracture 
may  occur  in  the  young,  even  before  the  union  of  the  epiphyses.  In  fact, 
fracture  of  the  femoral  neck  is  not  very  uncommon  in  children  and  in  young 
and  vigorous  adults  (Royal  Whitman,  "Med.  Record,"  March  19,  1904).  I 
have  seen  one  case  in  a  man  of  twenty-eight  and  several  cases  in  those  under 
forty-five.  In  the  aged  the  fractiire  is,  of  course,  complete,  but  in  children 
and  even  in  young  adults  it  is  usually  incomplete,  and  for  this  reason 
the  fracture  is  often  not  recognized  in  children  and  young  adults. 

Symptoms. — In  intracapsular  fracture  there  is  usually  shortening  to  the 
extent  of  from  half  an  inch  to  an  inch;  but  in  some  cases  no  shortening  can 
be  detected.  Shortening  of  a  quarter  of  an  inch  does  not  count  in  making 
a  diagnosis,  for  one  Hmb  is  often  naturally  a  httle  shorter  than  the  other. 
If  the  reflected  portion  of  the  capsule  is  not  torn,  the  shortening  is  trivial 
in  amount  or  is  entirely  absent.  In  some  cases  shortening  gradually  or 
suddenly  increases  some  little  time  after  the  accident.  This  is  due  to  separa- 
tion of  a  penetration,  tearing  of  the  previously  unlacerated  fibrous  synovial 
reflection,  or  restoration  of  muscular  strength  after  traumatic  paresis  has 
passed  away.  A  gradually  increasing  shortening  arises  from  absorption  of  the 
head  of  the  bone.  Shortening  is  due  chiefly  to  pulUng  upon  the  lower  frag- 
ment by  the  hamstring,  the  glutei,  and  the  rectus  muscles. 

Pain  is  usually  present  anteriorly,  posteriorly,  and  to  the  side.  The  area 
of  pain  is  localized,  and  motion  or  pressure  greatly  increases  the  suffering. 
Pain  is  not  commonly  severe  except  upon  motion,  when  it  may  be  localized  in 
the  joint.     In  some  cases  the  pain  is  violent. 

Eversion  exists  and  is  spoken  of  as  "  helpless  eversion, "  though  in  a  very  few 
instances  the  patient  can  still  invert  the  leg.  This  eversion  is  due  to  the 
force  of  gravity,  the  limb  rolling  outward  because  the  line  of  gravity  has 
moved  externally.  That  eversion  is  not  due  to  the  action  of  the  external 
rotator  muscles,  as  was  taught  by  Astley  Cooper,  is  proved  by  the  fact  that 
when  a  fracture  happens  in  the  shaft  below  the  insertion  of  these  muscles 
the  lower  fragment  still  rotates  outward.  This  is  further  demonstrated  by 
the  considerations  that  the  internal  rotators  are  more  powerful  than  the 
external,  that  some  patients  can  still  invert  the  limb  after  a  fracture,  and 
that  eversion  persists  during  anesthesia.*  In  some  unusual  cases  inversion 
attends  the  fracture.  Inversion,  if  it  exists,  is  due  to  the  fact  that  the  limb 
was  adducted  and  inverted  at  the  time  of  the  accident,  and  after  the  accident 
it  remains  in  this  position  (Stokes).  Besides  shortening  and  eversion,  the 
leg  is  somewhat  flexed  on  the  thigh  and  the  thigh  on  the  pelvis,  the  extremity 
when  rolled  out  resting  upon  its  outer  surface.  Abduction  is  commonly 
present. 

Loss  0}  power  is  a  prominent  s}Tnptom:  the  limb  can  rarely  be  raised  or 
inverted;  although  in  rare  cases,  when  the  fibrous  synovial  envelope  is  untorn, 
the  patient  may  stand  or  even  take  steps.  Crepitus  often  cannot  be  found, 
either  because  the  fragments  cannot  be  approximated,  because  penetration 
exists,  or  because  the  bone  is  greatly  softened  by  fatty  change.  To  obtain  crep- 
itus the  front  of  the  joint  must  be  examined  while  the  hmb  is  extended  and 
rotated  inward.  But  why  try  to  obtain  crepitus?  The  diagnosis  is  readily 
*  Edmund  Owen:  "A  Manual  of  Anatomy." 


Intracapsular  Fracture  of  the  Femur  591 

made  without  it;  in  many  cases  it  cannot  be  detected,  and  the  endeavor  to  ob- 
tain it  inflicts  pain  and  may  produce  damage.  These  fractures  in  the  aged 
offer  a  not  very  flattering  chance  of  repair,  and  efforts  to  find  crepitus  may 
produce  serious  damage.     Limited  abduction  suggests  impaction. 

Altered  Arc  0}  Rotation  0}  the  Great  Trochanter  {DesauWs  Sign). — The 
pivot  on  which  the  great  trochanter  revolves  is  no  longer  the  acetabulum, 
and  the  great  trochanter  no  longer  describes  the  segment  of  a  circle,  but 
rotates  only  as  the  apex  of  the  femur,  which  rotates  around  its  own  axis. 
It  is  needless  to  try  to  obtain  this  sign;  to  do  so  inflicts  violence  on  the  parts. 

Relaxation  0}  the  fascia  lata  (Allis's  sign)  simply  means  shortening.  The 
fascia  lata  is  attached  to  the  ilium  and  the  tibia  (iho-tibial  band),  and  when 
shortening  brings  the  tibia  nearer  to  the  ilium,  this  band  relaxes  and  permits 
the  surgeon  to  push  his  fingers  more  deeply  inward  on  the  injured  side,  between 
the  great  trochanter  and  the  ihac  crest,  and  near  the  knee  above  the  outer 
condyle,  than  on  the  sound  side.  In  this  examination  each  limb  should  be 
adducted.  Allis  has  pointed  out  another  sign:  when  the  patient  is  recum- 
bent the  sound  thigh  cannot  be  Hfted  to  the  perpendicular  without  flexing 
the  leg;   the  injured  thigh  can  be. 

Lagoria's  sign  is  relaxation  of  the  extensor  muscles. 

Ascent  of  the  Great  Trochanter  above  Nelaton's  Line. — This  line  is  taken 
from  the  anterior  superior  iliac  spine  to  the  most 
prominent  part  of  the  ischial  tuberosity  (Fig.  297). 
In  health  the  great  trochanter  is  below,  and  in 
intracapsular  fracture  it  is  above,  this  Hne. 

Relation  of  the  Trochanter  to  BryanVs  Triangle 
(Fig.  297). — Place  the  patient  recumbent,  carry  a 
line  around  the  body  on  a  level  with  the  anterior 
superior  iliac  spines,  draw  a  line  from  the  anterior 
iliac  spine  on  each  side  to  the  summit  of  the  cor-         ^ig-  297-— a  c  d,  Bryant's 

1-  iii-i  J  iiu  ilio-femoral  triangle ;  A  B,  N61a- 

respondmg  great  trochanter,  and  measure  the  base      ^^,^,3  ^^^^^  (Owen) 

of  the  triangle  from  the  great  trochanter  to  the 

perpendicular  line  to  determine  the  amount  of  ascent.     The  difference  in 

measurement  between  the  two  sides   shows  the  amount  of   ascent  of  the 

trochanter;    that  is,  shows  the  extent  of  shortening. 

Morris's  measurement  shows  the  extent  of  inward  displacement.  Measure 
from  the  median  line  of  the  body  to  a  perpendicular  line  drawn  through 
the  trochanter  on  each  side  of  the  body. 

Diagnosis. — The  :v-rays  are  a  valuable  aid  to  diagnosis  (Fig.  296).  Intra- 
capsular fracture  without  separation  of  fragments  may  be  mistaken  for  a 
mere  contusion,  and  the  diagnosis  may  continue  obscure  unless  the  frag- 
ments separate.  Loss  of  function  in  contusion  is  rarely  complete  or  pro- 
longed, although  occasionally  the  head  of  the  bone  is  absorbed.  Early 
after  a  contusion,  and  usually  throughout  the  case,  there  is  no  alteration 
between  the  relation  of  the  spine  of  the  iHum  and  the  trochanter,  and  no  shorten- 
ing. Some  little  time  after  a  severe  contusion  the  head  of  the  bone  may  be 
absorbed.  Contusion  of  a  rheumatic  joint  leads  to  much  difficulty  in  diagnosis. 
Intracapsular  fracture  may  be  confused  with  extracapsular  fracture  or  with  a 
dislocation  of  the  hip-joint.  Extracapsular  fracture,  vv^hich  is  common  in  ad- 
vanced life,  but  is  met  with  in  middle  life  or  even  occasionally  in  the  young,  re- 


592 


Diseases  and  Injuries  of  Bones  and  Joints 


suits  usually  from  great  violence  over  the  great  trochanter;  if  non-impacted, 
there  are  noted  shortening  of  from  one  and  a  half  to  three  inches,  crepitus  over 
the  great  trochanter,  and  usually,  but  not  invariably,  eversion;  if  impacted, 
there  is  less  eversion,  crepitus  is  almost  or  entirely  absent,  and  the  shortening 
is  limited  to  about  an  inch.  The  extensor  muscles  are  relaxed.  Great  tender- 
ness exists  over  the  great  trochanter  in  both  impacted  and  non-impacted  frac- 
tures. In  dislocation  on  the  dorsum  of  the  ilium  the  patient  is  usually  a  strong 
young  adult.  There  is  a  histor)'  of  forcible  internal  rotation.  There  are  in- 
version (the  ball  of  the  great  toe  resting  on  the  instep  of  the  sovmd  foot),  rigidity, 
ascent  of  the  great  trochanter  above  Nekton's  line,  and  shortening  of  from  one 


Fig.  298. — Recent  intracapsular  fracture  in  a  woman  aged  forty  successfully  nailed. 


to  three  inches.  The  head  of  the  bone  is  felt  on  the  dorsum  of  the  ilium,  and 
the  trochanter  movmts  up  toward  the  spine  of  the  ihum,  and  pressure  upon 
it  causes  no  pain.  In  dislocation  into  the  th}Toid  notch  there  is  possibly 
eversion,  but  it  is  Hnked  with  lengthening. 

In  fracture  0}  the  hrim  0/  the  acetabulum  there  is  shortening,  which  occurs 
on  the  removal  of  extension,  inversion,  abduction,  flexion  of  the  knee,  the 
head  of  bone  is  drawn  upward  and  backward  with  the  acetabular  fragment, 
and  there  is  retention  of  the  power  of  eversion  and  of  adduction  (Stokes). 
Crepitus  is  most  distinctly  appreciated  by  a  hand  resting  on  the  ilium.    In 


Intracapsular  Fracture  of  the  Femur  593 

fracture  of  the  fundus  (if  the  acetabulum  there  is  shortening,  and  the  head 
of  the  bone  enters  the  pelvis  (Stokes). 

Prognosis. — The  prognosis  is  not  very  favorable.  Some  aged  patients  die 
in  a  day  or  two  from  shock.  Not  a  few  perish  later  from  hypostatic  con- 
gestion of  the  lungs,  kidney  failure,  or  exhaustion.  The  majority  of  cases 
recover  with  a  little  shortening,  some  stiffness,  and  a  permanent  limp.  There 
is  a  much  better  chance  for  firm  union  if  the  fracture  is  impacted  than  if 
it  is  not.  Even  if  non-union  results  after  an  intracapsular  fracture,  and  it 
is  not  unusual,  a  patient  may  get  about  fairly  well  with  a  proper  support.  In 
some  cases  after  intracapsular  fracture  rheumatoid  arthritis  develops.  Many 
surgeons  have  maintained  that  bony  union  never  occurs,  but  it  certainly  does 
sometimes  take  place.  Stokes  holds  that  bony  union  is  possible  in  fractures 
with  penetration,  and  even  in  fractures  without  penetration  when  the  frac- 
ture is  within  the  periosteum.* 

Treatment. — In  treating  a  very  feeble  old  person  for  intracapsular  frac- 
ture make  no  attempt  to  obtain  union.  Keep  the  patient  in  bed  for  tv/o  weeks; 
give  lateral  support  by  sand-bags;  tie  around  the  ankle  a  fillet,  attach  a 
weight  of  a  few  pounds  to  the  fillet,  and  hang  the  weight  over  the  foot-board 
of  the  bed.  When  pain  and  tenderness  abate,  order  the  patient  to  get  into 
a  reclining-chair,  and  permit  him  very  soon  to  get  about  on  crutches.  If 
hypostatic  congestion  of  the  lungs  sets  in,  if  bed-sores  appear,  if  the  appetite 
and  digestion  utterly  fail,  or  if  diarrhea  persists,  abandon  attempts  at  cure 
in  any  case,  and  get  the  patient  up  and  take  him  into  the  sunshine  and  fresh 
air,  simply  immobilizing  the  fracture  as  thoroughly  as  possible  by  means 
of  pasteboard  splints  or  plaster-of-Paris.  In  the  vast  majority  of  cases,  no 
matter  how  old  the  patient  may  be,  undertake  treatment.  We  may  be  forced 
to  abandon  it,  but  should  at  least  attempt  to  obtain  a  cure.  If  it  is  deter- 
mined to  treat  the  case,  place  the  patient  on  a  hair  mattress,  several  boards 
being  laid  under  the  mattress  transversely  in  order  to  prevent  unevenness  and 
the  formation  of  hollows.     A  fracture-bed  is  a  valuable  adjunct  to  treatment. 

Treatment  by  the  extension  apparatus  0}  Gurdon  Buck:  Extend  the  knee, 
and  place  the  leg  in  a  natural  posture,  and  put  a  pillow  beneath  the  knee. 
Combine  extension  with  lateral  support  by  means  of  sand-bags.  The  exten- 
sion should  be  gentle,  never  forcible.  It  is  not  wise  to  pull  apart  a  penetration 
in  an  old  person,  but  it  should  always  be  done  in  a  young  or  middle-aged  per- 
son»  Place  the  subject  on  a  firm  mattress.  If  the  paiient  be  a  man,  shave 
the  leg.  Cut  a  foot-piece  out  of  a  cigar-box,  perforate  it  to  admit  the  passage 
of  a  cord,  wrap  it  with  adhesive  plaster  as  shown  in  Plate  6,  Figs.  15  and  16, 
run  the  weight-cord  through  the  opening  in  the  wood,  and  fasten  a  piece 
of  adhesive  plaster  on  each  side  of  the  leg,  from  just  below  the  seat  of  fracture 
to  above  the  malleolus  (PL  6,  Fig.  14).  The  plaster  is  guarded  from  sticking 
to  the  malleoli  by  having  another  piece  stuck  to  its  under  siurface  opposite 
each  of  these  points.  Apply  an  ascending  spiral  reversed  bandage  over 
the  plaster  to  the  groin  (Fig.  299),  and  finish  the  bandage  by  a  spica  of  the 
groin.  Slightly  abduct  the  extremity.  Put  a  brick  under  each  leg  of  the 
bed  at  its  foot,  thus  obtaining  counter-extension  by  the  weight  of  the  body. 
Run  a  cord  over  a  pulley  at  the  foot  of  the  bed,  and  obtain  extension  by  the 

*  See  the  masterly  paper  by  Stokes,  before  quoted. 
38 


594  Diseases  and  Injuries  of  Bones  and  Joints 

use  of  weights.  In  an  adult  from  fifteen  to  twenty  pounds  will  probably 
be  necessary  at  first,  but  after  a  few  days  from  eight  to  ten  pounds  nill  be 
found  sufficient  (remember  that  a  brick  weighs  about  five  pounds).  Daw- 
barn's  rule  as  to  the  proper  weight  to  be  attached  is  one  pound  for  every 
year  up  to  twenty.  \A'hen  the  foot  of  the  bed  is  raised  and  the  weight  to 
make  extension  is  appUed,  very  gently  rotate  the  extremity,  put  the  foot 
at  a  right  angle  with  the  leg,  and  make  a  bird's-nest  pad  of  cotton  or  oakum 
to  save  the  heel  from  pressure.  Take  two  canvas  bags,  one  long  enough 
to  reach  from  the  crest  of  the  ilium  to  the  outer  malleolus,  the  other  long 
enough  to  reach  from  the  perineum  to  the  inner  malleolus.  Fill  the  bags 
three-quarters  full  of  dry  sand,  sew  up  their  ends,  cover  the  bags  with  sUps, 
and  put  the  bags  in  place  in  order  to  correct  eversion.  The  slips  may  be 
changed  every  third  or  fourth  day.     Keep  the  bed-clothing  from  coming  in 


Fig.  299. — Adhesive  plaster  applied  to  make  extension. 

contact  with  the  foot  by  means  of  a  cradle  (Figs.  300,  301).  The  bowels 
are  to  be  emptied  and  the  urine  is  to  be  voided  in  a  bed-pan,  unless  using  a 
fracture-bed.  For  two  weeks  the  patient  remains  recumbent,  after  which  time 
he  can  be  propped  up  on  pillows.  Maintain  extension  for  three  weeks,  then 
simply  maintain  support  by  sand-bags  or  molded  pasteboard  splints  upon 
the  part,  and  keep  up  this  support  three  to  five  weeks  more.  After  remo\ing 
the  extension  he  can  be  transferred  daily  to  a  couch.  In  from  six  to  eight 
weeks  after  the  infliction  of  the  injury  he  can  be  moved  about  in  a  wheeling- 
chair,  the  leg  being  extended  or  the  knee  flexed  in  accordance  with  the  dictates 
of  comfort.  After  a  week  or  so  of  such  movement  a  thick-soled  shoe  is  placed 
on  the  sound  foot  and  the  patient  is  allowed  to  use  crutches ;  but  weight  is  not 
put  upon  the  injured  extremity  until  from  ten  to  twelve  weeks  have  elapsed 
from  the  time  of  the  accident.  For  many  months,  at  least,  and  possibly  per- 
manently, he  walks  with  the  aid  of  a  cane.  Union,  if  it  takes  place,  is  usually 
cartilaginous,  but  is  sometimes  bony,  and  there  will  surely  be  some  shortening 
and  also  some  stiffness  of  the  joint.  Passive  motion  is  not  made  until  at  least 
eight  weeks  have  elapsed  since  the  accident.  Treatment  by  the  extension 
apparatus  is  far  from  satisfactor}%  as  it  does  not  afford  sufficient  immobil- 
ization. 

Semi's  method:  Senn  claims  that  by  this  method  of  "immediate  reduction 
and  permanent  fixation"  bony  union  is  obtained  in  fractures  of  the  neck  of 
the  femur  within  the  capsule.  He  "places  the  patient  in  the  erect  position, 
causing  him  to  stand  with  his  sound  leg  upon  a  stool  or  box  about  two  feet 
in  height;  in  this  position  he  is  supported  by  a  person  on  each  side  until 
the  dressing  has  been  applied  and  the  plaster  has  set. 


Intracapsular  Fracture  of  ihe  Femur 


595 


"Another  person  takes  care  of  the  fractured  limb,  which  in  impacted 
fractures  is  gently  su|)ported  and  immovably  held  until  permanent  fixation 
has  been  secured  by  the  dressing.  In  non-impacted  fractures  the  weight  of 
the  fractured  limb  makes  auto-extension,  which  is  often  quite  sufficient   to 


Fig.  300. 


Fig.  301. 
Figs.  300,  301. — Cradle  to  keep  clothing  from  leg,  made  from  two  barrel-hoops  (Scudder). 


restore  the  normal  length  of  the  limb;  if  this  is  not  the  case,  the  person  who 
has  charge  of  the  limb  makes  traction  until  all  shortening  has  been  overcome 
as  far  as  possible,  at  the  same  time  holding  the  hmb  in  position,  so  that  the 
great  toe  is  on  a  straight  line  with  the  inner  margin  of  the  patella  and  the 
anterior  superior  spinous  process  of  the  ilium.  In  applying  the  plaster-of- 
Paris  bandages  over  the  seat  of  fractiire  a  fenestrum,  corresponding  m  size 
to  the  dimensions  of  the  compress  with  which  the  lateral  pressure  is  to  be 
made,  is  left  open  over  the  great  trochanter. 

"To secure  perfect  immobihty  at  the  seat  of  fractures,  it  is  hot  only  nec- 
essary to  include  in  the  dressing  the  fractured  limb  and  the  entire  pelvis, 
but  it  is  absolutely  necessary  to  also  include  the  opposite  limb  as  far  as  the  knee 
and  to  extend  the  dressing  as  far  as  the  cartilage  of  the  eighth  rib. 

"The  sphnt  (Fig.  302)  is  incorporated  in  the  plaster -of-Paris  dressing, 
and  it  must  carefully  be  applied,  so  that  the  compress,  composed  of  a  well- 


596 


Diseases  Eftid  Injuries  of  Bones  and  Joints 


cushioned  pad  with  a  stiff,  unyielding  back,  rests  directly  upon  the  tro- 
chanter major,  and  the  pressure,  which  is  made  by  a  set-screw,  is  directed  in 
the  axis  of  the  femoral  neck.  Lateral  pressure  is  not  applied  until  the  plas- 
ter has  completely  set.  Syncope  should  be  guarded  against  by  the  adminis- 
tration of  stimulants. 

"As  soon  as  the  plaster  has  sufficiently  hardened  to  retain  the  limb  in 
proper  position  the  patient  should  be  laid  upon  a  smooth,  even  mattress, 
without  pillows  under  the  head,  and  in  non-impacted  fractures  the  foot  is 
held  in  a  straight  position  and  extension  is  kept  up  until  lateral  pressure  can 
be  applied. 

"No  matter  how  snugly  a  plaster-of-Paris  dressing  is  applied,  as  the 
result  of  shrinkage  it  becomes  loose,  and  without  some  means  of  making 
lateral  pressure  it  would  become  necessary  to  change  it  from  time  to  time 
in  order  to  render  it  efficient.  But  by  incorporating  a  splint  in  the  plaster 
dressing   (Fig.  303)   this  is  obviated,  and  the   lateral  pressure  is  regulated, 


Fig.  302. — Senn's  apparatus.        Fig.  303. — Senn's  apparatus  applied. 


day  by  day,  by  moving  the  screw,  the  proximal  end  of  which  rests  on  an 
oval  depression  in  the  center  of  the  pad." 

Treatment  by  Thomases  splint:  Scudder,  in  his  valuable  treatise  on  "The 
Treatment  of  Fractures,"  advocates  in  intracapsular  fracture  the  use  of 
Thomas's  hip  spUnt.  If  the  bones  are  unimpacted,  the  fragments  are  brought 
into  apposition  by  extension,  inversion,  and  pressure  upon  the  great  tro- 
chanter, and  the  Thomas  splint  is  bent  to  fit,  is  padded,  and  is  applied  (Figs. 
306,  307).  WTien  the  bed-pan  is  to  be  used  or  the  bed  is  to  be  smoothed, 
the  patient  can  be  Hfted  without  disturbing  the  fracture.  He  can  be  turned 
on  the  sound  side.  If  hypostatic  congestion  is  developing,  raise  the  head  of 
the  bed  and  tie  the  sphnt  to  the  iron  of  the  head  of  the  bed.  In  addition 
to  the  use  of  the  sphnt  Scudder  advocates  the  making  of  lateral  pressure  over 
the  great  trochanter  by  a  graduated  compress  and  a  bandage.     The  sphnt  is 


Extracapsular  Fracture 


597 


worn  for  six  or  eight  weeks.     It  is  then  removed,  the  patient  remaining  in 
bed  four  weeks  longer  without  any  apparatus  (Scudder,  from  Ridlon). 


Fig   ^04  -The  lone  spica  as  applied  for  fracture  of  the  neck  of  the  femur  in  the  adult ;  illustrating 
the  Advantage  oTrappliancewfTch  permit 
an  opening  has  been  nmde  to  lessen  the  constriction  of  the  abdomen  (Wh.tman). 

Whitman^s  Treatment  in  Abduction:  The  plan  advocated  by  Royal  Whit- 
man  ("Med.  Record,"  March  19,  1904)  is  a  most  exceUent  one.  It  aims  to 
abolish  traumatic  depression  of  the  neck  of  the  femur.  ^ 

We  can  apply  this  plan  in  a  young  person  to  any  fracture  even  if  im- 
pacted.  In  an  aged  person  we  apply 
it  only  in  a  :omplete  non-impacted 
fracture.  In  a  young  person  we  give 
ether  and  pull  apart  an  impaction  by 
abduction.  In  an  aged  person  we 
should  not  do  so. 

The  extremity  is  set  in  extension 
and  extreme  abduction  and  plaster-of- 
Paris  is  appHed.  The  tension  of  the 
capsule  pushes  the  outer  fragment 
against  the  inner  and  holds  it;  fixation 
is  obtained  by  the  neck  of  the  femur 
being  in  contact  with  the  acetabulum 
and  the  great  trochanter  with  the  pelvis, 
deformity  cannot  be  caused  by  muscu- 
lar action,  and  the  psoas  helps  pull  the 
fragments  together  (Whitman). 

Extracapsular  Fracture  (Fracture 
0}  the  Base  of  the  Neck  of  the  Femur). 
—The  line  of  extracapsular  fracture  is 

at  the  junction  of  the  neck  with  the  great  trochanter,  and  is  partly  withm  and 
partly  without  the  capsule,  the  fracture  being  generally  comminuted  and  often 


Fig.  305.— Reduction  and  fixation  in  abduc- 
tion, showing  security  assured  by  direct  bony 
contact  of  the  neck  and  trochanter  with  the 
pelvis,  also  the  effect  of  the  attitude  on  muscu- 
lar action  (Whitman),  a.  Abductor  group; 
b,  ilio-psoas  ;  c,  capsule. 


598 


Diseases  and  Injuries  of  Bones  and  Joints 


impacted.  The  cause  is  violent  direct  force  over  the  great  trochanter  (as  by  fall- 
ing upon  the  side  of  the  hip).  This  fracture  is  most  usual  in  elderly  people,  but 
is  not  very  uncommon  in  young  adults.  Stokes  has  described  six  forms  of  extra- 
capsular fracture:  extracapsular  fracture  with  partial  impaction  posterior; 
fracture  with  complete  impaction;  fracture  with  partial  impaction  above;  frac- 
ture with  partial  impaction  below,  the  shaft  being  split;  splitting  the  neck 
longitudinally  without  impaction;  comminuted  non-impacted  fracture.* 

Symptoms. — When  impaction  is  absent  there  is  marked  crepitus  on 
motion,  which  is  manifested  most  distinctly  when  the  fingers  are  placed 
upon  the  great  trochanter;  there  is  severe  pain,  pressure  upon  the  great 
trochanter  is  very  painful,  swelHng  and  ecchymosis  are  marked;  there  is 
absolute  inability  on  the  part  of  the  patient  to  move  the  limb,  and  passive 
movements  cause  violent  pain;   there  is  shortening  to  the  extent  of  at  least 


Fig.  306. 


-Thomas's  single  hip-splint  in  posi- 
tion (Ridlon). 


Fig.  307, — Thomas's  double  hip-splint  in  posi- 
tion (Ridlon). 


one  and  a  half  inches,  and  sometimes  to  the  extent  of  three  inches,  which 
shortening  is  made  manifest  by  noting  the  ascent  of  the  trochanter  above 
Nelaton's  line,  by  a  comparison  of  measurements  of  the  injured  limb  and  the 
sound  limb,  and  by  measuring  the  base-line  of  Bryant's  triangle  on  each  side. 
Absolute  eversion  usually  exists  with  slight  flexion  both  of  the  leg  and  the 
thigh.  In  some  rare  cases  there  is  inversion.  This  happens  if  at  the  time  of 
the  accident  the  hmb  was  inverted  and  adducted  (Stokes).  Lagoria's  sign, 
Desault's  sign,  and  Allis's  signs  are  present.  All  these  symptoms  follow  vio- 
lent direct  lateral  force.  In  the  impacted  form  of  extracapsular  fracture,  in 
addition  to  the  aid  given  the  surgeon  by  the  history,  there  is  severe  pain, 
which. is  intensified  by  movement  or  pressure;  shortening  to  the  extent  of 
one  inch  at  least,  which  is  not  corrected  by  extension;  limited  abduction; 
great  loss  of  function;  and  whereas  the  limb  may  be  straight  or  even  inverted, 
*  Brit.  Med.  Jour.,  Oct.  12,  1895. 


Operative  Treatment  of  Fracture  of  the  Femoral  Neck         599 

it  is  usually  everted.  The  trochanter  is  above  Nekton's  line,  the  base-line  of 
Bryant's  triangle  is  shortened,  but  not  so  much  as  in  the  unimpacted  form; 
there  is  no  crepitus  unless  the  impaction  is  pulled  apart,  and  the  arc  of  rotation 
of  the  great  trochanter  is  larger  than  in  a  non-impacted  fracture. 

Treatment. — In  impacted  extracapsular  fracture  it  is  best  to  pull  apart 
the  impaction  if  the  patient  is  in  good  physical  condition.  Southam,  of  Man- 
chester, in  an  impressive  article,  has  insisted  on  the  absolute  necessity  of 
pulHng  apart  an  impaction.  He  gives  ether,  and  when  the  patient  is  an- 
esthetized unlocks  the  fragments.*  This  unlocking  is  best  accomplished  by 
abduction,  the  rim  of  the  acetabulum  acting  as  the  fulcrum  of  the  lever  (Whit- 
man). In  treating  non-impacted  extracapsular  fracture  make  extension, 
raise  the  foot  of  the  bed,  and  apply  the  extension  apparatus  with  sand-bags  for 
three  weeks  and  then  apply  a  plaster  dressing.  Get  the  patient  on  crutches 
after  the  plaster  has  been  in  place  for  two  weeks.  Remove  the  plaster  at  the 
end  of  four  weeks.  Thomas's  splint  may  be  used  instead  of  Buck's  extension 
or  the  treatment  suggested  by  Whitman  may  be  employed  (page  597). 

Fractures  of  the  Femoral  Neck  in  Children. — Fracture  of  the  femoral 
neck  in  children  and  in  young  adults  can  scarcely  be  regarded  as  very  unusual, 
and  is  certainly  more  often  encountered  than  is  separation  of  the  upper  epiphy- 
sis. The  accident  results  from  a  fall  rather  than,  as  in  an  adult,  from  a  twist, 
and  it  is  the  product  of  considerable  violence  rather  than  of  slight  force.  In 
children  such  fractures  may  be  impacted  and  most  of  those  which  are  unim- 
pacted are  of  the  green-stick  variety.  The  disabihty  is  not  nearly  so  great  as 
in  an  adult;  in  fact,  it  is  not  unusual  for  the  victim  of  such  an  injury  to  be  able 
to  hobble  about  a  few  days  afterward.  The  symptoms  are  shortening,  some 
eversion,  impairment  of  joint-movements,  and  a  limp  when  the  patient  gets 
about.  Fractures  of  the  hip  in  children  are  often  unrecognized  and  lead 
frequently  to  permanent  impairment  because  of  the  development  of  coxa 
vara.     The  jc-rays  should  be  used  in  making  the  diagnosis. 

A  green-stick  fracture  may  be  treated  with  Thomas's  splint,  and  after  four 
weeks  in  bed  "the  child  may  be  allowed  up,  wearing  a  traction  hip-splint 
for  several  months  until  union  is  so  firm  that  the  danger  from  coxa  vara 
is  practically  eliminated.  A  hght  plaster-of-Paris  spica  bandage  from  the 
calf  to  the  axilla  will  maintain  immobihty  after  the  splint  is  omitted"  (Scudder, 
on  "The  Treatment  of  Fractures").  An  impacted  fracture,  after  the  impac- 
tion has  been  pulled  apart,  is  treated  exactly  as  is  a  green-stick  fracture. 
Royal  Whitman's  plan  for  treating  a  green-stick  fracture  is  very  satisfactory. 
This  surgeon  ("Med.  Record,"  March  19,  1904)  dresses  these  cases  by  plac- 
ing the  hmb  in  extreme  abduction  and  holding  it  so  by  means  of  a  plaster-of- 
Paris  spica  (Figs.  304,  305).  In  a  case  of  acute  disability  of  the  hip- joint 
in  a  child,  following  some  time  after  fracture  of  the  femoral  neck,  make  a 
careful  differentiation  from  tuberculous  disease  of  the  joint  and  apply  a  trac- 
tion splint  to  support  the  body  and  give  rest  to  the  joint.  If  coxa  vara  becomes 
marked  and  causes  great  disability,  osteotomy  is  justifiable. 

Operative  Treatment  of  Fracture  of  the  Femoral  Neck. — I  have  per- 
formed this  once  in  a  recent  case.  The  patient  was  a  woman  forty-two  years 
of  age  and  the  result  was  excellent  (Fig.  298).     The  operation  is  not  indicated 

*  Lancet,  Dec.  21,  1895. 


6oo 


Diseases  and  Injuries  of  Bones  and  Joints 


in  elderly  subjects.  It  is  not  indicated  at  all  if  the  fragments  can  be  coaptated 
and  retained  Ijy  extension  and  counterextension  or  by  abducrion.  In  a 
youth  or  middle-aged  person  in  which  retention  in  correct  posture  is  impossible 
it  is  indicated. 

Some  advocate  incision,  suture  of  the  torn  capsule,  and  nailing.  In  my 
case  I  nailed  through  a  very  small  skin  incision  and  did  not  suture  the 
capsule.  It  is  held  that  suture  of  the  capsule  improves  the  circuladon  in  the 
broken  off  head,  but  possible  attainment  of  the  object  is  not  justification  for 


Fig.  308. — Deformity  following  fracture  of  upper  third  of  femur. 


the  risk.     The   small  cutaneous  incision  and  nailing  answers  the  purpose. 
It  is  not  necessary  to  drill  the  trochanter  as  Konig  did. 

Before  operating,  an  x-ray  picture  is  taken,  while  the  fragments  are  brought 
into  abduction  by  obstruction  or  by  extension  and  counter-extension.  From 
this  picture  the  angle  of  the  neck  is  noted  and  the  length  of  nail  required  is 
determined.  A  silver  nail  is  used.  When  ready  to  operate,  the  fragments  are 
again  brought  into  apposition  by  extension  and  counter-extension  or  abduc- 
tion.    An  incision  is  made  through  the  skin  over  the  external  aspect  of  the 


Separation  of  the  Epiphysis  of  the  Great  Trochanter  6oi 

great  trochanter,  and  the  nail  is  driven  through  the  trochanter  and  neck  into 
the  head.  The  wound  is  closed  and  dressed.  The  pelvis  and  extremity  are 
then  put  up  in  plaster,  a  trap-door  being  cut  over  the  seat  of  incision.  The 
plaster  dressing  is  retained  for  five  or  six  weeks.  Cure  is  obtained  without 
shortening  and  with  retention  of  joint  mobihty.  This  operation  is  also  used 
for  uncorrected  fracture.  It  has  been  advocated  in  certain  recent  fracture  by 
Ci.  G.  Davis. 

Separation  of  the  upper  epiphysis  of  the  femoral  head  is  a  very  rare 
result  of  accident;  it  occurs  most  often  from  disease.  It  is  met  with  in 
early  youth,  results  in  considerable  permanent  shortening,  and  perhaps  in 
coxa  vara. 

Symptoms  and  Treatment. — The  symptoms  are  like  those  of  fracture  of 
the  neck,  except  that  the  crepitus  is  soft.  The  treatment  is  as  for  fracture  of 
the  neck. 

Fractures  of  the  Great  Trochanter.— This  is  a  very  rare  injury.  There 
seem  to  be  only  8  cases  on  record,  but  probably  the  diagnosis  has  been  missed  in 
some  cases  in  which  the  fragment  was  held  to  the  bone  by  periosteum.  This 
process  may  be  (i)  broken  off  without  any  other  injury.  In  some  cases  it 
is  completely  broken  off;  in  some  it  remains  attached  by  periosteum  and  fibrous 
tissue.  (2)  The  Une  of  fracture  may  run  through  the  trochanter  and  leave 
one  portion  of  the  trochanter  attached  to  the  head  and  neck  and  the  other 
part  attached  to  the  shaft  of  the  femur.  The  cause  is  violent  direct  force  over 
and  behind  the  great  trochanter  or  a  fall  (Armstrong,  in  "Annals  of  Surgery," 
August,  1907).  Neck  reported  a  case  due  to  muscular  acdon  ("Zentralb. 
fiir  Chir.,"  1903). 

Symptoms  and  Treatment. — The  symptoms  of  the  first  form  resemble 
those  of  epiphyseal  separadon  and,  of  course,  there  is  no  shortening.  The 
symptoms  of  the  second  form  are  similar  to  those  of  extracapsular  fracture. 
On  rotating  the  femur  the  lower  part  of  the  trochanter  moves  with  it,  but 
not  the  upper.  The  lower  fragment  goes  upward  and  backward  and  pro- 
jects by  the  side  of  the  sciatic  notch.  There  are  shortening,  eversion, 
crepitus,  and  altered  position  of  the  trochanter.  The  treatment  of  the  second 
form  is  like  that  in  extracapsular  fracture,  and  the  first  form  is  treated  like 
separation  of  the  epiphysis  of  the  trochanter. 

Separation  of  the  epiphysis  of  the  great  trochanter  is  a  rare  accident, 
but  not  so  rare  in  youths  as  is  fracture  in  adults.  The  cause  is  direct  violence 
and  the  injury  occurs  in  those  under  eighteen  years  of  age.  Poland  in  1898 
collected  12  cases. 

Symptoms.— The  trochanter,  if  completely  separated,  is  found  to  have 
ascended  and  passed  posteriorly;  there  is  no  shortening  of  the  thigh;  all  the 
motions  of  the  hip-joint  can  be  obtained;  if  the  thigh  is  flexed,  abducted,  and 
rotated  externally,  and  the  fragment  is  pushed  dovmward  and  forward,  crepitus 
is  obtained — soft  in  epiphyseal  separation,  hard  in  fracture.  There  is  no 
shortening.  If  the  process  is  not  completely  separated,  diagnosis  is  impossible 
without  the  .v-rays. 

Treatment. — If  the  epiphysis  is  not  completely  separated,  immobilize  the 
limb  in  the  position  of  abduction.  If  it  is  completely  separated,  incise  the 
soft  parts  and  either  suture  or  nail  the  fragment  in  place. 


6o2 


Diseases  and  Injuries  of  Bones  and  Joints 


2.  Fractures  of  the  shaft  of  the  femur  may  affect  any  portion  of  the 
shaft,  but  especially  the  middle  third,  and  may  occur  at  any  age.  Fracture 
of  the  upper  third  is  a  rare  accident.  Allis  estimates  that  each  year  in  Phila- 
delphia there  is  i  case  of  fracture  of  the  upper  third  of  the  femur  to  every 
100,000  inhabitants.  Separation  of  the  lower  epiphysis  occasionally  occurs. 
The  cause  of  fractures  in  the  upper  third  is  usually  indirect  force;  fractures 
in  the  lower  third  are  due  to  direct  force;  and  in  fractures  of  the  middle  third 
these  two  causes  are  about  equally  potential.  Fracture  from  muscular  action 
occasionally  occurs.  Oblique  fracture  is  the  usual  variety.  In  many  cases 
the  soft  parts  are  badly  lacerated  and  sometimes  a  great  vessel  is  torn. 

Symptoms. — The  chief  symptom  in  fracture  of  the  shaft  of  the  femur 
is  great  displacement,  except  when  impaction  occurs,  when  the  break  is 
due  to  direct  force,  or  when  the  injury  is  in  a  child.  In  a  child  the  line  of 
fracture  is  often  transverse  and  the  periosteum  may  be  untorn.     Green- 


Fig.  309. — Dressing  of  fracture  of  the  femur  in  the  upper  third  with  extension  upon  a  double 

inclined  plane  (Agnew). 


stick  fractures  occur  in  children.  As  a  rule,  in  fracture  of  the  shaft  of  the 
femur  the  lower  fragment  is  dra,wn  upward  and  the  upper  end  of  the  lower 
fragment  is  found  posterior  and  somewhat  to  the  inside  of  the  lower  end 
of  the  upper  fragment,  and  the  lower  fragment  also  undergoes  external  rotation 
(the  drawing  up  is  due  to  the  rectus  and  hamstrings;  the  passing  inward 
is  due  to  the  adductor  muscles;  the  rotation  outward  arises  from  the  weight 
of  the  limb).  If  a  fracture  of  the  lower  two-thirds  of  the  shaft  is  produced 
by  direct  force,  there  is  usually  but  little  deformity,  because  the  line  of  frac- 
tvure  is  nearly  transverse.  If  produced  by  indirect  force,  there  is  often  great 
deformity,  the  line  of  fracture  being  oblique.  In  fracture  of  the  lower  third 
of  the  shaft  the  gastrocnemius  pulls  upon  the  condyles  and  tilts  the  lower 
fragment,  so  that  its  upper  end  projects  into  the  popliteal  space  and  may 
damage  the  vessels.  In  fracture  of  the  upper  third  the  upper  fragment  is 
apt  to  be  thrown  strongly  forward  and  outward  (Fig.  308).  Some  attribute 
this  to  the  action  of  the  psoas,  iliacus,  and  external  rotator  muscles,  but  Allis 
thinks  it  is  due  chiefly  to  the  lower  fragment  pushing  the  upper  fragment  into 
this  position,  a  part  of  the  tendon  of  the  gluteus  maximus  acting  as  a  hinge 
for  the  fragments.*    In  rare  cases  the  angular  deformity  is  backward.     In 

*  "  Fracture  in  the  Upper  Third  of  the  Femur  Exclusive  of  the  Neck,"  by  Oscar  H. 
Allis,  Medical  News,  Nov.  21,  1891. 


Fractures  of  the  Shaft  of  the  Femur 


603 


fracture  of  the  shaft  of  the  femur  there  is  complete  loss  of  function,  the 
thigh  and  leg  are  slightly  tlexed  and  usually  everted.  In  somes  cases  the 
leg  and  lower  fragment  are  inverted.  There  are  shortening  to  the  extent  of 
two  or  three  inches,  pain  on  movement,  preternatural  mobiHty,  crepitus, 
and  obvious  deformity,  and  the  ends  of  the  fragments  can  be  felt  by  the  sur- 
geon. In  impaction  there  is  alteration  of  the  axis  of  the  limb  and  some  short- 
ening. Always  feel  for  the  pulse  below  the  fracture  to  learn  if  the  artery  is 
damaged. 

Treatment. — In  setting  and  dressing  a  fracture  of  the  thigh  ether  should 
be  given  and  the  parts  must  be  handled  with  great  care  to  prevent  a 
sharp  end  of  bone  from  tearing  the  soft  parts  and  puncturing  the  skin. 
In  fracture  of  the  shaft  of  the  femur,  if  impaction  exists,  the  fragments  must 
be  pulled  apart,  when  the  case  should  be  treated  exactly  as  is  a  non-impacted 
fracture.  After  a  fracture  of  the  shaft  of  the  femur  some  amount  of  perma- 
nent shortening  is  almost  inevitable.  In  fracture  of  the  upper  third  treat- 
ment is  usually  unsatisfactory,  and  there  is  permanent  shortening  from 
angular  union  or  from  overlapping. 
Horizontal  extension  fails  to  correct 
the  displacement  of  the  upper  frag- 
ment in  fracture  of  the  upper  third. 
The  double  inclined  plane  will  not  cor- 
rect the  tilting  of  the  upper  fragment 
while  shortening  exists.  Agnew  used  a 
double  inclined  plane  and  corrected 
shortening  by  the  use  of  extension  in  the 
axis  of  the  partly  flexed  thigh  (Fig.  309) . 
This  plan  is  the  most  serviceable  of 
those  usually  employed,  but  it  too  fails 
to  completely  correct  the  displacement. 
If,  notwithstanding  position  and  ex- 
tension, the  upper  fragment  projects, 
it  should  be  pushed  into  place  and 
be  retained  if  possible  by  short  splints 
bound    upon    the    thigh.      Extension 

should  be  continued  for  foiu"  weeks,  a  plaster-of-Paris  bandage  being  used 
for  four  weeks  more,  the  patient  being  then  allowed  to  go  about  on  crutches. 
Some  surgeons,  in  fracture  of  the  upper  third,  apply  a  plaster-of-Paris  bandage 
to  the  leg,  thigh,  and  pelvis,  extension  being  made  from  the  foot  while  the 
dressing  is  being  apphed.  This  method  does  not  give  good  results  because 
such  extension  will  not  correct  the  tilting  of  the  upper  fragment.  The  anterior 
splint  of  Nathan  R.  Smith  is  used  by  some  in  treating  fractures  of  the  upper 
third  of  the  femur  (Fig.  310).  It  is  bent  to  the  desired  shape,  fastened  to 
the  anterior  surfaces  of  the  leg  and  thigh,  and  hung  to  a  gallows,  the  limb 
being  suspended  at  the  desired  height.  This  splint  is  open  to  the  same 
objection  as  the  double  inclined  plane.  In  fact,  in  many  fractures  of  the 
upper  third  of  the  shaft  of  the  femur  no  apparatus  will  maintain  reduction. 
In  such  cases  it  is  advisable  to  incise,  separate  the  muscles  from  between 
the  fragments,  and  fasten  the  ends  of  the  bone  fragments  together  with  bone 


Fig.  310. — Smith's  anterior  splint. 


6o4  Diseases  and  Injuries  of  Bones  and  Joints 

ferrules,  silver  wire,  kangaroo-tendon,  steel  screws,  steel  pins,  or  a  bone- 
clamp.  This  radical  treatment  has  certain  dangers  of  its  own,  but  it  is 
the  only  plan  which  promises  to  secure  a  thoroughly  good  limb.  In  frac- 
ture of  the  middle  third  or  upper  part  of  the  lower  third  of  the  shaft  of  the 
femur,  the  extension  apparatus  and  sand-bags  will  usually  secure  a  satis- 
factory result  (PI.  6,  Fig.  14).     The  strips  of  adhesive  plaster  are  carried  to 


Fig.  311.— Hodgen's  apparatus  as  applied  by  Dr.  George  S.  Brown. 


just  below  the  seat  of  fracture,  and  the  turns  of  the  roller  bandage  should 
be  taken  to  a  httle  above  this  point.  Extension  should  be  continued  for  four 
weeks,  when  the  plaster-of-Paris  bandage  ought  to  be  applied.  The  plaster 
is  kept  in  place  for  four  weeks.  Many  surgeons  use  Hodgen's  splint  in 
treating  fractures  of  the  thigh.     The  limb  is  susoended  in  a  cradle  and  ex- 


Fractures  of  the  Shaft  of  the  Femur  in  Children 


605 


tension  is  obtained  by  strapi^ng  the  foot  to  the  cross-bar  of  the  frame  and 
pulling  upon  the  frame  by  cords  (Fig.  311).  Hodgen's  apparatus  as  applied 
by  Brown,  of  Birmingham,  Ala.,  is  one  of  the  most  satisfactory  methods  of 
treatment  in  fracture  below  the  upper  third.  The  extremity  can  be  raised 
or  lowered  at  will  without  disturbing  the  approximation  of  the  fragments, 
extension  to  the  required  degree  can  be  obtained,  and  the  patient  can  be  moved 
in  bed.  I  consider  this  apparatus  the  most  comfortable  apphance  which 
can  be  worn  and  excellent  results  are  obtained  by  its  use.  In  fracture  of 
the  middle  third  or  upper  part  of  the  lower  third  of  the  shaft  if  the  line  of 
fracture  is  transverse  and  there  is  little  deformity,  as  is  seen  often  after  a 
fracture  bv  direct  force,  and  often  in  children,  immobihzation  in  an  im- 


Fig  312. — Mclntyre's  splint. 


movable  dressing  may  be  all  that  is  required;  but  if  shortening  exists,  exten- 
sion must  be  used.  If  extension  is  used,  continue  it  for  four  weeks  and  then 
substitute  a  plaster-of-Paris  dressing  for  four  weeks.  The  amount  of  weight 
required  is  pointed  out  by  Dawbarn — one  pound  for  each  year  up  to  twenty.* 
In  fracture  near  the  knee-joint  (lower  part  of  the  lower  third  of  the  femur)  it 
may  be  impossible  to  effect  reduction  by  horizontal  traction.  In  such  a  case 
make  traction,  and  while  it  is  being  made  gradually  bring  the  leg  to  a  right 
angle.  Place  the  Hmb  in  a  double  inclined  plane  (PI.  6,  Fig.  2).  A  Mcln- 
tyre  spHnt  (Fig.  312)  is  a  useful  form  of  double  incHned  plane.  After  four 
weeks  of  the  use  of  a  double  inclined  plane  apply  a  plaster-of-Paris  dressing, 
which  is  to  be  worn  for  four  weeks. 

Fractures  of  the  Shaft  of  the  Femur  in  Children. — In  children  under 
three  years  of  age  the  extension  apparatus  will  not  satisfactorily  immobilize 
the  fragments.  Fractures  of  the  thigh  in  children  are  reduced  by  extension 
and  counter-extension;  a  well-padded  spHnt  reaching  from  the  axilla  to  below 
the  sole  of  the  foot  may  be  applied  to  the  outer  side  of  the  limb  and  body.  This 
spUnt  is  held  in  place  by  bandages  which  are  overlaid  with  plaster-of-Paris. 
It  is  worn  for  four  weeks,  at  which  time  it  is  removed  and  a  plaster  bandage, 
applied  so  as  to  include  the  entire  limb,  is  worn  for  four  weeks. 

*  Annals  of  Surgery,  Oct.,  1897. 


6o6 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  313-— Bryant's  exten- 
sion for  fracture  of  the  thigh 
in  a  child. 


Bryant'' s  extension  is  very  satisfactory  in  treating  a  child  (Fig.  313).  Both 
the  injured  limb  and  the  sound  limb  should  be  flexed  to  a  right  angle  with  the 
pelvis,  fixed  by  light  splints,  and  fastened  to  a  bar 
above  the  bed.  The  weight  of  the  body  produces 
counter-extension  and  the  child  can  be  easily 
cleaned.* 

Another  plan  is  that  of  Theodore  Dunham.f 
The  child  is  placed  upon  a  table,  and  the  knee 
and  thigh  are  partly  flexed.  After  first  applying 
flannel  rollers,  plaster-of-Paris  bandages  are  ap- 
plied from  the  roots  of  the  toes  to  the  spine  of  the 
tibia,  and  as  a  spica  about  the  upper  part  of  the 
thigh  and  pelvis.  Two  pieces  of  iron,  suitably 
bent,  are  used  to  anchor  the  two  plaster  bandages 
together.  One  end  of  one  iron  is  attached  to  the 
plaster  over  the  groin  and 
one  end  of  the  other  iron 
is  attached  to  the  plaster 
over  the  front  of  the  leg. 
The  free  ends  of  the  irons 
overlap.  At  the  points  over  the  joints  and  the  front 
of  the  leg  where  the  irons  are  to  rest  masses  of  plas- 
ter are  placed.  The  iron  is  sunk  into  the  plaster 
and  supported  at  each  spot  by  several  turns  of  a 
plaster  bandage.  While  the  irons  are  being  adjusted 
the  thigh  is  so  held  as  to  prevent  bending  or  rotation, 
and  the  hip  and  knees  are  semiflexed.  Wlien  the 
plaster  has  set  an  assistant  makes  extension  on  the 
leg  and  another  assistant  makes  counter-extension 
by  pressing  on  the  pelvis.  Any  shortening  is  thus 
reduced  and  the  two  irons  are  lashed  together  with 
strong  cord  (Fig.  314)- 

Van  ArsdaWs  triangular  splint  is  a  very  useful 
appliance.  It  is  made  of  binders'  board.  A.  Ernest 
Gallant  J  describes  its  preparation  and  applica- 
tion as  follows:  Measure  the  length  of  the  sound 
thigh  from  the  middle  of  the  groin  to  the  end  of 
the  femur.  Draw  upon  cardboard  an  outline  of  a 
double  spade  (playing-card  spade)  (Fig.  315). 
Each  of  the  four  sections  {A,  B,  C,  D)  must  be 
equal  to  the  length  of  the  child's  thigh,  the  flanged  portions  being  equal  to 
the  widest  part  of  the  thigh.  The  figure  is  then  cut  out.  The  cardboard 
is  moistened  on  one  side  and  folded  on  the  dotted  line,  section  A  being 
lapped  over  Z),  so  as  to  form  a  triangle.  It  is  fastened  together  by  adhesive 
plaster.  The  thigh  is  flexed  and  the  triangle  is  applied  so  that  one  flanged  por- 
tion embraces  the  thigh  and  the  other  flanged  portion  rests  upon  the  abdomen 

*  Thomas  Bryant's  "  Practice  of  Surgery."  fPhil.  Med.  Jour.,  April  23,  1898. 

X  Jour.  Amer.  Med.  Assoc,  Dec.  18,  1897. 


Fig.  314. — Dunham's  appa- 
ratus for  treating  fractures  of 
the  thigh  in  infants  and  chil- 
dren. 


Fractures  of  the  Shaft  of  the  Femur  in  Children 


607 


(Fig.  318).  The  triangle  is  fixed  in  position  by  bandages,  ligure-of-eight  turns 
being  made  around  the  knee  and  around  the  thigh  and  body.  Plaster  or  starch 
bandages  are  then  applied 
to  fix  the  splint  firmly. 
The  leg  should  be  bandaged 
from  the  toe  to  the  knee  to 
prevent  swelling  (Fig.  318). 
This  splint  is  worn  for 
three  weeks.  A  child  wear- 
ing this  splint  can  sit  on  a 
chair,  nurse,  play  on  the 
floor  and  crawl  about,  may 
sleep  on  either  side,  and 
the  dressing  is  not  soiled 
by  the  evacuations. 

If  a  thigh  is  fractured 
during  partiu-ition,  or  dur- 
ing the  first  few  weeks  of 

life,  Wyeth's  dressing  may  be  very  serviceable.  It  is  applied  as  follows :  The  leg 
is  flexed  on  the  thigh  and  the  thigh  on  the  abdomen.  A  flannel  bandage  is 
appHed  so  as  to  include  the  leg,  the  thigh,  and  the  body  from  the  axilla  to 
the  pelvis.     Plaster-of-Paris  is  applied  over  this;    the  dressing  is  worn  for 


Fig- 3'^5-~''^'  Diagram  showing  outline  of  Van  Arsdale's 
splint ;  the  end  band  to  be  folded  on  the  dotted  lines  ;  each 
section  to  equal  the  length  of  the  child's  thigh.  2,  Diagram, 
splint  folded,  fastened  by  rubber  plaster,  flanges  bent  to  em- 
brace the  thigh  and  abdomen,  ready  for  adjustment  (Gallant). 


Fig.  316.— Ware's  combined  pasteboard  triangle  and  plaster-of-Paris  spica  apparatus  for  fracture  of 
the  femur  in  infancy  (Ware,  in  "  Annals  of  Surgery,"  August,  1905). 


6o8 


Diseases  and  Injuries  of  Bones  and  Joints 


four  weeks.  A  better  dressing  than  the  above  is  Ware's,  a  modification  of 
Van  Arsdale's  splint  ("Annals  of  Surg.,"  August,  1905)  (Fig.  3r6).  It 
is  lighter,  the  patient  can  be  moved  about  with  ease,  the  child's  toilet  can  be 
easily  carried  out,  and  breathing  is  not  embarrassed.     A  right-angled  triangle 


F^'S-  317' — Ware's  apparatus  for  treatment  of  fracture  of  both  femora  (Ware,  in  "Annals  of  Surgery," 

August,  1905). 

is  made  of  bookbinders'  board.  The  length  of  one  side  is  the  distance  from 
the  trunk  at  the  level  of  the  lower  angle  of  the  scapula  to  the  inguinal  fold. 
The  length  of  the  other  side  is  the  length  of  the  thigh.  The  hypotenuse  is,  of 
course,  longer  than  the  sides.     The  cardboard  is  marked,  bent  into  the  tri- 


Fig-3i8. — Showing  Van  Arsdale's  triangular  splint  in  position.    Note  the  wide  space  between  the 
dressings  and  the  excretory  passages  (Gallant). 

angle,  and  the  overlapping  edges  are  secured  by  means  of  adhesive  plaster. 
The  thigh  is  flexed  and  abducted,  the  inner  surface  of  the  sphnt  is  padded,  the 
apparatus  is  applied  and  retained  by  a  muslin  spica  about  the  trunk  and  thigh. 
Several  turns  of  a  de.xtrin  bandage  are  applied  over  this  to  give  strength.     Ihe 


Longitudinal  Fractures 


609 


Fig.  319.— Mechan- 
ism of  fracture  of  the 
patella  by  muscular 
action  (after  Treves). 


leg  hangs  free.  The  dressing  is  worn  for  three  or  four  weeks.  Fig.  316 
shows  this  dressing  applied  for  fracture  of  the  right  femur  and  Fig.  317  shows 
it  applied  when  both  bones  are  broken. 

Fractures  Just  above  the  Condyles  of  the  Femur. — The  line  of  frac- 
ture above  the  condyles  is  well  above  the  epiphyseal  line.     The  femoral  artery 
is  in  danger  from  the  fragments.     The  cause  of  the  break,  as  a  rule,  is  direct 
s'iolence.     Indirect  force  is  sometimes  responsible  (faUs 
upon  the  feet).     The  knee-joint  may  be  opened.     The 
fracture  is  sometimes  compound. 

Symptoms. — The  upper  end  of  the  lower  fragment  is 
drawn  upward  and  backward,  because  of  the  action  of 
the  rectus,  hamstrings,  gastrocnemius,  and  popliteus. 
The  upper  fragment  passes  inward,  and  t?ie  deformity 
is  very  manifest.  There  are  shortening,  crepitus,  and 
mobility.  The  ends  of  the  fragments  can  be  felt  by  the 
surgeon.  If  the  force  has  been  ver}'  great,  a  T-fracture 
results.  In  T-fracture  the  knee  is  broadened  and 
crepitus  is  obtained  by  moving  the  condyles,  one  up 
and  the  other  down.  Always  feel  for  the  pulse  below  the  fracture. 
Treatment. — In  treating  fracture  above  the  condyles,  reduce  the  deformity 
by  horizontal  extension.  If  this  fails,  make  traction  at  the  same  time,  gradu- 
ally bringing  the  leg  to  a  right  angle  ^^ith  the  thigh.  Place  the  limb  on 
a  double  inclined  plane  for  five  weeks,  then  begin  passive  motion  once  every 
other  day,  restoring  the  limb  to  the  splint  after  the  movements  are  completed. 

At  the  end  of  eight  weeks  after  the  acci- 
dent remove  the  dressings,  and,  if  the 
knee-joint  be  stiff,  use  for  some  time 
massage,  passive  motion,  hot  and  cold 
douches,  ichthyol  inunctions,  etc.  Bryant 
treats  this  fracture  in  extension,  cutting 
the  tendo  Achillis,  if  necessar)',  to  amend 
deformity.  It  is  occasionally  necessary  to 
wire  the  fragments.  Some  cases  demand 
amputation  because  of  injury  to  the  struc- 
tures in  the  popliteal  space. 

Fracture  Separating   Either  Con- 
dyle.— The  cause  is  direct  force. 

Symptoms     and     Treatment.  —  The 

broken  piece  is  drawn  upward,   the  leg 

bends  toward  the  injuiy,  crepitus  exists, 

the  knee  is  much  broadened,  there  is  no 

shortening,  and  considerable  swelling  is 

sure    to    arise.      In    treating   a   fracture 

separating  either  condyle,  use  a  double  inclined  plane  as  directed  above. 

Longitudinal  fractures  run  upward  from  the  knee-joint.     The  cause 

is  a  fall  upon  the  feet  or  the  knees. 

Symptoms  and  Treatment. — The  s^-mptoms  of  longitudinal  fractiu-e  are 
often  obscure.  The  femur  is  broadened  when  the  knee  is  flexed.  The  spUt 
may  be  detected  between  the  condyles.  The  treatment  is  the  straight  posi- 
tion in  plaster  for  eight  weeks. 


Fig.  320. — Fracture  of  the  patella. 


6io 


Diseases  and  Injuries  of  Bones  and  Joints 


Separation  of  the  lower  epiphysis  occurs  only  before  the  twenty-first 
year.     It  is  not  a  very  rare  accident  in  children. 

Symptoms. — The  symptoms  in  separation  of  the  lower  epiphysis  are  like 
those  of  transverse  fracture,  but  crepitus  is  moist.  The  lower  fragment  is 
tilted,  so  that  the  articular  surface  looks  forward.  The  lower  end  of  the  upper 
fragment  projects  into  the  popliteal  space.  There  is  danger  to  the  struc- 
tures in  the  popliteal  space  and  that  the  growth  of  bone  will  be  stunted.  Feel 
for  the  pulse  in  the  leg  or  foot. 

Treatment. — Reduction  may  be  effected  in  some  cases  by  horizontal  ex- 
tension.    Occasionally  this  is  impossible.*     In  such  a  case  adopt  the  plan  of 


I'lg-  321. — Fracture  of  the  patella  (Periiipylvaiiia  Hospital  case;  skiagraphed  by  Dr.  Gaston  Torrance). 

Hutchinson  and  Barnard,  make  extension,  and  while  it  is  being  made  gradually 
place  the  leg  at  a  right  angle  to  the  thigh.  This  is  effected  by  an  assistant 
making  traction  on  the  leg,  while  the  surgeon  clasps  his  hands  beneath  the 
lower  part  of  the  thigh  and  draws  upward.  The  treatment  for  separation  of 
the  lower  epiphysis  is  the  use  of  a  double  inclined  plane  as  above  directed. 
In  some  cases  replacement  is  impossible  without  incision.  In  a  case  of  my 
own  amputation  was  performed  because  of  laceration  of  the  popliteal  vessels. 
Fracture  of  the  patella  is  a  very  common  accident.  Thefaa^e  is  direct  force 
(often  producing  vertical,  star-shaped,  or  oblique  hnes  of  fracture,  but  uncom- 
monly transverse)  or  muscular  action  (producing  a  transverse  line  of  fracture). 

*  See  the  case  reported  by  Jonathan  Hutchinson,  Jr.,  and  Howard  L.  Barnard,  Lan- 
cet, May  13,  1899, 


Transverse  Fractures  of  the  Patella 


6ii 


Transverse  Fractures  of  the  Patella. — The  knee  cap  is  more  often 
broken  by  muscular  action  than  is  any  other  bone.  When  the  knee  is  partly 
flexed  the  middle  third  of  the  patella  rests  upon  the  condyles  of  the  femur  and 
the  upper  third  of  the  knee-cap  projects  above  them;  when  in  this  position 
a  contraction  of  the  quadriceps  may  easily  cause  a  fracture  near  the  center 
of  the  bone  (Fig.  319).  The  accident  may  be  caused  by  sudden  flexion  of 
the  knee  when  the  quadriceps  is  contracting.  The  most  usual  cause  is  a 
fall  or  an  attempt  of  the  patient  to  save  himself  from  a  fall.  Both  patellae 
may  be  broken  at  once.  In  fracture  of  the  patella  the  joint,  and  often  the  pre- 
patellar bursa,  is  opened.     Fractures  by  muscular  action  are  transverse.     The 


Fig.  322. — Fracture  of  the  patella  (Pennsylvania  Hospital  case;  skiag^raphed  by  Dr.  Gaston  Torrance). 


injiu-y  is  more  common  in  males  than  in  females,  and  is  extremely  rare  in  the 
very  young  and  the  old.     It  is  an  injury  of  active  manhood  and  middle  hfe. 

Symptoms. — When  the  accident  happens  there  is  often  an  audible  crack. 
As  a  rule,  the  patient  will  not  try  to  use  the  hmb,  although  it  is  possible  for 
him  to  stand,  to  walk  backward,  and  to  move  slowly  forward  when  the  ex- 
tremity is  kept  straight.  After  the  accident  there  is  rapid  and  enormous 
swelhng,  due  to  the  effusion  first  of  blood  and  then  of  synovia  and  inflamma- 
tory products  into  and  around  the  joint.  The  patient  is  absolutely  unable  to 
raise  the  limb  from  the  bed.  The  fragments  are  movable  and  usually  widely 
separated  (Fig.  321),  this  separation  being  distinctly  manifest  to  the  touch 


6l2 


Diseases  and  Injuries  of  Bones  and  Joints 


unless  swelling  is  great.  The  separation  is  accentuated  by  flexion  of  the  leg. 
The  separation  may  be  to  the  extent  of  one  inch  or  even  more.  In  cases  in 
which  the  lateral  fibrous  expansions  and  periosteum  are  but  slightly  torn,  there 
ma)'  be  slight  separation  or  no  separation.  Separation  is  due  in  part  "to  the 
retraction  of  the  quadriceps  and  the  tension  of  the  fascia  lata,  and  in  part  to 

distention  of  the  joint  by  blood  and  exu- 
date."* If  fragments  are  not  approximated 
and  union  does  not  occur,  the  separation 
becomes  gradually  greater  because  of  the  pro- 
gressive shortening  of  the  muscle  and  the  re- 
traction of  the  hgamentum  patellee  (Stimson). 
In  some  cases  an  anterior  angular  displace- 
ment occurs  because  of  the  intra-articular 
distention  (Fig.  322).  It  may  be  produced 
by  the  pressure  of  bandages  or  strips  of  plas- 
ter when  the  fragments  have  been  brought 
together.  Crepitus  is  detected  if  the  upper 
fragment  can  be  pushed  do\\Ti  until  it  touches 
the  lower  piece;  but  if  swelling  is  great,  or  if 
fibrous  tissue  is  interposed  between  the  bones, 
crepitus  cannot  be  ehcited.  It  is  not  neces- 
sary  to  obtain  crepitus  in  order  to  make  the 
diagnosis:  the  condition  is  ob^dous  with- 
out this  sign.  The  anterior  fibroperiosteal 
layer  is  torn,  and  the  tear  does  not  corre- 
spond exactly  with  the  fine  of  fracture.  A 
portion  of  this  torn  fibroperiosteal  layer  may,  as  Macewen  pointed  out,  drop 
between  the  fragments  and  prevent  union  (Fig.  323).  The  lateral  expan- 
sions of  the  capsule  are  usually  extensively  torn.  If  union  occurs  after  a 
transverse  fracture,  it  will  probably  be  ligamentous,  and  if  the  patient  gets 
about  too  soon,  even  apparently  well-united  fragments  will  by  degrees  stretch 
far  asunder. 

Treatment  of  Transverse  Fractures  of  the  Patella. — The  Conser- 
vative Plan. — If  the  swelling  is  so  great  as  to  prevent   approximation  of 


Fig.  323 — Transverse  fracture  of 
the  patella  ;  fractured  surface  partially 
covered  by  irregular  flaps  of  torn  apyo- 
neurosis  (HofEa). 


524. — Needle  specially  designed  to  carry  a  thick  wire.     The  eye  is  drilled  obliquely,  and  should 
receive  only  a  little  loop  on  the  end  of  the  wire ;  this  loop  should  be  made  previously. 


the  fragments,  reduce  it  by  bandaging  for  a  day  or  two,  by  using  ice-bags,  or 
by  aspirating  the  joint.  As  a  rule,  the  blood  does  not  coagulate  for  several 
days.  After  it  coagulates  it  cannot  be  withdrawn  by  aspiration,  but  only  by 
incision.  "WTien  the  swelling  diminishes,  bring  the  two  fragments  into  ap- 
position, pull  them  together  by  adhesive  plaster,  and  put  on  a  well-padded 
*Stimson's  "Treatise  on  Fractures  and  Dislocations." 


Treatment  of  Transverse  Fractures  of  the  Patella 


6i^ 


Fig-  325  —  Needle  {a)  introduced  behind  the  fragments,  and 
receiving  one  end  (6)  of  the  silver  wire  (d,  c)  (Barker). 


posterior  splint.     Carry  a  piece  of  adhesive  plaster  over  the  upper  end  of  the 

upper  fragment,  draw  the  bone 

down,  and  fasten  the  plaster 

to  the  splint  behind  and  below 

the  level  of  the  joint.     Carry 

another  piece  of  plaster  over 

the  lower  end  of  the  fragment, 

draw  the  bone  up,  and  fasten 

the  plaster  to  the  splint  behind 

and  above  the  joint.    Carry  a 

third  piece  over  the  junction  of 

the  fragments  to  prevent  tih- 

ing.  Agnew's  splint  admirably 

accompUshes  this  approxima- 
tion (PI.  6,  Figs,  ii,  12).  A  ban- 
dage holds  the  spHnt  in  place, 

and  may  be  carried  around  the 

knee  by  iigure-of-eight  turns. 

The  heel  is  sometimes  raised 

upon  a  pillow  so  as  to  extend 

the  leg   and  to  semiflex   the 

thigh,  but  this  is  not  essential. 

Remove    and     reapply      the 

dressing  every  few  days,  as  it 

inevitably  becomes  loose.     At  each  removal  employ  massage.     At  the  end  of 

three  weeks  remove  the  sphnt  per- 
manently and  apply  a  plaster-of- Paris 
dressing  from  just  above  the  ankle  to 
the  middle  of  the  thigh,  and  get  the  pa- 
tient about  on  crutches.  Have  the 
plaster  cut  so  that  it  may  be  easily 
removed  and  every  day  employ  mas- 
sage and  gentle  passive  movements, 
the  surgeon  fixing  the  upper  end  of  the 
upper  fragment  by  his  thumb  during 
the  movements.  The  dressing  is  to 
be  worn  for  five  weeks.  After  eight 
weeks  of  treatment  allow  the  patient  to 
walk  with  canes,  the  joint  being  left 
free  at  night,  but  kept  fixed  during  the 
day  for  four  weeks  more  when  about 
on  crutches,  by  pasteboard  sphnts  or 
by  a  Hght  plaster-of-Paris  bandage. 
For  months  after  remo\'ing  the  spHnts 
and  plaster  a  lacing  knee-cap  of  leather 
should  be  worn  in  the  daytime  to  sup- 
port the  joint.     The  plan  of  prolonged 

immobilization   render   more   or   less   muscular  atrophy   and  joint-stiffness 

certainties,  but  there  are  less  serious  impediments  than  the  uide  separation 


Fig.  326. — Needle  (a)  passed  in  front  of  the 
fragments  and  receiving  the  other  end  (c)  of 
the  silver  wire  {b,  c)  (Barker). 


6i4 


Diseases  and  Injuries  of  Bones  and  Joints 


of  the  fragments  that  inevitably  attends  an  early  use  of  the  joint.     Bryant,  of 
New  York,  has  devised  an  ambulatory  dressing. 

Operative  Treatment. — Malgaigne's  hooks  are  obsolete. 
It  is  said  that  John  Rhea  Barton  wired  an  ununited  fracture  of  the  patellla 
in  1843.  In  1877  Hector  Cameron  wired  an  ununited  fracture  of  the  patella, 
and  a  few  months  later  I^ord  Lister  operated  on  a  fracture  of  the  knee-cap  two 
weeks  after  the  accident.  The  question  of  the  advisability  of  suturing  a 
recent  fracture  is  very  much  disputed.  The  ordinary  non-operative  plans  of 
treatment  do  not  endanger  life  and  generally  give  a  fairly  good  functional  result, 
although  the  joint  remains  insecure  on  extension,  the  patient  is  apt  to  fall,  and 
a  fall  may  refracture  the  bone.     The  operative  method  will  usually  succeed, 

and  is  capable  of  obtaining  a 
better  functional  result  and  of 
obtaining  it  more  rapidly. 
There  is  some  danger  of  infec- 
tion, and  if  infection  should  oc- 
cur, the  results  will  be  most 
disastrous.  Some  cases  obvi- 
ously cannot  be  treated  by  the 
ordinary  method  with  any 
chance  of  success;  cases,  for 
instance,  in  which  a  flap  of 
libroperiosteum  intervenes  be- 
tween the  fragments,  or  cases  in 
which  from  some  other  cause 
the  bones  cannot  be  approxi- 
mated. Such  cases  should,  of 
course,  be  operated  upon.  But 
in  the  great  majority  of  cases 
a  good  result  will  follow  con- 
servative treatment,  and  con- 
servative treatment  should  be 
trusted  to  unless  the  case  is  in 
the  hands  of  a  surgeon  and  in 
a  jjlace  where  every  antiseptic  precaution  can  be  taken.  We  agree  with  Stim- 
son  when  he  says  that  operative  methods  can  be  used  with  confidence  when 
surrounded  with  every  protection;  he  habitually  uses  them,  but  he  never  teaches 
them  as  proper  routine  practice,  and  strongly  advises  against  their  use  except 
by  those  who  have  had  experience  in  operating,  who  have  formed  the  habit  of 
taking  precaudons,  and  who  have  the  aid  of  skilled  assistants.*  Operation 
should  only  be  performed  on  healthy  persons  of  suitable  age,  when  the  sepa- 
ration is  over  one-half  an  inch  or  when  there  is  much  laceration  of  the  cap- 
sule.f  If  a  patient  is  still  able  to  extend  the  Hmb  and  the  lateral  expansions  of 
the  quadriceps  have  not  been  widely  torn,  a  useful  limb  will  be  obtained  by 
conservative  treatment  even  if  the  bone  fragments  separate,  and  operation  is 
not  demanded.  A  working  man  needs  the  operadon  more  than  a  gentleman 
of  leisure  because  he  is  in  more  vital  need  of  a  sound  knee-joint.  A  young 
or  middle-aged  person  is  more  active  than  an  elderly  person,  hence,  in  him 

*  Annals  of  Surgery,  Aug.,  1898. 

t  Powers,  in  Annals  of  Surgery,  July,  i8q8. 


Fig.  327. — Wire  in  position  round  fragments  and 
threaded  through  metal  bars.  The  lower  and  posterior 
wire  runs  upward  to  the  left  of  the  upper,  ready  for 
twisting  (Barker). 


Treatment  of  Transverse  Fractures  of  the  Patella 


615 


operation  is  more  strongly  indicated  than  in  an  elderly  man.  Barker  believes 
strongly  in  wiring  recent  transverse  fractures.  He  does  it  with  antisej)tic  care 
soon  after  the  accident,  and  permits  passive  motion  or  even  slight  active 
motion  immediately  after  the  operation.  Massage  is  begun  the  day  after  the 
operation,  and  is  practised  daily  for  two  weeks. 

Barker*  uses  a  special  needle  (Fig.  324)  and  silver  wire  of  the  thickness  of  a 
No.  I  English  catheter.    This  wire  is  straightened  and  softened  in  a  spirit-flame. 


Fig.  328. 


-Wired  fracture  of  the  patella  (St.  Joseph's  Hospital  case;  operated  upon  and  skia- 
graphed  by  Dr.  Nassau). 


He  rubs  the  bone  fragments  together  in  order  to  dislodge  blood  or  fibrous 
material,  and  when  marked  grating  occurs,  introduces  the  wire.  A  punc- 
ture with  a  small  knife  is  made  through  the  middle  of  the  upper  attachment  of 
the  patellar  ligament.  The  needle,  not  carrying  any  wire,  is  made  to  enter 
through  this  opening  into  the  joint,  is  passed  back  of  the  fragments,  pierces 
the  tendon  of  the  quadriceps  at  the  upper  edge  of  the  upper  fragment,  and  its 
point  is  cut  upon  with  a  knife.  The  wire  is  inserted  into  the  eye  of  the  needle 
and  the  needle  is  withdrawn  and  unthreaded.  The  empty  needle  is  pushed 
through  the  lower  opening,  is  carried  in  front  of  the  patella,  is  made  to  emerge  at 

*  See  the  objections  of  Sir  William  Stokes  to  Barker's  method,  in  Brit.  Med.  Jour., 
Dec.  3,  1898. 


6i6  Diseases  and  Injuries  of  Bones  and  Joints 

the  upper  opening,  is  threaded  \nth  the  protruding  wire  and  \nthdra\vn 
(Figs.  325,  326).  The  uires  are  threaded  into  bars  and  twisted  (Fig.  327), 
the  ends  are  cut  off,  and  antisepdc  dressings  are  applied.  There  are  object- 
tions  to  Barker's  operation:  It  does  not  allow  us  to  remove  blood-clots  from 
the  joint;  if  a  bit  of  tissue  intervenes  between  the  fragments,  it  cannot  be 
removed;  and  a  foreign  body  is  left  permanently  in  the  joint.*  If  an  opera- 
tion is  thought  advisable,  we  deem  it  best  to  do  an  open  operation,  making 
a  semilunar  or  a  central  longitudinal  incision,  freeing  the  joint  from  blood- 
clots  by  irrigation  with  hot  salt  solution,  removing  all  tissue  from  between  the 
fragments,  drilHng  the  fragments,  passing  silver  wire,  twisting  the  wire  and 
drawing  the  fragments  together,  and  closing  the  wound  (Fig.  328).  Instead 
of  wire,  silk  may  be  used.  In  cases  in  which  there  is  no  very  strong  tendency 
to  separation  the  fragments  can  be  held  together  by  several  catgut  sutures 
through  the  periosteum  at  the  fractured  edges  or  by  a  strong  catgut  suture 
passed  through  the  ligamentum  patellae  and  the  quadriceps  tendon  and  carried 
in  front  of  the  fracture  (Stimson).  The  hmb  should  be  placed  on  a  posterior 
splint.  In  seven  or  eight  days  the  superficial  sutures  are  removed  and  a  plas- 
ter-of -Paris  splint  is  apphed.  In  a  few  days  the  patient  gets  about  on  crutches. 
In  a  month  the  dressing  is  cut  down  the  front  and  worn  only  in  the  daytime, 
and  passive  motion  is  begun.  The  splint  is  discarded  at  the  end  of  the  third 
month,  t  Among  other  operative  procedures  we  may  mention  the  following: 
EncircUng  the  fragments  with  a  silk  suture  (the  circumferential  suture). 
This  suture  may  impair  bone  nutrition  and  retard  union.  Ceci  drills  the 
bones  subcutaneously  and  passes  wire  through  the  drill-holes  in  the  form  of  a 
figure-of-eight.  Passing  subcutaneously  a  Ugature  around  and  over  the  frag- 
ments (Butcher).  Incision  and  approximation  of  the  fragments  by  fixation- 
hooks  or  metal  pins. 

Fractures  of  the  patella  by  direct  force  are  verrical.  stellate,  obhque,  V- 
shaped,  or  transverse;  are  often  incomplete  and  occasionally  compound  or  com- 
minuted. Ransahoff  maintains  that  fractures  from  direct  force  are  more 
common  than  from  muscular  action  and  are  usually  transverse  and  associated 
with  some  comminution  ("Jour.  Am.  Med.  Assoc,"  Oct.  13,  1906). 

Compound  fracture  of  the  patella  is  very  rarely  seen  in  Philadelphia  hospitals. 
The  records  of  the  Boston  City  Hospital  (an  insdtudon  in  which  mulritudes  of 
fractures  are  treated)  show  only  8  compound  fractures  of  this  bone  in  forty- 
two  years  (Scannell,  in  "Boston  Med.  and  Surg.  Jour.,"  Nov.  15,  1906). 

Symptoms. — Fractiu-es  of  the  patella  by  direct  force  are  followed  by  dis- 
coloration, swelling,  great  difficulty  in  movement,  and  much  pain.  There  may 
or  may  not  be  crepitus.  The  degree  of  separation  of  the  fragments  depends 
upon  the  direction  of  the  fine  of  fracture  and  the  extent  of  bone  involved. 
Bony  union  is  apt  to  occiur  after  such  a  fracture. 

Treatment. — A  fracture  resulting  from  direct  force  may  often  be  treated 
with  a  posterior  splint  and  the  application  of  a  bandage.  If  there  is  any  separa- 
tion, the  fragments  should  be  approximated  by  adhesive  strips,  bandages,  and 
compresses.  At  the  end  of  three  weeks  remove  the  posterior  splint,  apply  a 
plaster-of-Paris  splint,  and  get  the  patient  about  on  crutches.  The  danger  in 
these  cases  is  ankylosis  rather  than  non-union;  hence,  in  the  fourth  week,  cut 
the  plaster  spHnt  down  the  front  and  begin  passive  motion  of  the  knee-joint. 

*Brit.  Med.  Jour.,  April  11,  1896. 

■j"  Stimson,  Annals  of  Surgery,  Aug.,  1898. 


Fractures  of  the  Ujjper  End  of  the  Tibia  617 

At  the  end  of  six  weeks  cease  wearing  the  dressing  in  the  daytime,  and  at  the 
end  of  three  months  discard  it  entirely.  In  those  rather  unusual  cases,  in  which 
an  oblique  fracture  with  wide  separation  arises  from  direct  force,  treat  as  advised 
for  transverse  fracture  from  muscular  action.  The  question  of  operation  is 
practically  the  same  as  for  transverse  fracture  from  muscular  action.  In  every 
compound  fracture  of  the  patella,  if  amputation  can  be  avoided,  incise  the  soft 
parts  freely  and  irrigate  the  joint  with  hot  saline  fluid.  Remove  hopelessly 
loosened  fragments.  Those  not  completely  separated  may  in  some  cases  be 
sutured  into  place.     Drain  twenty-four  or  forty-eight  hours. 

Ununited  and  Badly  United  Fracture  of  the  Patella. — There  is  usually 
a  band  of  union,  but  it  may  be  very  thin  and  the  fragments  may  be  far  asun- 
der. It  is  commonly  taught  that  the  degree  of  functional  impairment  depends 
directly  on  the  amount  of  separation.  This  is  not  strictly  true.  There  may 
be  great  separation  and  but  Httle  impairment  of  function,  the  fragments 
being  firmly  united  with  a  dense  fibrous  band.  There  may  be  little  separation 
and  yet  lameness,  stiffness  of  the  joint,  and  imperfect  power  of  extension. 
The  reason  for  this  has  been  pointed  out  by  Bruns,  of  Tubingen.*  He  says 
there  may  be  complete  failure  of  union,  even  when  the  separation  is  trivial,  and 
failure  of  union  produces  impaired  function.  If  separation  is  considerable,  the 
fragments  are  apt  to  tilt  and  tissue  is  often  interposed  between  them.  Func- 
tional difficulty  is  more  often  met  with  when  the  fragments  are  far  apart  than 
when  they  are  near  together,  because  non-union  is  more  common.  Even  if 
non-union  occurs,  in  some  cases  the  cjuadriceps  is  still  able  to  act  upon  the  tibia 
by  means  of  the  fascia  lata,  ligaments  at  the  sides  of  the  joint,  or  bands  from 
the  vasti  to  the  lower  fragment.  Besides  non-unian,  functional  impairment 
may  be  due  to  anchoring  of  the  upper  fragment  to  the  femur.  The  upper  frag- 
ment is  anchored  to  the  femur  by  the  interposition  of  the  fibrous  investment  of 
the  knee-cap,  which  covers  the  fractured  surface  of  the  upper  fragment  and 
grows  fast  to  the  capsule  of  the  joint  (Bruns). 

The  treatment  of  ununited  and  badlv  united  fracture  is  discussed  on  page 

538- 

Fractures  of  the  Leg. — In  leg-fractures  both  bones  or  only  one  bone  may 

be  broken. 

Fractures  of  the  tibia  are  divided  into  (i)  fractures  of  the  upper  end;  (2) 
separation  of  the  upper  epiphysis;  (3)  fractures  of  the  shaft;  (4)  fractures  of 
the  lower  end;  and  (5)  separation  of  the  lower  epiphysis. 

Fractures  of  the  upper  end  of  the  tibia  are  uncommon.  They  may  be 
transverse,  oblique,  or  vertical,  running  into  the  joint.  The  cause  is  direct 
violence. 

Symptoms. — In  fracture  of  the  upper  end  of  the  tibia  there  is  contusion  of 
the  soft  parts.  In  a  transverse  fracture  there  are  mobility  and  crepitus,  but 
there  is  little  displacement.  In  oblique  fracture  crepitus  and  mobihty  are 
marked,  the  axis  of  the  hmb  is  altered,  and  the  fragment  may  be  displaced. 
In  fractures  entering  the  joint  there  is  great  swelling  of  the  knee-joint.  In 
comminuted  fractures,  which  exhibit  marked  signs,  union  is  readily  obtained, 
but  if  the  joint  has  been  damaged,  stiffness  is  sure  to  ensue. 

Treatment. — Reduce  displacement  by  extension  and  manipulation.  The 
special  apparatus  used  depends  on  the  case.     In  some  cases  extension  is  re- 

*  "  Beitrage  zur  klinischen  Chirurgie,"  "  Mittheilungen  aus  der  chirurg.  KUnik  zu 
Tubingen,"  Bd.  iii,  Heft  2,  1888. 


6i8  Diseases  and  Injuries  of  Bones  and  Joints 

quired,  in  some  a  posterior  splint  is  applied  and  the  limb  is  suspended  from  a 
gallows,  in  some  a  double  inclined  plane  is  employed,  and  in  some  a  plastcr-of- 
Paris  splint  is  used. 

The  double  inclined  plane  in  the  form  of  Mclntyre's  splint  is  frequently 
employed,  or  a  double  inclined  plane  in  the  form  of  a  fracture-box  may  be 
preferred.  The  extremity  should  be  immobilized  for  four  weeks,  when  passive 
motion  should  be  begun.  Passive  motion  is  to  be  made  daily,  the  dressing 
being  reapplied  after  each  seance.  In  five  or  six  weeks  the  dressings  are  re- 
moved and  the  patient  allow^ed  to  go  about  on  crutches.  The  crutches  are 
soon  abandoned  for  a  cane,  and  later  all  support  is  dispensed  with.  If  a 
fracture  extends  into  the  knee-joint  and  the  ill-adjusted  fragments  block  the 
articulation,  the  joint  should  be  opened  and  the  fragments  placed  in  proper 
position. 

Separation  of  the  tubercle  of  the  tibia  is  due  to  violent  contraction  of  the 
quadriceps,  and  occurs  only  in  those  under  twenty  years  of  age.  The  frag- 
ment is  drawn  up  and  can  be  felt,  and  the  patient  is  unable  to  use  the  limb. 
In  a  case  in  which  the  tibial  spine  has  been  torn  off,  the  limb  should  be  placed 
on  a  posterior  straight  splint  and  the  fragment  should  be  pulled  down  into  place 
by  adhesive  strips  and  bandages.     The  splint  should  be  worn  for  five  weeks. 

Avulsion  of  the  Spine  of  the  Tibia. — This  is  a  very  rare  accident. 
There  are  but  4  cases  on  record,  and  in  only  i  of  them  (Pringle's)  was  the 
diagnosis  made  during  life,  and  it  was  made  in  that  case  by  exploratory  in- 
cision. The  tibial  spine  is  torn  off  by  the  anterior  crucial  hgament.  The 
causative  force  is  probably  flexion,  abducdon,  and  internal  rotation  of  the  leg 
(J.  Hogarth  Pringle,  "Annals  of  Surg.,"  August,  1907).  After  the  accident 
the  leg  at  the  knee  is  in  extreme  abducdon.  Explorator}'  incision  may  be 
necessary  for  diagnosis.  The  treatment  is  to  suture  the  bone  fragment  into 
place. 

Separation  of  the  Upper  Epiphysis  of  the  Tibia. — This  is  an  injury 
of  extreme  rarity.  It  does  not  seem  to  occur  after  the  sixteenth  year.  It 
is  caused  by  a  twist  or  by  violent  abduction  or  adduction  of  the  leg.  It  may 
lead  to  lessened  growth  of  the  limb.  The  treatment  is  as  for  a  fracture  of  the 
upper  end  of  the  bone. 

Fractures  of  the  Shaft  of  the  Tibia. — The  causes  of  these  fractures 
are  direct  force,  indirect  force,  or  torsion.  A  fracture  in  the  upper  part  of  the 
bone  is  usually  transverse;  in  the  lower  part  it  is  usually  obHque  (T.  Picker- 
ing Pick). 

Symptoms. — In  transverse  fracture  of  the  shaft  of  the  tibia  there  is  no 
deformity,  and  the  support  of  the  fibula  may  even  permit  of  walking;  there 
is  fixed  pain;  there  may  or  may  not  be  inequality  of  the  fragments  felt  by 
the  finger;  and  there  are  crepitus,  mobility,  and  often  linear  ecchymosis. 
In  oblique  fractures  there  usually  exist  crepitus,  a  little  mobility,  and  distinct 
deformity.  The  deformity  depends  on  the  direction  of  the  fine  of  fracture, 
and,  as  this  line  is  usually  from  above  downward,  inward,  and  a  Httle  for- 
ward, the  lower  fragment  usually  passes  behind  the  upper  fragment  and  ro- 
tates inward. 

Treatment. — In  treating,  fractures  of  the  shaft  of  the  tibia  effect  reduc- 
tion by  making  extension  from  the  foot  and  counterextension  from  the  knee, 
the  knee-joint  being  in  partial  flexion.  If  there  is  much  swelling,  put  the 
Hmb  in  a  fracture-box  (Figs.  329,  330,  and  PI.  6,  Fig.  i),  swing  the  box  from  a 


Fractures  of  the  Lower  End  of  the  Tibia 


619 


gallows,  and  apply  an  ice-bag  for  a  day  or  two.  A  silicate  of  sodium  or  a 
plaster-of- Paris  dressing  is  applied  when  the  swelling  subsides,  or  the  dressing 
may  be  used  at  once  instead  of  a  fracture-box  if  swelling  is  slight.  As  soon  as 
the  limb  is  immobilized  in  a  sihcate  or  plaster  dressing  the  patient  gets  about  on 
crutches.  The  dressing  is  removed  after  five  weeks,  and  the  patient  goes  about 
for  one  week  on  crutches,  lightly  using  the  foot,  and  then  for  a  time  walks  with 
the  aid  of  a  cane.  At  the  end  of  eight  or  nine  weeks  the  cane  may  often  be 
dispensed  with,  the  amount  of  use  of  the  leg  being  daily  augmented. 


Figs.  329,  330. — Fracture-box  in  fractures  of  the  bones  of  the  leg. 

Fractures  of  the  Lower  End  of  the  Tibia:  Fracture  of  the  Inner 
Malleolus. — The  cause  of  fracture  of  the  inner  malleolus  is  direct  force  or 
traction  upon  the  internal  lateral  ligament. 

Symptoms  and  Treatment. — The  symptoms  of  fracture  of  the  inner  malleolus 
are  some  downward  displacement,  depression  above  the  ends  of  the  fragments, 
mobility,  and  crepitus.  The  treatment  is  to  push  the  fragments  into  place 
and  use  side-splints  or  a  fracture-box  for  two  weeks,  when  a  plaster-of-Paris 
or  a  silicate  dressing  may  be  substituted  and  the  patient  be  ordered  to  use 
crutches.  Remove  the  plaster  four  or  five  weeks  after  it  is  appHed,  and  direct 
the  patient  to  gradually  bear  his  weight  upon  the  leg,  as  outlined  above. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  a  rare  accident,  but 


620 


Diseases  and  Injuries  of  Bones  and  Joints 


is  commoner  than  separation  of  the  upper  epiphysis.     The  treatment  is  a, 
fixed  dressing  for  six  weeks. 

Fracture  of  the  fibula  alone  is  commoner  by  far  than  is  fracture  of 
the  tibia  alone.  Fractures  in  the  upper  two-thirds,  which  are  rare,  are 
usually  due  to  direct  force.  Fractures  in  the  lower  third  are  frequent,  and 
arise  from  indirect  force. 

Fractures  of  the  Upper  Two-thirds  of  the  Fibula. — In  these  fractures 
the  cause  is  direct  force. 

Symptoms. — In  fracture  of  the  upper  two-thirds  of  the  fibula  the  patient 

is  frequently  able  to  walk.  The  bone  is  deeply 
situated,  and  displacement  cannot  often  be  de- 
tected. There  is  a  fixed  pain,  which  is  in- 
tensified by  movement  and  by  pressure.  Pres- 
sure upon  the  lower  fragment  does  not  move 
the  upper  fragment.  Crepitus  is  sometimes 
obtained,  and  a  linear  ecchymosis  is  apt  to 
appear.  The  bone  is  normally  elastic,  hence 
slight  mobility  is  of  no  value  diagnostically. 

Treatment. — In  treating  a  fracture  of  the 
upper  two-thirds  of  the  fibula  apply  a  plaster- 
of-Paris  or  a  silicate  bandage  and  direct  that 
it  be  worn  for  five  weeks.  Weight  is  not  to 
be  put  upon  the  foot  for  six  weeks  after  the 
accident. 

Fractures  of  the  Lower  Third  of  the 
Fibula. — In  these  fractures  the  cause  is  indi- 
rect force,  especially  twists  of  the  foot.  For- 
cible inversion  of  the  foot  pulls  upon  the  ex- 
ternal lateral  ligament  and  the  external  mal- 
leolus, forces  the  fibula  outward,  and  tends  to 
break  it,  the  lower  fragment  being  displaced 
outward.  Forcible  eversion  pulls  the  internal 
lateral  ligament  off  from  the  inner  malleolus 
(often  breaks  the  malleolus)  and  fractures 
the  fibula  above  the  ankle,  the  bone  being  dis- 
placed inward. 

Pott's  Fracture. — By  the  term  Pott's  frac- 
ture is  meant  a  fracture  of  the  lower  fifth  of 
the  fibula  produced  by  eversion  and  abduction 
of  the  foot.  Stimson  points  out  that  the  pro- 
duction of  Pott's  fracture  is  often  aided  by 
the  weight  of  the  body.  The  lesions  which  arise 
depend  upon  whether  the  chief  force  is  eversion  or  abduction.  "If  eversion 
is  the  sole,  or  main,  movement,  the  force  is  exerted  through  the  internal  lateral 
ligament  and  breaks  the  internal  malleolus  squarely  off  at  its  base;  then  it  presses 
the  external  malleolus  outward,  rupturing  the  tibiofibular  ligament,  and  breaks 
the  fibula  close  above  the  malleolus.  Sometimes  instead  of  pure  rupture  of 
the  tibiofibular  ligament  there  is  avulsion  of  the  portion  of  the  tibia  to  which  it 
is  attached."*  Stimson  further  points  out  that  if  abduction  is  the  preponderat- 
*  "  A  Practical  Treatise  on  Fractures  and  Dislocations,"  by  Lewis  A.  Stimson. 


Fig.  a  I .  —Pott's  fracture.  Dupuy- 
tren's  splint.  Note  length  of  splint ; 
position  of  straps;  arrangement  of 
padding;  space  between  foot  and 
splint  (Scudder). 


Pott's  Fracture  621 

ing  force  there  is  an  oblique  fracture  of  the  anterior  portion  of  the  internal 
malleolus  or  more  frequently  rupture  of  the  anterior  portion  of  the  internal 
lateral  ligament.  There  are,  as  in  the  former  case,  rupture  of  the  tibiofibular 
ligament  and  an  obhque  fracture  of  the  fibula  several  inches  above  the  exter- 
nal malleolus.  It  is  evident  that  the  degree  of  injury  produced  by  eversion 
and  abduction  depends  on  the  point  at  which  the  force  is  arrested.  It  may 
be  arrested  after  the  inner  malleolus  has  been  separated  or  the  anterior  fibers 
of  the  deltoid  ligament  torn,  and  in  this  case  the  tibiofibular  articulation 
remains  intact  and  the  fibula  is  not  broken.  It  may  cease  after  separating 
the  tibiofibular  articulation,  and  in  this  case  too  the  fibula  escapes.  It  may 
be  continued  until  the  filjula  breaks.  In  this  fracture  the  astragalus  passes 
outward,  somewhat  backward  and  also  upward,  the  later  deviation  being  due 
to  separation  of  the  tibiofibular  articulation. 

Symptoms. — The  foot  is  displaced  outward,  and  a  little  backward  and 
upward,  and  the  inner  malleolus  or  the  tibia  from  which  it  was  torn  is  ex- 
tremely prominent.  There  is  great  lateral  mobility  and  often  anteroposterior 
mobility  at  the  ankle-joint.  Stimson  points  out  that  there  are  three  points 
where  pressure  is  certain  to  provoke  pain:  in  front  of  the  tibiofibular  ligament, 
at  the  base  or  anterior  border  of  the  inner  malleolus,  and  over  the  seat  of 
fracture  through  the  fibula. 

Treatment. — Thorough  reduction  is  of  the  greatest  importance.  If 
thorough  reduction  is  effected,  a  good  result  will  probably  be  obtained;  but 
if  thorough  reduction  is  not  effected,  the  patient  will  be  permanently  crippled 
to  a  greater  or  less  extent.  In  order  to  effect  reduction  it  may  be  necessary 
to  anesthetize  the  patient;  The  deformity  is  corrected  "by  pressing  the 
calcaneum  forward  and  inward;  the  hand  is  placed  against  the  back  and 
outer  side  of  the  heel  and  pressed  forward  and  then  forcibly  inward."  * 

Some  surgeons,  at  once  after  reduction,  apply  a  plaster-of-Paris  bandage. 
This  treatment  is  objectionable  because  the  deformity  may  be  partially 
reproduced  after  the  application  of  the  dressing,  the  surgeon  being  unable 
to  see  it  and  unable  to  correct  it. 

If  there  seems  to  be  no  strong  tendency  to  a  recurrence  of  deformity,  a  frac- 
ture-box can  l^e  used.  After  reducing  displacement  in  such  a  case,  place  the 
limb  in  a  fracture-box  containing  a  soft  pillow.  A  bird's-nest  pad  of  cotton  or 
oakum  is  made  for  the  heel  (Figs.  329,  330).  A  fillet  around  the  ankle  fastens 
the  foot  to  the  foot-piece  of  the  box;  a  pad  of  oakum  rests  between  the  foot-piece 
and  the  sole.  A  compress  is  placed  below  the  outer  malleolus  and  another  one 
above  the  inner  malleolus.  Close  the  sides  of  the  box  and  tie  them  together 
with  a  bandage,  and  swing  the  box  on  a  gallows.  Every  day  let  down  the  sides 
of  the  box  and  rub  the  leg,  the  ankle,  and  the  foot  with  alcohol.  In  ten  days 
apply  a  plaster-of-Paris  bandage  and  let  the  patient  get  about  on  crutches. 
Remove  the  plaster  at  the  end  of  the  fifth  week  after  the  accident,  and 
let  the  patient  go  about  with  crutches  for  one  week  and  with  a  cane  for  a  week 
longer. 

I  am  accustomed  to  dress  most  cases  of  Pott's  fracture  with  a  Dupiiytren 

splint.     This  is  a  straight  splint  (Fig.  331  and  PI.  6,  Fig.  g)  which  reaches 

from  the  head  of  the  tibia  to  below  the  sole  of  the  foot.     This  splint  is  padded, 

and  a  pyramidal  pad  with  the  base  down  is  laid  upon  the  inner  surface  of 

*  Stimson's  "Practical  Treatise  on  Fractures  and  Dislocations." 


622  Diseases  and  Injuries  of  Bones  and  Joints 

the  leg,  above  the  inner  malleolus,  the  sphnt  being  put  upon  the  inner  sur- 
face of  the  leg,  over  the  pad.  The  splint  is  fastened  as  shown  in  Plate  6, 
Fig.  9,  and  Fig.  331.  If  the  short  sphnt  shown  in  Plate  6  is  used,  the  leg 
is  semiflexed  upon  the  thigh  and  is  laid  upon  the  outer  surface  on  a  pillow. 
After  ten  days  apply  the  plaster-of-Paris  bandage,  which  is  to  be  worn  as 
above  directed.  Bryant  treats  Pott's  fracture  with  a  posterior  splint,  two 
lateral  spHnts,  and  a  swing.  Stimson  uses  a  posterior  and  lateral  splint 
of  plaster-of-Paris.  This  splint  does  not  shp,  as  may  Dupuytren's  dressing, 
and  does  not  hide  the  seat  of  fracture  from  view  as  does  complete  encasement 
with  plaster  of  Paris.  It  is  a  most  useful  dressing.  I  have  given  above  the 
conservative  treatment  of  Pott's  fracture.  I  have  come  to  the  conclusion 
that  operation  should  be  the  rule  in  this  injury  and  not  the  exception.  The 
fracture  is  so  often  followed  by  pain,  sweUing,  and  disabihty,  pain  and  disa- 
bihty  are  so  largely  due  to  malunion  or  fibrous  union  of  the  broken  malleolus, 
and  it  is  so  easy  to  fix  the  fragment  in  place  by  sutures,  that  the  conclusion 
seems  obvious  that  in  proper  subjects  operation  should  be  performed.  As 
Heath  and  Selby  show,  in  an  important  ardcle  ("  Annals  of  Surg.,"  Jan., 
1908),  operation  allows  us  to  return  the  tibialis  posticus  to  its  normal  position 
and  thus  flat-foot  is  prevented.  The  plan  suggested  by  Heath  and  Selby  is 
excellent  (Ibid.).  The  fragment  may  be  sutured  in  place  by  silver  wire  or 
chromic  gut.  If  the  tendon  of  the  posterior  tibial  is  displaced,  the  torn 
annular  is  sutured  to  replace  the  tendon,  a  drain  of  rubber  tissue  is  carried 
down  to  the  bone,  and  the  soft  parts  are  sutured.  The  parts  are  dressed 
and  a  fixation  apparatus  is  applied.  The  drain  is  removed  in  twenty-four 
hours.  In  eight  weeks  he  should  be  walking  freely  (see  cases  reported  by 
Heath  and  Selby,  "  Annals  of  Surgery,"  Jan.,  1908).  Pott's  fracture  may  be 
compound,  a  portion  of  the  inner  malleolus  or  of  the  tibia  projecring  through 
the  wound.  If  it  is  necessary  to  introduce  through-and-through  drainage,  the 
foot  must  be  placed  and  kept  at  a  right  angle  to  the  leg.  If  a  compound 
fracture  exists,  the  malleolus  must  be  nailed  in  place  or  sutured  by  silver  Avire 
or  chromic  gut.  In  a  reported  case  the  wire  was  passed  through  the  joint  and 
around  the  fragment,  and  the  resiilt  was  good.*     Nailing  seems  a  better  plan. 

Fracture  of  both  bones  of  the  leg  is  a  very  common  injury,  is  often 
compound,  and  is  not  unusually  comminuted.  Fractures  by  direct  force, 
such  as  blows  or  kicks,  are  commonest  in  the  upper  half  of  the  leg.  Fractures 
by  indirect  force,  as  by  falls,  are  commonest  in  the  lower  half  of  the  leg. 
In  fractures  from  indirect  force  the  tibia  breaks  first,  and  then  the  fibula 
breaks  at  a  higher  level.  The  point  of  greatest  liability  to  fracture  from 
indirect  force  is  the  junction  of  the  lower  and  middle  thirds.  Fractures 
of  the  leg  are  usually  oblique,  but  they  may  be  transverse  if  arising  from 
direct  force.  Spiral,  torsion,  or  V-shaped  fractures  and  longitudinal  breaks 
sometimes  occur.  In  obhque  fractures,  as  a  rule,  the  line  of  fracture  runs 
from  behind,  downward,  inward,  and  a  little  forward. 

Symptoms. — Fracture  of  both  bones  of  the  leg  is  easy  of  recognition. 
The  fibular  fracture  is  detected  as  before  described.  By  running  the  finger 
along  the  crest  of  the  tibia  displacement  will  be  found,  except  in  transverse 
fractures,  when  it  may  not  occur.  The  common  displacement  is  for  the 
lower  fragment  to  ascend  and  pass  behind  the  lower  end  of  the  upper  frag- 
*Rev.  de  Chir.,  vol.  viii,  1888. 


Fractures  of  the  Bones  of  the  Foot  623 

ment  and  to  rotate  a  little  outward,  and  for  the  upper  fragment  to  project 
in  front.  The  ascent  of  the  lower  fragment  is  due  to  the  action  of  the  gas- 
trocnemius and  soleus  muscles.  If  the  line  of  fracture  is  in  a  direction  the 
reverse  of  that  which  is  usual,  the  lower  fragment  ascends  in  front  of  the 
lower  end  of  the  upper  fragment.  In  fracture  of  both  bones  of  the  leg  there 
are  marked  mobility  and  crepitus,  severe  pain,  and  inability  to  walk.  In 
fractures  from  direct  force  there  is  more  or  less  damage  to  the  soft  parts. 
A  fracture  of  the  shaft  of  the  tibia  near  the  ankle  is  distinguished  from  a 
dislocation  by  the  fact  that  the  deformity  is  easily  reduced,  but  tends  to 
recur  in  the  fracture,  and,  further,  that  in  a  fracture  the  relations  of  the  mal- 
leoli to  the  tarsus  are  unaltered,  whereas  in  a  dislocation  they  are  altered. 

Treatment. — If  the  fracture  is  near  the  ankle-joint,  the  action  of  the 
tendo  Achillis  may  maintain  deformity,  and  in  such  cases  the  tendon  should 
be  divided.  In  treating  a  simple  fracture  of  the  lower  two-thirds  of  the 
bones  reduce  by  extension  and  counter-extension,  and  use  a  fracture-box 
(Figs.  329, 330),  though  the  compresses  used  in  Pott's  fracture  are  not  required. 
If  the  soft  parts  are  bruised,  use  an  ice-bag  for  a  day  or  two;  if  they  are 
abraded,  apply  antiseptic  dressings.  The  fracture-box  should  be  swung 
upon  a  gallows.  After  three  weeks  apply  a  plaster-of-Paris  or  silicate  of 
sodium  dressing  and  let  the  patient  sit  up  in  a  chair  daily  for  one  week;  at 
the  end  of  this  time  the  patient  may  get  about  with  crutches.  At  the  end 
of  six  weeks  after  the  accident  remove  the  plaster,  and  let  the  sufferer  go 
about  on  crutches  for  two  weeks  and  with  a  cane  for  two  weeks  more.  Brinton 
dresses  a  fracture  of  both  bones  of  the  leg  for  two  weeks  in  a  fracture-box, 
for  two  weeks  in  side-splints  made  of  metal,  and  for  two  weeks  in  an  immova- 
ble dressing,  allowing  the  patient  to  get  about  on  crutches  as  soon  as  the 
plaster  is  put  on.  Instead  of  the  fracture-box,  we  may  use  a  posterior  splint, 
two  lateral  splints,  .and  a  swing.  Nathan  R.  Smith's  anterior  sphnt  is  used 
by  some  in  the  treatment  of  fractures  of  the  leg.  Many  surgeons  apply 
plaster-of-Paris  in  the  form  of  an  ambulatory  dressing.  In  this  dressing  a 
solid  apparatus  reaches  to  the  lower  third  of  the  thigh  and  below  the  sole 
of  the  foot.  When  the  patient  walks  the  weight  is  transmitted  to  the  thigh 
(Figs.  248  and  249).  In  fractures  of  the  upper  third  of  the  leg  the  Mclntyre 
splint  or  the  double  inclined  plane  is  used.  If  the  fracture  is  compound, 
asepticize  thoroughly,  make  a  counter-opening,  insert  a  drainage-tube,  dress 
with  bichlorid  gauze,  apply  a  plaster  bandage,  and  cut  trap-doors  over  the 
openings  of  the  tube  (see  Fig.  253),  or  dress  with  the  bracketed  splint  and 
plaster-of-Paris  (Fig.  254).  Remove  the  tube,  as  a  rule,  in  about  forty-eight 
hours;   but  the  patient's  temperature  is  the  guide,  not  time  of  retention. 

Fractures  of  the  bones  of  the  foot  are  rather  rare  accidents,  although 
not  so  unusual  as  we  once  thought,  for  the  a;-ray  has  taught  us  that  a  con- 
siderable number  of  supposed  sprains  are  in  reality  fractures.  Owing 
to  the  number  of  the  bones  and  to  the  elasticity  of  their  connections,  the 
force  of  blows  and  falls  is  spread  and  dissipated.  The  bones  most  often 
broken  are  the  astragalus  and  the  os  calcis.  Fractures  from  direct  force  are 
often  compound.  The  cause  of  fracture  of  either  the  scaphoid,  the  cuboid, 
or  one  of  the  cuneiform  bones  is  direct  force.  Simple  fractures  of  the  os 
calcis  and  astragalus  may  arise  from  crushes  or  twists  of  the  foot,  but  resuh, 
as  a  rule,  from  indirect  force,  such  as  falls.  The  calcaneum  may  be  broken 
by  a  direct  blow.     In  rare  instances  the  os  calcis  has  been  broken  by  con- 


624  Diseases  and  Injuries  of  Bones  and  Joints 

traction  of  the  great  calf-muscles.  Forcible  dorsal  flexion  of  the  foot  may 
fracture  the  neck  of  the  astragalus  (Eisendrath).  Compound  fractures 
may  result  from  gunshot-wounds,  crushes,  and  falls. 

Symptoms. — The  history  of  the  nature  of  the  accident  is  of  great  impor- 
tance. In  fracture  of  the  os  calcis  there  are  severe  pain,  swelling,  crepitus, 
mobiUty,  often  an  apparent  widening  of  the  bone,  and  not  unusually  a  loss 
of  the  arch  of  the  foot  (Pick).  In  some  cases  the  posterior  fragment  is  drawn 
up  by  the  calf-muscles,  and  in  other  cases  there  is  deformity.  In  fracture 
of  the  astragalus  displacement  may  occur  which  resembles  that  of  a  dis- 
location. Crepitus  may  or  may  not  be  detected.  It  can  be  elicited,  as  a 
rule,  by  rotating  the  foot  while  the  heel  is  firmly  held.  If  crepitus  cannot 
be  detected,  we  are  not  certain  that  a  fractiure  is  present,  even  though  the  pa- 
tient may  be  unable  to  stand  and  there  are  swelling  and  pain  on  pressure. 
The  malleoli  may  seem  on  a  lower  level  than  normal  if  the  astragalus  and 
OS  calcis  have  been  crushed.  Sometimes  the  foot  is  shortened,  and  perhaps 
the  fragments  have  been  dislocated  (Eisendrath,  in  "Annals  of  Surg.," 
March,  1905).  The  .r-rays  will  make  the  diagnosis  certain.  Fractures  of 
the  other  bones  are  difficult  of  detection  except  by  the  x-rays.  There  may 
or  may  not  be  crepitus,  which,  if  it  exists,  is  hard  to  localize;  there  is  pain 
on  standing  and  on  pressure,  and  there  is  bruising  of  the  soft  parts. 

Treatment. — In  simple  fracture  of  the  os  calcis  and  astragalus  without 
displacement  place  the  foot  at  a  right  angle  to  the  leg  and  apply  a  plaster 
cast.  This  is  cut  down  the  front  so  that  it  may  be  removed  easily.  On 
the  third  or  fourth  day  follow  Eisendrath's  advice  and  begin  massage  to  reduce 
swelhng  and  prevent  muscular  atrophy  ("Annals  of  Surg.,"  March,  1905). 
The  cast  is  worn  for  eight  weeks,  when  the  patient  may  begin  to  put  weight 
upon  the  extremity.  If  a  flat  foot  has  resulted  from  the  accident,  a  support 
must  be  worn  (page  759).  If  there  is  displacement  in  a  simple  fracture  of 
the  OS  calcis  or  astragalus  it  is  wisest  to  operate.  Perfect  correction  is  not 
possible  otherwise  and  no  apparatus  is  satisfactory.  The  fragments  are 
restored  after  incision  and  may  be  nailed  or  wired  in  place.  A  fragment 
may  require  removal  or  the  badly  splintered  bone  itself  may  have  to  come 
away.  If  the  tendo  Achillis  is  torn  loose,  it  should  be  sutured  to  the  os  cal- 
cis (Eisendrath).  Fractures  of  the  other  bones  of  the  tarsus  are  almost 
always  compound,  and  the  injury  may  require  drainage  and  immovable 
dressing,  excision  of  bones,  or  even  amputation.  If  they  are  not  compound, 
they  may  be  treated  by  a  plaster-of-Paris  dressing  or  may  require  incision 
and  fixation  or  removal. 

Fractures  of  the  metatarsal  bones  are  almost  invariably  due  to  direct 
force  and  are  almost  always  compound.  Robert  Jones  has  published  skia- 
graphs of  a  fracture  of  the  fifth  metacarpal  bone  from  indirect  force.  Crepitus 
may  be  absent  because  of  impaction  or  fixation  by  interosseous  ligaments. 
Jones  says  such  a  fracture  may  be  produced  by  the  pressure  of  the  body- 
weight  on  an  inverted  foot  the  heel  of  which  is  raised  ("Annals  of  Sur- 
ger}'', "  June,  1902).  When  only  one  bone  is  broken,  displacement  is  sHght, 
there  is  severe  pain  on  motion  and  pressure,  and  crepitus  can  generally  be 
obtained.  Pain  is  produced  by  flexing  the  toes,  putting  weight  upon  the 
toes,  as  in  walking,  and  by  inverting  or  everting  the  foot.  Fracture  of  the  third 
metatarsal  is  apt  to  destroy  the  arch  of  the  foot.     A  simple  fracture  of  a  meta- 


Acute  Simple  Synovitis  625 

tarsal  bone  is  treated  by  an  immovable  dressing  for  four  weeks.  Fractures 
from  crushes  usually  demand  excision  or  amf)utati()n. 

Fractures  of  the  phalanges  of  the  toes  are  due  to  direct  force  and 
are  often  compound.     They  may  require  immediate  amputation. 

Treatment. — In  a  compound  fracture  where  amputation  is  unnecessary, 
drain  with  strands  of  catgut  for  forty-eight  hours  and  dress  antiseptically, 
at  the  end  of  this  time  apply  over  the  bichlorid  gauze  a  gutta-percha  or  a 
pasteboard  splint  extending  from  beyond  the  end  of  the  toe  to  well  up  upon 
the  sole  of  the  foot,  and  fix  the  splint  in  place  with  a  spiral  bandage  of  the 
toe  and  instep.  The  splint  is  to  be  worn  for  four  weeks.  In  a  simple  fracture 
fasten  the  injured  toe  to  an  adjacent  toe  or  toes  by  a  plaster  bandage  and 
wear  the  dressing  for  three  weeks. 

Diseases  of  the  Joints. 

Synovitis  is  a  primary  inflammation  of  the  synovial  membrane  alone. 
If  other  structures  besides  the  synovial  membrane  are  involved,  the  con- 
dition is  known  as  "arthritis. "  Two  forms  of  simple  synovitis  exist — namely, 
acute  and  chronic.     Some  surgeons  speak  also  of  subacute  cases. 

Acute  Simple  Synovitis. — The  causes  of  acute  simple  synovitis  are  con 
tusions,  sprains,  twists,  and  overuse.  The  causative  influence  of  exposure 
to  cold  or  damp  has  been  much  debated.  It  seems  probable  that  in  some 
cases  cold  produces  vasomotor  paresis  of  the  vessels  of  the  synovial  mem- 
brane, a  condition  which  may  be  followed  by  inflammation.  In  synovitis 
the  synovial  membrane  is  red  and  swollen,  and  the  joint  contains  an  excess 
of  turbid  fibrinous  fluid.  If  the  inflammation  advances,  arthritis  arises  and 
sometimes  blood  is  eft'used. 

Symptoms. — A  prominent  symptom  of  acute  sjmovitis  is  pain,  which  is 
increased  by  motion  of  the  joint,  by  pressure  upon  the  articulation,  and  by  a 
dependent  position  of  the  limb,  and  which  is  worse  at  night.  Pressure  upon 
the  cartilage  does  not  cause  pain,  but  friction  of  the  synovial  membrane  at 
once  develops  it.  The  patient  places  the  limb  in  the  position  which  gives 
the  greatest  ease,  and  the  part  becomes  more  or  less  fixed  in  this  position 
because  the  muscles  about  the  joint  are  rigid.  A  fluctuating  swelling  is  noted 
in  a  superficial  joint,  most  marked  between  the  ligaments,  w'hich  swelling 
bulges  out  the  synovial  area  and  hides  or  obscures  the  articular  heads  of  the 
bones.  The  swelling  is  due  early  to  excessive  secretion  of  synovia,  and  later 
to  effusion  of  liquor  sanguinis.  Bulging  takes  place  at  points  where  the  cap- 
sule is  thin,  and  at  such  points  fluctuation  may  be  detected.  Fluctuation  in 
the  elbow  is  sought  for  posteriorly.  Fluctuation  in  the  knee  is  sought  for 
on  either  side  in  front.  A  large  effusion  in  the  knee  floats  the  patella  up 
from  the  condyles  {floating  patella).  A  small  efl'usion  in  the  knee  can  be 
detected  by  Fiske's  plan,  which  is  as  follows:  Tell  the  patient  to  bend  for- 
ward at  the  hips,  resting  each  hand  on  the  front  of  the  corresponding  thigh. 
The  anterior  structures  of  the  joint  are  thus  relaxed,  and,  by  tapping  the 
patella,  even  a  small  effusion  can  be  discovered.  Bulging  cannot  be  dis- 
tinctly recognized  in  the  hip  or  shoulder,  unless  effusion  is  great.  The  skin 
over  the  joint  is  rarely  reddened,  but  feels  hot  to  the  hand  of  the  observer 
(over  superficial  joints,  but  not  over  the  shoulder  and  hip);  the  joint  is  partly 
flexed;  fever  exists,  varying  in  degree  with  the  size  of  the  joint,  the  acute- 
40 


626  Diseases  and  Injuries  of  Bones  and  Joints 

ness  of  the  attack,  and  the  nature  of  the  cause.  Suppuration  rarely  follows 
simple  synovitis,  but  it  may  do  so,  the  area  of  synovitis  being  a  point  of  least 
resistance  to  organisms  carried  by  the  blood  or  lymph.  If  suppuration  takes 
place,  rigors  occur,  there  is  a  septic  temperature,  and  the  joint  soon  gives 
evidences  of  containing  pus.  These  evidences  are  violent  pain,  increased 
tenderness,  dusky  discoloration  if  the  joint  be  superficial,  greater  muscular 
spasm,  periarticular  edema,  and  constitutional  symptoms  of  sepsis.  Trau- 
matic synovitis  without  infection  tends  toward  cure  without  suppuration  if 
the  patient  is  healthy,  and  after  it  ankylosis  is  rare. 

Treatment. — In  treating  acute  synovitis  immobilize  the  joint.  In  severe 
cases  place  it  in  such  a  position  that  the  limb  will  still  be  useful  even  if  anky- 
losis occurs.  In  mild  cases  immobilize  in  the  position  of  rest,  apply  leeches, 
and  use  the  ice-bag  or  the  Leiter  coil.  After  a  day  or  two  apply  gentle  pres- 
sure, intermittent  heat,  and  iodin  and  ichthyol.  If  the  effusion  is  very  great 
and  persistent,  and  pressure,  heat,  and  sorbefacients  fail  to  remove  it,  aspirate 
with  aseptic  care.  If  effusion  recurs  after  aspiration,  apply  plaster-of 
Paris  dressing  or  use  flying  blisters  and  massage.  A  rubber  bandage  is  often 
useful  toward  the  termination  of  a  case. 

Chronic  Synovitis. — Chronic  synovitis  follows  acute  synovitis  or  it  may 
be  chronic  from  the  start.  Many  cases  called  chronic  synovitis  are  in  truth 
tuberculous  disease.  The  synovial  membrane  looks  nearly  natural,  but  is 
edematous,  and  the  joint  contains  an  excess  of  fluid.  If  the  quantity  of  fluid 
is  large,  the  disease  is  called  ^^ hydrops  articuli,^'  or  "dropsy.^'  A  large 
amount  of  fluid  in  the  knee-joint  "floats"  the  patella  upward.  Tuberculous 
infection  is  apt  to  occur  in  very  prolonged  cases.  In  prolonged  chronic 
synovitis  the  synovial  membrane  thickens  in  some  places,  softens  in  others, 
is  often  adherent,  and  the  villous  processes  hypertrophy.  If  the  membrane 
becomes  extensively  softened  (pulpy  degeneration),  the  softened  areas  bulge 
and  caseation  eventually  occurs.  In  the  knee-joint  a  traumatic  synovitis  is 
sometimes  linked  with  inflammation  of  the  semilunar  cartilages.  Roux  tells 
us  that  this  inflammation  may  be  produced  by  a  squeeze,  a  twist,  or  a  direct 
force,  but  a  squeeze  is  the  common  cause.  Hyperextension  of  the  knee  may 
squeeze  the  cartilage,  and  so  may  attempting  to  rise  from  a  stooping  posture.* 
If  this  injury  has  taken  place,  the  disability  will  be  prolonged. 

Symptoms. — In  chronic  synovitis  pain  is  absent  or  is  only  present  during 
exercise  or  from  pressure,  and  is  slight  even  then;  there  is  some  limitation 
of  movement;  passive  motion  may  develop  creaking  or  joint-crepitus;  fluc- 
tuation is  apparent  and  there  is  atrophy  in  the  muscle  about  the  joint.  The 
atrophy  of  the  muscles  associated  with  an  inflamed  joint  is  a  reflex  atrophy 
and  is  named  after  Charcot.  The  hypodermatic  needle  will  draw  out  a 
viscid,  straw-colored  or  bloody  fluid. 

Treatment. — Rest  and  pressure  are  of  great  service.  Pressure  may  be  ob- 
tained by  the  apphcation  of  Martin's  rubber  bandage.  A  plaster-of-Paris 
dressing  is  probably  the  best  way  to  combine  rest  and  compression.  Massage, 
douches,  frictions,  passive  movements,  and  flying  blisters  should  be  used. 
Painting  the  joint  with  iodin  and  spreading  over  it  blue  ointment,  and  rub- 
bing in  ointment  of  ichthyol  (50  per  cent,  wdth  lanolin)  may  do  good.  Coun- 
ter-irritation by  the  actual  cautery  is  a  valuable  expedient.  The  Bier  treat- 
ment (page  116)  is  often  of  benefit.  Chronic  synovitis  is  often  greatly  bene- 
*Gaz.  des  Hop.,  No.  125,  1895. 


Chronic  Synovitis 


627 


fited  by  the  use  of  a  hot-air  apparatus.  The  limb  is  wrapped  in  flannel  and 
is  placed  in  an  oven.  The  oven  is  heated  by  Bunsen  burners.  The  tempera- 
ture is  raised  to  250°  or  even  300°  F.,  and  the  limb  is  subjected  to  this  for 
one  hour.  The  oven  should  be  used  daily,  and  as  the  patient  becomes  accus- 
tomed to  it  even  a  higher  degree  of  heat  can  be  tolerated.  This  high  degree 
of  heat  can  be  borne  only  when  it  is  perfectly  dry.  Any  moisture  scalds  the 
patient.  The  Lentz  oven  has  in  it  ventilation  openings  to  get  rid  of  moisture 
and  the  sweat  is  taken  up  by  the  flannel.  This  flannel  must  not  be  applied 
so  thickly  as  to  keep  the  heat  notably  from  the  joint,  nor  must  so  little  of  it 
be  used  as  to  permit  of  its  soaking  with  sweat.  Fig.  332  shows  the  Sprague 
hot  dry-air  apparatus,  and  P'ig.  2,^^  exhibits  a  cross-section  of  the  same  ap- 


Fig.  332. — Sprague  hot  dry-air  apparatus. 


paratus.  Dr.  H.  A.  Wilson  inserts  in  the  oven  humidin,  a  product  obtained 
in  the  purification  of  salt,  which  material  entirely  absorbs  the  moisture.  Cotton 
should  not  be  used  to  wrap  the  Hmb,  because,  if  the  bottom  of  the  oven  be- 
comes red  hot,  the  cotton  may  ignite  and  burn  the  patient.  A  physician  or 
nurse  should  constantly  watch  the  apparatus  during  its  employment.*  Aspira- 
tion and  the  subsequent  use  of  a  plaster-of-Paris  bandage  may  be  tried  in  some 
cases  of  chronic  synovitis.  Some  surgeons  ad\'ise  aspiration,  washing  out  with 
salt  solution,  injecting  a  5  per  cent,  solution  of  carbohc  acid,  and  immobihz- 
ing.  Incision  and  drainage  constitute  a  radical  but  proper  plan  in  cases  un- 
amended by  simpler  methods.  If  pulpy  degeneration  exists,  perform  an  ex- 
*H.  A.  Wilson,  in  Annals  of  Surgery,  Feb.,  1899. 


628 


Diseases  and  Injuries  of  Bones  and  Joints 


cision  or  an  erasion.     If  pus  forms,  incise  at  once  and  drain.     Internaliy,  treat 
any  existing  diathesis  and  give  nutritious  food,  tonics,  and  stimulants. 

Arthritis. — By  this  term  is  meant  not  only  inflammation  of  a  synovial 
membrane,  but  also  of  other  structures  composing  and  surrounding  a  joint. 
It  may  follow  traumatic  synovitis;  it  may  be  due  to  pus-organisms,  to  tubercle 
bacilli,  to  infectious  diseases  (gonorrhea  and  typhoid  fever),  to  rheumatism, 
to  gout,  to  syphilis,  and  to  lesions  of  the  spinal  cord.  Arthritis  may  be  either 
acute  or  chronic. 

Tuberculous  Arthritis  (White  Swelling;  Strumous  Joint;  Pulpy  Degen- 
eration).— Pathology  and  Symptoms. — The  predisposing  causes  of  tubercu- 
lous arthritis  may  be  strains,  blows,  twists,  or  cold.  The  real  cause  is 
the  tubercle  bacillus.  A  single  joint  is  attacked.  Other  joints  may  sub- 
sequently become  involved  so  that  several  suffer  simultaneously,  but  it  is 
rare  that  the  process  is  active  in  more  than  one  joint  at  the  same  time. 
During  the  course  of  tuberculous  disease  of  a  joint  (except  of  the  shoulder- 
joint)  phthisis  is  not  common,  although  it  not  unusually  develops  after  the 
joint  gets  well.  The  same  is  true  of  tuberculous  glands.  During  the  ex- 
istence of  phthisis  or  tuberculous  glands  tuberculous  arthritis  does  not 
frequently  arise.  The  primary  infection  with  tubercle  bacilli  is  usually  in 
the  bone,  though  it  may  be  in  the  synovial  membrane,  the  joint-capsule, 
or  the  structures  about  the  joint.  The  frequency  of  the  bony  origin 
of    tuberculous    arthritis    is    shown    by     Murphy's     statement     that     in 

128  cases  of  tuberculosis  of  the 
knee  it  was  demonstrated  in  all 
but  2  that  the  condition  originated 
in  the  bone  (John  B.  Murphy, 
in  "Jour.  Am.  Aled.  Assoc,"  May 
20-27,  June  3,  1905).  If  the 
primary  infective  focus  is  in  the 
bone,  a  portion  of  the  cartilage 
is  destroyed  and  the  joint  is 
opened,  or  a  sinus  forms  and 
perforates  the  synovial  membrane. 
When  tuberculous  inflammation  at- 
tacks the  synovial  membrane  granu- 
lation tissue  is  formed,  and  the 
capsule  and  periarticular  structures 
soon  become  involved  in  the  proc- 
ess; the  parts  thicken  and  soften 
from  caseation,  and  they  may  be 
covered  with  tubercles,  though  but 
little  fluid  is  usually  effused  into 
the  joint.  Some  few  cases  present 
large  joint  effusions,  but  in  most 
cases  fluctuation  is  absent.  Cap- 
sular thickening  may  or  may  not  be 
manifest.  Soon  after  tuberculous 
arthritis  begins  the  joint  becomes  rigid,  irritation  having  induced  mus- 
cular spasm.  This  reflex  rigidity  fixes  the  joint  more  or  less  completely, 
and  atrophy  of  the  rigid  muscles    soon  begins.      There  is  usually  pain 


Fig.  333.  ^Cross-section  of  Sprague  hot  dr^*- 
air  apparatus :  a,  a,  Air  intakes ;  b,  circulating 
air  space ;  e,  jacketed  space  for  products  of 
combustion;  G,  treatment  chamber;  m,  m,  cork 
ribs  ;  n,  n,  perforations  admitting  heated  air  ;  o, 
base  holding  apparatus  ;  p,  p,  gas-burners. 


Tuberculous  Arthritis  629 

in  tuberculous  arthritis,  but  it  may  be  referred  to  a  distant  part. 
For  instance,  in  hip-joint  disease  the  pain  is  often  referred  to  the  inner 
side  of  the  knee,  and  in  Pott's  disease  of  the  spine  the  pain  may  be 
referred  to  the  abdomen.  Attempts  at  motion  demonstrate  the  limitation  of 
movement  due  to  muscular  rigidity  and  also  produce  pain.  A  child  that 
suffers  from  a  tuberculous  joint  is  apt  to  be  restless  in  sleep,  moaning  and 
tossing,  and  to  wake  at  times  crying  out  in  terror  {night-cries  and  night- 
terrors).  In  the  ordinary  form  of  tuberculous  arthritis  there  occurs  what  is 
known  as  "gelatinijorw  degeneration'' ;  the  granulation  tissue  is  formed  in 
large  amount  as  fungous  growths;  the  structures  are  markedly  edematous 
and  softened;  the  relaxed  Hgaments  yield  under  pressure;  the  natural  con- 
tour of  the  joint  is  lost,  and  it  becomes  spindle-shaped;  all  the  structures, 
articular  and  periarticular,  are  glued  into  one  mass;  the  skin  about  the  joint 
is  white,  thick,  and  adherent,  and  in  it  one  or  more  large  veins  are  seen;  fluct- 
uation or  pseudo-fluctuation  is  noted  when  caseation  has  occurred;  pain  is 
not  often  severe,  but  it  can  usually  be  elicited  by  certain  motions  or  by  firm 
pressure,  but  the  pain  will  always  be  severe  when  the  epiphysis  is  involved; 
the  temperature  of  the  part  is  seldom  elevated;  deformity  results  from  destruc- 
tion of  bone,  cartilage,  and  ligament,  from  muscular  spasms,  and  from  the 
habitual  assumption  of  certain  attitudes  to  secure  relief  from  pain.  There 
is  soon  impairment  of  joint-motions.  When  the  products  of  a  tubercu- 
lous arthritis  caseate,  the  thick  liquid  seeks  exit  by  forming  sinuses  from 
which  caseous  pus  flows.  If  a  sinus  becomes  infected  with  pyogenic  cocci, 
and  the  joint  itself  becomes  their  prey,  acute  suppuration  arises  in 
the  joint,  and  constitutional   involvement   is  pronounced   and  perilous   to 

life. 

In  pannous  synovitis  a  large  effusion  is  formed,  there  is  but  little 
granulation  tissue,  though  the  tubercles  are  present  in  large  numbers, 
and  the  ligaments  and  structures  about  the  joint  are  slightly  or  not  at  all 
implicated. 

Diagnosis  and  Prognosis. — Tuberculous  chronic  synovitis  produces  great 
swelling  and  distinct  thickening  of  the  capsule  with  obliteration  of  the  out- 
lines of  the  joint,  but  there  are  no  spasm,  no  atrophy,  no  limitation  of  motion, 
no  severe  pain,  and  no  tendency  to  subluxation  (Shaffer).  Tuberculous 
arthritis  rarely  causes  distinct  fluctuation,  does  not  thicken  the  capsule,  causes 
reflex  muscular  spasm,  rigidity  of  the  joint,  muscular  atrophy,  severe  pain  on 
movement,  and  eventually  subluxation  (Shaffer).  In  syphilitic  arthritis 
there  is  usually  some  fluctuation,  distinct  enlargement  of  the  joint,^  Hmitation 
of  motion,  no  reflex  spasm,  trivial  atrophy,  but  distinct  pain  on  motion  (James 
K.  Young,  "Therapeutic  Gazette,"  June  15,  1902).  Acute  rheumatism 
attacks  more  than  one  joint,  is  very  rare  in  childhood,  and  produces  high 
fever.  The  ic-rays  aid  in  the  diagnosis  of  tuberculous  arthritis  and  enable  us 
to  tell  the  extent  of  bone-involvement. 

The  diagnosis  in  a  tuberculous  joint  is  often  difficult,  and  sometimes 
impossible,  and  the  prognosis  is  always  grave.  In  only  a  very  few  cases 
even  when  recognized  early,  is  a  cure  obtained  without  some  impairment  of 
joint-function.  The  best  that  can  usually  be  accomplished  is  a  cure  with  more 
or  less  ankylosis,  fibrous  or  bony;  and  often  ankylosis  is  complete.  Long 
after  the  disease  is  apparently  cured,  it  may  break  forth  anew.     Tuberculous 


630  Diseases  and  Injuries  of  Bones  and  Joints 

lesions  may  arise  in  a  distant  organ,  or  general  tuberculosis  may  occur. 
Caseation  is  apt  to  produce  severe  constitutional  disorder.  Infection  by 
pus-organisms  gives  rise  to  grave  danger  of  septicemia.  Death  is  not  unusual 
from  exhaustion,  from  septicemia,  from  disseminated  tuberculosis,  from 
tuberculosis  of  an  important  organ,  or  from  amyloid  disease. 

Treafment. — Conservative  treatment  is  especially  successful  in  children. 
According  to  Hofifa,  in  75  per  cent,  of  cases  in  children  non-operative  treat- 
ment will  produce  cure  ("  Die  Bekampfung  der  Knochen-  u.  Gelenktuberculose 
in  Kindesalter  Tuberculosis,"  iv,  i,  1905).  This  conser\'ative  treatment 
consists  in  open-air  life,  if  possible  in  a  sanitarium,  the  following  of  the  plans 
outlined  under  Tuberculosis,  immobiUzation  and  extension  of  the  joint,  and 
injections  of  iodoform  emulsion.  Even  when  tuberculous  pus  forms  the  same 
treatment  may  be  followed  unless  there  is  ^^olent  pain  or  elevated  tempera- 
ture which  does  not  quickly  abate,  in  which  case  operation  must  be  performed. 
Cases  treated  early  by  conservative  methods  may  get  well  with  a  movable 
joint,  but  in  most  cases  there  is  a  stiff  joint  when  the  disease  is  arrested.  Con- 
stitutionally, the  treatment  is  directed  against  the  tuberculous  diathesis.  The 
patient  should  be  placed  under  good  hygienic  conditions.  A  change  of  cli- 
mate is  often  of  the  greatest  importance.  Many  cases  do  well  at  the  seaside; 
others  require  high  altitudes,  and  all  should  live  in  the  open  air.  Locally, 
rest  is  of  the  first  importance,  and  fixation  is  maintained  for  many  weeks.  Rest 
is  best  secured  by  immobilization  and  traction,  and  traction  is  applied  or  main- 
tained by  splints,  by  plaster-of-Paris  bandages,  or  by  extension  appKances. 
The  hot-air  apparatus  may  be  of  some  benefit.  If  it  is  employed,  it  should  be 
used  daily,  the  limb  being  immobilized  during  the  remainder  of  the  twenty- 
four  hours.  Fixation  must  be  maintained  as  long  as  pain  exists  or  can  be 
induced  by  movement  or  pressure.  Fixation  must  be  abandoned  gradually, 
and  mobilit}'  is  to  be  slowly  regained.  During  restoration  to  mobility,  if  pain 
arises,  the  part  must  be  again,  but  temporarily,  immoljilized.  ^Movements 
should  never  be  violent,  prolonged,  or  repeated  at  too  close  intervals.  Forci- 
ble breaking  up  of  an  ankylosis  is  never  ad\-isable  in  the  knee,  ankle,  or  hip; 
it  is  seldom  advisable  in  the  arm.  Such  an  attempt  may  be  followed  by  a 
fresh  outbreak  of  the  disease.  Osteotomy  or  resection  will  more  safely  correct 
a  faulty  and  disabling  deformity.  In  tuberculous  joints  intra-articular  in- 
jections of  iodoform  are  often  of  the  greatest  value.  This  drug  strongly 
stimulates  the  formation  of  fibrous  tissue.  If  sufficient  fibrous  tissue  is  formed 
the  tuberculous  foci  will  be  firmly  encapsuled  and  the  case  will  be  cured.  Bier's 
plan  of  inducing  passive  hyperemia  is  often  of  great  service  (page  1 16).  Aspi- 
ration or  incision  can  be  used  for  fluid  accumulations.  Caseous  masses  are 
often  let  alone,  or  an  aspirator  is  used  and  the  joint  drained,  washed  out  with 
saline  solution,  and  injected  with  an  emulsion  of  iodoform  and  glycerin  (10 
per  cent.) .  From  i  to  2  drams  are  injected  into  the  joint  of  a  child,  from  2  to 
5  drams  into  the  joint  of  an  adult.  Even  surface  lesions  are  not  curetted. 
Bier's  treatment  should  be  associated  with  immobihzation  and  systemic  treat- 
ment. It  is  more  serviceable  in  tuberculosis  of  the  small  joints  than  in  disease 
of  the  large  articulations.  There  are  certain  contra-indications  to  Bier's 
treatment,  \iz. :  serious  pulmonary  involvement,  extensive  amyloid  degenera- 
tion, and  the  existence  of  such  an  unfavorable  position  of  the  parts  that  cure 
by  ankylosis  would  mean  a  less  useful  hmb  than  cure  by  resection  (Bier  at 


Tuberculous  Arthritis  631 

Internat.  Surg.  Congress  of  1905).  One  advantage  of  this  treatment  is 
that  we  can  employ  active  and  passive  motion  early,  except,  according  to  Bier, 
when  the  foot  or  knee  is  diseased.  In  many  very  serious  cases  cure  is  obtained 
without  any  limitation  of  activity  and,  as  the  patient  can  get  about,  it  is  not 
necessary  to  restrain  him  long  in  a  hospital.  Personally  I  beheve  that  fixation 
should  be  the  basis  of  treatment  in  most  cases  and  that  passive  hyperemia, 
compression,  counter-irritation,  and  iodoform  injections  should  be  additions 
to  fixation.  Injections  of  balsam  of  Peru  or  of  iodoform  emulsion  about  the 
joint  once  a  week  are  efficient  in  some  cases.  It  is  not  wise  to  attempt  to 
correct  faulty  position  until  the  focus  is  well. 

Fistulae  are  treated  by  the  method  of  Beck,  of  Chicago,  that  is,  by  the  in- 
jection of  a  paste  containing  bismuth.  In  early  cases  a  bismuth-vaselin  paste 
is  used,  in  late  cases  a  bismuth-wax-paraffin  paste. 

Beck  described  his  method  in  the  "IlHnois  Med.  Jour.,"  April,  1908. 
The  vaseHn  paste  is  composed  of  30  parts  of  subnitrate  of  bismuth  and  60 
parts  of  vaselin,  mixed  while  boiling.  The  paste  for  later  cases  is  composed  of 
30  parts  of  subnitrate  of  bismuth,  5  parts  of  white  wax,  5  parts  of  soft  paraffin, 
and  60  parts  of  vaselin,  mixed  while  boiling.  One  per  cent,  formalin  is  often 
added  to  these  pastes.  The  paste  is  injected  before  an  x-ray  picture  is 
taken,  and  the  picture  shows  all  the  ramifications  of  the  fistula.  The  paste 
is  left  in  for  treatment.  If  a  sequestrum  exists  it  should  be  removed  before 
the  paste  is  injected.  It  is  not  necessary,  but  is  advisable,  to  dry  the  fistula 
before  injecting. 

The  paste  is  steriUzed  l^efore  using.  It  is  sucked  up  into  the  syringe 
while  still  hquid  and  is  cooled  to  the  requisite  temperature  and  hardened  to  the 
proper  consistency  by  running  cold  water  over  the  syringe.  It  is  injected  very 
slowly  and  the  injection  is  continued  until  a  sense  of  pressure  annoys  the 
patient.  Then  the  syringe  is  laid  aside,  a  bit  of  gauze  is  held  for  a  time  over  the 
outlet  of  the  fistula  to  keep  the  paste  from  running  out,  and  an  ice-bag  is  put 
over  the  region  to  quickly  harden  the  injected  material.  There  is  no  pain 
from  such  an  injection.  Beck  employs  the  first  paste  until  pus  disappears  and 
then  uses  the  second. 

The  value  of  this  paste  is  that  it  distends  and  fills  the  abscess- cavity  and 
sinus,  and  affords  a  trestle  or  frame  for  granulations  to  grow  upon.  Con- 
siderable of  the  paste  may  run  out  of  the  fistula  during  the  first  twenty-four 
hours.  In  shallow  sinuses  it  all  runs  out.  In  deep  and  tortuous  fistulas  much 
of  it  remains  for  weeks  and  is  slowly  absorbed.  In  empyema  and  bone  ca^•ities 
it  is  slowly  absorbed.  Beck  holds  that  the  paste  is  bactericidal,  astringent, 
and  non-toxic.  Cases  of  ulceration  in  the  mouth  from  absor[)tion  of  bismuth 
have  been  recorded  and  at  least  one  death  is  on  record  (Eggenberger,  in  "Zen- 
tralblatt  fiir  Chir.,"  Oct.  31,  1908).  Beck  hmits  the  first  dose  to  loc  gm.,  but 
increases  the  amount  later.  This  is  undoubtedly  a  valuable  method.  I  have 
seen  sinuses  heal  under  it  after  they  had  resisted  various  other  plans  of  treat- 
ment. It  may  be  used  in  sinuses,  cold  abscesses,  empyema,  tuberculous  joints, 
and  other  conditions. 

If  these  means  fail,  if  the  patient  gets  worse,  if  there  is  persistent  fever  or 
violent  pain,  if  sequestra  exist,  if  there  is  mixed  infection,  or  if  the  condi- 
tion of  the  sufferer  renders  dangerous  the  prolonged  conservative  course, 
operate,  removing  the  entire  diseased  area  by  erasion,  by  excision,  or  possi- 


632 


Diseases  and  Injuries  of  Bones  and  Joints 


bly  by  amputation.  If  the  .r-ray  picture  shows  extensive  sequestrum  forma- 
tion, operation  is  indicated.  If  amyloid  degeneration  exists,  conservative 
treatment  is  contraindicated  and  so  is  resection.  Amputation  must  be  done. 
Always  remember  that  an  incomplete  operation  or  a  partial  removal,  unless  it 
consists  of  simple  drainage,  is  worse  than  no  operation,  as  it  opens  the  portals 
to  systemic  infection,  and  may  be  responsible  for  the  development  of  general 
tuberculosis,  septicemia,  or  pyemia.  Simple  drainage,  as  previously  stated,  is 
seldom  advisable.  Garre  is  of  the  opinion  that  the  hip,  wrist,  and  shoulder 
do  best  by  conservative  treatment;  the  knee,  elbow,  and  ankle  by  operative 
treatment  (John  W.  Churchman,  in  "Am.  Medicine,"  April,  1906). 

Tuberculosis  of  Special  Joints.— Tuberculosis  of  the  Sacro- 
iliac Joint  {Sacro-iliac  Disease). — This  is  an  uncommon  affection,  and  is 
especially  rare  before  the  age  of  fifteen.  The  disease  may  begin  in  the  joint, 
may  arise  in  adjacent  bones,  or  may  result  from  a  cold  abscess  burrowing 
into  the  joint.  In  some  cases  it  is  associated  with  extensive  disease  of  the 
pelvic  bones.  The  disease,  if  undetected,  may  lead  to  dissemination  of 
tubercle,  to  abscess,  or  even  to  death. 

Symptoms  are  often  obscure.  The  disease  is  frequently  confounded  with 
vertebral  caries,  hip-joint  disease,  or  sciatica.    The  patient  limps  on  walking, 


Fig.  334.— Sacro-iliac  disease ;  operated  upon  and  cured. 


but  can  stand  on  either  leg;  there  is  pain  in  the  sacro-iliac  joint,  about  the 
hip,  and  down  the  thigh;  tenderness  is  manifest  on  pressure  over  the  joint 
and  on  pushing  the  ilia  together;  there  is  fulness  over  the  sacro-iliac  joint; 
but  the  hip  is  not  flexed  unless  iliac  abscess  exists.* 

Treatment. — Rest  in  bed  for  months,  using  also  a  felt  case  for  the  pelvis. 

Counter-irritation  by  blisters  and  the  actual  cautery.     In  some  cases  injection 

of  iodoform;  in  others,  incision  and  curetting.     I  have  opesated  on  six  cases, 

with  one  death.     In  one  case  in  the  Jefferson  Medical  College  Hospital  the 

*See  A.  G.  Miller,  Edinburgh  Med.  Jour.,  May,  1895. 


Tuberculosis  of  the  Hip-joint  633 

abscess  was  pointing  in  both  the  back  and  groin.  Both  areas  were  incised, 
the  diseased  bone  was  removed,  and  the  boy  uhimately  recovered  (Fig.  334). 
In  another  case  the  abscess  pointed  in  the  groin.  The  treatment  was  as  pre- 
viously set  forth,  and  the  patient,  a  woman,  recovered. 

Tuberculosis  of  the  Hip-joint  {Hip  Disease;  Morbus  Coxariiis;  Mor- 
bus Coxce;  Coxitis;  Hip-joint  Disease). — The  primary  lesion  may  be  in  the 
synovial  membrane,  but  it  is  more  often  in  the  bone.  It  may  begin  in  the 
acetabulum;  it  may  begin  in  the  femur.  In  95  percent,  of  cases  it  begins  in 
the  head  of  the  femur.  If  it  begins  in  the  femur,  it  usually  arises  on  "the 
distal  side  of  the  epiphyseal  cartilage"  (Senn).  Sometimes  primary  tubercu- 
losis arises  in  the  trochanter  major,  and  never  involves  the  joint.  W^hen 
the  synovial  membrane  becomes  involved  at  any  point,  spreading  throughout 
the  joint  is  rapid.  In  many  cases  the  articular  cartilages  are  attacked,  and  in 
some  cases  the  epiphyseal  cartilage  is  destroyed.  It  is  commonest  in  children, 
but  it  may  arise  in  adults  and  even  occasionally  in  those  of  advanced  years; 
62  per  cent,  of  cases  arise  in  children  under  ten  years  of  age  and  80  per  cent, 
of  cases  occur  before  the  twentieth  year  (Bryant).  Traumatism  and  cold  may 
be  predisposing  causes.  The  disease  strongly  tends  to  caseation  and  the 
formation  of  sequestra. 

Symptoms. — It  has  been  usual  to  divide  the  disease  into  three  stages:  (i) 
the  stage  of  microbic  deposition  and  multiplication,  the  products  of  the 
bacilli  causing  irritation  and  new  growth;  (2)  the  stage  of  progression,  with 
formation  of  masses  of  granulation  tissue  and  effusion  into  the  joint;  and  (3) 
the  stage  of  caseation,  with  destruction  of  the  joint  and  often  of  the  structures 
about  it.  Bradford  and  Lovett*  protest  against  this.  They  say:  "It  has 
been  customary  to  divide  hip-disease  into  stages,  and  to  ascribe  to  these 
stages  certain  definite  symptoms.  Neither  from  a  clinical  nor  a  pathological 
point  of  view  is  it  desirable  to  attempt  such  a  division."  As  H.  Augustus 
Wilson  says:  "Tuberculous  bone  and  joint  disease  should  be  considered  as 
the  primary  invasion  or  incipiency,  and  all  other  symptoms  should  be  re- 
garded as  results  and  not  as  an  integral  and  necessary  part  of  the  trouble." 

The  symptoms  of  incipient  coxalgia  are  shght  and  may  be  overlooked 
entirely.  In  a  child  there  are  night-terrors;  on  getting  about  in  the  morning 
the  child  shows  no  lameness,  but  a  limp  develops  during  the  day,  and  the  little 
one  soon  grows  tired  while  playing  and  lies  down  to  rest.  There  is  a  slight 
hmp;  some  adductor  spasm  is  noted,  and  pain  may  be  complained  of  at  night 
in  the  hip,  in  the  front  of  the  thigh,  or  at  the  inside  of  the  knee.  Tapping  the 
sole  of  the  foot,  the  thigh  and  leg  being  extended,  may  develop  pain,  just  as 
it  will  develop  pain  in  any  inflammatory  involvement  of  the  joint.  But  the 
employment  of  this  method  is  objectionable.  It  may  injure  a  joint  already 
damaged  by  the  tuberculous  process,  and  it  gives  no  information  which 
cannot  be  obtained  by  a  safer  mode  of  investigation.  After  all,  pain  on 
tapping  the  sole  of  the  foot  means  only  what  muscular  rigidity  means,  and 
muscular  rigidity  is  always  present  and  is  easily  demonstrable  by  careful  man- 
ipulation.    The  diagnosis  in  this  stage  is  more  or  less  problematical. 

As  the  disease  progresses  more  positive  symptoms  are  observed.  The 
limp  grows  worse;  the  adductor  muscles  become  rigid;  the  hip  is  broadened  by 
an  effusion  into  the  joint,  and  fluctuation  may  possibly  be  detected;  the  thigh- 

*  Orthopedic  Surgery. 


634 


Diseases  and  Injuries  of  Bones  and  Joints 


muscles  atrophy;  the  extremity  is  pushed  forward,  abducted,  and  everted 
(the  patient  tiks  the  pelvis  so  as  to  rest  his  weight  on  the  sound  limb).  In 
some  few  cases  adduction  exists  rather  than  abduction.  The  abduction,  which 
is  usual,  releases  tension  of  the  fascia  lata,  and  thus  abolishes  pressure  upon 
the  joint  through  lessening  of  pressure  upon  the  great  trochanter  (Allis). 
The  thigh  is  somewhat  flexed.  This  flexion  relaxes  the  psoas  muscle  and 
prevents  pressure  of  its  tendon  upon  the  front  of  the  joint  (Allis).  Pain 
exists,  often  sudden  or  starting,  and  is  located  in  the  joint,  on  the  front  of 
the  thigh,  and  to  the  inner  side  of  the  knee  in  the  course  of  the  obturator 
nerve;  the  pain  is  aggravated  at  night;  and  full  extension  and  complete 
abduction  are  not  possible.  The  gluteal  muscles  waste,  and  the  gluteal  crease 
is  on  a  lower  level  than  is  that  of  the  sound  side.  The  gluteal  crease  may 
be  nearly  or  quite  effaced,  because  of  hypertrophy  of  the  subcutaneous  layer 
( Alexandrofl") .  Jarring  of  the  heel  when  the  extremity  is  in  extension  causes 
pain  in  the  hip.  The  above  s}Tnptoms  arise  chiefly  from  unconscious  efforts 
to  obtain  ease,  from  joint-effusion,  reflex  irritation,  and  involuntary  or  spas- 
modic muscular  contractions.  There  is  an  appearance  of  lengthening,  or 
shortening,  but  it  is  only  apparent,  not  real.  The  real  position  is  shown  on 
Plate  7,  Fig.  4.     The  fluid  effusion  may  be  absorbed  or  may  find  its  way 


Fig.  335.— Positions  in  hip-joint  disease  (after  the  plan  of  Howard  Marsh  and  Treves):  K.—ef, 
lumbar  spine;  b  d,  limb  fixed  in  flexion  and  abduction— useless  for  walking.  B.—ef,  lumbar  spine. 
Patient  corrects  the  condition  in  Figure  A  by  cur\'ing  the  lumbar  spine  fonvard  and  rotating  the 
pelvis  on  its  transverse  axis,  thus  making  the  femur  point  downward.  The  lumbar  spine  is  curved 
laterally,  the  pelvis  ascending  on  the  sound  side  and  descending  on  the  affected  side  (apparent  length- 
ening), c— *  d,  limb  fixed  in  flexion  and  adduction.  D.—e/,  cur\e  of  lumbar  spine  to  correct  con- 
dition in  Figure  c  (apparent  shortening). 

externally  by  means  of  sinuses.  The  latter  condition  is  known  as  "abscess 
0}  the  hip."  The  absorption  of  the  exudate  or  the  rupture  of  the  capsule 
permits  the  contracting  miiscles  to  bring  the  head  of  the  femur  into  firm  con- 
tact with  the  acetabulum  or  its  brim;  the  bones  are  worn  away  and  destroyed, 
shortening  results,  abduction  gives  way  to  adduction,  and  flexion  is  increased, 
as  shortening  occurs. 

In  advanced  cases  of  coxalgia  the  head  of  the  femur  passes  upward  and 
outward  upon  the  rim  of  the  acetabulum,  the  thigh  is  flexed  and  fixed,  and 
attempts  at  extension  when  the  patient  is  recumbent  cause  the  pelvis  to  tilt 
forward  and  occasion  a  marked  lumbar  curve  (lordosis)  (PI.  7,  Fig.  2),  which  is 
due  to  the  pelvis  moving  with  the  femur  as  if  ankylosed,  and  which  disappears  on 
flexion.  In  this  condition  adduction  occurs  because  of  the  ascent  and  move- 
ment outward  of  the  head  of  the  bone.  Shortening  is  marked.  After  a  hip- 
abscess  finds  an  external  outlet  pyogenic  infection  is  very  apt  to  take  place 


Tuberculosis  of  the  Hip-joint  635 

and  suppuration  arises,  which  is  followed  by  that  state  which  is  designated 
as  "hectic."  If  a  cure  follows  advanced  coxalgia,  partial  or  complete  anky- 
losis takes  place;  if  death  ensues,  it  may  be  due  to  septicemia,  tuberculosis 
of  the  viscera,  exhaustion,  or  amyloid  degeneration. 

Diagnosis  is  very  easy  in  well-estal)lished  cases  of  hip-disease,  but  very 
difficult  when  the  disease  is  incipient.  Always  make  a  systematic  and  thor- 
ough examination.  Undress  the  patient  and  place  him  recumbent  with  his 
legs  extended  upon  a  table  or  a  hard  mattress.  Note  if  the  heels  are  level 
and  if  the  iliac  spines  are  on  the  same  level  (a  depressed  spine  on  the  affected 
side  means  abducted  extremity,  the  degree  of  which  is  determined  by  carrying 
the  limb  out  until  the  spines  are  horizontal;  elevation  of  the  ihac  spine  on  the 
affected  side  means  adduction,  the  amount  of  which  is  determined  by  adducting 
the  limb  until  the  spines  are  horizontal;  Fig.  335).  Try  all  the  movements 
belonging  to  the  joint,  to  detect  any  limitations ;  observe  if  bringing  down  the 
knee  produces  lordosis;  look  for  swelling  and  for  muscular  wasting;  feel  if 
the  head  of  the  bone  is  enlarged;  determine  if  motion  produces  pain  or  if 
pressure  develops  tenderness;  and  always  carefully  elicit  the  history  of  the 
attack,  of  the  person,  and  of  the  family. 

Hip  disease  may  be  confounded  with  spinal  caries  in  which  a  psoas  or  a 
lumbar  abscess  has  formed,  with  sacro-iliac  disease,  with  infantile  paralysis, 
with  congenital  dislocation  of  hip,  with  lordosis  from  rickets,  with  gluteal 
abscess,  and  with  bursitis  of  the  gluteal  bursa\  In  hip  disease  there  is  always 
some  lameness;  pain  may  be  severe,  may  be  trivial,  or  may  be  absent  entirely, 
and  may  be  in  the  hip  or  be  referred  to  the  front  of  the  thigh  or  the  inner  side 
of  the  knee.  Always  remember  that  the  pain  is  not  characteristic,  and  that 
pain  in  the  same  locahties  may  arise  from  aneurysm  of  the  femoral  or  ihac 
arteries,  from  abscess  in  Scarpa's  triangle,  from  caries  of  the  lumbar  vertebrae, 
from  sacro-iliac  disease,  and  from  cancer  of  the  rectum.  Altered  position  of 
the  limb,  hmitation  of  movement  in  the  hip-joint,  muscular  wasting,  and 
swelling  soon  arise  in  hip-joint  disease. 

In  disease  of  the  sacro-iliac  joint  examination  shows  that  the  movements 
of  the  hip-joint  are  unhmited  and  produce  no  pain,  and  that  pain  is  developed 
by  pressure  over  the  sacro-iliac  articulation  and  by  pressing  the  iha  together. 
In  infantile  paralysis  there  is  no  pain,  but  there  is  paralysis  with  great  muscular 
atrophy,  which  comes  on  with  considerable  rapidity.  In  spinal  caries  with 
psoas  abscess  the  evidences  of  disease  of  the  vertebra;  are  clear  and  a  collection 
of  fluid  is  located  in  the  groin  external  to  the  femoral  vessels.  The  tuberculous 
pus  of  hip-abscess  generally  gathers  under  the  tensor  vagina  femoris  muscle, 
but  it  may  reach  Scarpa's  triangle  by  passing  through  the  cotyloid  notch  or 
through  the  bursa  under  the  psoas  muscle;  it  may  even  appear  under  the  glutei. 
Matter  from  a  caseating  acetabulum  may  reach  the  interior  of  the  pelvis  and 
appear  above  Poupart's  ligament. 

In  gluteal  bursitis  the  symptoms  last  for  many  months,  and  do  not  remit 
as  the  symptoms  of  early  hip  disease  are  apt  to  do.  The  pain  is  but  moderate, 
and  is  aggravated  by  exercise,  but  passes  away  on  going  to  bed,  and  is  felt  back 
of  the  hip  and  back  of  the  knee.  There  are  a  certain  amount  of  Hmitation  of 
motion  and  a  positive  hmp,  which  arises  early.  In  marked  cases  fluctuation 
can  be  detected  in  the  upper  gluteal  region.* 

*  See  E.  G.  Brackett's  important  paper  on  "  Gluteal  Bursitis  "  in  the  Transactions 
of  the  American  Orthopedic  Association,  vol.  x. 


636 


Diseases  and  Injuries  of  Bones  and  Joints 


Prognosis. — If  the  case  of  hip  disease  is  seen  early,  the  chances  of  cure  are 
excellent  in  children,  in  whom  the  disease  may  be  arrested  at  any  stage.  The 
longer  the  duration  of  the  disease  and  the  older  the  subject,  the  more  unfavor- 
able is  the  prognosis.  Many  months  will  be  required  to  elapse  before  a  cure 
can  be  effected,  and  advanced  cases  only  get  well  by  means  of  ankylosis  with 
shortening  and  deformity.  Hip  disease  may  recur  years  after  apparent  cure, 
and  a  person  who  has  or  has  had  hip  disease  runs  a  strong  chance  of  develop- 
ing visceral  tuberculosis. 

Complications. — The  complications  that  may  accompany  hip  disease  are 
the  following:  Abscess,  as  above  noted.  Tuberculous  meningitis,  or  the  con- 
dition known  as  "acute  hydrocephalus"  or  "water  on  the  brain,"  may  arise 
during  the  progress  of  the  case  or  after  apparent  cure,  and  is  apt  to  ensue  upon 
incomplete  operations.  It  is  almost  inevitably  fatal.  Phthisis  pulmonalis  is 
a  rare  complication,  but  is  a  common  sequence,  being  apt  to  arise,  sooner  or 
later,  after  the  hip  disease  is  cured.  Amyloid,  lardaceous,  or  waxy  degenera- 
tion 0}  viscera  follows  upon  profuse  and  long-continued  suppurations  and  is  apt 
to  arise  in  the  liver,  spleen,  kidneys,  or  intestinal  mucous  membrane.  Tuber- 
culosis is  not  the  only  cause  of  amyloid  degeneration,  syphilis  being  responsi- 
ble for  at  least  30  per  cent,  of  all  cases.  In  amyloid 
disease  of  the  liver  this  organ  is  much  enlarged, 
smooth,  painless,  and  of  increased  consistency;  there 
is  no  jaundice,  the  spleen  is  apt  to  be  enlarged,  and 
albuminuria  is  the  rule.  In  amyloid  kidney  large 
amounts  of  pale  urine  of  low  specific  gravity  are 
voided;  albumin  is  usually  present  in  large  amount, 
but  may  be  absent;  globulin  may  often  be  found,  as 
may  also  hyaline,  fatty,  or  granular  casts;  the  patient 
is  anemic,  and  dropsy  usually  exists.  Test  the  hya- 
line casts  with  iodin  for  amyloid  material.  Amyloid 
changes  are  usually  slow  in  onset;  but  they  may  be 
rapid;  they  are  commoner  in  men  than  in  women, 
and  are  most  frequently  encountered  in  individuals 
between  the  ages  of  ten  and  thirty.  Slight  amyloid 
change  may  be  recovered  from,  but  an  extensive 
degeneration  brings  about  a  fatal  result.  Dickinson's 
theory  of  how  this  tissue-change  is  caused  is  that 
the  flow  of  pus  drains  off  from  the  body  the 
alkaline  salts,  especially  the  salts  of  potassium, 
which  drainage  results  in  visceral  depositions  of  dealkalinized  fibrin. 

Treatment. — In  most  of  these  cases  conservative  treatment  is  advisable. 
Antituberculous  treatment  is  used  in  all  cases.  In  incipient  hip  disease  the 
treatment  usually  advocated  is  rest.  The  patient  is  placed  upon  a  sohd  mat- 
tress and  extension  is  applied.  In  children  under  ten  years  of  age  a  weight 
of  from  three  to  five  pounds  is  used;  in  individuals  between  ten  and  twenty 
a  weight  of  from  five  to  eight  pounds  is  used.  A  long  splint  is  often  applied 
to  the  sound  side  to  keep  the  patient  recumbent  and  horizontal.  A  cradle 
is  employed  to  hold  up  the  bed-clothing.  The  extension  is  applied  in  the 
long  axis  of  the  limb,  the  extremity  being  placed  in  the  line  of  the  deformity  due 
to  disease  and  being  properly  supported.  In  lordosis  from  thigh-flexion  the  limb 


Fig.   336. — Thomas'    poste- 
rior splint. 


Tuberculosis  of  the  Hip-joint 


637 


is  raised  until  the  iliac  spine  is  straight  (PI.  7,  Fig.  5) .  If  the  spine  is  depressed 
on  the  afifected  side,  the  limb  is  abducted  (PI.  7,  Fig.  6) ;  if  the  spine  is  elevated, 
the  limb  is  adducted  until  the  spines  are  horizontal  (PI.  7,  Fig.  7).  The  object 
of  extension  is  to  overcome  muscular  s[)asm  and  so  put  the  part  in  a  condition 
of  physiological  rest.  Muscular  spasm  is  a  great  factor  in  destroying  structures. 
Spasm  presses  the  parts  together,  and  as  a  result  of  pressure  plus  bacterial 
action  destruction  occurs.  The  extension  and  traction  tire  out  the  muscles  and 
cause  spasm  to  cease.  Extension  will  remove  flexion  in  two  weeks  in  a  recent 
case  and  in  the  course  of  some  months  in  an  older  case.  As  flexion  is  reUeved 
the  pillows  are  removed  and  the  leg  lowered,  but  extension  is  maintained  in  the 


Sayre's  long  splint. 


Fig.  338. — Wyeth's  combination  method. 


long  ax-is  of  the  thigh.     Abduction  and  adduction  cannot  be  removed  by  simple 
extension  in  the  axis  of  the  limb. 

Abduction  demands  no  special  treatment.  In  a  movable  joint  it  will  dis- 
appear, and  in  an  ankylosed  joint  it  is  an  advantage,  compensating  by  apparent 
lengthening  for  the  shortening  due  to  bone-absorption  or  to  stunned  growth 
of  the  Hmb.  Adduction  requires  an  addition  of  several  pounds  to  the  extension 
weight,  the  use  of  a  long  sphnt  on  the  sound  limb,  and  the  drawing  up  of 
the  sound  side  by  a  rope  and  pulley  toward  the  head  of  the. bed.  The 
weight  used  to  pull  the  sound  side  toward  the  head  of  the  bed  is  equal  to  that 
used  to  pull  the  damaged  side  to  the  foot  of  the  bed.  This  expedient  is  used 
for  a  month  or  six  weeks.  In  old  cases  where  the  weight  ^^^ll  not  bring  about 
extension,  the  patient  is  anesthetized,  the  Hmb  is  gently  straightened  a  very 
Uttle,  and  the  weight  is  reapphed. 


638  Diseases  and  Injuries  of  Bones  and  Joints 

Extension  in  a  mild  case  must  be  continued  for  three  months  after  the 
symptoms  have  disappeared,  and  in  a  severe  case  the  period  must  be  six 
months.  The  weight  is  gradually  taken  off;  if  symptoms  recur,  the  weight 
is  reapplied;  if  they  do  not  recur,  apply  a  traction  splint  or  a  plaster  dressing, 
put  a  high-heeled  boot  on  the  sound  limb,  and  send  the  patient  out  on  crutches. 
In  young  children  extension  can  be  made  while  the  child  is  in  a  wheeled 
carriage,  thus  enabling  the  patient  to  go  out  in  the  fresh  air  and  sunlight. 
The  general  treatment  is  tonic  and  restorative.  The  joint  is  so  deeply  placed 
that  external  applications  are  useless.  In  the  treatment  of  hip  disease 
Thomas'  spHnt  (Fig.  336)  is  used  by  many,  and  it  may  be  combined  with 
weight  extension;  or  Sayre's  spUnt  (Fig.  337)  may  be  employed.  Wyeth's 
apparatus  (Fig.  338)  is  a  favorite  with  many  American  surgeons. 

If  the  limb  is  in  good  position,  or  has  been  brought  into  good  position,  either 
by  weight  extension  or  straightening  under  ether,  plaster  of  Paris  is  a  useful 
dressing.  It  is  appUed  from  the  toes  up,  and  includes  the  entire  extremity  and 
also  the  pelvis.  A  patient  wearing  plaster  may  get  about  on  crutches  when 
the  sole  of  the  foot  of  the  sound  extremity  is  raised  by  the  wearing  of  a  thick- 
soled  shoe. 

Treatment  hy  Weight-hearing  and  Fixation  by  Hip  Spica  of  Plaster  of  Paris 
{Lorenz^s  Method) . — This  plan  is,  in  most  cases,  vastly  preferable  to  extension 
in  bed.  To  keep  the  patient  in  bed  is  to  keep  him  from  the  open  air  and  sun- 
light, which  are  so  necessary  in  tuberculosis.  Such  confinement  favors  muscu- 
lar atrophy,  leads  to  anemia,  and  lessens  vital  resistance.  The  hip  is  placed  in 
20  degrees  of  flexion,  20  degrees  of  abduction,  and  5  degrees  of  external  rotation, 
and  is  fixed  by  a  short  plaster  spica  of  the  hip.  The  patient  walks  and  so 
antagonizes  muscular  spasm.  The  joint  surfaces  bear  weight,  which  leads  to 
a  useful  increase  of  blood  supply  (curative  hyperemia),  but  do  not  grind  upon 
each  other,  hence,  the  spread  of  the  disease  is  not  favored.  That  muscles 
increase  in  size  is  shown  by  the  fact  that  the  cast  gets  tight  and  must  be 
changed  from  time  to  time.  The  open-air  life  and  exercise  are  of  the  greatest 
benefit  to  the  patient  and  a  gain  in  weight  is  the  rule.  Cases  in  a  debilitated 
condition  or  those  with  discharging  sinuses  must  not  be  treated  by  this  plan 
"without  the  temporary  use  of  crutches"  (H.  A.  Wilson,  in  "Southern  Med. 
Jour.,"  Dec,  1908).  Incipient  cases  are  most  suitable  for  treatment  by  this 
plan.  The  average  duration  of  treatment  is  about  ten  months  (H.  A.  Wilson, 
Ibid.). 

Intra-articular  Injections  and  Operation. — If  in  spite  of  treatment  the 
condition  does  not  improve  or  if  it  becomes  worse,  use  intra-articular  in- 
jections of  iodoform  or  of  bismuth  paste.  Always  try  these  injections  be- 
fore doing  a  resection  unless  the  x-rays  show  a  large  sequestrum.  Some- 
times they  succeed,  and  if  they  do,  resection  is  unnecessary.  Asepticize 
the  surface,  carry  a  small  aspirating  needle  into  the  joint,  irrigate  the  joint 
with  salt  solution,  and  inject  a  sterile  emulsion  of  iodoform  and  glycerin 
(10  per  cent.).  In  one  week,  if  reaction  has  ceased,  repeat  the  injection. 
In  another  week  repeat  it  again.  It  may  be  necessary  to  give  from  ten  to 
twenty  injections.  The  proper  spot  for  puncture  is  thus  determined.  Draw 
a  line  from  a  point  half  an  inch  outside  of  the  middle  of  Poupart's  ligament 
to  the  outer  edge  of  the  great  trochanter.  Puncture  at  the  middle  of  the  outer 
half  of  this  line  (De  Vos).     I  have  not  attempted  to  remove  the  disease  sur- 


HIP-JOINT    DISEASE. 


Pt.ate  7. 


I,  2.  Effects  on  the  Lumbar  Spine  of  Flexing  and  Extending  the  Diseased  Leg  in  Hip  Disease 
(Albert).  3,4.  Positions  In  Coxalgia  (Albert).  5.  Extension  in  Hip  Disease  (Treves).  6.  Ex- 
tension of  the  Limb  in  a  Flexed  and  Adducted  Position  (Treves).  7.  Extension  of  the  Limb  in  a 
Flexed  and  Abducted  Joint  (Treves). 


Knee-joint  Disease  639 

gically  early  in  any  case  and  greatly  doubt  the  wisdom  of  doing  so.  Hun- 
tington and  some  other  surgeons  advocate  early  operation  in  children  instead 
of  simply  fixation,  extension,  and  rest.  Huntington  ("Am.  Jour.  Med. 
Sciences,"  July,  1905)  recalls  that  when  the  lesion  is  in  the  head  of  the  femur, 
it  tends  to  perforate  into  the  joint  and  he  advises  trephining  at  the  lower  border 
and  outer  aspect  of  the  great  trochanter  and  tunnelling  the  neck  and  head 
of  the  femur  with  a  curette.  Bradford  objects  to  this  method  in  most  cases 
on  the  ground  that  unless  the  disease  is  localized  and  the  cavity  is  well  walled 
off  and  unless  injury  to  the  localizing  barrier  is  avoided,  the  operation  may 
be  responsible  for  dissemination  of  the  bacteria. 

If  an  abscess  forms,  incise  it  with  the  most  thorough  antiseptic  care,  let  the 
fluid  drain  away,  irrigate  the  cavity  with  salt  solution,  remove  any  sequestra, 
inject  with  iodoform  emulsion,  sew  up  without  drainage,  and  dress  antiseptic- 
ally.  In  some  cases  the  sequestrum  is  extra-articular.  In  many  cases  no 
sequestrum  is  found.  If  this  method  fails,  drainage  must  be  employed.  The 
old  plan  of  not  operating  until  rupture  was  seen  to  be  inevitable  was  wrong. 
To  open  early  and  antiseptically  often  means  rapid  healing,  the  prevention  of 
burrowing,  a  lessened  danger  of  visceral  infection,  and  an  earlier  cure.  In 
contrast  to  what  happens  when  a  very  large  cold  abscess  is  opened  hectic 
will  rarely  arise  when  a  tuberculous  joint  is  opened  with  antiseptic  care. 

Excision  of  the  hip  is  to  be  performed  when  there  is  a  large  sequestrum 
or  severe  fistulae  (Garre,  "Deutsch.  med.  Woch.,"  1905,  Nos.  47  and  48); 
when  the  head  of  the  femur  is  detached  and  lies  loose  in  the  joint;  when 
profuse  suppuration  continues  for  a  long  time,  and  other  methods  fail  to 
arrest  it;  when  amyloid  disease  is  threatening;  or  when  very  faulty  position 
is  inevitable  without  operation.  Excision  is  an  operation  of  considerable 
danger,  and  the  older  the  person,  the  greater  the  danger.  Schede  advocates 
arthrectomy  in  some  cases  as  a  substitute  for  resection.  Senn  tells  us  that 
opinion  as  to  resection  has  greatly  changed  of  late,  and  it  is  now  taught  that 
the  operation  is  advisable  in  all  cases  where  fixation,  extension,  intra-articu- 
lar  and  parenchymatous  injections  have  failed  to  arrest  the  disease  (Senn 
on  "Tuberculosis  of  Bones  and  Joints").  Resection  of  the  hip  does  not 
give  a  very  satisfactory  functional  result.  When  there  is  extensive  disease 
of  the  femur,  when  excision  has  been  tried  and  has  failed,  when  the  patient 
has  not  the  recuperative  power  to  withstand  the  long  siege  of  illness  following 
excision,  or  when  there  is  amyloid  disease,  amputate.*  Amputation  of  the 
hip-joint  for  tuberculous  disease  is  a  very  successful  procedure. 

Knee-joint  Disease  (White  Swelling). — After  the  hip,  the  knee  is,  of  all 
joints,  the  commonest  site  for  tuberculous  disease.  Knee-joint  disease  can 
begin  as  a  synovitis,  but  oftener  begins  as  tuberculous  inflammation  of  the 
femoral  or  the  tibial  epiphysis.  Tuberculous  disease  rarely  attacks  the  bone 
on  the  diaphyseal  side  of  the  epiphyseal  line;  a  single  focus  only  exists,  as  a 
rule,  and  a  sequestrum  is  rarely  formed.  In  very  rare  instances  the  patella 
or  the  semilunar  cartilage  is  primarily  attacked.  It  may  begin  at  any  age, 
but  is  most  common  in  children  and  young  adults.  If  an  acute  synovitis 
ushers  in  the  case,  there  may  be  a  large  effusion  into  the  knee-joint  and  par- 
tial flexion,  but  swelling  is  usually  slight  in  knee-joint  disease.  Pulpy  degen- 
eration of  the  synovial  membrane  occurs;   the  joint  enlarges;   the  ligaments 

*See  the  admirable  article  of  Howard  Marsh  in  Treves's  "Manual  of  Surgery." 


640 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  339.— Sayre's 
knee  splint  applied. 


Fig.  340.  — Hutch- 
inson's knee-joint 
splint. 


soften;  the  skin  becomes  edematous,  and  muscular  spasm  arises.  The 
leg  becomes  flexed;  the  bones  displaced  backward  and  outward;  the  foot 
everted;  and  lameness  arises,  due  chiefly  to  deformity.  Pain  may  be  absent, 
is  often  slight,  and  is  rarely  severe.    When  the  disease  begins  in  the  bone  or 

an  epiphysis  there  are  pain,  tenderness, 
lameness,  swelling,  inability  to  extend  the 
limb  completely,  sudden  spasmodic  mus- 
cular contractions,  and  final  involvement 
of  the  joint.  When  an  abscess  forms,  it 
may  destroy  the  joint  very  rapidly  or  it 
may  break  externally. 

Treatment.  —  In  treating  knee-joint 
disease  conservative  treatment  is  usually 
tried  but  often  fails.  A  plan  of  doubtful 
\'alue  is  to  make  a  mixture  of  guaiacol  and 
tincture  of  iodin  or  guaiacol  and  olive 
oil  (1:4).  Once  a  day  the  surface  of 
the  knee  is  exposed  by  removing  dress- 
ings, is  painted  with  this  mixture,  and 
the  painted  surface  is  covered  with 
cotton-wool.  Rest  is  of  the  first  impor- 
tance, and  may  be  secured  by  the  applica- 
tion of  spKnts  (Figs.  339,  340),  the  use 
of  extension  (Fig.  341),  or  the  employ- 
In  any  case  the  patient  must  be  kept  in  bed 
for  a  few  weeks;  he  may  then  be  permitted  to  go  out  upon  crutches,  wearing  a 
high-heeled  shoe  upon  the  foot  of  the  sound  limb.  In  cases  in  which  treatment 
is  begun  early  the  disease  may  often  be  arrested  in  from  eight  to  twelve  months. 
If  the  symptoms  do  not  abate  after  a  number  of  weeks,  or  if  the  condition  grows 
worse  and  caseation  occurs,  aspirate,  irrigate,  and  inject  iodoform  emulsion 
or  bismuth  paste.  Intra-articular  injections  are  not  unusually  curadve.  Insert 
the  needle  in  the  angle  between  the  outer  edge  of  the  patella  and  the  ligament  of 
the  patella  (De  Vos).  Repeat  the  injecdon  in  one  week  if  reaction  has  abated, 
and  continue  as  directed  for  the  injection  of  the  hip-joint.  If  this  plan  fails,  in- 
cise the  capsule,  remove  all  fragments  and  tuberculous  foci,  irrigate  with  normal 
salt  solution,  inject  iodoform  emulsion,  and  sew  up  without  drainage  (Neuber's 
plan) .  A  more  severe  case  requires  drainage.  If  these  means  fail,  or  if  the  case  is 
too  far  advanced  to  permit  of  their  use,  open  the  joint  and  perform  an  excision 
or  an  erasion  (page  709).  Excision  gives  a  satisfactory  result  in  most  cases, 
although  it  leaves  a  stiff  knee  and  marked  shortening.  Garre  considers  any 
shortening  over  5  cm.  a  bad  result,  and  he  got  such  a  bad  result  in  7.5  per 
cent,  of  his  117  cases.  In  children  shortening  follows  even  conservative 
treatment,  and  the  shortening  which  follows  excision  is  due  in  part  to  removal 
of  bone  and  in  part  to  impairment  of  the  nutritive  power  of  the  epiphyseal 
cartilage.  Some  cases  demand  amputation,  which,  if  the  patient's  health 
is  much  impaired  or  if  amyloid  disease  exists,  is  to  be  preferred  to  excision. 
Amputation  is  preferred  to  excision  in  very  young  children  and  aged  people. 
Ankle-joint  disease  may  begin  in  the  synovial  membrane,  in  the  tibial 
epiphysis,  or  in  the  tarsus,  but  the  origin  is  usually  synovial.     The  symptoms 


mentof  a  plaster-of-Paris  bandage. 


Shoulder-joint  Disease 


641 


are  pain,  swelling,  lameness,  limitation  of  joint-movements,  and  atrophy  of 
the  calf-muscles.     Caseation  often  occurs  and  sinuses  form. 

Treatment. — Conservative  treatment  with  iodoform  injections  will  cure 
many  cases.  Rest  is  obtained  by  means  of  splints  or  ])laster-of-Paris  bandages. 
Caution  the  patient  to  avoid  standing  upon  the  diseased  extremity.  In 
making  an  intra-articular  injection  insert  the  needle  below  the  outer  malleolus. 
When  caseation  occurs,  it  is  advisable  to  open  the  joint,  wash  out  with  nor- 
mal salt  solution,  inject  iodoform  emulsion,  sew  up  the  incision,  and  put  up 


Fig.  341-  — Sayre's  double  extension  of  the  knee-joint. 


the  ankle-joint  in  plaster.  When  there  is  considerable  bone  disease,  when  fis- 
tulc-e  exist,  when  adjacent  joints  or  tendons  are  diseased,  or  when  joint-disor- 
ganization occurs,  perform  an  excision  or  an  erasion.  Some  cases  demand 
amputation  (Syme's  amputation  being  preferred  by  some,  amputation  above 
the  ankle  being  approved  by  many).  Osteoplastic  resection  is  sometimes 
advised  (Wladimiroff-Mikulicz  operation).  Operative  treatment  is  more 
satisfactory  in  children  than  in  adults  (Garre). 

Shoulder- joint  disease  is  not  common;  it  is  rare  in  children  and  is  com- 
monest in  adults;  it  may  begin  in  the  synovial  membrane,  but  usually  begins 
in  the  head  of  the  humerus.  The  glenoid  cavity  is  rarely  attacked.  Pain 
is  slight,  atrophy  of  the  deltoid  and  other  muscles  is  noted,  the  joint  is  stiff, 
and  the  scapula  follows  the  motions  of  the  humerus.  Caries  sicca  is  the 
usual  cause  of  destruction.  In  many  cases  swelHng  is  not  obvious,  the  joint 
shrinking  because  of  destruction  of  the  head  of  the  bone  and  contraction  of 
the  capsule  (Senn).  Abscess-formation  is  unusual.  If  an  abscess  forms, 
it  may  open  in  the  axilla,  through  the  deltoid  muscle,  or  at  some  far  distant 
point.     It  is  frequently  complicated  by  pulmonary  tuberculosis. 

Treatment. — A  majority  of  cases  recover  from  conservative  treatment,  a 
stiflf  joint  resulting.  Put  on  a  shoulder-cap,  apply  the  second  roller  of 
Desault,  and  hang  the  hand  in  a  sling.  Maintain  rest  for  at  least  four 
months.  Aspiration  and  injection  of  iodoform  emulsion  or  of  bismuth 
paste  are  of  great  service  in  synovial  tuberculosis.  In  making  an  intra- 
articular injection  the  needle  is  entered  below  the  acromion,  while  the  arm 
is  held  against  the  side  and  the  forearm  is  at  right  angles  to  the  arm^  and 
across  the  front  of  the  chest  (De  Vos) .  If  caseation  occurs,  open  the  joint, 
remove  tuberculous  foci,  wash  with  hot  saline  fluid,  inject  iodoform  emulsion, 
and  close  without  drainage,  or,  in  a  rather  severe  case,  drain.  In  rare  m- 
stances  dead  bone  will  have  to  be  gouged  away.  Caries  sicca  may  occur 
Excision  is  sometimes  required,  but  the  results  are  seldom  satisfactory. 


41 


642  Diseases  and  Injuries  of  Bones  and  Joints 

Elbow-joint  disease  may  begin  in  the  humerus  or  the  ulna.  The  head 
of  the  radius  is  rarely  the  primary  focus.  In  some  cases  the  synovial  mem- 
brane is  first  attacked.  The  disease  is  most  frequent  in  young  adults.  The 
joint  is  swollen,  its  movements  are  somewhat  limited,  muscular  wasting  is  pro- 
nounced, and  pain  is  generally  slight.     Tuberculous  pus  may  form. 

Treatment. — In  treating  early  elbow-joint  disease,  especially  in  young 
children,  conservative  treatment  is  very  successful.  Rest  is  secured  by  means 
of  an  anterior  angular  splint  (Fig.  342)  and  a  triangular  sling  or  a  plaster-of- 
Paris  dressing.     Splints  are  to  be  worn  for  from  four  months  to  a  year.     Injec- 


Pig.  342. — Siromeyer's  anterior  angular  splint. 

tions  of  iodoform  emulsion  are  usually  employed.  Insert  the  needle  for  injec- 
tion by  the  side  of  the  olecranon.  In  a  cure  by  conservative  methods  a  stiff 
joint  will  result.  It  may  be  necessary  to  perform  resection  because  of  exten- 
sive bone  disease.     Resection  gives  an  excellent  functional  result. 

Wrist- joint  disease  may  arise  at  any  age,  and  is  sometimes  met  with  in 
late  middle  life  or  even  in  old  age.  The  joint  presents  a  puffy  swelling,  loses 
its  normal  contour,  and  becomes  spindle-shaped.  Hand-movements  are 
impaired,  pronation  and  supination  cannot  completely  or  satisfactorily  be  per- 
formed, the  joint  is  stiff  and  partly  flexed,  the  grasp  is  enfeebled,  pain  may  be 
severe  or  slight,  the  skin  is  sometimes  but  seldom  hot,  and  muscular  atrophy 
is  marked.  This  form  of  tuberculosis  may  begin  in  the  synovial  membrane, 
in  the  bones,  or  in  the  tendon-sheaths. 

Treatment  is  usually  conservative  and  very  successful,  giving,  as  a  rule,  a 
funcdonally  useful  joint  and  movable  fingers.  Garre  recommends  a  trial  of  the 
method  even  when  there  are  fistulae  and  when  there  is  necrosis  of  the  carpus. 
Apply  a  Bond  splint  and  sling  or  put  on  a  plaster-of-Paris  bandage  and  main- 
tain strict  rest  for  from  four  to  six  months.  Aspiration  and  injection  of  iodoform 
emulsion  or  bismuth  paste  are  used.  Enter  the  needle  at  the  dorsal  edge  of  the 
radial  styloid  process,  and  again  at  the  upper  edge  of  the  pisiform  Ijone  (DeVos) . 
In  some  cases  it  is  well  to  incise,  wash  \\nth  salt  .solution,  inject  iodoform 
emulsion,  and  close  without  drainage.  Severe  cases  demand  incision  and 
drainage  with  the  maintenance  of  rest.  Resection  is  to  be  avoided  if  possible. 
It  gives  a  bad  functional  result,  the  amount  of  bone  removed  leaving  the  ten- 
dons too  long  and  contractions  of  muscle  being  common  (Garre).  It  may 
be  demanded  because  of  extensive  caries  or  sequestra  formadon.  Amputation 
is  occasionally  necessar}^ 

Non-tuberculous  Arthritis. — Most  of  these  cases,  acute  and  chronic,  are 
of  infectious  origin.     Some  of  them  are  non-infectious.     Among  the  non-in- 


Infective  Arthritis  643 

fective  forms  the  joint  lesions  of  locomotor  ataxia  and  syringomyelia — con- 
stitutional conditions,  as  gout,  purpura,  hemophilia,  and  scurvy — functional 
derangements  expressed  by  articular  neuralgia  or  intermitting  hydrops  and 
traumatic  states  (see  Hoffa,  in  "Zentralbl.  f.  Chir.,"  1907,  xxxiv;  and  Blood- 
good,  in  "Progressive  Medicine,"  Dec.  i,  1907). 

Traumatic  Arthritis. — This  may  be  due  to  a  single  injury  (a  s|)rain  or  a 
bruise)  or  to  some  continuing  cause  (genu  valgum  may  cause  arthritis  of  the 
knee;  llat-foot  may  be  responsible  for  arthritis  of  the  knee  or  hip). 

If  a  contusion  or  sprain  causes  relaxation  of  the  capsule  or  fixing  tendons, 
the  joint  becomes  loose  and  injures  itself  again  and  again  during  movement. 
It  does  the  same  thing  when  there  are  loose  bodies  or  enlarged  synovial 
fringes.  Traumatic  arthritis  usually  involves  but  one  joint.  A  recent  trau- 
matic arthritis  is  treated  by  protecting  the  joint,  massage,  hot  air,  and  pas.sive 
motions. 

If  a  continuing  cause  is  present  it  is  to  be  removed.  Distant  causes  may 
be  removed  by  orthopedic  apparatus  or  by  operation.  Causes  within  the  joint 
may  be  sought  for  by  arthrotomy  and  when  found  they  should  he  removed. 
For  instance,  in  the  knee,  inflamed  synovial  fringes  may  be  responsible  for 
chronic  inflammadon.  They  get  caught  between  the  joint  surfaces,  are 
squeezed,  and  trip  the  victim.  They  should  be  removed.  Lockwood  ("Brit. 
Med.  Jour.,"  July  3,  1909)  points  out  that  an  overgrowth  of  fat  may  get 
between  the  tibia  and  femur  and  be  squeezed.  This  surgeon  calls  attention 
to  the  fact  that  there  are  "adipose  pads  immediately  above  the  articular  sur- 
face of  the  femur,  and  on  either  side  of  the  upper  end  of  the  patella"  (Ibid.). 
He  calls  them  the  pads  of  Malgaigne,  after  the  French  surgeon  who  described 
them  in  1859.  If  they  are  subject  to  repeated  traumatism  they  should  be 
removed. 

Infective  Arthritis. — In  this  condition  the  inflammation  is  due  to  bac- 
teria. In  some  cases  pus  forms  and  pyogenic  bacteria  are  demonstrable  in 
fluid  removed  by  aspiration.  In  other  cases,  perhaps  exhibiting  as  acute 
symptoms,  no  pus  forms  and  no  bacteria  are  demonstrable  in  the  fluid  removed 
by  aspiration.  The  latter  cases  are  due  to  toxins  or  to  bacteria  of  attenuated 
virulence.  Secondary  infection  may  occur.  In  wounds  and  in  most  cases  the 
disease  is  polyarticular,  but  if  osteomyelitis  is  the  cause  it  may  be  monarticular. 
The  bacteria  may  reach  a  joint  by  way  of  a  wound,  from  an  adjacent  focus  of 
osteomyelitis,  from  a  near  or  distant  area  of  infection,  from  the  genito-urinary 
tract,  or  by  way  of  the  tonsils.  Organisms  not  directly  introduced  into  the 
joint  reach  it  by  way  of  the  blood  or  lymph. 

The  disease  may  arise  during  the  course  of  gonorrhea  or  any  infectious 
process.  It  may  arise  when  no  area  of  infection  can  be  discovered.  It  may 
arise  in  the  course  of  an  acute  infectious  disease  (such  as  erysipelas,  typhoid 
fever,  pneumonia,  influenza,  mumps,  dysentery,  diphtheria,  measles,  scarlatina, 
variola),  and  may  be  due  to  pyogenic  cocci,  to  the  specific  micro-organism  of 
the  acute  infectious  disease,  or  purely  to  microbic  products.  Joint  inflam- 
mation arising  in  the  course  or  as  a  sequel  of  an  acute  infectious  disease  may 
or  may  not  suppurate. 

Symptoms. — If  no  suppuration  takes  place,  the  symptoms  of  the  attack 
resemble  those  of  rheumatism;  if  suppuration  occurs,  the  symptoms  are  the 
same  as  those  of  acute  suppurative  arthritis,  with  which  disease  this  form  of 


644  Diseases  and  Injuries  of  Bones  and  Joints 

infective  arthritis  is  identical.  Sui)puration  rarely  occurs.  Ashby  has  well 
described  the  arthritis  which  sometimes  follows  scarlatina.  It  involves  the 
wrists,  finger-joints,  tendons  of  the  forearms,  the  knees,  ankles,  or  spine. 
The  joints  are  painful,  but  are  rarely  much  swollen  or  discolored  (Howard 
Marsh).  We  can  distinguish  infecdve  arthrids  from  rheumadsm  by  the 
fact  that  it  does  not  migrate  and  is  uninfluenced  by  antirheumatic  remedies. 

Treatment. — In  every  case  in  which  we  suspect  the  condidon,  diagnostic 
aspiration  is  performed.  If  the  fluid  obtained  contains  bacteria,  arthrotomy 
and  irrigation  are  indicated.  In  all  clinically  severe  cases  and  in  all  prolonged 
cases,  open  and  irrigate,  first  with  corrosive  sublimate  solution  (i:  looo),  then 
with  normal  salt  solution.  Recent  cases  which  are  not  very  acute  and  are  free 
from  pus  may  be  closed  without  drainage. 

Pyogenic  or  Acute  Suppurative  Arthritis. — This  condition  is  a  form  of 
infecdve  arthritis  and  is  usually  due  to  the  staphylococcus  pyogenes  aureus  or 
to  the  streptococcus  pyogenes,  which  find  entrance  by  means  of  a  wound,  by 
the  spontaneous  evacuation  into  a  joint  of  the  products  of  an  osteomyelids, 
by  extension  of  suppurative  inflammadon  through  condguous  structures,  or 
by  the  blood-stream.  It  is  necessary  to  remember  that  causative  bacteria 
may  have  entered  the  blood  or  lymph  at  a  point  near  to  or  distant  from  the 
joint  (tonsils,  ethmoid  cells,  urethra,  a  focus  of  osteomyehds,  etc.) .  Of  course, 
a  wound  into  a  joint  may  be  the  open  gateway  for  infection.  A  traumatism 
may  create  a  point  of  least  resistance  and  bacteria  may  be  derived  from  the 
blood  or  lymph.  It  is  not  very  unusual  for  a  traumatic  arthritis  to  eventuate  in 
a  pyogenic  arthritis.  Particularly  in  youths  and  young  children  the  symp- 
toms of  an  arthritis  may  overlie  and  hide  a  causative  osteomyehtis.  Sometimes 
gonorrhea  is  the  cause  and  in  rare  cases  septicemia  is  causal.  In  pyogenic 
arthritis  all  the  joint-structures  are  involved  and  suppuration  rapidly  appears. 
Synovial  membrane  is  converted  into  granulation  tissue  and  cartilage  is  de- 
stroyed by  pus.  The  greater  the  inflammation  the  larger  the  amount  of  gran- 
ulation tissue,  hence,  ultimately,  the  greater  the  amount  of  scar  tissue  to  repair 
and  the  greater  impairment  of  joint  function. 

Symptoms. — The  symptoms  of  acute  suppurative  arthritis  are  usually  a 
chill  followed  by  fever  and  a  rapid  pulse.  There  are  severe  pain,  which  is 
aggravated  by  motion  and  is  worse  at  night;  discoloration,  heat,  and  edema  of 
the  skin;  partial  flexion  of  the  joint;  fluctuation;  and  marked  constitutional 
symptoms  of  sepsis.  The  joint  tends  to  rapid  disorganization,  and  fatal  sep- 
ticemia is  very  apt  to  occur.     In  pyemic  arthritis  several  joints  become  infected. 

Treatment. — In  every  suspicious  case  immediately  aspirate.  If  bacteria 
are  found  in  the  aspirated  fluid,  at  once  open  the  joint  {arthrotomy')  and  ir- 
rigate it  with  corrosive  sublimate  solution  (i :  looo)  and  then  with  salt  solution. 
In  early  cases  which  are  not  very  violent  the  wound  may  be  closed,  the  limb 
being  immobilized  after  the  operation.  In  a  late  case  or  a  violent  case,  drain 
by  rubber  tissue.  Always  be  sure  that  arthritis  is  not  the  result  of  osteomye- 
litis. In  conditions  due  to  staphylococci  and  streptococci  it  often  is  secondary 
to  bone  suppuration.  If  a  periosteal  abscess  exists  the  joint  condition  is 
almost  certainly  secondary.  If  osteomyelitis  exists  it  requires  prompt  and 
radical  treatment  (page  503).  In  advanced  cases  involving  the  knee,  Allen 
and  Alden  ("Surgery,  Gynecology,  and  Obstetrics,"  July,  1909)  open  the 
joint  by  a  transverse  incision  below  the  patella,  disinfect  with  pure  carbolic 


Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism  645 

acid  followed  hy  alcohol,  and  pack  with  iodoform  gauze.  I  would  only  regard 
this  as  justifiable  in  advanced  and  very  severe  cases,  as  it  is  sure  to  be  fol- 
lowed by  ankylosis.  Although  in  late  cases  which  recover  after  arthrotomy 
and  irrigation  there  is  always  more  or  less  ankylosis,  many  cases  treated 
early  recover  without  impairment  of  joint  function.  Early  arthrotomy  is  of 
the  utmost  importance  and  if  the  aspirated  fluid  contains  bacteria  we  should 
never  postpone  operation  or  hold  it  in  reserve  while  we  employ  Bier's  hyper- 
emic  or  any  other  conservative  method.  RadicaHsm  is  here  the  course  which 
promises  the  greater  safety,  and  the  surest  retendon  of  joint  function. 

Typhoid  Arthritis. — This  disease  is  a  form  of  infective  arthritis.  That 
the  bacteria  of  typhoid  may  inflame  the  joints  is  proved,  and  it  seems  certain 
that  they  can  cause  suppuration,  although  their  pyogenic  power  has  been 
disputed.  Some  claim  that  mixed  infecdon  is  the  real  cause  of  pus  formadon 
in  a  typhoid  joint.  The  typhoid  bacilli  enter  the  bones  in  many  typhoid  cases 
and  sometimes  cause  osteomyehtis.  Joint-disease  is  more  common  than  bone- 
disease.  Typhoid  disease  of  a  joint  begins  when  the  fever  is  abating,  and 
more  than  one  joint  may  be  involved.  Typhoid  joints  may  recover  perma- 
nently, may  become  ankylosed,  may  dislocate,  or  the  joint-disease  may  lead 
to  fatal  sepsis.  In  most  cases  the  joints  recover.  In  slight  cases  the  .synovial 
membrane  only  is  involved;  in  more  severe  cases  capsule,  cartilages,  ligaments, 
and  even  bones  are  involved.  Some  cases  suppurate.  Septic  typhoid  arthritis 
results  from  a  mixed  infection  with  typhoid  bacilli  and  pyogenic  bacteria, 
and  is  identical  in  symptoms  and  progress  with  an  ordinary  septic  arthritis. 
Typhoid  arthritis  proper  may  be  monarticular  or  polyarticular,  the  mon- 
articular form  being  the  most  common,  and  the  hip-joint  being  the  articula- 
tion most  hable  to  be  attacked.  In  most  cases  typhoid  arthritis  causes  but 
Httle  pain.  The  swelling  is  marked,  although  in  the  hip  it  is  concealed.  Pus 
rarely  forms.  Keen  calls  attention  to  the  fact  that  in  the  84  cases  he  col- 
lected, spontaneous  dislocation  occurred  in  43,  nearly  all  in  the  hip.*  Fluid 
from  a  typhoid  joint  may  be  sterile  (bacteria  having  died),  may  show  mixed 
infection,  or  may  give  a  pure  culture  of  typhoid  bacilli  (see  A.  G.  Ellis  in 
"Jour,  of  Infectious  Diseases,"  April  i,  1909). 

Treatment. — A  mild  case  is  treated  as  a  simple  synovitis.  If  diagnostic 
puncture  obtains  fluid  free  from  bacteria,  no  more  radical  method  than 
aspiration  and  irrigation  is  required.  If  the  fluid  contains  bacteria,  incision 
and  drainage  are  demanded. 

Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism. — During  the  prog- 
ress of  gonorrhea  the  development  of  a  painful  joint  does  not  of  necessity 
prove  the  existence  of  gonorrheal  rheumatism,  for  ordinary  rheumatism  is 
just  as  likely  to  arise  when  a  man  has  clap  as  when  he  has  not  this  malady. 
Furthermore,  the  term  is  inaccurate,  as  gonorrheal  rheumatism  is  not  rheu- 
matism at  all,  but  is  an  infective  disorder  of  the  joints  or  of  the  synovial 
membranes,  the  infective  material  being  contained  primarily  in  the  urethral 
discharge.  Gonorrheal  rheumatism  is  one  of  the  forms  of  infective  arthri- 
tis. Occasionally  this  form  of  arthritis  arises  from  gonorrheal  ophthalmia 
(Heiman's  case);  it  sometimes,  though  rarely,  arises  during  the  height  of 
a  gonorrhea,  but  it  is  more  frequently  met  with  in  chronic  cases  or  when 
the  intensity  of  the  inflammation  is  abating  in  acute  cases.  Men  suffer 
*Keen  on  "The  Surgical  Complications  and  Sequels  of  Typhoid  Fever." 


646  Diseases  and  Injuries  of  Bones  and  Joints 

from  gonorrheal  arthritis  far  more  frequently  than  do  women,  and  the  seizure 
is  very  apt  to  recur  again  and  again.  In  some  cases  many  joints  are  involved, 
but  in  most  cases  only  a  few  joints  suffer.  Osier  states  that  the  knees  and 
ankles  are  most  apt  to  be  involved  in  gonorrheal  rheumatism,  and  that  this 
form  of  arthritis  is  peculiar  in  often  attacking  joints  that  are  apt  to  be  exempt 
in  acute  rheumatism  ("  the  sternoclavicular,  the  intervertebral,  the  tem- 
poromaxillary,  and  the  sacro-iliac").  There  are  two  forms  of  gonorrheal 
rheumatism — an  acute  and  a  chronic  form.  The  poison  reaches  the  joint 
by  way  of  the  blood.  In  some  cases  gonococci  are  found  in  the  joint  fluid; 
in  other  cases  they  are  not  found.  I  am  inclined  to  believe  that  in  the  milder 
cases,  which  recover  without  genuine  pus-formation,  only  toxins  are  present 
in  the  joint.  In  the  severe  cases  the  organisms  themselves  exist  in  the  articu- 
lar tfuid.  Osier  suggests  that  the  non-suppurative  cases  are  due  to  the  action 
of  toxins  taken  up  from  the  area  of  primary  infection,  and  that  the  suppura- 
tive cases  are  due  to  infection  with  pyogenic  bacteria.  Endocarditis  may 
occur,  and  it  is  due  always  to  micro-organisms  and  not  to  toxins. 

Changes  in  and  about  the  Joint. — The  inflammation  of  gonorrheal  arthritis 
may  be  located  around  rather  than  in  the  joint,  and  especially  in  the 
tendon-sheaths.  Suppuration  is  unusual,  but  it  may  occur  in  joints  and  in 
tendon-sheaths.  Cultivation  of  the  exudate  may  or  may  not  show  the 
gonococci.  Cover-glass  preparations  carefully  stained  may  or  may  not  show 
gonococci. 

Symptoms. — The  acute  form  attacks,  as  a  rule,  but  a  single  joint,  but  may 
attack  several  joints.  The  joint  trouble  begins  with  great  suddenness,  and 
is  often  ushered  in  by  chilly  sensations  or  by  a  distinct  chill.  Moderate 
fever  arises.  The  pain  in  the  joint,  severe  from  the  first,  becomes  excruciat- 
ing. If  superficial  joints  suffer,  the  skin  over  them  becomes  red  and  hot,  and 
periarticular  edema  soon  presents  itself.  The  fluid  in  the  joint  is  in  most 
cases  serous,  but  may  become  purulent.  If  pus  forms,  the  fever  becomes 
very  high  and  chills  may  occur. 

A  chronic  condition  may  follow  the  acute,  but  the  condition  may  be 
chronic  from  the  start.  The  symptoms  resemble  those  of  the  acute  form, 
but  are  far  milder,  although  acute  exacerbations  may  occur.  The  joint  fluid 
is  usually  serous.*  In  gonorrheal  arthritis  there  may  be  transitory,  inter- 
mittent, and  wandering  pain  in  and  about  the  joint,  without  any  other  symp- 
tom; one  or  more  joints  may  become  swollen  and  painful,  and  moderate 
fever  may  develop.  One  joint,  especially  the  knee,  may  swell  to  an  enormous 
extent,  pain,  pariarticular  edema,  redness,  and  fever  being  absent  (hydrar- 
throsis, or  dropsy  of  the  joint).  Suppuration  in  this  form  of  the  disease  sel- 
dom occurs.  The  tendons,  the  tendon-sheaths,  the  bursae,  and  the  periosteum 
may  inflame.  Whether  the  joints  are  inflamed  or  not  inflamed,  the  tendon- 
sheaths  about  the  wrist  and  ankle  and  the  retrocalcaneal  bursas  may  suffer. 
In  some  cases  numerous  bursae  are  involved.  It  is  often  difficult  and  is 
perhaps  impossible  to  check  gonorrheal  arthritis.  It  may  last  for  a  long 
period,  and  tends  to  recur  again  and  again.  Iritis,  pleuritis,  endocarditis, 
and  pericarditis  have  been  observed  as  complications. 

The  diagnosis  between  gonorrheal  arthritis  and  acute  rheumatism  rests 
chiefly  on  the  great  chronicity,  the  sHght  degree  of  fever,  the  excessive  ten- 
*  See  Schuller  in  Aerztl.  Pract.,  No.  17,  1896. 


Pncumococciis  Arthritis  ^47 

rheumatsm    ana  on  recurrence,  the  greater  proneness  to 

::retr     1    ru-lt    Ld  the%reat   liabiHty  to  -diac  and  v.cera 
coml>lication.  in  rheumatic  fever.    Furthermore,  m  gonorrheal  arthrms  a 
3  h  IT  infection  (urethral  or  ocular)  certainly  exists  or  recently  existed 
fn  ordinary  rheumatism  a  urethral  discharge  may,  of  course,  happen  to  be 
present     Gonorrheal  arthritis  is  apt  to  affect  certain  joutts  wh.ch  acute 

^'"7>:';r,;-Bec:ui':f  the  lingering  character  and  dangerous  nature  of 
gon  rTh  1  rthrWs  and  because  if  unchecked  it  is  liable  top™<luc.  grave  ™^ 
mirment  of  function,  treatment  should  be  prompt  and  radical,  "-advocated 
Ty  Ha  1  nearly  tw;nty  years  ago.    The  Joint  should  be  asp-ted  a^d     'h 

Tntrn^beTed  without  drainage.     ^^  r  VZf  iTti:' '"^- 
Hrain    and  immoblMze.     Conservative  treatment  is  of  little  value  in  gono 
coc  ai  arthrr   The  salicylates,  the  alkahes,  and  salol  are  useless    iron, 
aSenic    and  "rvchnin  are  possibly  of  some  benefit.     Quimn  is  helpfu    m 
Ze  cases     lodid  of  potafsium  seems  to  be  of  a  certain  amount  of  value. 
The  inflTr^ed    oints  are  usually  wrapped  in  cotton  and  bandaged,  ^nde«.y 
dav  a  little  blue  ointment  is  rubbed  into  the  skin  about  them.     If  the  intlam 
miion  Itagers,  it  is  customary  to  use  the  hot-air  oven  -s-ge^  ^f^f^/  ^ P^t 
sive  motioS,  apply  blisters,  or  counter-irritate  with  the  hot  iron.    It  is  though 
by  some  competent  chnicians  that  antigonococcic  serum  P-^-J  *.  net 
value   creatly  alleviating  pain  and  favoring  the  restoration  of  Joint  mobih^^ 
Mre^ptTence  with  it  i!l  yet  too  insignificant  to  jusdfy  me  in  expressing  an 

""'the  value  of  vaccine  treatment  (injections  of  dead  bacteria)  is  as  yet  unde- 

'"tfumococcus  Arthritis.-This  is  a  rare  condition   although  Hert^ck 

u  11  .t.A  CO  nses  ("  Amer    Tour,  of  Med.  Sciences,"  July,  1902).     J^x 

mprrirk^      I  havc  sccn  2  cases :  in  one  case  the  knee  oni>   wa 
["Lr  boTh  knees,  one  elbow,  and  -  sh-'^tUrth^ t' joi  t" 
Cole's  series  of  41  cases,  .3  exhibited  involvement  "'  ™;'=J^^"J„„J,  „- 
The  inflamed  joint  is  frequently  completely  destroyed.    P"™™"  H^j^t 
Iritis  develops,  as  a  rule?  soon  after  the  crisis  of  pneumonia,  but  Herrick 


648  Diseases  and  Injuries  of  Bones  and  Joints 

of  septic  symptoms,  and  the  signs  of  joint  inflammation.  It  is  confirmed 
by  aspiration  and  examination  of  the  fluid.  The  disease  is  very  fatal.  In 
Herrick's  series  of  cases  over  65  per  cent,  were  fatal.  In  Cole's  series  of 
cases  there  were  28  deaths  and  13  recoveries.  Even  if  the  patient  recovers, 
the  convalescence  is  prolonged  and  more  or  less  ankylosis  is  to  be  expected. 

Treatment. — A  non-purulent  effusion  may  be  treated  by  aspiration  if 
bacteria  are  not  found  in  the  fluid.  If  the  aspirated  fluid  contains  bacteria, 
the  joint  should  be  opened  and  drained. 

Syphilitic  Arthritis. — See  page  322. 

Acute  Rheumatic  Arthritis;  Rheumatic  Fever  or  Acute  Rheuma- 
tism.— Acute  rheumatism  is  a  self-limited  febrile  malady  whose  character- 
istic features  are  polyarthritis,  profuse  acid  sweats,  and  a  tendency  to  heart- 
involvement.  There  is  some  evidence  to  indicate  that  acute  rheumatism  is 
a  form  of  infective  arthritis,  the  bacteria  being  deposited  in  the  synovial 
tissues  and  later  perhaps  entering  into  the  joint  cavity.  Arthritis  of  many 
joints  has  followed  intravenous  injection  into  animals  of  diplococci  obtained 
from  the  throat  of  a  man  suffering  from  rheumatic  angina  (Poynton  and  Paine 
at  Manchester  meeting  of  the  Brit.  Med.  Assoc,  1902).  John  O'Conor* 
believes  that  acute  rheumatism  is  a  condition  "something  similar  to  gon- 
orrheal arthritis  and  pyemia,  the  germ  or  toxin  gaining  admission  to  the 
body  through  the  tonsil  or  other  microbic  trap-door,  and  that  the  joint  inva- 
sion is  promptly  followed  by  a  form  of  infective  arthritis  accompanied  with 
general  toxemia;  and,  furthermore,  the  infected  joints  serve  as  incubators, 
where  the  poison  is  elaborated  and  passed  into  the  circulation  and  thus 
conveyed  to  other  articulations  and  to  the  heart." 

Symptoms  0}  Acute  Rheumatism. — In  acute  rheumatism  the  case  begins 
with  malaise  and  fever,  and  one  or  more  joints  become  affected.  The  in- 
flammation spreads  from  joint  to  joint,  is  apt  to  be  symmetrical,  and  when 
it  arises  in  fresh  joints,  usually  disappears  quickly  in  those  previously  aft'ected. 
The  temperature  is  high,  the  skin  sweats  profusely,  the  joints  are  red,  swollen, 
hot,  and  excruciatingly  painful,  and  the  structures  about  the  joints  are  edema- 
tous. After  a  short  time  the  inflammation  subsides  in  one  joint  and  passes 
into  another,  the  joint  first  attacked  regaining  its  functions.  Suppuration 
does  not  take  place.  Anemia  is  pronounced,  exhaustion  is  profound,  the 
sweat  is  sour,  the  saliva  is  acid;  the  urine  is  acid,  scanty,  high-colored,  often 
contains  albumin,  and  is  deficient  in  chlorids.  Cardiac  disease  is  apt  to 
be  produced  (endocarditis,  pericarditis,  or  myocarditis).  Nodules  may  form 
upon  fibrous  structures  hyperpyrexia  is  not  unusual,  and  cerebral  or  pul- 
monary complications  may  occur. 

Chronic  Rheumatism. — Sometimes  follows  repeated  attacks  of  acute 
rheumatism,  but  oftener  arises  insidiously  in  people  who  have  been  exposed 
to  cold  and  damp,  who  have  suffered  from  poverty,  hardship,  and  privation, 
or  have  had  much  worry.  The  capsule  and  tendon-sheaths  thicken,  and 
there  is  usually  but  little  effusion  in  the  joint,  but  the  articulation  becomes 
stiff  and  painful.  The  joint-cartilages  are  occasionally  eroded.  Muscular 
atrophy  occurs. 

Symptoms  0}  Chronic  Rheumatism. — In  chronic  rheumatism  the  affected 
joints  are  stiff  and  painful  and  are  a  little  swollen,  but  not  red.     Dampness 

*  Lancet,  Jan.  24,  1903. 


Chronic  Rheumatism 


649 


and  cold  aggravate  the  symptoms.  One  joint  or  many  may  be  affected, 
but  usually  several  are  involved.  Passive  movements  cause  the  joint  to 
creak  and  develop  crepitus  in  the  tendon-sheaths.  The  muscles  are  wasted. 
Anemia  is  usually  pronounced.  The  smaller  blood-vessels  become  sur- 
rounded by  fibrous  tissue  which  progressively  contracts  and  lessens  the 
blood-supply  of  the  synovial  structures.  The  joints  may  ankylose.  There 
is  no  fever  and  no  tendency  to  suppuration,  and  the  disease  is  incurable. 

The  treatment  of  acute  rheumatism  comprises  the  use  of  alkalies,  sali- 
cylates, etc.  (See  a  book  upon  practice  of  medicine.)  O'Conor  is  a  believer 
in  incising  and  draining  the  inflamed  joints;  and  if  the  theory  of  an  infective 
origin  is  correct,  this  treatment  is  rational.  I  have  never  ventured  to  do  it, 
but  would  consider  the  advisability  of  doing  so  if  the  ordinary  treatment 
proved  futile.     O'Conor  operates  early  and  beheves  that  this  is  the  real  way 


^ 


Fig.  343. — Chronic  gout  (Patterson). 


to  arrest  the  disease  and  prevent  complications,  but  his  views  have  not  met 
with  general  acceptance.*  In  chronic  rheumatism  maintain  the  general 
health  of  the  patient,  give  courses  of  iron,  arsenic,  and  strychnin,  and  an 
occasional  course  of  iodid  of  potassium  or  a  salt  of  lithium,  and,  if  possible, 
send  him  every  winter  to  a  warm  climate.  Turkish  baths  give  considerable 
temporary  relief.  The  waters  and  regimen  of  Carlsbad  and  Vichy  are  of 
positive  though  temporary  benefit,  and  the  sufferer  may  obtain  relief  at  the 
hot  springs  of  Virginia.  The  patient  must  avoid  damp  and  must  wear 
woolens.  Frictions,  the  douche,  massage,  flying  blisters,  counter-irritation 
with  the  hot  iron,  ichthyol  ointment,  and  mercurial  ointment  are  of  benefit. 
Subjecting  the  diseased  joint  to  a  very  high  temperature  by  placing  it  daily  in 
a  hot-air  apparatus  often  does  great  good.  In  partial  ankylosis  it  is  proper 
in  some  cases  to  give  ether  and  break  up  the  adhesions. 

*  Lancet,  Jan.  24,  1903. 


650  Diseases  and  Injuries  of  Bones  and  Joints 

Gouty  arthritis,  which  appears  especially  in  the  smaller  joints  (as  the 
fingers  and  the  metatarsophalangeal  joints  of  the  great  toes),  is  due  to  a 
deposition  of  urate  of  sodium  in  the  joint  and  in  the  periarticular  structures. 
The  irritant  virate  of  sodium  causes  inflammation,  inflammation  leads  to 
the  formation  of  granulation  tissue,  granulation  tissue  is  converted  into 
fibrous  tissue,  and  the  fibrous  tissue  contracts  and  thus  deforms  the  joint 
and  limits  its  mobiUty.  A  great  mass  of  urates  in  a  joint  constitutes  a  ''chalk- 
stone.''^ 

Symptoms. — The  premoniton,'  symptoms  may  be  obser\'ed  for  a  day  or 
so,  but  the  acute  seizure  usually  occurs  early  in  the  morning,  the  patient, 
as  a  rule,  being  aroused  by  excruciating  pain  in  the  metatarsophalangeal 
articulation  of  one  of  the  great  toes.  The  joint  swells,  and  the  skin  over 
it  feels  hot  to  the  touch  and  becomes  red  and  shiny.  There  is  often  consider- 
able fever.  After  a  few  hours  the  intensity-  of  the  seizure  abates,  only  to  recur 
again  with  renewed  \'iolence  early  the  next  morning,  these  remissions  and 
recurrences  taking  place  for  six  or  eight  days,  when  the  attack  subsides. 
In  patients  with  chronic  gout  (Fig.  343)  many  joints  are  stiffened  and  deformed 
as  a  result  of  repeated  attacks.  Chalk-stones  form,  and  the  skin  above  them 
may  ulcerate.  Such  patients  are  chronic  dyspeptics,  have  high-tension 
pulses,  their  hearts  are  h}'pertrophied,  and  their  urine  contains  albimiin 
and  casts. 

The  treatment  of  gouty  arthritis  belongs  to  the  physician,  and  not  to 
the  siu-geon,  although  to  the  latter  the  symptoms  of  the  disease  should  be 
known,  so  that  it  may  be  diagnosticated  from  other  maladies. 

Osteo-arthritis  {Rheumatoid  Arthritis;  Arthritis  Deformans;  Rheumatic 
Gout. — In  this  disease,  which  is  not  a  combination  of  gout  and  rheumatism, 
the  syno\-ial  membrane  and  cartilages  are  affected,  the  periarticular  struc- 
tures are  involved,  and  masses  of  new  bone  are  formed. 

Osteo-arthritis  probably  has,  as  John  K.  Mitchell  long  ago  pointed  out, 
a  nervous  origin.  It  arises  especially  in  persons  who  have  been  worried, 
driven,  and  harassed.  There  is  apt  to  be  muscular  atrophy,  trophic  lesions  of 
the  hair  and  nails  are  likely  to  appear,  and  the  sjTnptoms  are  disposed  to  be 
symmetrical.  The  causative  lesion  has  not  been  determined.  The  disease  is 
commoner  in  women  than  in  men.  The  greatest  Hability  e.xists  between 
the  ages  of  twenty  and  forty,  but  children  may  acquire  the  disease,  and  it 
may  also  be  developed  in  people  far  beyond  middle  life.  Apes  in  captivity 
may  develop  it.  .Arthritis  deformans  may  attack  the  rich  or  the  poor;  it  does 
not  result  from  gout,  nor  does  it  often  follow  rheumatism;  it  is  not  caused  by 
damp  and  cold;  and  only  in  rare  cases  does  it  arise  after  traumatism  of  a  joint. 

Osteo-arthritis  difi'ers  from  gout  in  the  entire  absence  of  urate  def>osit, 
and  it  differs  from  chronic  rheiunatism  in  the  extensive  alterations  in  the 
joint-structures.  The  changes  begin  in  the  cartilage;  the  cartilage-cells 
multiply,  the  intercellular  substance  degenerates,  the  pressure  of  the  bone 
causes  thinning,  and  at  length  the  cartilage  is  entirely  destroyed  and  the 
bone  exposed.  The  ex-posed  bone  is  altered  in  shape,  is  hardened,  and 
is  worn  away  in  the  center,  the  peripher}-  increasing  in  thickness  by  ossific 
deposit,  the  center  deepening  by  absorption.  The  margins  are  not  only 
thickened,  but  are  bulged  and  lengthened  by  deposit.  The  fringes  of  the 
S)Tio\'ial  membrane  h}-pertrophy  and  multiply,  and  some  of  them  are  apt 


Osteo-arthritis  651 

to  break  off  {loose  cartilages).  The  capsule  and  the  ligaments  of  the  joint, 
as  a  rule,  become  fibrous  and  contract;  but  they  may  soften,  relax,  and  permit 
of  dislocation.  The  joint  usually  contains  no  effusion,  but  in  some  cases 
there  is  great  effusion  {hydrarthrosis).  The  tendons  about  the  joint  may 
become  fibrous  and  contracted,  they  may  qssify,  they  may  be  separated 
from  the  bone,  or  they  may  be  destroyed  entirely.  Deformity  is  marked 
and  motion  is  limited.  The  fingers,  when  involved,  show  nodules  on  the 
sides  of  the  joints  (Heberden's  nodules).  The  vertebras  may  be  involved. 
Almost  all  the  joints  may  suffer.     Suppuration  does  not  occur. 

Symptoms. — Charcot  divides  osteo-arthritis  into  three  forms,  and  gives 
their  symptoms,  as  follows : 

1.  Heberden's  nodosities,  which  condition  is  commoner  in  women  than 
in  men,  comes  on  between  the  ages  of  thirty  and  forty,  and  is  especially 
common  in  neurotic  subjects.  The  interphalangeal  joints  become  the  victims 
of  attacks  of  moderate  swelling  and  of  some  tenderness,  which  attacks  are 
not  severe,  but  recur  again  and  again.  After  a  time  small  hard  swellings 
(nodosities)  appear  upon  the  sides  of  the  dorsal  surface  of  the  second  and 
third  phalanges,  remain  permanently,  and  slowly  increase  in  size.  The 
joints  become  stiff  and  creak  on  movement,  the  cartilages  are  destroyed, 
and  contractions  and  rigidity  develop,  but  there  is  no  fever  and  the  larger 
joints  are  not  involved.     The  malady  is  incurable. 

2.  Progressive  rheumatic  gout,  which  may  be  acute  or  chronic.  The  acute 
form  begins  as  does  rheumatic  fever.  There  are  moderate  fever  and  swelling, 
without  redness,  of  a  number  of  joints,  of  bursae,  and  of  tendon-sheaths; 
the  joints  are  stiff  and  crepitate,  and  are  apt  to  be  symmetrically  involved; 
muscular  atrophy  begins  early  and  rapidly  becomes  decided;  pain  is  slight. 
This  acute  form  is  apt  to  arise  in  young  women  after  pregnancy,  but  is  not 
unusual  at  the  climacteric  and  in  children.  Anemia  always  exists.  The 
case  is  apt  to  advance  progressively  until  a  number  of  joints  are  firmly  locked, 
when  it  may  become  stationary.  Another  pregnancy  will  develop  anew  the 
acute  symptoms.  In  the  chronic  form  swelling  and  pain  on  movement  are 
noted  in  certain  joints.  The  involvement  is  apt  to  be  symmetrical.  Attacks 
of  swelling  and  pain  alternate  with  periods  of  quiescence,  but  the  disease 
does  not  cease  its  advance.  Articulation  after  articulation  is  attacked  by 
the  malady  until  almost  all  the  joints  are  involved;  deformity  and  stiffness 
become  pronounced,  and  pain  may  or  may  not  be  severe.  There  is  no  fever. 
Muscular  atrophy  is  marked. 

3.  Partial  rheumatic  gout  attacks  one  articulation,  and  it  is  most  often 
met  with  in  old  men.  It  may  fix  itself  on  the  vertebral  column,  on  the  knee, 
on  the  shoulder,  on  the  elbow,  or  on  the  hip.  The  joint  grates  and  becomes 
stiff,  swollen,  and  deformed;  the  muscles  atrophy;  there  is  usually  pain,  but 
fever  is  absent. 

Osteo-arthritis  or  partial  rheumatic  gout  of  the  hip-joint  seldom 
occurs  before  the  age  of  forty-five,  but  is  occasionally,  though  very  rarely, 
met  with  in  persons  under  twenty-five.  If  the  disease  arises  in  an  elderly 
person,  it  is  often  called  morbus  coxcb  senilis.  In  some  cases  only  the  hip- 
joint  is  attacked;  in  many  cases  other  joints  are  also  diseased.  Osteo-arthritis 
of  the  hip  may  follow  an  injury.  Usually  the  disease  is  unconnected  with 
traumatism,  begins  very  gradually,  and  advances  slowly.     There  is  pain, 


652  Diseases  and  Injuries  of  Bones  and  Joints 

often  mistaken  for  sciatica,  in  and  about  the  joint,  and  there  is  increasing 
stiffness.  The  pain  and  stiffness  are  worse  when  the  patient  first  moves 
after  resting.  Lameness  becomes  noticeable,  and  grating  can  be  detected 
in  and  about  the  joint.  The  symptoms  become  gradually  worse,  although  at 
times  they  may  seem  to  improve  for  brief  periods.  The  lameness  and  the 
stiffness  are  greatly  aggravated,  and  the  pain  becomes  very  severe,  even 
when  at  rest.  Shortening  takes  place,  the  great  trochanter  ascends  above 
Nelaton's  line,  the  limb  is  usually  abducted,  but  in  very  rare  cases  is  adducted, 
and  finally  ankylosis  occurs. 

Partial  rheumatic  gout  of  the  vertebral  articulations  causing  fixation  is 
called  ''spondylitis  deformans"  (p.  866). 

Treatment. — Osteo-arthritis  cannot  be  cured,  but  in  some  cases  it  remains 
stationary  for  many  years.  Treat  the  anemia  by  iron,  arsenic,  nourishing 
food,  and  have  the  patient  out  in  the  fresh  air  as  much  as  possible.  De- 
biUty  is  met  by  the  administration  of  strychnin.  Hot  baths  of  mineral  water 
do  good.  It  is  claimed  that  the  hot-air  apparatus  is  of  service.  Douches 
improve  these  cases,  but  electricity  is  useless.  Counter-irritants  do  no  good. 
Massage  retards  the  progress  of  the  case,  relieves  the  pain,  aids  in  the  ab- 
sorption of  effusion,  and  delays  fixation.  During  an  acute  exacerbation  the 
joint  should  be  put  at  rest  for  a  time  and  evaporating  lotions  applied.  In 
an  exacerbation  in  disease  of  the  hip  the  patient  should  be  put  to  bed  and 
have  extension  applied.  The  patient  is  unfortunately  liable  to  develop  the 
opium-habit.  If  dropsy  of  a  joint  arises,  try  compression  with  a  Martin 
bandage,  and,  if  this  fails,  aspirate  and  wash  out  the  joint  with  a  2  per  cent. 
solution  of  carbolic  acid.  Patients  with  rheumatic  gout  do  best  in  a  warm, 
dry  climate.  Cod-liver  oil  does  good,  as  it  improves  nutrition  and  hence 
retards  the  progress  of  the  disease.  Do  not  be  tempted  to  immobilize  the 
joints  beyond  a  day  or  two :  fixation  only  hastens  ankylosis.  Howard  Marsh* 
maintains  that,  as  a  rule,  but  little  good  comes  from  manipulation.  He 
makes  the  following  exceptions:  when  one  joint  onh'  is  afi'ected;  when  the 
joint  is  very  stiff  but  not  very  painful;  when  the  patient  is  in  good  general 
health  and  is  not  beyond  middle  age. 

Charcot's  Disease  {Tabetic  Arthropathy;  Charcot's  Joint;  Neuropathic 
Arthritis). — This  condition  is  an  osteo-arthritis  due  to  trophic  disturbance, 
arising  in  a  sufferer  frjDm  locomotor  ataxia,  and  is  anatomically  identical 
with  osteo-arthritis,  which  was  described  above.  The  knee  is  most  apt  to 
be  attacked,  and  the  hip  suffers  more  often  than  any  joint  but  the  knee.  The 
condition  may  develop  in  the  shoulder  or  elbow.  The  smaller  joints  some- 
times, though  seldom,  are  involved.  More  than  one  joint  may  suffer.  The 
disease  in  most  cases  begins  acutely,  often  as  a  sudden  effusion,  which  after 
a  time  may  disappear.  In  most  cases,  however,  the  joint  becomes  rapidly 
disorganized.  The  swelHng  is  usually  very  marked  and  is  sometimes  enor- 
mous. In  the  earhest  stages  it  is  due  to  periarticular  edema  and  to  articular 
effusion.  Pain  is  slight  or  is  absent,  there  is  no  constitutional  involvement, 
and  the  condition  is  unconnected  with  injury.  Some  cases  begin  without 
this  prehminary  acute  swelling,  disorganization  being  manifest  from  the 
beginning.  \Mien  disorganization  has  once  begun,  it  continues  inexorably. 
Bony  masses  form  around  the  articular  canty,  in  the  ligaments,  and  in  the 
*  "  Diseases  of  the  Joints  and  Spine." 


Hysterical  Joint  653 

cartilages.  The  bones  and  cartilages  are  rapidly  destroyed  and  absorbed; 
fracture  is  apt  to  occur;  the  joint  creaks  and  grates;  the  softening  and  relax- 
ation of  the  ligaments  permit  an  extensive  range  of  movement ;  great  deform- 
ity ensues;  dislocation  is  apt  to  occur;  muscular  atrophy  is  decided;  and 
pus  occasionally,  though  very  rarely,  forms.  There  is  not  the  slightest  dis- 
position to  repair.  Charcot's  joint  differs  from  rheumatoid  arthritis  in  the 
usual  acute  onset  and  the  painless  course.  The  complete  or  nearly  com- 
plete freedom  from  pain  is  one  of  the  most  striking  features  of  the  condition. 
In  saying  there  is  freedom  from  pain  we  mean  freedom  from  pain  in  the  joint, 
from  the  pain  and  tenderness  in  the  regions  in  which  we  expect  to  find  them  in 
an  inflamed  joint.  Usually  these  patients,  though  free  from  pain  in  the  joint, 
suffer  much  from  the  lightning  pains  of  locomotor  ataxia.  Gastric  crises  are 
not  uncommon  (Bramwell).  Charcot's  joint  is  more  common  in  female  than 
in  male  tabetics.  In  saying  that  Charcot's  is  often  of  sudden  origin,  we  mean 
in  a  single  night,  as  Charcot  pointed  out,  swelling  of  a  joint  may  arise.  In  a  day 
or  two  the  joint  swelling  becomes  great,  and  if  aspiration  is  performed,  yellow 
serum  is  obtained.     In  a  week  or  two  the  joint  begins  to  creak  on  movement. 

Treatment. — The  treatment  of  Charcot's  disease  consists  in  the  wearing 
of  an  apparatus  to  sustain  the  joint.  Resection  is  recommended  by  some, 
but  most  surgeons  do  not  advise  its  performance.  Southam  advocates  ampu- 
tation for  certain  cases  of  Charcot's  joint.  He  has  performed  the  operation 
on  four  patients.  He  amputated  twice  for  ankle-joint  disease  and  twice  for 
disease  of  the  tarsus.  In  every  case  the  stumps  healed  quickly  and  without 
suppuration.  Southam  was  lead  to  perform  amputation  on  his  first  case  by 
the  report  of  Jonathan  Hutchinson's  case  of  amputation  of  the  leg  for  perfor- 
ating ulcer  and  disease  of  the  bones  of  the  foot  in  a  tabetic. 

Osteo-arthropathie  Hjrpertrophiante  Pneumique  {Marie's  Disease). — 
A  condition  associated  with,  and  possibly  springing  from,  pulmonary  disease, 
and  characterized  by  enlargement  of  joints,  thickening  of  the  finger-ends, 
and  the  formation  of  a  dorsolumbar  kyphosis.  The  joints  are  painful,  the 
skin  undergoes  pigmentation,  and  profuse  perspiration  is  often  present.  The 
head  entirely  escapes  in  this  disease,  which  immunity  marks  a  distinction 
from  acromegaly. 

Hysterical  joint  (Brodie's  joint)  is  a  condition  mostly  encountered  in 
young  women.  The  disease  occurs  most  commonly  in  the  knee  and  the 
hip,  and  often  follows  a  sHght  injury  which  acts  as  an  autosuggestion,  a  latent 
hysteria  being  awakened  into  action  and  localized,  though  severity  of  the 
injury  does  not  determine  the  severity  of  the  symptoms.  The  disease  may 
ensue  upon  a  synovitis  or  an  arthritis,  or  may  arise  without  apparent  cause. 
The  patient  complains  of  pain  in  and  stiffness  of  the  joint,  resists  passive 
motion  strenuously,  and  claims  that  it  causes  much  pain.  There  is  occasion- 
ally some  muscular  atrophy  from  want  of  use,  and  the  joint  is  a  little  swollen. 
The  skin  is  hyperesthetic,  and  a  light  touch  causes  more  pain  than  does 
deep  pressure.  The  muscles  may  be  rigid.  The  joint  may  be  maintained 
either  in  flexion  or  in  extension,  but  it  is  rarely  in  the  exact  degree  of 
flexion  assumed  for  ease  in  a  true  joint-inflammation,  and  the  position  is  apt 
to  be  changed  from  day  to  day  or  from  hour  to  hour.  The  skin  is  usually 
pale  and  cool,  but  may  be  red  and  hot,  because  of  hyperemia.  A  periodi- 
cally developed  heat  may  be  observed,  especially  at  night,  accompanied  ap- 


654  Diseases  and  Injuries  of  Bones  and  Joints 

patently  by  much  pain.  The  alleged  pain  in  some  cases  is  neuralgia,  but 
in  most  cases  is  a  pain-hallucination.  There  is  no  effusion  into  the  joint, 
and  swelling  does  not  exist,  although  occasionally  there  is  slight  periarticular 
edema.     In  some  rare  cases  organic  disease  arises  in  a  hysterical  joint. 

Hysterical  phenomena  are  seldom  isolated,  but  are  associated  with  certain 
stigmata  which  may  be  latent.  These  stigmata  are  concentric  contraction 
of  the  visual  fields,  pharyngeal  anesthesia,  convulsions,  hysterogenic  zones, 
globus  hystericus,  clavicus  hystericus,  zones  of  anesthesia,  especially  hemi- 
anesthesia, and  hyperesthetic  areas.  Such  patients  are  predisposed  by  in- 
heritance, and  have  previously,  as  a  rule,  had  nervous  troubles.  Hysterical 
phenomena,  be  it  remembered,  lack  regularity  of  evolution,  and  are  pro- 
duced, altered,  or  aboHshed  by  mental  influences  and  physical  sensations 
which  are  without  effect  in  causing,  modifying,  or  curing  organic  disease. 
The  general  health,  as  a  rule,  is  good,  but  neurasthenia  may  coexist.  In 
examining  these  patients  the  observer  will  note  that  the  symptoms  disappear 
when  the  attention  is  diverted;  that  they  are  out  of  all  proportion  to  the 
local  evidences  of  disease;  that  there  is  no  sign  of  joint-destruction;  and 
that  a  light  touch  may  cause  more  pain  than  does  firm  pressure.  If  the 
patient  is  anesthetized,  perfect  joint  mobiHty  will  be  found. 

Treatment. — The  treatment  for  a  hysterical  joint  comprises  attention  to 
the  general  health,  the  employment  of  nourishing  and  easily  digested  food, 
the  prevention  of  constipation,  and  the  administration  of  tonics  if  they  are 
needed.  The  surgeon  must  dominate  his  patient's  mind  and  make  her 
reahze  that  he  is  master  of  the  case.  He  is  to  be  an  inexorable  but  just 
ruler — never  a  brutal  or  a  cruel  one.  If  possible,  send  the  patient  away 
from  the  harmful  sympathies  of  her  home  and  let  her  have  the  rest  treatment 
of  S.  Weir  Mitchell.  Local  remedies  applied  to  the  joint  do  harm,  as  a  rule, 
by  concentrating  afresh  the  patient's  attention  upon  the  articulation,  although 
the  hot  iron  sometimes  does  good.  Suggestion  in  the  hypnotic  state  may 
be  tried.  The  use  of  morphin  should  be  avoided  as  being  the  worst  of 
enemies.  Never  immobilize  the  joint,  and  always  use  massage,  passive 
motions,  and  frictions. 

Neuralgia  of  the  joints  as  an  independent,  isolated  affection  is 
extremely  rare,  though  as  a  complication  of  other  diseases  it  is  by  no  means 
uncommon.  Neuralgia  is  more  common  outside  of  the  joints  than  in  them,  and 
periarticular  neuralgia  is  especially  frequent  about  the  knee  and  the  ankle. 
Joint-neuralgia  may  arise  in  any  person,  but  it  is  more  commonly  present  in 
young  neurotic  females.  The  pain  may  be  persistent,  or  it  may  occur  in  peri- 
odic storms,  and  it  is  often  associated  with  neuralgia  in  other  parts.  The  pain 
may  be  dull  and  aching,  but  it  is  more  often  sharp  and  shooting.  Joint-neural- 
gia is  associated  with  tenderness  on  pressure,  soreness  on  motion,  often  with 
transitory  sweUing  without  redness,  and  sometimes  with  numbness  of  the  ex- 
tremities. The  diagnosis  depends  on  the  temperament  of  the  patient,  the  sud- 
den onset  of  the  pain,  the  absence  of  constitutional  symptoms,  and  the  free 
mobility  of  the  joint,  especially  under  ether.  Articular  neuralgia  may  depend 
upon  disease  or  injury  of  the  central  nervous  system,  upon  malaria,  syphilis, 
neurasthenia,  rheumatism,  gout,  hysteria,  and  neuritis,  and  may  be  due  to 
reflected  irritation,  especially  from  the  ovaries,  the  uterus,  or  the  rectum. 

Treatment. — The  treatment  to  be  observed  in  joint-neuralgia  is  to  main- 


Sprains  655 

tain  the  general  health.  Examine  for  a  possible  exciting  cause,  and,  if  found, 
remove  it.  Give  a  long  course  of  iron,  quinin,  and  strychnin  or  arsenic. 
In  rheumatic  or  gouty  subjects  administer  suitable  drugs  and  insist  upon 
the  use  of  a  proper  diet.  During  the  attack  use  phenacetin.  Morphin  must 
occasionally  be  given  in  severe  cases,  but  be  careful  of  it,  and  never  tell  the 
patients  they  are  taking  it,  as  there  is  a  possibility  of  their  forming  the  opium- 
habit.  Locally,  employ  frictions,  ointment  of  aconite,  heat,  and  keep  upon 
the  part  a  piece  of  flannel  soaked  in  a  mixture  of  soap  Hniment,  laudanum,  and 
chloroform  (Gross).  Never  allow  the  joint  to  stiffen;  any  tendency  to  stiff- 
ness should  be  met  by  daily  massage,  frictions,  passive  motion,  and  hot  and 
cold  douches.  In  some  rare  cases  nerve-stretching  or  neurectomy  becomes 
necessary. 

Articular  Wounds  and  Injuries. — A  penetrating  wound  is  very 
serious,  and  it  may  be  due  to  a  compound  fracture,  to  a  compound  dislocation, 
to  a  gunshot-wound,  or  to  a  stab.  If  a  bursa  near  a  joint  be  injured,  secondary 
penetration  may  occur  as  a  result  of  suppuration.  In  a  penetrating  wound, 
besides  pain,  hemorrhage,  and  swelling,  there  is  a  flow  of  synovial  fluid. 
A  small  amount  of  synovia  flows  from  an  injured  bursa,  a  large  amount 
from  an  open  joint. 

Treatment. — If  a  joint  is  opened  aseptically  (as  when  incised  by  the 
surgeon),  the  wound  heals  nicely  under  rest  and  antisepsis.  If  a  joint  is 
opened  by  a  septic  body,  suppurative  arthritis  is  apt  to  arise,  and  the  surgeon 
endeavors  to  prevent  it  by  asepticizing  the  surface,  irrigating  the  joint,  drain- 
ing, applying  antiseptic  dressing,  and  securing  rest.  Normal  salt  solution 
is  the  best  agent  for  irrigation,  as  it  does  not  injure  joint-endotheHum.  Active 
antiseptics  are  apt  to  lessen  tissue-resistance,  and  thus  may  actually  favor 
infection.  In  gunshot-wounds  inflicted  by  pistol  bullets  or  sporting  rifle 
bullets,  if  antisepsis  is  not  employed,  suppuration  is  inevitable;  hence  military 
surgeons  in  the  past,  as  a  rule,  have  advocated  amputation  or  excision  in 
gunshot-splinterings  of  large  joints.  Recent  experience  shows  that  the  wound 
of  a  large  joint  produced  by  a  hard-jacketed  and  small-caliber  bullet  may  heal 
with  little  trouble.  In  articular  wounds  the  surface  is  sterilized,  and  usually 
the  wound  is  enlarged,  the  finger  is  introduced  to  discover  and  remove  for- 
eign bodies,  through-and-through  drainage  is  secured,  a  tube  is  inserted, 
the  joint  is  irrigated,  antiseptic  dressings  are  apphed,  and  the  extremity  is 
placed  upon  a  splint.  Very  severe  joint-injuries  demand  resection  or  even 
amputation.  Ankylosis,  more  or  less  complete,  often  follows  a  gunshot- 
wound  of  a  joint.  If  the  joint  suppurates,  the  drainage  must  be  made  more 
free,  sinuses  must  be  slit  up  and  packed,  sloughs  must  be  cut  away,  dead 
bone  must  be  gouged  out,  and  the  patient  must  be  placed  upon  a  stimulant 
and  tonic  plan  of  treatment.  The  above  remarks  do  not  apply  to  wounds 
inflicted  with  the  modern  military  projectile.  Such  wounds  are  not  of  neces- 
sity infected,  and  recovery  may  be  prompt  and  uneventful  if  the  surface  is 
sterilized  and  antiseptic  dressings  and  splints  are  applied. 

Sprains. — A  sprain  is  a  joint-wrench  due  to  a  sudden  twist  or  traction, 
the  ligaments  being  pulled  upon  or  lacerated  and  the  surrounding  parts 
being  more  or  less  damaged.  A  sprain  is  often  a  self-reduced  dislocation 
(Douglas  Graham).  The  joints  most  liable  to  sprains  are  the  knee,  the 
elbow,  and  the  ankle.     The  smaller  joints  are  also  often  sprained,  but  the 


656 


Diseases  and  Injuries  of  Bones  and  Joints 


ball-and-socket  joints  are  infrequently  sprained,  their  normal  range  of  free 
movement  saving  them;  they  do  occasionally  suffer  severely,  however,  as  a 
result  of  abduction.  In  a  bad  sprain  the  ligaments  are  torn;  the  synovial 
membrane  is  contused  or  crushed;  cartilages  are  loosened  or  separated; 
hemorrhage  takes  place  into  and  about  the  joint;  muscles  and  tendons  are 
stretched,  displaced,  or  lacerated;  vessels  and  nerves  are  damaged;  the  skin 
is  often  contused;  and  portions  of  bone  or  cartilage  may  be  detached  from 
their  proper  habitat,  though  still  adhering  to  a  ligament  or  tendon  (sprain- 
fractures).  Sprains  are  commonest  in  young  persons  and  in  adults  with 
weak  muscles.  They  happen  from  sudden  twists  and  movements  when  the 
muscles  are  relaxed.  A  large  part  of  the  support  of  joints  comes  from  muscles, 
and  when  they  are  suddenly  caught  unawares  they  do  not  properly  support 
the  joint,  and  a  sprain  results.     A  joint  once  sprained  is  very  liable  to  a 


Fig.  344. — Gibney's  method  of  strapping  in  sprains  of  the  ankle. 

repetition  of  the  damage  from  sHght  force.  Sprains  are  common  in  a  limb 
with  weak  muscles,  in  a  deformed  extremity  in  which  the  muscles  act  in 
unnatural  lines,  and  in  a  joint  with  relaxed  ligaments. 

Symptoms. — There  is  severe  pain  in  the  joint,  accompanied  by  general 
weakness.  Nausea,  vomiting,  and  even  syncope  may  occur.  There  is  im- 
pairment or  loss  of  ability  to  move  the  joint.  The  above-described  condition 
is  succeeded  by  a  season  of  relief  from  pain  while  at  rest,  numbness  being  com- 
plained of,  and  pain  on  motion  being  severe.  Swelling  arises  very  early  if 
much  blood  is  effused.  In  any  case  swelling  begins  in  a  few  hours.  Extensive 
effusion,  by  separating  joint-surfaces,  produces  slight  lengthening  of  the  limb. 
Movements  of  the  joint  become  dilftcult  or  impossible;  the  tear  in  the  ligament 
may  sometimes  be  distinctly  detected  by  the  examining  fingers;  pain  and  ten- 
derness become  intense ;  joint-crepitus  will  be  manifested ;  and  in  a  day  or  two 
discoloration  becomes  marked.  Moullin  and  others  have  pointed  out  that 
when  a  muscle  is  strained  the  skin  above  it  becomes  sensitive,  especially  at 
tendinous  insertions  over  joints.  As  muscles  are  invariably  strained  when  a 
joint  is  sprained,  there  is  always  some  cutaneous  tenderness.     There  is  also 


Treatment  of  Sprains  657 

tenderness  over  a  sprained  joint  due  to  capsular  injury,  bands  of  adhesions,  etc . 
Tenderness  is  apt  to  arise  at  certain  reasonably  fixed  points:  in  a  hip- joint  in- 
jury it  is  found  behind  the  great  trochanter,  in  a  knee-joint  injury  by  the  side 
of  the  patella,  in  an  ankle-joint  injury  to  the  inner  side  of  the  external  malleolus 
(Gulp).  When  the  vertebral  articulations  are  sprained,  the  muscles  of  the 
back  are  rigid,  the  skin  is  often  sensitive,  pain  may  be  awakened  by  pressure  or 
by  certain  movements,  but  there  is  no  sign  of  cord  injury  in  an  uncomplicated 
case. 

Diagnosis  and  Prognosis. — Sprain-fractures  can  be  diagnosticated  with 
certainty  only  by  the  ^--rays.  In  the  diagnosis  of  a  sprain,  fracture  and  dis- 
location must  be  considered.  In  fracture,  crepitus  and  mobility  exist;  in  dis- 
location, rigidity.  The  diagnosis  of  sprain  should  be  made  by  a  consideration 
of  the  joint  involved,  of  the  age,  of  the  nature  of  the  force,  of  the  length  of  the 
limb,  of  the  fact  that  the  patient  could  use  the  joint  for  at  least  a  short  time  after 
the  accident,  and  of  the  local  feel  and  movements  of  the  part.  In  some  cases 
examine  under  ether,  in  some  apply  the  .Y-rays.  Many  injuries  about  the  ankle 
which  we  would  have  formerly  regarded  as  sprains,  are  often  shown  by  the 
:v-rays  to  be  fractures.  The  prognosis  depends  on  the  size  of  the  joint,  on 
the  extent  of  laceration,  on  the  amount  of  intra-articular  hemorrhage,  and  on 
the  age  of  the  patient.  The  danger  is  ankylosis.  In  rare  cases  after  a  sprain 
of  the  hip- joint  osteo-arthritis  arises.  In  some" few  cases  after  a  sprain  of  the 
hip  the  head  of  the  bone  undergoes  absorption. 

Treatment. — In  a  mild  sprain  apply  at  once  a  silicate  or  plaster-of-Paris 
dressing.  The  first  indication  after  the  infliction  of  a  severe  sprain  is  to  arrest 
hemorrhage  and  limit  inflammation.  For  the  first  few  hours  apply  pressure  and 
an  ice-bag.  Wrap  the  joint  in  absorbent  cotton  wet  with  iced  water,  apply  a  wet 
gauze  bandage,  and  put  on  an  ice-bag.  After  some  hours  place  the  extremity 
upon  a  sphnt  and  to  the  joint  apply  flannel  kept  wet  with  lead-water  and  lau- 
danum, iced  water,  tincture  of  arnica,  alcohol  and  water,  or  a  solution  of 
chlorid  of  ammonium.  These  evaporating  lotions  produce  cold.  Instead  of 
them,  an  ice-bag  may  be  used  for  a  day  or  two.  Leeches  around  the  joint  do 
good.  Constitutionally,  employ  the  remedies  for  inflammation.  Morphin  or 
Dover's  powder  is  given  for  the  pain.     Judicious  bandaging  limits  the  swelling. 

After  a  day  or  two,  if  the  symptoms  continue  or  if  they  grow  worse,  use  hot 
fomentations,  the  hot-water  bag,  plunge  the  extremity  frequently  in  very  hot 
water,  or  apply  heat  by  Leiter's  tubes.  When  the  acute  symptoms  begin  to 
subside,  rub  stimulating  liniments  upon  the  joint  once  or  twice  a  day  and 
employ  firm  compression  by  means  of  a  bandage  of  flannel  or  rubber.  Fric- 
tions should  be  made  from  the  periphery  toward  the  body.  Many  cases  do 
well  at  this  stage  under  the  local  use  of  ichthyol  and  lanolin  (50  per  cent.), 
tincture  of  iodin,  or  blue  ointment.  Later  in  the  case  use  hot  and  cold  douches, 
massage,  frictions,  passive  motion,  and  the  bandage.  Passive  motion  is  begun 
a  day  or  so  after  swelling  ceases.  If  massage  causes  the  swelling  to  return, 
abandon  it  for  several  days  and  then  try  it  again.  Blisters  are  used  when 
tender  spots  persist  and  stiffness  is  manifest.  If  stiffness  becomes  marked, 
move  the  joint  forcibly.  Give  iodid  of  potassium  and  tonics  internally,  and 
insist  on  open-air  exercise.  If  the  person  is  gouty  or  rheumatic,  use  appro- 
priate remedies.  Van  Arsdale  treats  sprains  by  massage  almost  from  the  start. 
Gibney  treats  them  by  strapping  with  adhesive  plaster.  Gibney's  dressing  is 
42 


658  Diseases  and  Injuries  of  Bones  and  Joints 

of  great  service  in  a  sprain  of  the  ankle  (Fig.  344).  Many  sprains  may  be 
put  up  in  an  immovable  dressing  the  first  day  or  two  after  the  accident.  If  the 
joint  contains  much  blood,  aspiration  should  be  practised  before  the  dressing  is 
applied. 

The  hot-air  oven  is  a  very  valuable  method  for  treatint^  recent  sprains,  and 
the  swelling,  pain,  and  stiffness  which  follow  sprains,  of  the  extremities.  The 
sprained  extremity  is  placed  in  an  oven,  and  the  part  is  subjected  to  heat  for  an 
hour.  The  next  day  the  treatment  is  repeated,  and  on  as  many  subsequent 
days  as  may  be  necessary.  In  an  acute  sprain  the  pain  often  disappears  during 
the  first  application  of  heat.  In  the  intervals  between  the  use  of  the  oven  the 
extremity  should  be  at  rest  upon  a  splint. 

Sprain  of  the  Sacro=iliac  Articulation.— A  fall,  lifting  a  heavy  weight, 
a  blow,  or  a  twist  may  injure  this  articulation.  Normally  there  is  slight 
motion,  rupture  or  stretching  of  ligaments  may  lead  to  increased  motion,  and 
any  considerable  range  of  motion  at  the  synchondrosis  means  lack  of  solidity 
and  want  of  support.  A  sprain  of  this  articulation  may  be  caused  by  partu- 
rition, and  also,  as  shown  by  Dunlop,  it  may  develop  during  anesthesia, 
because  of  obliteration  of  the  normal  lumbar  curve  by  lying  on  a  flat  table 
without  a  support  under  the  lumljar  region  ("  N.  Y.  Med.  Jour.,"  July  10, 
1909).  Dunlop  thus  explains,  and  I  think  truly,  the  severe  backache  which 
is  so  common  after  anesthesia. 

A  sprain  causes  severe  pain,  greatly  aggravated  by  standing,  by  rising  up 
from  recumbency,  by  movements  of  the  ilia  which  jar  the  joint,  and  often 
by  direct  pressure  upon  the  synchondrosis.  There  is  often  lateral  spinal 
curvature  due  to  spasm,  and  the  concavity  is  toward  the  injured  side. 

There  is  pain  in  the  injured  articulation,  but  there  may  be  a  general 
backache,  and,  just  as  in  sacro-iliac  tuberculosis  (page  632),  there  maybe 
pain  in  the  sciatic  nerve,  in  the  groin,  and  in  the  hip-joint. 

When  the  ligaments  become  distinctly  relaxed  we  get  the  chronic  condi- 
tion described  by  John  Dunlop  ("  N.  Y.  Med.  Jour.,"  July  10,  1909)  and 
which  he  calls  sacro-iliac  relaxation.  When  this  exists  the  individual  may 
injure  the  articulation  again  and  again  because  of  its  unsteadiness,  he  may 
now  and  then  have  trouble,  he  may  be  in  a  constant  condition  of  helpless- 
ness, with  backache,  groinache,  pain  in  the  hip  and  over  the  ischial  tuberosity, 
lumbar  rigidity  producing  lateral  curvature,  etc.  I  believe  with  Dunlop  in 
the  reality  of  the  condition. 

Treatment. — A  recent  sprain  is  treated  by  rest  in  bed  and  adhesive- 
plaster  strapping,  reinforced  by  a  canvas  roller  around  the  pelvis.  In  a 
chronic  case  (sacro-iliac  relaxation),  insist  on  rest  and  apply  a  spica  bandage 
of  plaster  of  Paris. 

Rupture  of  the  Crucial  Ligaments  of  the  Knee.— This  is  a  rare 
injury.  Rupture  of  Ijoth  ligaments  is  very  unusual  except  in  very  grave  injury, 
such  as  complete  dislocation,  and  then  other  Hgaments  are  also  torn  or  de- 
stroyed. 

The  anterior  crucial  ligament  instead  of  ruj)turing  from  force  may  cause 
avulsion  of  the  tibial  s])ine  (page  618).  When  this  jxirtion  of  bone  is  not  torn 
off,  the  ligament  itself  tears  off  from  the  femur  rather  than  from  the  tibia. 
The  posterior  ligament,  too,  tends  to  tear  off  from  femur  rather  than  tibia. 
Pagenstecher  ("Deutsch.  Med.  Wochenschrift,"  Bd.  xxix)  believes  that  the 


Ankylosis  659 

anterior  ligament  may  be  ruptured  by  forced  flexion  of  the  knee  and  by  blows 
applied  to  the  posterior  f)art  of  the  head  of  the  tibia  when  the  knee  is  flexed. 
The  same  surgeon  maintains  that  the  anterior  ligament  may  be  ruptured  by 
blows  applied  to  the  front  of  the  head  of  the  tibia  when  the  knee  is  flexed. 
Pringle  ("Annals  of  Surgery,"  August,  1907)  maintains  that  the  anterior  liga- 
ment may  be  ruptured  by  "flexion,  abduction,  and  internal  rotation  of  the  leg 
at  the  knee."  If  the  ligaments  are  ruf)tured  there  will  probably  be  abnormal 
freedom  of  anteroposterior  movement  between  the  femur  and  tibia. 

Pringle  ("Annals  of  Surg.,"  1907)  states  that  if,  after  an  injury,  the  knee 
joint  becomes  distended  with  blood,  the  inference  should  be  that  one  or  other 
crucial  ligament  has  been  injured  or  that  the  tibial  spine  has  been  torn  off, 
unless  some  other  lesion  is  obviously  present;  that  if  internal  rotation  of  the 
extended  leg  is  possible  at  the  knee,  or  if  the  head  of  the  tibia  can  be  brought 
forward  on  the  femur,  or  if  there  is  unnatural  abduction,  the  indications  are 
that  the  anterior  crucial  ligament  has  been  injured  or  the  tibial  spine  torn  off; 
that  injury  of  the  posterior  crucial  is  suggested  by  the  possibility  of  pushing 
the  head  of  the  tibia  backward  during  flexion  of  the  knee-joint. 

In  most  cases  exploratory  incision  is  required  to  make  the  diagnosis. 

The  treatment  is  to  open  the  joint  and  suture  the  torn  ligament. 

Ankylosis. — When  a  joint-inflammation  eventuates  in  the  formation  of 
new  tissue  in  and  about  the  joint,  contraction  of  this  tissue  limits  or  destroys 
joint-mobility,  producing  the  condition  known  as  "ankylosis."  Ankylosis  may 
be  complete  (bony)  or  incomplete  (fibrous) ;  it  may  arise  from  contractures  in 
the  joint  {true  or  intra-articulor  ankylosis)  or  from  contractures  in  the  struc- 
tures external  to  the  joint  {false  or  extra-articular  ankylosis) . 

There  are  qualifying  terms  to  indicate  the  extent  of  stiffness — viz.,  false, 
spurious,  true,  bony,  ligamentous,  partial,  complete,  or  incomplete  ankylosis. 
The  significance  of  the  above  terms  will  be  better  appreciated  if  ankylosis  is 
considered  as  meaning  a  stiff  joint.  It  may  be  stiff  with-out  being  rigid. 
Fibrous  adhesions  produce  stiff  joints  and  they  become  rigid  only  when  bony 
union  takes  place  between  the  bones  forming  a  joint. 

Spondylitis  deformans  is  bony  ankylosis  of  vertebrae. 

Arthritis  ossificans  is  a  progressive  bony  ankylosis  in  which  numerous 
joints  are  involved  and  are  finally  completely  obliterated.  It  is  an  ossifying 
arthritis. 

Etiology. — There  are  various  causes — viz.,  traumatism  and  eruptive 
fevers  resulting  in  acute  or  suppurative  synovitis  or  arthritis,  gonorrheal 
arthritis,  tuberculous  arthritis,  svphilitic  affections  of  joints,  bony  fixation 
when  a  fracture  is  near  or  extends  into  a  joint,  and  osteitis  deformans. 

Pathology. — In  complete — i.  e.  bony — ankylosis  the  bones  forming  a  joint 
become  united  by  callus  in  much  the  same  manner  as  bone  fragments  are 
united  after  a  fracture,  or  osseous  bridging  takes  place  at  one  or  more  places 
around  the  joint.  Osseous  ankylosis  is  preceded  by  a  more  or  less  prolonged 
stage  of  fibrous  or  partial  ankylosis.  In  fibrous  ankylosis,  bands  of  fibrous 
connective  tissue  unite  the  bones  forming  a  joint,  thereby  limiting  the  motion. 
In  cases  of  joint  stiffness  produced  by  extra-articular  fibrous,  tendinous,  or 
cicatricial  contracture,  the  joint  proper  remains  free  from  adhesions  for  years, 
provided  it  is  not  and  has  not  been  involved  in  inflammaton,-  action. 

Diagnosis  of  bony  ankylosis  is  usually  made  without  difficulty  except  where 


66o  Diseases  and  Injuries  of  Bones  and  Joints 

there  are  several  joints  near  together,  as  the  carpus,  tarsus,  and  the  spine. 
When  there  are  several  joints  near  together  the  hmitadon  of  motion  in  one 
joint  is  generally  compensated  for  by  the  excess  in  mobility  of  another,  thereby 
rendering  the  associated  parts  capable  of  closely  approaching  normal  function. 
Fibrous  ankylosis  is  more  difficult  to  recognize,  especially  if  pain  accompanies 
manipulative  measures.  It  is  most  apt  to  be  confused  with  fibrous,  liga- 
mentous, or  cicatricial  contractures  of  soft  parts  outside  of  a  joint,  but  having 
more  or  less  direct  functional  relations  therewith. 

Extra-articular  thickening  may  usually  be  detected  by  the  existence  of 
resistance  to  free  joint  motion  in  one  direcdon  only,  /.  c,  that  produced  by  the 
fibrous  contracture  while  the  joint  moves  freely  in  other  directions.  Muscular 
contracture,  whether  voluntary  or  involuntary,  is  but  temporary,  and  is  easily 
detected  by  the  preternatural  rigidity  of  surrounding  parts.  In  bony  ankylosis 
no  voluntary  muscular  action  can  be  detected,  inasmuch  as  in  the  process  of 
the  formation  of  the  callus  uniting  the  bones  the  muscles  have  become 
atrophied  from  disuse.  Conversely,  voluntary  muscle  acdon  about  a  joint 
always  indicates  that  joint  mobilit}'  is  not  endrely  destroyed. 

As  muscular  rigidity  is  one  of  the  most  important  and  reliable  symptoms  of 
joint  inflammation  and  tuberculous  invasion,  it  is  a  serious  error  to  anesthetize 
a  patient  for  examinadon  of  a  joint  undl  the  full  significance  of  the  muscular 
action  has  been  carefully  studied. 

Anesthesia  removes  the  pain  and  abolishes  muscle  fixation  and  thus  leaves 
the  unguarded  joint  free  for  manipulative  movements,  which  are  generally 
prejudicial  and  rarely  beneficial.  Where  no  muscle  fixation  is  present,  much 
may  be  learned  by  the  careful  study  of  a  joint  while  the  patient  is  anesthetized. 
We  thus  determine  tiie  character  of  the  adhesions,  whether  they  are  extra- 
articular or  interarticular,  whether  they  are  fibrous,  cicatricial  or  osseous,  and 
if  bony  union  exists,  whether  it  involves  the  entire  joint  or  onl}  a  portion  of  it. 

Skiagraphs  are  invaluable  helps  in  making  an  accurate  diagnosis,  espe- 
cially when  stereoscopic  plates  are  made.  Definite  information  can  thus  be 
obtained  as  to  the  character  of  the  uniting  material,  its  extent,  and  definite 
location.  Positive  information  will  be  given  as  to  the  relationship  of  the  bones 
composing  the  joint,  whether  there  is  luxation,  subluxation,  flexion,  or  other 
abnormal  position  that  may  influence  decision  as  to  the  therapeutic  measures 
to  be  adopted.  It  is  important  to  remember  that  a  joint  very  rarely  becomes 
ankylosed  in  the  position  of  extension.  The  almost  invariable  rule  is  that 
flexion  is  the  posture  of  such  joints,  and  the  tendency  is  toward  increase  of 
the  flexion  until  bony  ankylosis  occurs.  In  the  steady  progress  of  the  fle.xion, 
sublu.xation    is  apt  to  be  induced. 

Treatment  of  Intra-articular  Ankylosis. — It  is  most  important  to  pre- 
vent the  occurrence  of  ankylosis,  or  in  the  event  of  its  becoming  inevitable, 
to  avoid  postures  that  will  render  the  parts  unfit  for  future  usefulness  when 
ankylosed. 

The  most  useful  position  for  a  stiff  joint  is  a  matter  of  indi\adual  opinion; 
no  definite  rules  have  been  accepted.  In  ankylosis  of  the  elbow,  the  flexed  posi- 
tion is  more  useful  in  certain  occupations  than  the  fully  extended  arm.  In 
other  occupations  the  extended  arm  is  most  useful.  In  walking  when  the 
knee  is  ankylosed  and  does  not  tend  toward  flexion  the  extended  leg  is  more 
useful  than  the  flexed  leg,  but  it  is  more  difficult  to  manage  when  sitting. 


Treatment  of  Intra-articular  Ankylosis  66i 

The  hip,  when  ankylosed  at  various  angles,  is  made  useful  by  the  increased 
latitude  of  motion  of  the  other  hip  and  by  the  compensatory  motion  of  the  lum- 
I)ar  si)ine.  To  such  an  extent  is  the  lower  spine  reciprocal  when  one  or  both 
hii)s  are  abnormal  that  it  has  been  termed  the  third  hij)-j()int.  For  general 
usefulness  the  best  position  for  an  ankylosed  hip  is  20  degrees  of  llexion,  20 
degrees  of  abduction,  and  5  degrees  of  external  rotation.  In  this  position, 
when  supplemented  by  reciprocal  action  of  the  other  hip  and  by  the  lower 
spine,  a  very  closely  approaching  normal  carriage  has  been  obtained  in  walk- 
ing, and  the  sitting  posture  has  been  possil)lc. 

Each  individual  joint  has  its  own  pecuHar  recjuirement  and  must  become  a 
subject  for  careful  study  in  determining  the  most  useful  posture  if  ankylosis 
is  to  be  permanent.  The  trend  of  modern  surgery  is  to  greatly  reduce  the 
time  of  fixation  of  a  fractured  bone  in  order  to  avoid  joint  stiffness  and  prevent 
muscular  wasting.  Early  passive  motion  when  judiciously  employed  does  not 
interfere  with  the  efficient  treatment  of  a  fracture,  but  does  prevent  the  joint 
stiffness  that  is  often  a  serious  and  painful  sequel. 

Brisement  force  is  a  term  applied  to  the  use  of  such  manipulative  force  as  the 
surgeon  can  judiciously  employ  in  freeing  a  joint  froni  fibrous  adhesions.  It  is 
important  to  keep  constantly  in  mind  the  danger  of  breaking  the  shaft  of  a  bone 
or  of  separating  the  epiphysis  when  unguarded  leverage  of  the  entire  shaft  of 
the  bone  is  used.  It  is  of  paramount  importance  to  avoid  brisement  force  in 
all  cases  where  the  ankylosis  has  resulted  from  tuberculosis. 

In  applying  manipulative  force  it  is  not  always  advantageous  to  have  the 
patient  profoundly  anesthetized.  If  he  is  profoundly  anesthetized  we  may 
be  tempted  to  apply  too  great  force.  Great  lacerations  of  fibrous  adhesions 
produce  painful  joints  which  necessitates  fixation  or  rest  for  several  days  to 
permit  the  reunion  of  the  torn  structures.  A  httle  gain,  care  being  taken  to 
maintain  the  motion  gained,  mobility  being  gradually  increased  by  short  pro- 
gressive steps,  is  always  better  than  attempts  to  do  a  great  deal  at  once.  Of 
course  the  patient's  cooperation  is  necessary. 

When  pain  is  great,  much  can  be  accomplished  during  primary  ether  anes- 
thesia or  while  the  patient  is  under  the  influence  of  nitrous  oxid.  Bromid  of 
ethyl  and  chlorid  of  ethyl  are  used  by  many  because  of  their  rapid  action  and 
brief  effect.    As  stated  elsewhere  (page  1 205),  I  seldom  use  either  of  these  drugs. 

Fixation  appliances  of  any  kind  are  contra-indicated  during  corrective 
manipulations,  as  increased  freedom  of  motion  is  essential  rather  than  fixation. 
Voluntary  efforts  are  needed  to  maintain  the  joint's  motion  already  secured  as 
well  as  to  increase  the  muscle  function  controlling  the  affected  joint. 

The  operative  procedures  applicable  to  intra-articular  ankylosis  are  excision 
to  obtain  a  false  joint  (pseudo-arthrosis),  excision  to  obtain  a  better  position  for 
the  usefulness  of  the  limb,  breaking  the  bone  after  partially  cutting  it  with 
an  osteotome  (osteotomy) ,  and  breaking  the  bone  without  any  excision  (osteo- 
clasis) .     These  several  procedures  have  special  advantages  in  different  joints. 

Lexer  ('"Zeit.  f.  Chir.  Med.  Orth.,"  Oct.,  1908,  p.  476),  after  resecting  a 
knee-joint  ankylosed  at  a  right  angle,  transplanted  the  entire  knee-joint  appa- 
ratus from  a  freshly  amputated  limb.  Complete  union  resulted.  Muscle 
training  was  subsequently  practised  to  improve  the  weak  muscular  control. 

Weglowski  ("Zent.  f.  Chir.,"  April  27,  1907)  resorted  to  cartilage  transplan- 
tation in  a  case  of  ankylosis  of  the  elbow.     After  freeing  and  re-forming  the 


662  Diseases  and  Injuries  of  Bones  and  Joints 

ends  of  the  three  bones,  two  plates  of  cartilage  (one-half  thickness  of  rib  car- 
tilage) with  perichondrium  were  taken  from  the  sixth  and  seventh  ribs  and 
placed  between  the  newly  formed  joint  surfaces,  the  perichondria!  surface 
being  turned  toward  the  humeral  epiphysis.  No  special  fixation  was  used.  No 
drainage  was  employed.  Active  and  passive  motion  was  begun  on  the  tenth 
day.  In  a  month  the  patient  had  60  degrees  of  free  flexion  and  extension  and 
full  pronation  and  supination.  Death  from  pleuropneumonia  of  three  days' 
duration  occurred  in  five  weeks.  Postmortem  showed  that  the  perichondrial 
surface  of  the  cartilage  was  united  to  the  humerus,  while  the  opposite  side  was 
smooth,  even  shining;  the  cartilage  was  enlarging  and  passed  \\ithout  definite 
margin  into  the  surface  of  the  humerus. 

Microscopic  examination  showed  newly  formed  blood-vessels  between  the 
cartilage  and  bone;  the  cartilage  was  well  preserved  in  its  entire  extent,  the 
cells  and  nuclei  staining  well. 

Hugier  and  Alurphy  advocate  a  novel  plan  ("  Traitement  des  Ankyloses 
par  la  Resection  Orthopedique  et  L'interposition  Musculaire,"  par  Le  Dr. 
Alphonse  Hugier). 

J.  B.  Murphy  ("Journal  American  Medical  Association,"  May  20-27, 
June  3,  1905)  reviews  the  literature  of  the  attempt  to  produce  new  joints  and 
says:  "In  our  work  we  have  been  able,  by  the  interposition  of  fascia  and 
muscle,  covered  with  a  layer  of  adipose  tissue,  to  produce  normal  movable 
joints  vdth  capsules  and  collagen  intra -articular  fluid."  In  cases  of  synovitis 
with  adhesions  he  resects  the  capsule  and  replaces  it  by  aponeurosis  or  muscle, 
and  it  is  desirable,  when  possible,  that  the  replacing  piece  contains  fat,  which, 
under  pressure,  will  form  a  hygroma  or  artificial  synovial  cavity.  In  bony 
ankylosis  he  operates,  separates  the  bones,  removes  adjacent  bony  promi- 
nences or  processes,  frees  the  soft  parts,  prevents  the  bones  coming  again  in 
contact,  and  interposes  between  them  tissue  which  will  remain  fibrous  or  will 
form  a  hygroma  or  artificial  synovial  surface.  After  wound  healing  has  taken 
place,  passive  motion,  active  motion,  and  forcible  extension  are  required. 

W.  S.  Baer  ("Am.  Jour.  Orth.  Surg.,"  1907,  p.  234)  advocates  the  use  of 
sterilized  olive  oil  injected  into  joints  to  prevent  the  form.ation  of  adhesions  and 
thus  increase  the  arc  of  motion.  It  may  also  be  poured  into  a  joint  after  arthrot- 
omy.  After  using  oil  in  the  manner  described,  Baer  summarizes  as  follows: 
"That  injection  of  oil  into  joints  under  proper  precautions  is  a  harmless  pro- 
cedure; that  the  joint  will  apparently  tolerate  as  much  as  it  will  hold. 

"It  is  most  useful  in  cases  where  adhesions  have  followed  some  acute 
infectious  process,  or  in  those  stift"  joints  which  are  classified  as  arthritis  defor- 
mans of  the  infectious  t}^)e. 

"  Passive  motions  are  made  with  less  pain  where  the  joint  contains  oil. 

"  It  plays  some  part  in  preventing  adhesions,  so  that  the  mobility  of  the 
joint  is  increased  more  rapidly." 

In  ankylosis  of  the  temporomaxillar\'  joint  it  was  once  the  custom  to 
wedge  the  jaws  apart  with  a  mouth-gag  and  afterward  insert  boxwood 
plugs  of  advancing  size  at  frequent  intervals.  This  method  invariably  fails. 
Esmarch's  operation  (removal  of  a  wedge-shaped  piece  of  bone  from  the 
ramus)  is  sometimes  useful.  Some  operators  excise  the  condyle  and  a  por- 
tion of  the  neck.     Swain  saws  the  bone  at  an  angle. 

W.  S.  Baer  ("American  Jour.  Orthopedic  Surg.,"  August,  1909)  reviews 


Loose  Bodies  in  Joints  663 

the  literature  of  the  operative  treatment  to  mobilize  joints,  and  advocates  the 
use  of  chromicized  pig's  liladder  as  the  most  satisfactory  material  to  place 
between  the  surfaces  of  excised  joints. 

He  refers  to  Helfereich,  who,  in  1893,  mobiUzed  the  temporomaxillary  joint 
by  the  insertion  of  a  flap  from  the  temporal  muscle.  This  was  repeated  by 
Lentz,Henle,  and  others.  Mikulicz,  in  1895,  used  a  flay)  from  the  masseter  mus- 
cle. Similar  procedures  were  employed  by  Bilezguski,  Hoffa,  and  Kusnetzow. 
Rochet  and  Schnudt  with  Gliick,  in  1902,  used  a  skin-flap  and  had  previously 
employed  ivory  joints  to  take  the  place  of  the  excised  structures.  Chlumsky, 
disappointed  with  the  results  of  muscle  flaps,  used  non-absorbable  materials, 
zinc,  rubber,  celluloid,  silver,  and  layers  of  coUoidin,  but  no  permanent  moljil- 
ity  was  obtained.  He  then  employed  absorbable  plates  of  decalcified  bone, 
ivory,  and  magnesium,  vdth  somewhat  better  results.  Baer's  method  of  insert- 
ing chromicized  pig's  bladder  followed  the  unsuccessful  employment  by  him 
of  Cargile  membrane.  The  pig's  bladder  is  tightly  stitched  around  the  re- 
cently denuded  bone  with  catgut  sutures  and  the  wound  closed.  A  hip-joint 
two  months  after  this  procedure  showed  a  voluntary  flexion  of  35  degrees; 
abduction,  15  degrees;  adduction,  10  degrees;  rotation,  25  degrees.  Seven 
months  after  operation  the  mobility  was  better  than  that  recorded  at  two 
months.     Similar  results  are  recorded  in  knee  and  elbow. 

Baer  emphasizes  the  necessity  of  having  the  pig's  bladder  absorbable  in 
thirty  to  forty  days.  It  should  be  pliable  enough  to  be  adapted  to  the  contour 
of  the  joint.  Every  raw  surface  should  be  absolutely  separated  by  it  from  that 
with  which  it  would  tend  to  come  in  contact. 

Treatment  of  Extra-articular  Ankylosis. — The  treatment  of  false  anky- 
losis depends  upon  the  case.  Recently  contracted  muscles  or  tendons  require 
motion,  massage,  frictions  with  stimulating  liniments,  hot  and  cold  douches, 
and  the  use  of  the  hot-air  apparatus.  Violent  breaking  up  is  not  satisfactory, 
neither  is  tenotomy  nor  myotomy.  Old  contractions  of  tendons  require  tendon 
lengthening  by  tendoplasty  or  myoplasty.  Chronic  inflammation  of  tendon- 
sheaths  with  adhesion  of  tendons  requires  excision  of  the  sheaths.  Whenever 
possible,  excise  a  cicatrix  that  causes  false  ankylosis,  and  fill  the  gap  with 
sound  cutaneous  tissue  and  fat.  When  the  fixation  is  due  to  adhesive  synovitis 
of  the  capsule,  excise  the  capsule  and  attached  ligaments;  "the  head  and  neck 
of  the  bone  should  then  be  surrounded  by  an  aponeurosis  or  muscle  to  prevent 
the  reforming  of  adhesions"  (John  B.  Murphy,  in  "Jour.  Am.  Med.  Assoc," 
May  20-27  and  June  3,  1905).  Bony  deposits  are  gouged  away  and  tumors 
are  removed.  Contractures  in  cases  of  paralysis  require  electricity,  passive 
motion,  frictions  with  stimulating  liniments,  the  hot-air  bath,  and  general 
treatment. 

Loose  Bodies  in  Joints  (Floating  Cartilages).— The  knee  is  the 
joint  affected  in  90  per  cent,  of  cases,  but  the  elbow,  shoulder,  hip,  wrist,  lower 
jaw,  and  ankle  may  suffer.  There  may  be  but  one  loose  body  in  a  joint, 
there  may  be  two  or  more,  there  may  be  many  or  even  hundreds.  More 
than  one  joint  may  be  involved.  The  condition  is  commonest  in  adult  men. 
These  bodies  may  be  free  or  each  may  have  a  stalk  or  pedicle;  they  may 
move  about  and  occasionally  block  the  joint,  or  may  He  quietly  in  a  joint- 
recess  or  diverticulum.  They  may  be  flat  or  ovoid,  smooth  or  irregular, 
as  small  as  peas  or  as  large  as  plums,  and  may  be  composed  of  fibrous  tissue, 
of  cartilage,  or  of  bone.     There  are  numerous  different  modes  of  origin  of 


664  Diseases  and  Injuries  of  Bones  and  Joints 

these  bodies,  many  being  "detached  ecchondroses  or  pieces  of  hyahne  car- 
tilage  hanging  l^y  narrow  pedicles"  (J.  Bland-Sutton),  and  they  result  from 
enlargement  and  chondrification  of  the  villi  of  the  synovial  membrane. 

Symptoms. — Many  bodies  give  rise  to  no  symptoms  for  a  long  time 
and  others  merely  cause  synovitis.  A  loose  body  may  produce  pain  and  inter- 
fere with  joint-function.  The  joint  is  weak  and  a  little  swollen,  and  the  patient 
can  perhaps  feel  the  body  and  often  can  push  it  into  a  superficial  area  of 
the  joint,  where  it  may  be  felt  by  the  surgeon.  From  time  to  time  the  body 
may  get  caught,  thus  suddenly  locking  the  joint  and  producing  intense  and 
sickening  pain,  extension  and  flexion  being  impossible  until  the  body  slips 
out.  It  may  slip  out  in  a  moment,  but  may  not  for  hours  or  even  for  many 
days.  A  rather  small  body  seems  more  apt  to  cause  locking  than  a  very  large 
one,  but  if  a  large  one  does  cause  locking,  it  is  more  difficult  to  dislodge  than  is 
a  small  one.  Locking  of  a  joint  Ijy  a  loose  body  is  followed  by  inflammation 
and  effusion.  If  the  loose  body  is  dense  or  long,  the  x-ray  may  disclose  it. 
In  some  cases  of  loose  body  in  the  knee  the  diagnosis  is  impossible  from  dis- 
location of  a  semilunar  cartilage,  inflamed  semilunar,  and  synovitis  with  pro- 
liferation of  villi. 

Treatment. — To  relieve  locking,  employ  forced  flexion  and  sudden  exten- 
sion. Cure  can  be  obtained  only  by  operation.  Let  the  patient  bring  the 
foreign  body  to  a  point  where  it  can  be  felt  by  the  surgeon,  so  that  he  can  deter- 
mine where  it  lodges.  Asepticize  the  knee  with  the  utmost  care.  Operate  if 
possible  under  cocain;  if  not,  give  ether.  If  the  body  is  felt  before  operating, 
fix  it  with  a  pin.  The  joint  is  now  opened,  the  foreign  body  extracted,  and 
a.i  exploration  made  to  see  that  no  other  bodies  are  present.  The  wound  is 
sutured  and  the  leg  is  placed  upon  a  splint.  Asepsis  must  be  most  rigid.  The 
operation  does  not  cure  the  causative  lesion,  and  these  bodies  are  apt  to  form 
again.  When  the  knee  is  involved,  some  surgeons  saw  the  patella  transversely, 
open  the  joint  widely,  remove  all  foreign  bodies,  and  seek  to  cure  any  causative 
lesion. 

Luxations  or  Dislocations. 

A  dislocation  is  the  persistent  separation  from  each  other,  partially  or  com- 
pletely, of  two  articular  surfaces.  A  self-reduced  dislocation  is  called  a 
sprain  (Douglas  Graham).  There  are  three  forms  of  dislocations:  (i)  trau- 
matic; (2)  spontaneous  or  pathological;  (3)  congenital. 

1.  Traumatic  dislocations  are  due  to  injury.  They  are  divided 
into — complete  dislocation,  in  which  the  two  articular  surfaces  are  entirely 
separated  and  the  ligaments  are  torn;  incomplete  or  partial  dislocation  or 
subluxation,  in  which  the  two  articular  surfaces  are  not  completely  separated 
and  the  ligaments  are  rarely  lacerated;  simple  dislocations,  in  which  there  is 
no  wound  leading  from  the  surface  to  the  articulation;  compound  dislocation, 
in  which  a  wound  leads  from  the  surface  to  the  joint;  complicated  dislocation, 
in  which,  besides  the  dislocation,  there  is  a  fracture,  extensive  damage  of  the 
soft  parts,  an  opening  which  makes  the  case  compound,  or  damage  of  a  nerve 
or  blood-vessel;  primitive  or  primary  dislocation,  in  which  the  bones  remain 
as  originally  displaced;  secondary  dislocation,  in  which  the  dislocated  bone 
assumes  a  new  position;  for  instance,  a  subglenoid  luxation  of  the  humerus  is 
primary,  and  it  may  become  secondarily  a  subcoracoid  luxation  because  of 
muscular  contraction  or  attempts  at  reduction;    recent  dislocation,  in  which 


Traumatic  Dislocations  665 

the  displaced  bone  is  not  firmly  fastened  by  tissue-changes  in  its  new  situation, 
and  its  old  socket  is  not  obliterated;  old  dislocation,  in  which  the  displaced 
bone  is  firmly  fastened  by  tissue-changes  in  its  new  habitat,  and  the  old 
socket  is  to  a  great  extent  obliterated  (whether  a  dislocation  is  old  or  new 
depends  on  the  state  of  the  parts  rather  than  on  the  time  which  has  elapsed 
since  the  accident);  double  dislocation,  in  which  corresponding  bones  on  each 
side  are  dislocated;  single  dislocation,  in  which  only  one  joint  is  dislocated; 
unilateral  dislocation,  in  which  one  articulation  of  one  bone  is  out  of  place; 
bilateral  dislocation,  in  which  symmetrical  articulations  are  dislocated;  and 
relapsing  or  habitual  dislocation,  which  recurs  constantly  from  slight  force 
because  of  relaxed  ligaments  or  lack  of  complete  repair  after  the  ligamentous 
rupture  of  a  first  dislocation. 

2.  Spontaneous,  Pathological,  or  Consecutive  Dislocations.— 
Spontaneous  dislocation  arises  from  such  very  slight  force  that  the 
cause  may  not  be  identified,  and  it  acts  on  a  joint  rendered  lax  by  disease. 
It  may  arise  in  the  course  of  chronic  synovitis,  tuberculous  joint-disease, 
or  rheumatoid  arthritis.  In  Charcot's  joint  a  spontaneous  dislocation  will 
occur  sooner  or  later.  In  typhoid  fever  spontaneous  dislocation  is  not  un- 
common. The  hip-joint  is  most  often  the  one  attacked.  Dislocation  in 
typhoid  jei'er  generally  occurs  at  the  hip-joint,  follows  a  severe  joint  in- 
flammation, is  usually  upon  the  dorsum  of  the  ilium,  and  is  frequently 
not  noticed  until  convalescence  has  set  in.  If  a  typhoid  dislocation  is 
seen  early,  reduction  is  easily  effected,  but  if  seen  late,  is  impossible.  The 
treatment  for  irreducible  typhoid  dislocation  is  the  same  as  for  any  other 
irreducible  dislocation. 

3.  Congenital  Dislocation. — A  congenital  dislocation  is  due  to  a  con- 
genital joint-malformation  which  renders  it  impossible  for  the  bone  to 
maintain  a  normal  position,  or  is  due  to  external  violence  during  the  period  of 
uterine  gestation.  Congenital  dislocations  should  not  be  confounded  with 
dislocations  produced  during  delivery.  The  hip  is  the  joint  most  often 
involved.  The  shoulder  suffers  occasionally.  Lannelongue  maintains  that 
congenital  dislocation  of  the  hip  is  due  to  atrophy  of  the  muscles  and  of  the 
acetabulum  following  spinal-cord  disease.  Verneuil  thinks  the  dislocation  is 
paralytic.  Broca  says  that  in  view  of  the  fact  that  the  head  of  the  bone 
is  larger  than  the  cavity  in  which  it  belongs,  it  is  useless  to  attempt  reduction 
by  manipulation  or  extension,  but  many  successful  cases  by  the  Lorenz 
bloodless  method  prove  Broca's  statement  to  have  been  too  sweeping. 
Lorenz  and  Hoffa  have  each  devised  an  operation  for  this  condition  (pages 
723,  724).  Congenital  dislocation  of  the  shoulder  requires  incision,  possibly 
excision,  or  the  paring  do\\Ti  of  the  head  to  fit  the  glenoid  ca\-ity  (Phelps) . 

Traumatic  Dislocations. — In  the  succeeding  pages  the  traumatic 
form  of  dislocations  will  be  particularly  considered. 

The  causes  of  traumatic  dislocations  are  divided  into  predisposing  and 
exciting. 

Predisposing  causes  are  :  (i)  age;  dislocations  are  commonest  in  middle  fife, 
the  usual  lesion  of  the  young  being  green-stick  fracture,  and  that  of  the  old 
being  fracture;  dislocations  of  the  radius  are  not  uncommon  in  youth;  (2) 
muscular  developynent,  dislocations  being  commonest  in  those  with  powerful 
muscles;  (3)  sex,  males  being  more  predisposed  than  females,  because  of  their 
occupations  and  muscular  strength;  (4)  occupation  predisposes  as  a   cause 


666  Diseases  and  Injuries  of  Bones  and  Joints 

according  as  it  demands  the  employment  of  muscular  force,  as  in  the  carrying 
of  burdens;  (5)  nature  0}  the  joint,  ball-and-socket  joints  being  more  liable  to 
luxation  than  are  ginglymoid  joints,  because  of  their  wide  range  of  motion;  (6) 
joint-disease  predisposes  by  relaxing  the  ligaments;  (7)  situation  oj  the  joint, 
some  joints  being  more  exposed  to  injury  than  others. 

Exciting  causes  are  divided  into — (i)  external  violence  and  (2)  muscular 
action.  External  violence  may  be  direct,  as  when  a  blow  upon  one  of  the  bones 
forces  it  directly  away  from  the  other;  or  it  may  be  indirect,  as  when  a  blow  at  a 
distant  part  of  a  bone  transmits  force  to  its  end  and  drives  the  bone  out  of  its 
socket.  Muscidar  action  is  a  cause  when  sudden  and  violent  muscular  con- 
traction occurs  during  the  maintenance  of  a  position  of  the  joint  which  gives 
the  muscles  full  sway,  and  throws  the  head  of  the  bone  against  the  weakest 
part  of  its  retaining  ligaments. 

Pathological  Conditions. — In  a  recent  complete  traumatic  dislocation 
the  ligaments  are  damaged,  and  may  perhaps  show  extensive  laceration,  or 
mav  show  only  a  buttonhole  laceration  through  which  a  bone  projects.  Exter- 
nal force  produces  much  laceration  and  little  stretching  of  the  ligaments; 
muscular  action  produces  little  laceration  and  much  stretching  of  the  liga- 
ments. In  some  cases  of  dislocation  due  to  external  violence  the  structures 
about  the  joint  are  bruised  or  otherwise  damaged;  the  old  socket  is  filled  with 
blood,  and  the  bone  in  its  new  situation  lies  in  a  bloody  area.  Large  vessels 
and  nerves  are  rarely  torn,  though  they  may  be  compressed. 

If  a  dislocation  is  not  soon  reduced,  inflammation  arises  in  the  old  joint  and 
about  the  displaced  bone,  and  the  whole  area  is  glued  together,  first  by  coagu- 
lated exudate,  and  finally  by  fibrous  tissue.  After  a  time,  in  ball-and-socket 
joints,  the  old  socket  fills  with  fibrous  tissue,  contracts,  becomes  irregular,  and 
may  even  be  obliterated;  the  head  of  the  dislocated  bone  is  altered  in  shape, 
its  cartilage  is  destroyed  or  converted  into  fibrous  tissue,  and  the  pressure 
of  the  head  of  the  bone  forms  a  hollow  in  its  new  situation,  which  hollow 
becomes  surrounded  by  fibrous  tissue  or  even  by  bone.  A  new  joint  may 
form,  the  surrounding  tissue  becoming  a  compact  capsule,  and  a  bursa  forming 
between  the  head  of  the  bone  and  its  new  socket.  In  a  dislocated  hinge- 
joint  the  ends  of  the  bone  alter  greatly  in  shape  and  their  cartilage  is  con- 
verted into  fibrous  tissue.  In  an  unreduced  dislocation  the  muscles  shorten 
or  lengthen  or  undergo  atrophy  or  fatty  degeneration,  as  the  case  may  be. 
An  unreduced  dislocation  of  a  ball-and-socket  joint  may  give  a  fairly  movable 
new  joint,  but  an  unreduced  dislocation  of  a  hinge -joint  rarely  allows  of 
much  motion. 

General  Symptoms  of  Traumatic  Dislocation.— In  general,  traumatic 
dislocations  are  indicated — (i)  by  pain  of  asickening,  nauseating  character;  (2) 
by  rigidity,  voluntary  motion  being  impossible  except  to  a  slight  extent  in  the 
direction  of  the  deformity.  (For  instance,  in  dislocation  of  the  inferior  maxil- 
lary the  jaw  can  be  opened  a  little  more,  but  it  cannot  be  closed.)  This 
rigidity  brings  about  loss  of  function.  When  the  surgeon  attempts  to  move 
the  joint  he  finds  it  very  rigid;  (3)  by  change  in  the  shape  0}  the  joint  (as 
flattening  of  the  shoulder  after  dislocation  of  the  humerus);  (4)  by  alteration 
in  the  mutual  relations  oj  bony  prominences  about  a  joint  (as  the  alteration  of 
the  relation  between  the  olecranon  and  humeral  condyles  in  dislocation  of 
the  elbow  backward);  (5)  by  feeling  the  displaced  bone  in  its  new  situation; 
(6)  by  missing  the  head  of  the  bone  from  its  proper  situation;  (7)  by  alteration 


Treatment  of  Traumatic  Dislocations  667 

in  the  length  of  the  limb  (in  dislocation  of  the  femur  into  the  thyroid  foramen 
the  limb  is  lengthened,  but  in  dislocation  onto  the  dorsum  of  the  ilium  it  is 
shortened);  and  (8)  by  alteration  in  the  axis  of  the  bone  (in  dislocation  upon 
the  dorsum  of  the  ilium  the  axis  of  the  injured  thigh  would,  if  prolonged,  pass 
through  the  lower  third  of  the  sound  thigh);  (9)  by  seeing  the  dislocation 
with  a  fluoroscope  or  looking  at  a  skiagraph  of  it. 

Diagnosis  of  Traumatic  Dislocation.— A  dislocation  may  be  mistaken 
for  a  fracture.  In  dislocation  there  is  rigidity,  in  fracture  there  is  preter- 
natural mobility;  in  dislocation  there  is  no  true  crepitus  (may  get  tendon-  or 
joint-crepitus),  in  fracture  there  usually  is  crepitus;  in  dislocation  the  deformity 
does  not  tend  to  recur  after  reduction,  in  fracture  it  does  recur  after  exten- 
sion is  relaxed.  In  a  sprain  the  movements  of  the  joint  are  only  limited,  not 
abolished,  by  the  almost  complete  rigidity  encountered  in  dislocation.  The 
change  which  a  sprain  may  cause  in  the  shape  of  a  joint  is  due  to  effusion  or 
to  bleeding;  there  is  no  alteration  in  the  relation  of  the  bony  prominences  to 
one  another;  there  is  no  notable  alteration  in  the  length  of  the  limb  (a  slight 
increase  in  length  may  arise  from  joint-effusion,  or  the  head  of  the  bone  may 
subsequently  be  absorbed  and  thus  produce  shortening  after  some  weeks); 
there  is  no  alteration  in  the  axis  of  the  bone;  the  bony  head  is  not  felt  in  a 
new  position,  and  it  is  found  in  its  normal  place.  Always  remember  that  a 
fracture  may  exist  with  a  dislocation.  In  any  doubtful  case — in  fact,  in 
most  cases — give  ether,  for  a  dislocation  should  be  reduced  while  the  patient 
is  anesthetized  (except  in  dislocation  of  the  jaw,  of  the  fingers,  of  the  carpus, 
etc.).  In  some  cases  swelling  renders  the  diagnosis  difiScult  or  impossible. 
Always  compare  the  injured  joint  with  the  corresponding  joint  of  the  sound 
side.     The  x-rays  constitute  a  valuable  aid  to  diagnosis. 

Treatment  of  Traumatic  Dislocations. — Recent  Simple  Dislocations. — 
Reduce  simple  dislocations  under  ether,  as  a  rule.  Try  manipulation,  a  pro- 
cedure which  seeks  to  make  the  bone  retrace  its  own  pathway.  If  this  pro- 
cedure fails,  employ  extension  and  counter-extension.  If  considerable  force 
is  needed,  an  assistant  makes  counter-extension,  and  the  surgeon  fastens  to 
the  extremity  a  clove-hitch,  which  he  ties  about  his  waist,  and  thus  secures 
powerful  extension.  Counter-extension  may  be  obtained  by  bands,  or,  in 
some  instances,  by  the  foot  of  the  surgeon.  The  clove-hitch  is  used  because 
it  will  not  tighten  by  traction;  a  tightening  band  would  lacerate  the  soft  parts 
(Fig.  351).  If  great  power  is  needed,  compound  pulleys  may  be  employed, 
such  as  the  Jarvis  adjuster  or  some  similar  appUance,  but  at  the  present  day 
pulleys  are  rarely  used  (see  page  678) .  If  these  means  fail,  cut  down  upon-the 
bone  and  restore  it  to  position;  operation  is  much  safer  than  is  the  application 
of  great  force.  After  reducing  a  dislocation,  immobilize  the  joint  for  a  time, 
which  varies  for  different  joints,  and  for  the  first  few  days  combat  sweUing 
and  inflammation  by  rest  of  the  part  and  the  use  of  evaporating  lotions  or 
an  ice-bag.  If  there  exists  a  fracture  of  the  dislocated  bone,  apply  splints 
and  then  try  to  reduce  by  manipulations,  grasping  the  limb  and  the  spUnts 
with  one  hand  below  and,  if  possible,  with  the  other  hand  above  the  seat  of 
the  fracture.  AUis  believes  that  a  dislocation  can  be  reduced  even  when  a 
fracture  exists.  It  is  possible  to  pull  the  dislocated  head  down  to  the  joint, 
because  a  portion  of  periosteum  and  possibly  tendinous  material  and  muscle 
still  hold  the  two  fragments  as  a  strap  might  unite  two  sticks.     The  head  can 


668  Diseases  and  Injuries  of  Bones  and  Joints 

be  forced  into  place  b}' the  fingers  while  traction  is  being  made.  If  the  fracture 
is  near  the  joint  and  the  fragments  cannot  be  fixed,  tr}'  to  reduce  the  dislo- 
cation, first  striving  to  press  the  bone  into  place.  This  attempt  can  be  greatly 
aided  by  traction  upon  the  lower  fragment.  In  some  cases  with  fracture 
reduction  can  be  much  aided  by  making  a  small  incision,  screwing  a  gimlet 
into  the  head  of  the  bone,  and  using  this  tool  as  a  handle.  McBurney  incises, 
drills  a  hole  in  each  bone,  inserts  hooks  into  them,  and  pulls  the  dislocated 
bone  into  position  (Figs.  250,  251,  and  252).  When  the  dislocation  has  been 
reduced,  the  bone  fragments  should  be  wired  together. 

Compound  Traumatic  Dislocations. — The  opening  in  the  soft  parts  may  be 
due  to  external  violence  or  to  projection  of  a  bone.  Compound  dislocations 
are  very  serious.  Hinge- joints  are  more  liable  to  these  injuries  than  are 
ball-and-socket  joints.  Many  cases  require  excision:  some,  amputation;  one 
that  does  not  demand  excision  or  amputation  should  be  treated  by  sterilizing 
the  parts,  restoring  the  dislocated  bone,  making  a  counter-opening,  draining, 
dressing  antiseptically,  and  immobilizing.  Considerable  ankylosis  generally 
ensues,  except  sometimes  in  the  small  joints.  It  is  scarcely  ever  necessary 
to  cut  away  any  portion  of  the  protruding  bone  to  effect  reduction.  If  a 
joint  i^  badly  splintered,  or  if  the  soft  parts  are  extensively  damaged,  it  may 
be  necessary  to  excise  or  amputate;  if  the  main  vessels  of  a  limb  are  ser- 
iously injured,  amputation  must  be  considered.  If  the  patient  is  so  old  or  so 
feeble  that  it  is  perilous  to  force  him  to  combat  a  long  illness,  amputation 
should  be  performed. 

Old  Traumatic  Dislocations. — The  problem  always  presented  in  an  old 
dislocation  is.  Shall  reduction  be  tried  or  shall  the  bones  be  let  alone?  Sir 
Astley  Cooper  laid  down  this  rule:  "Do  not  attempt  to  reduce  a  shoulder- 
dislocation  after  three  months,  nor  a  hip-dislocation  after  two  months";  but 
this  rule  was  put  forth  before  the  days  of  ether.  Do  not  select  any  fixed  period 
of  time  to  determine  what  action  is  advisable.  In  dislocation  of  a  ball-and- 
socket  joint  considerable  motion  may  become  possible  and  a  new  joint  may 
form.  If  movement  does  not  produce  pain,  a  useful  new  joint  may  be  obtained 
by  the  persistent  emplo}Tnent  of  active  and  passive  movements;  if  move- 
ment of  the  Hmb  does  produce  pain,  enough  motion  will  not  be  attempted 
by  the  patient  to  produce  a  useful  joint.  In  the  former  case  it  may  be  best 
to  ivy  to  obtain  a  useful  new  joint,  and  in  the  latter  case  the  surgeon  should 
endeavor  to  reduce  the  old  dislocation.  Always  remember  that  dislocation 
of  a  hinge-joint,  if  left  unreduced,  will  never  eventuate  in  a  useful  new  joint. 

In  trying  to  reduce  an  old  dislocation  give  ether,  make  movement  to 
break  up  adhesions,  and  persist  in  making  these  motions  until  the  head  of 
the  bone  is  felt  to  move;  then  try  at  once  to  reduce  by  manipulation  or  exten- 
sion and  counter-extension,  not  waiting  for  two  days,  as  some  suggest. 
If  the  head  of  the  bone  cannot  be  made  to  move,  the  Dieffenbach  plan  has 
been  advised,  which  is  to  cut  the  tense  restraining  bands  with  a  tenotome. 
Lord  Lister,  being  much  impressed  with  the  danger  inevitably  linked  with 
forcibly  dragging  old  dislocations  into  place,  prefers  to  cut  down  and  restore 
the  bone,  employing,  of  course,  the  strictest  asepsis,  and  surgeons  in  general 
have  adopted  this  view.  In  some  old  dislocations  excision  of  the  head  of 
the  bone  is  the  proper  operation. 

Special  Traumatic  Dislocations.— Lower  Jaw.— A  dislocation 
of  the  lower  jaw,  when  there  is  no  fracture,  is  almost  invariably  forward. 


Special  Traumatic  Dislocations  669 

Backward  dislocation  without  fracture  is  extremely  rare,  and  some  have 
maintained  that  it  cannot  occur.  Croker  King  reported  a  case  in  1858. 
Theim  has  observed  it  seven  times  in  five  women.  The  condyle  passes  under 
the  lower  surface  of  the  auditory  canal.*  The  common  dislocation  is  for- 
ward, and  this  is  the  form  meant  when  we  simply  speak  of  dislocation  of 
the  jaw.  There  are  two  forms  of  forward  dislocation — the  unilateral,  which 
is  rare,  and  the  bilateral,  which  is  common.  Dislocations  of  the  jaw  are 
commonest  in  women  and  during  middle  life.  When  the  mouth  is  open, 
contraction  of  the  external  pterygoid  muscle  may  pull  the  condyle  over  the 
articular  eminence;  this  contraction  may  be  brought  about  by  yawning, 
vomiting,  scolding,  etc.  When  the  mouth  is  open,  dislocation  of  the  lower 
jaw  may  be  caused  by  a  blow  upon  the  chin ;  it  may  also  be  caused  by  forcing 
the  mouth  more  widely  open  by  pushing  a  bulky  body  between  the  teeth. 

Symptoms  of  Lower-jaiv  Dislocations. — In  the  bilateral  form  the  mouth  is 
open  and  fixed,  and  it  cannot  be  closed,  though  it  can  be  opened  a  little  more. 
The  condyles  are  in  front  of  the  articular  eminences,  and  are  fixed  by  the 
action  of  the  masseters  and  internal  pterygoids,  the  coronoid  processes  being 
wedged  against  the  malar  bones.  The  lower  jaw  is  advanced  in  front  of 
the  upper  jaw  and  the  face  looks  longer  than  natural.  The  Hps  cannot 
close,  the  saHva  dribbles,  swallowing  and  speech  are  difficult,  there  is  a  depres- 
sion in  front  of  each  ear,  the  condyles  are  recognizable  in  their  new  abodes,  the 
coronoid  processes  are  detected  by  a  finger  in  the  mouth,  and  the  masseters 
and  temporals  stand  out  in  a  state  of  rigidity.  Pain  may  be  severe,  may 
be  moderate,  or  may  be  absent.  In  the  unilateral  form  the  chin  goes  toward 
the  sound  side,  and  the  mouth  is  not  so  widely  open  as  in  the  bilateral  form, 
neither  is  the  jaw  so  fixed.  The  symptoms  are  similar  to  those  of  a  bilateral 
luxation,  but  are  not  so  pronounced.  The  hollow  in  front  of  the  ear  and 
the  abnormal  situation  of  the  condyle  are  detected  upon  one  side  only.  In 
an  unreduced  dislocation  the  patient  may  after  a  time  estabHsh  some  move- 
ment of  the  jaw,  but  the  power  of  mastication  will  always  be  seriously  impaired. 

Treatment  of  Lower- jaw  Dislocations.— In  reducing  a  dislocation  of  the 
lower  jaw  the  patient  is  placed  with  his  head  against  the  back  of  a  chair  or 
against  the  body  of  an  assistant.  The  surgeon,  after  wrapping  up  his  thumbs 
to  protect  them  from  being  bitten,  stands  in  front  of  the  patient,  puts  his 
thumbs  upon  the  last  molar  teeth,  and  grasps  the  chin  with  his  free  fingers. 
He  now  presses  downward  and  backward  on  the  jaw,  and  as  soon  as  the 
condyle  is  loosened,  closes  the  jaw  over  the  thumbs  by  pushing  up  the  chin, 
using  his  thumbs  as  levers.  If  this  procedure  fails,  wedges  should  be  put 
between  the  molar  teeth  and  the  chin  should  be  pushed  up  either  by  the 
hands  or  by  a  tourniquet  whose  band  is  round  the  head  and  chin.  In  a  uni- 
lateral dislocation  the  wedge  should  be  used  only  on  the  injured  side.  In 
difficult  cases  Sir  Astley  Cooper  pushed  a  round  wooden  ruler  between  the 
molar  teeth,  used  the  upper  teeth  as  a  fulcrum,  and  raised  the  end  of  the 
ruler  as  the  handle  of  a  lever.  The  forceps  used  by  an  anesthetist  may 
depress  the  condyle  from  its  point  of  fixation,  whereupon  the  chin  may  be 
pushed  up  and  back.  Nelaton  advises  that  the  surgeon  place  his  thumbs 
in  the  mouth  of  the  patient  and  push  the  coronoid  processes  backward. 
After  reduction  a  Barton  bandage  should  be  applied  and  worn  for  over  two 
weeks.  The  dressing  should  be  renewed  once  a  day,  and  passive  motion 
*  Theim,  in  Rev.  de  Chin,  vol.  \nii,   1888. 


670 


Diseases  and  Injuries  of  Bones  and  Joints 


is  to  be  begun  in  the  second  week.  The  bandage  may  be  discarded  at  the 
end  of  the  third  week.  Liquid  diet  is  advisable  for  three  weeks  after  the 
accident.  In  an  old  dislocation  reduction  is  always  attempted,  at  least  up 
to  a  period  of  six  or  seven  months  after  the  accident.  An  irreducible  dis- 
location requires  osteotomy  of  the  neck  of  the  bone  if  the  part  cannot  be 
restored  after  incision. 

Dislocation  of  the  Clavicle. — Sternal  End. — There  are  three  forms  of 
dislocation  of  the  sternal  end  of  the  clavicle,  namely:  (i)  forward;  (2)  back- 
ward; and  (3)  upward. 

Forward  Dislocation  of  the  Sternal  End  of  the  Clavicle. — The  causes 
of  forward  dislocation  of  the  clavicle  are  blows,  falls,  or  pulls  which  drive 
or  draw  the  shoulder  backward. 

Symptoms  and  Treatment  of  Forward  Dislocation  oj  the  Sternal  End  of 
the  Clavicle. — The  symptoms  manifest  in  dislocation  of  the  clavicle  are: 


Fig.  345. — Rhoads's  apparatus  for  treating  dislocation  upward  of  the  acromial  end  of  the  clavicle. 


prominence  in  front  of  the  sternum;  the  acromion  is  nearer  to  the  sternum 
on  the  injured  than  on  the  sound  side;  the  clavicular  origin  of  the  sterno- 
cleidomastoid muscle  is  rigid;  movement  is  difficult  and  painful.  To  reduce 
a  dislocation  of  the  clavicle,  pull  the  shoulders  back  against  the  knee  of  the 
surgeon,  which  is  placed  between  the  scapulae.  Dress  with  a  posterior  figure- 
of-eight  bandage  (Fig.  747)  or  a  Velpeau  bandage  (Fig.  749),  the  dressing 
to  be  worn  for  three  weeks.  After  removal  of  the  dressing  apply  a  truss,  the 
pad  of  which  is  put  over  the  head  of  the  clavicle,  and  which  instrument  is 
to  be  worn  for  a  month.  Dislocation  of  the  clavicle  is  difficult  to  keep  reduced, 
but  even  if  it  becomes  fixed  in  deformity,  the  motions  of  the  arm  will  not 
be  impaired  permanently.     It  can  be  reduced  and  fixed  by  incision  and  wiring. 

Backward  dislocation  of  the  sternal  end  of  the  clavicle  is  very  rare. 
The  causes  are  direct  violence  and  indirect  force,  such  as  falls  or  blows  which 
drive  the  shoulder  forward  and  inward. 

Symptoms  and  Treatment  of  Backward  Dislocation  of  the  Sternal  End  of 
the  Clavicle. — The  symptoms  are:  pain;  loss  of  function  in  the  arm;  inclina- 
tion of  head  toward  the  injured  side;  stiffness  of  the  neck;  the  shoulder  passes 


Dislocation  of  the  Acromial  End  of  the  Clavicle  671 

fonvard  and  inward,  and  often  falls  downward;  a  depression  exists  over  the 
sternoclavicular  joint;  the  head  of  the  clavicle  cannot  be  felt,  or  is  found  back 
of  the  sternum.  The  displaced  clavicle  may  press  upon  the  trachea,  the 
esophagus,  or  the  great  vessels,  inducing  dyspnea,  dysphagia,  obliteration  of 
pulse  in  the  arm  of  the  injured  side,  or  great  venous  congestion  of  the  head 
(see  Pick).  The  usual  method  of  treatment  is  to  pull  the  shoulders  backward 
and  apply  a  posterior  iigure-of-eight  bandage  (Fig.  747),  which  must  be 
worn  for  three  weeks.  If  pressure-symptoms  are  urgent,  it  is  the  rule  to  incise, 
restore  the  bone  to  place  and  wire  it,  or  resect  the  displaced  head. 

Upward  dislocation  of  a  clavicle  is  very  rare.  The  cause  is  indirect 
force  which  carries  the  shoulder  downward,  inward,  and  backward  (Smith). 

Symptoms  and  Treatment  0}  Upward  Dislocation  of  the  Sternal  End  of  the 
Clavicle. — The  chief  symptom  is  impaired  function  of  the  arm;  the  shoulder 
passes  downward  and  inward,  the  clavicular  axis  is  altered,  and  the  displaced 
head  is  felt.  Dyspnea  may  or  may  not  exist.  To  treat  this  dislocation,  put  a 
pad  in  the  axilla  and  press  the  elbow  to  the  side  in  order  to  throw  the  bone  out- 


Fig.  346. — Dislocation  upward  of  acromial  end  of  clavicle. 

ward,  and  try  to  push  the  head  into  place.  Apply  a  Desault  bandage  (Fig. 
750)  and  place  a  firm  pad  over  the  sternoclavicular  joint.  The  deformity  is 
apt  to  recur,  but  a  useful  limb  will  nevertheless  be  obtained.  The  best 
method  of  treatment  is  to  wire  the  bones  in  place. 

Dislocation  of  the  acromial  end  of  the  clavicle  is  almost  always 
upward,  but  it  may  be  below  the  acromion.  The  cause  is  violent  force, 
which,  if  so  applied  to  the  scapula  as  to  drive  the  shoulder  forward,  may 
produce  a  dislocation  upward.  A  dislocation  downward  is  due  to  blows 
upon  the  upper  surface  of  the  outer  end  of  the  clavicle. 

Symptoms  and  Treatment. — In  dislocation  of  the  acromial  end  of  the 
clavicle  upward  there  are  noted:  prominence  of  the  clavicle  upon  the  top  of 
the  acromion;  impaired  function  of  the  arm  (it  cannot  be  hfted  over  the  head); 
the  shoulder  falls  downward  and  passes  inward;  there  is  apparent  lengthening 
of  the  arm;  the  head  is  bent  toward  the  injured  side,  and  the  clavicular  origin 
of  the  trapezius  is  strongly  outlined  (Pick),  In  dislocation  downward  both 
the  acromion  and  the  coracoid  are  very  prominent,  the  clavicular  axis  is 
altered,  and  there  is  depression  over  the  sternoclavicular  joint.     The  surgeon 


672 


Diseases  and  Injuries  of  Bones  and  Joints 


usually  endeavors  to  reduce  a  dislocation  upward  by  placing  the  patient 
supine  on  a  hard  table,  pulling  the  shoulder  back,  and  pushing  the  bone 
into  place.  After  reduction  the  old  method  of  treatment  was  to  apply  a  De- 
sault  bandage,  which  was  kept  on  for  three  weeks,  and  decided  deformity, 
enduring  pain,  and  disability  were  looked  for  as  inevitable.  Stimson  used 
to  apply  dressings  of  adhesive  plaster.  The  author  has  seen  one  case  treated 
by  the  apparatus  of  Thomas  Leidy  Rhoads.  The  apparatus  completely  cor- 
rected the  deformity,  and  the  patient  made  a  most  satisfactory  recovery. 
The  essential  element  of  Rhoads 's  apparatus  is  a  trunk-strap  applied  as  is 
shown  in  Fig.  345.  If  the  deformity  can  be  completely  corrected,  Rhoads 's 
apparatus  will  serve  a  good  purpose,  but  in  many  cases  it  is  impossible  really 
to  reduce  the  deformity  or  after  apparent  reduction  the  deformity  at  once 
returns.  This  is  due,  as  Moore  points  out  ("Annals  of  Surgery,"  May,  1902) 
to  the  fact  that  the  superior  acromioclavicular  ligament  is  torn  from  the  clav- 
icle but  remains  attached  to  the  scapula,  and  when  reduction  is  attempted,  is 
pushed  under  the  clavicle  and  nothing  remains  to  hold  the  clavicle  "  in  place 
but  the  skin  and  superficial  fascia."  I  agree  ^\^th  ISIoore  that  the  best  treat- 
ment is  incision,  replacement,  and  suturing  the  acromion  to  the  outer  end  of 
the  clavicle.  The  bones  are  sutured  with  silver  wire  or  kangaroo  tendon,  the 
acromioclavicular  ligament  is  sutured  with  catgut,  the  wound  is  closed  with 
sutures  of  silkworm  gut,  and  the  patient  is  kept  supine  in  bed  for  three  weeks. 
I  have  operated  successfully  on  four  of  these  cases. 

Dislocation  downward  is  reduced  and  treated  in  the  same  manner  as  dis- 
location upward. 

Simultaneous  dislocation  of  both  ends  of  the  clavicle  is  a  very  rare  injury. 
It  is  treated  as  is  single  dislocation. 

The  so-called  dislocation  of  the  lower  angle 
of  the  scapula  is  not,  as  was  long  taught, 
a  dislocation  at  all.  The  lower  angle  and 
vertebral  border  deviate  from  the  chest.  This 
condition  was  thought  to  be  due  to  the  bone 
slipping  from  under  the  latissimus  dorsi  muscle, 
but  it  is  now  known  to  be  due  to  paralysis  of  the 
serratus  ma  gnus  muscle,  the  bone  being  acted 
upon  by  the  trapezius,  pectoralis  minor,  levator 
anguli  scapulae,  and  rhomboid  muscles.  Ex- 
amination shows  that  the  scapula  will  not 
rotate  normally  forward.  This  is  demonstrated 
by  extending  the  arms  in  front  to  a  right  angle, 
the  gliding  forward  of  the  scapula  upon  the  sound 
■.ias^i^^^^^E^m  ^^  ^^^^  being  marked  and  upon  the  diseased  side 
^.  ^^^^^^^KbI^h     ^^i^g  slight  or  absent. 

Treatment  of  paralysis  of  the  serratus 
magnus  muscle  comprises  massage,  electricity, 
passive  motion,  and  deep  injections  of  strychnin. 
Dislocations  of  the  Humerus  (Shoulder- 
joint)  . — These  injuries  are  quite  frequent  because 
of  the  free  mobility  of  the  shoulder-joint,  its  an- 
atomical insecurity,   and   its   exposed   situation; 


l--ig. 


347. — .\xillary  dislocation 
of  the  right  humerus. 


they  rarely  occur   in   the   very  young  and  in  the  aged,  and  are  oftenest 


Dislocations  of  the  Humerus 


673 


encountered  in  muscular  young  adults.  Shoulder  dislocation  is  produced  by 
throwing  the  arm  into  extreme  abduction.  In  this  position  the  head  of  the 
humerus  presses  against  the  lower  and  front  part  of  the  cai)sule,  that  is,  against 
the  thinnest  and  most  {)oorly  sup])orted  portion  of  the  capsule.  In  almost 
all  cases  the  tear  in  the  capsule  occurs  between  the  tendon  of  the  subscapularis 
and  the  triceps.  Hence,  most  dislocations  are  primarily  subglenoid,  although 
the  bone  usually  moves  to  some  other  position,  being  dragged  or  driven  there 
by  the  injuring  force  or  being  pulled  there  by  muscular  action.  Dislocation  for- 
ward is  much  more  common  than  dislocation  backward  because  the  long  head 
of  the  triceps  keeps  the  head  of  the  bone  from  going  posterior  and  because  the 
anterior  are  stronger  than  the  posterior  muscles.    Four  chief  forms  of  shoulder- 


Fig.  348. — Subcoracoid  dislocation  of   the  left   humerus   (St.  Joseph's  Hospital  case;   photo- 
graphed by  Dr.  Nassau). 


joint  dislocation  exist,  namely:  (i)  forward,  inward,  and  downward,  under  the 
coracoid  process — subcoracoid;  (2)  downward,  forward,  and  inward,  beneath 
the  glenoid  cavity — subglenoid;  (3)  backward,  inward,  and  downward, 
under  the  spine  of  the  scapula — subspinous;  and  (4)  forward,  inward, 
and  upward,  under  the  clavicle — subclavicular. 

A  very  rare  form  of  shoulder- joint  dislocation  has  been  described,  which 
is  known  as  the  snpracoracoid.     Another  rare  form  is  the  luxatio  erecta. 

Subcoracoid  Luxation. — The  subcoracoid  variety  of  dislocation  embraces 

three-fourths  of  all  the  shoulder-joint  luxations.     It  may  be  caused  by  direct 

force  driving  the  head  of  the  humerus  forward  and  inward,  or  by  indirect 

force,  such  as  falls  upon  the 'hand  or   the  elbow.     In  this  dislocation  the 

43 


674  Diseases  and  Injuries  of  Bones  and  Joints 

head  of  the  bone  Hes  against  the  anterior  surface  of  the  scapular  neck  below 
the  coracoid  process.  A  part  of  the  anatomical  neck  of  the  humerus  lies 
upon  the  anterior  margin  of  the  glenoid  cavity,  and  the  head  of  the  bone  is 
above  the  tendon  of  the  subscapularis  muscle. 

Subclavicular  luxation  is  very  rare.  It  is  caused  by  the  same  sort  of 
violence  which  produces  subcoracoid  luxation.  The  head  of  the  bone  rests 
upon  the  thorax,  below  the  clavicle,  and  underneath  the  pectoralis  major 
muscle. 

Subglenoid  or  Axillary  Luxation  (Fig.  347).— May  be  produced  by  con- 
traction of  the  great  pectoral  and  latissimus  dorsi  muscles  when  the  arm  is 
at  a  right  angle  to  the  body,  but  it  is  usually  due  to  falls  upon  the  hand  or 
the  elbow  when  the  arm  is  raised  and  the  head  of  the  bone  is  against  the  lower 
portion  of  the  capsule.  In  this  dislocation  the  head  of  the  bone  rests  upon 
the  border  of  the  scapula,  below  the  tendon  of  the  subscapularis,  in  front  of 
the  long  head  of  the  triceps,  and  above  the  teres  muscles.  Some  observers 
hold  that  most  dislocations  of  the  shoulder  are  primarily  subglenoid,  the  posi- 
tion having  been  altered  by  muscular  action.  Lnxatio  erecta  is  an  unusual 
form  of  subglenoid  dislocation.  The  arm  is  upright  and  the  forearm  rests 
behind  the  occiput  or  on  the  top  of  the  head,  and  the  patient  holds  it  there  to 
avoid  pain.     Judd,  Hulke,  and  Cleland  have  related  cases. 

Subspinous  Luxation. — Is  a  rare  injury.  Pick  met  with  this  accident  in  a 
man  who,  while  having  his  hands  in  his  pockets,  fell  upon  the  front  of  the 
point  of  the  shoulder.  The  head  of  the  bone  reposes  beneath  the  scapular 
spine,  between  the  infraspinatus  and  teres  minor  muscles. 

Supracoracoid  luxation  is  seldom  encountered.  The  head  of  the  humerus 
rests  upon  the  coraco-acromial  ligament  or  upon  the  acromion  process,  and 
the  acromion  or  the  coracoid  is  always  fractured. 

Luxatio  Erecta.— In  this  injury  the  arm  is  markedly  abducted  and  in  some 
cases  the  elbow  is  actually  raised  above  the  patient's  head.  In  such  an  injury 
the  head  of  the  bone  has  passed  under  the  subscapularis  muscle  and  also  under 
the  teres  major  or  the  lower  border  of  the  great  pectoral. 

Symptoms  of  Dislocation  of  the  Shotdder-joint.—'Disiocsitkm  is  diagnos- 
ticated by— (i)  pain  of  a  sickening  character;  (2)  flattening  of  the  shoulder, 
the  head  of  the  bone  having  ceased  to  bulge  out  the  deltoid  muscle;  (3)  ap- 
parent projection  of  the  acromion  through  sinking  in  of  the  deltoid;  (4) 
hollow  beneath  the  acromion,  over  the  empty  glenoid  cavity,  and  the  bone 
missed  from  its  normal  habitat.  This  hollow  may  be  easily  appreciated 
by  the  finger,  especially  when  the  extremity  is  somewhat  abducted;  (5)  rigidity 
(some  movement  is  possible,  in  the  direction  especially  of  an  existing  de- 
formity, but  mobility  is  strictly  limited  and  attempts  at  motion  produce 
great  pain);  (6)  Dugas's  sign:  the  elbow  cannot  touch  the  side  when  the 
hand  is  placed  upon  the  sound  shoulder,  and  the  hand  cannot  be  placed 
upon  the  sound  shoulder  if  the  elbow  is  to  the  side  (this  is  due  to  the  rotundity 
of  the  chest.  In  a  dislocation  the  head  of  the  bone  is  already  touching  the 
chest,  and  the  bone,  being  approximately  straight,  cannot  touch  it  in  two 
places  at  the  same  time.  If  the  elbow  can  be  placed  against  the  chest  with 
the  hand  on  the  sound  shoulder,  there  cannot  be  dislocation;  if  it  cannot 
be  so  placed,  there  must  be  dislocation);  (7)  finding  the  head  of  the  bone 


Dislocations  of  the  Humerus 


675 


in  a  new  situation;  (8)  examining  by  means  of  the  x-rays.  Symptoms  i  to 
5  inclusive  mav  be  grouped  as  Erichsen's  list  of  signs.  The  form  of  dis- 
location is  made  out  by  a  study  of  the  direction  of  the  axis  of  the  hmb,  the 
existence  and  extent  of  lengthening  or  of  shortening,  and  the  situation  of  the 

head  of  the  bone. 

In  a  shoulder-joint  dislocation  the  head  of  the  bone  may  press  upon  the 
brachial  plexus  and  produce  pain  and  numbness,  and  occasionally  traumatic 
neuritis  or  paralysis;  sometimes  pressure  upon  the  axillary  vein  causes  intense 
edema,  and  pressure  upon  the  axillary  artery  diminishes  or  obliterates  the 
pulse.  '  The  axiUarv  vessels  may  be  torn  and  the  muscles  may  be  lacerated 
badly.  The  capsule  is  torn  and  considerable  blood  is  usually  effused.  ^  Swell- 
ing is  due  first  to  hemorrhage,  and  secondly  to  inflammation.  Partial  dis- 
locations sometimes,  though  rarely,  occur.  What  is  usually  spoken  of  as 
"partial  dislocation"  or  "subluxation"  is  a  condition  in  which  the  head  of 
the  humerus  passes  forward  under  the  coracoid  because  of  rupture  of  the 
long  head  of  the  biceps  or  because  this  tendon  slips  out  of  its  groove,  the 
ligaments  of  the  shoulder-joint  being  intact. 

The  following  table  from  T.  Pickering  Pick's  work  on  "Fractures  and 
Dislocations"  makes  the  above  points  clear: 


Subcoracoid. 

Subglenoid. 
Subspinous. 

Subcla\'icular, 


Direction  of  the  Axis 
OF  THE  Limb. 


The  elbow  is  carried 
backward  and  slightly 
away  from  the  side. 

The  elbow  is  carried 
away  from  the  trunk 
and  slightly  backward. 

The  elbow  is  raised 
from  the  side  and  car- 
ried forward. 

The  elbow  is  carried 
outward  and  backward. 


Alteration  in  the 
Length  of  the  Limb. 


Very  slight  lengthen- 
ing. 

Very  considerable 
lengthening. 

Lengthening  interme- 
diate in  degree  between 
the  subglenoid  and  the 
subcoracoid. 

Shortening. 


Presence  of  the  Head 

OF  the  Bone  in  New 

Situation. 


The  head  of  the  bone 
cannot  easily  be  felt;  it  is 
found  at  the  upper  and 
inner  part  of  the  axilla. 

The  head  of  the  bone 
can  easily  be  felt  in  the 
axilla. 

The  head  of  the  bone 
can  be  felt  and  be  grasped 
beneath  the  spine  of  the 
scapula. 

The  head  of  the  bone 
can  readily  be  seen  and  be 
felt  beneath  the  clavicle. 


Diagnosis  of  Shoulder-joint  Dislocation.— lx\  jracture  of  the  neck  0}  the 
scapula  the  acromion  is  prominent,  a  hollow  is  detected  below  it,  and  a  hard 
body  is  felt  in  the  axilla;  but  the  coracoid  process  descends  with  the 
head  of  the  humerus,  which  it  does  not  do  in  dislocation.  Furthermore,  in 
fracture  there  is  mobihty;  in  dislocation,  rigidity.  In  fracture  crepitus  is 
present ;  in  dislocation  it  is  absent.  In  fracture  the  deformity  is  easily  reduced, 
but  it  at  once  recurs;  in  dislocation  the  deformity  is  with  difficulty  reduced, 
but  does  not  recur.  In  fracture  the  elbow  can  be  made  to  touch  the  side 
when  the  hand  is  upon  the  sound  shoulder;  in  dislocation  it  cannot  be  so 
manipulated.  In  jracture  of  the  anatomical  neck  of  the  humerus  deformity 
is  slight;  the  head  of  the  humerus  is  found  in  place,  does  not  move  when 
the  shaft  is  rotated,  and  is  not  in  Hne  with  the  axis  of  the  bone.     Crepitus 


676  Diseases  arid  Injuries  of  Bones  and  Joints 

exists  in  the  fracture  if  impaction  is  absent.  In  paralysis  of  the  deltoid  mus- 
cle there  is  distinct  flattening,  but  the  bone  is  felt  in  place  and  there  is  no 
rigidity.     The  x-rays  are  a  great  aid  to  diagnosis. 

Treatment  of  Shoulder-joint  Dislocation. — Reduction  by  manipulation  is 
usually  readily  obtained  in  recent  cases  of  shoulder-joint  dislocation.  If  a 
simple  trial  without  ether  fails,  an  anesthetic  should  be  administered.  Ether 
is  given,  but  not  chloroform,  for  chloroform  seems  to  be  particularly  dan- 
gerous to  life  when  given  to  enable  the  surgeon  to  reduce  a  dislocation  of 
the  shoulder.  Forward  dislocations  (subcoracoid,  subclavicular,  and  axillary) 
are  reduced  by  Kocher''s  method  (Fig.  349).  This  method  was  introduced  by 
Kocher  in  1870  ("Sammlung  klin.  Vortrage,"  No.  83).  Reduction  by  this 
method  can  frequently  be  effected  without  the  aid  of  ether.  The  patient 
should  be  recumbent.  Slowly  but  forcibly  adduct  the  abducted  elbow  and 
get  it  finally  against  the  side.  At  the  same  time  it  is  drawn  slightly  backward. 
The  forearm  is  flexed.  If  there  is  much  muscular  resistance,  follow  Keetley's 
advice,  and  not  only  bring  the  elbow  to  the  side,  but  push  it  backward  and 
inward  toward  the  spine.  Grasp  the  elbow  with  one  hand,  and  the  wrist  with 
the  other,  and  slowly  make  external  rotation  until  the  forearm  points  outward 
from  the  body.  We  thus  carry  the  head  of  the  humerus  to  the  margin  of  the 
glenoid  cavity.  External  rotation  must  be  done  slowly  and  gently.  When 
we  first  try  it  there  is  much  muscular  resistance.  If  enough  force  is  used  to 
overcome  the  resistance  the  surgical  neck  of  the  bone  may  be  broken.  By 
gently  and  gradually  persisting  in  external  rotation  the  muscles  are  finally 
tired  out.  Next  lift  the  elbow  anteriorly  as  far  forward  as  it  will  go,  so  as  to 
bring  the  head  of  the  humerus  to  the  glenoid  margin  just  opposite  the  cap- 
sular tear  (Keetley).  Then  throw  the  bone  into  place  by  gradually  swing- 
ing the  forearm  inward  across  to  the  other  side  of  the  chest,  that  is,  by 
internal  rotation.  The  formula  is,  flexion  of  the  forearm,  external  rotation, 
lifting  the  elbow  forward,  internal  rotation  of  the  arm,  and  lowering  the 
elbow.  The  motions  to  unlock  the  bone  and  start  it  to  retrace  the  steps 
it  took  when  emerging  should  be  gentle,  not  forcible,  slow,  not  sudden,  and 
rigid  muscles  should  be  tired  out  and  made  to  relax  by  steady  traction  upon 
them.  Sudden  and  violent  motions  increase  rigidity.  Adduction  stretches 
the  upper  portion  of  the  capsule  and  presses  the  head  against  the  glenoid. 
External  rotation  opens  the  tear  in  the  capsule.  Elevation  relaxes  the  untorn 
part  of  the  capsule  and  coracohumeral  ligament  and  stretches  the  torn  por- 
tion. On  this  fulcrum,  the  head,  which  is  the  end  of  a  lever,  is  forced  into 
place.  If  in  trying  Kocher's  plan  external  rotation  of  the  humerus  does  not 
take  place,  abandon  the  method,  as  persistence  will  fracture  the  humerus.  An- 
other method  of  manipulation  is  as  follows:  if  the  right  shoulder  is  dislocated, 
the  surgeon  stands  behind  the  patient  (who  is  sitting  erect) ;  if  the  left  shoulder 
is  dislocated,  he  stands  in  front  of  the  patient.  The  surgeon  holds  the  fore- 
arm flexed  upon  the  arm  with  his  right  hand  and  makes  external  traction 
and  rotation,  and  with  the  fingers  of  his  left  hand  he  tries  to  force  the  bone 
into  place. 

In  Henry  H.  Smith's  method  for  forward  dislocations  the  surgeon  stands 
in  front  of  the  patient.  If  the  left  shoulder  is  dislocated,  the  surgeon  grasps 
it  with  his  left  hand;  if  the  right  shoulder  is  dislocated,  he  grasps  it  with  his 


Dislocations  of  the  Humerus 


677 


right  hand,  the  thumb  resting  on  the  head  of  the  bone.  With  his  disengaged 
hand  the  surgeon  grasps  the  elbow,  abducts  it,  makes  traction  and  external 
rotation,  and  suddenly  sweeps  the  elbow  inward,  aiming  it  at  the  sternum, 
and  tries  with  his  thumb  to  push  the  bone  into  place.  In  subspinous  luxa- 
tions reduction  may  be  effected  if  the  surgeon  stands  behind  the  ])alient, 
makes  abduction,  traction,  and  internal  rotation,  sweeps  the  elbow  inward 
toward  the  spine,  and  with  the  thumb  aids  the  bone  in  its  return  into  position. 
Raising  the  elbow  far  above  the  head  and  sweeping  it  inward  will  reduce 
some  dislocations.  As  the  head  of  the  bone  slips  back  a  distinct  jar  is  felt 
and  a  snap  is  heard,  the  motions  of  the  joint  are  again  obtainable,  and  with 
the  hand  on  the  opposite  shoulder  the  elbow  may  be  made  to  touch  the 
side. 

Reduction  by  Extension. — Before  attempting  the  reduction  of  a  dislo- 
cation of  the  shoulder- joint  by  extension,  the  patient  should  be  anesthetized 
and  placed  upon  a  low  bed  or  upon  the  floor.     The  surgeon  then  places 


Fig.  349. — Kocher's  method  of  reduction  by  manipulation  ;  a.  First  movement,  outward  rotation; 
b,  second  movement,  elevation  of  elbow  ;  c,  third  movement,  inward  rotation  and  lowering  of  the 
elbow  (Ceppi). 


his  foot,  covered  only  by  a  stocking,  in  the  axilla.  Place  the  sole  of  the 
foot,  not  the  heel,  against  the  chest  high  up,  the  instep  being  made  to  touch 
the  humerus  and  the  heel  the  border  of  the  shoulder-blade,  a  towel  being 
first  put  into  the  axilla  to  rest  the  foot  against  (Fig.  350).  If  the  left  arm 
is  dislocated,  use  the  left  foot,  and  vice  versa.  The  elder  Gross  approved 
of  making  extension  while  sitting  between  the  patient's  limbs.  Make  steady 
extension,  which  will  in  many  cases  bring  about  the  reduction.  If  it  fails 
to  cause  reduction,  bring  the  patient's  arm  across  the  chest  and  use  the  foot 
as  the  fulcrum  of  a  lever.  If  the  humerus  is  pretty  firmly  fixed  in  its  abnor- 
mal position,  make  counter-extension  with  a  foot  in  the  axilla  and  make 
extension  by  fixing  a  clove-hitch  (Fig.  351)  above  the  elbow  and  fastening 
to  it  bands  which  go  over  one  shoulder  and  under  ,the  other  shoulder  of  the 
surgeon.  The  back  may  thus  be  used  for  extension,  the  hands  being  left  free 
for  manipulation  (Allis's  and  Pick's  plan).  Lateral  extension  is  used  by 
some  surgeons.  The  patient  lies  down,  a  large  piece  of  canvas  is  split,  the 
arm  is  passed  through  the  split,  and  the  body  is  thus  fixed.  The  arm  is 
pulled  to  a  right  angle  with  the  body  and  traction  is  applied. 

The  late  Prof.  Joseph  Pancoast  favored  Sir  Astley  Cooper's  method  of 


678 


Diseases  and  Injuries  of  Bones  and  Joints 


placing  the  unanesthetized  patient  in  a  chair  and  using  the  knee  as  a  fulcrum, 

pushing  the  elbow  to  the  side  (Fig.  352). 
Brunus,  in  the  thirteenth  century,  de- 
vised the  method  of  iipivard  exten- 
sion.    In    applying    this    method    the 


Fig.  350. — Reduction  of  shoulder-joint  disloca- 
tion by  the  foot  in  the  axilla  (Cooper). 


Fig.  351.— Clove-hitch  knot  applied  above 
the  wrist.  In  dislocation  of  the  shoulder  this 
knot  is  put  above  the  elbow  (after  Erichsen). 


surgeon  takes  his  place  behind  the  patient,  steadies  the  scapula  with  his 
hand,  and  carries  the  patient's  arm  upward  and  backward  above  his  head, 
making  extension  and  external  rotation  (Fig.  353).  La  Alothe's  method  is 
applied  with  the  patient  supine  upon  the  floor.  The  surgeon  places  his  foot 
upon  the  shoulder  to  make  counter-extension,  and  makes  extension  as  in 
Brunus's  method.     It  is  a  useful  expedient,  when  either  of  these  plans  is 

applied,  to  have  an  assistant  make  the  trac- 
tion v.hile  the  surgeon  manipulates  the  head 
of  the  bone.  Cock  advises,  when  reduction 
fails,  that  an  air-pad  be  placed  in  the  axilla 


Fig.  352. — Reduction  of  shoulder- 
joint  dislocation  by  the  knee  in  the 
axilla  (Cooper). 


Fig.  353. — Reduction  of  shoulder-joint  dislocation  by 
upward  extension  (Cooper). 


and  the  arm  be  bound  to  the  side — a  method  by  which  reduction  will  some- 
times take  place  after  two  or  three  days. 

Pulleys  should  not  be  used  to  pull  the  bone  into  place,  as  they  develop  a 
dangerous  force.  In  a  dislocation  irreducible  by  ordinary  force,  antiseptic 
incision  is  safer  and  better  than  the  pulleys.  After  incision  try  to  restore  the 
bone  to  place. 

In  reducing  a  dislocation  the  axillan,'  artery  or  vein  may  be  ruptured, 
fracture  of  the  neck  of  the  humerus  may  take  place,  injur)'  to  the  brachial 
plexus  may  occur,  or  the  soft  parts  may  be  badly  damaged.  After  reducing 
a  dislocation  apply  a  Velpeau  bandage,  keep  the  shoulder  immobile  for  one 
week,  then  make  passive  motion  daily,  reapplying  the  dressing  after  each 
seance.  The  patient  may  wear  a  sling  alone  during  the  third  week,  after 
which  period  he  may  use  the  arm.     (For  compound  dislocations  see  page  668.) 


Unreduced  and  Irreducible  Dislocations  of  the  Shoulder        679 


Unreduced  and  Irreducible  Dislocations  of  the  Shoulder. — In  some 
cases  where  \vc  find  there  is  considcral)le  movement  without  y)ain  we  can,  by 
mani[)ulation  and  active  motion,  seek  to  increase  the  range  of  movement  and 
usefulness  of  the  new  joint. 

As  a  rule,  in  a  youth  or  a  middle-aged  person  we  attempt  bloodless  reduction 
if  we  see  the  case  by  or  before  the  ninetieth  day  after  the  accident.  Give 
ether,  break  up  adhesions 
by  forced  flexion  and  ex- 
tension, and  tr}'  Kocher's 
method,  and,  if  this  fails,  the 
other  methods,  but  never  use 
violent  force.  In  reducing 
an  old  dislocation  we  may 
fracture  the  surgical  neck  of 
the  humerus.  I  have  seen 
this  happen  twice.  The 
proper  treatment  is  incision 
and  pulling  the  head  into 
place  with  McBurney's 
hooks.  In  attempting  re- 
duction of  an  old  dislocation 
the  brachial  plexus  may  be 
lacerated  or  one  or  both  of 
the  axillary  vessels  may  be 
torn.  If  an  axillary  vessel 
is  torn,  it  must  be  at  once  exposed  by  incision.  A  large  tear  in  either  vessel 
requires  a  ligature  about  the  vessel  on  each  side  of  the  tear.  A  small  tear 
may  be  sutured  (Keetley,  in  "Lancet,'*  Jan.  23,  1904).  Rather  than  use 
sufficient  force  to  endanger  the  vessels  in  attempting  to  reduce  an  old  dis- 
location, practise  incision.  In  some  cases  after  incision  the  head  of  the  bone 
can  be  pulled  into  place.     In  other  cases  the  head  must  be  resected.      After 

reduction  of  an  old  dislocation  immO' 
bilize  for  three  weeks,  and  begin  pas- 
sive motion  after  seven  days. 

If  a  dislocation  is  complicated  by 
a  fracture  oj  the  humerus,  iry  to  pull 
the  head  of  the  bone  opposite  the  joint. 
This  may  be  possible  if  the  two  frag- 
ments are  held  partly  together  by  a 
fair  amount  of  periosteum  and  muscle. 
Traction  is  exerted  upon  the  arm,  and 
an  attempt  is  made  to  manipulate  the 
head  into  the  socket  (AUis's  plan  in  the 
hip).  McBurney  incises,  fixes  a  hook 
in  the  scapula  and  a  hook  in  the  head  of  the  humerus,  pulls  the  head  into  place, 
and  wires  the  fragments  (Figs.  250,  251,  252).  In  an  emergency  gimlets  may 
be  used  instead  of  the  hooks.  In  some  cases  it  is  necessary  to  excise  the  head 
of  the  bone. 


Fig.  354.— Dislocation  of  both  bones  of  the  forearm  backward. 


,f^ 


I^'g-  355.— Reduction  of  elbow-joint  dislocation. 


68o  Diseases  and  Injuries  of  Bones  and  Joints 

Habitual  or  Recurrent  Dislocations. — Habitual  or  recurrent  dislocation 
of  the  shoulder,  following  an  original  traumatic  dislocation,  results  usually 
from  a  slight  or  trivial  force.  It  usually  takes  place  while  the  arm  is  in  ab- 
duction, slight  rotation  frequently  being  necessary.  In  some  cases  rotarion 
will  produce  a  dislocation  while  the  arm  is  near  the  side  of  the  body.  Litde 
is  known  of  the  frequency  with  which  these  cases  occur,  but  they  are  probably 
much  more  frequent  than  is  generally  supposed.  The  frequency  of  the  recur- 
rences in  the  individual  cases  varies  widely.  In  some  they  occur  more  or  less 
regularly  every  two  or  three  years,  while  in  others  they  have  been  known  to 
take  place  daily  and  even  several  times  a  day.  In  most  cases  in  the  intervals 
between  the  recurrences  the  joint  functionates  normally  without  diflficulty, 
although  the  padent  fears  abduction  because  of  its  influence  in  favoring  a 
recurrence.  In  rare  cases  pain  persists  a  long  time  after  each  dislocation,  so 
that  if  the  recurrences  are  frequent,  the  patient  may  be  compelled  to  give  up 
work. 

Cause. — The  essential  cause  is  a  relaxation  of  the  capsule  at  the  site  of  the 
original  tear,  due  to  the  addidon  to  the  old  or  original  portion  of  the  capsule 
of  a  new  or  cicatricial  portion  bridging  over  the  gap  between  the  margins  of 
the  tear  produced  by  the  first  dislocation.  The  failure  of  these  margins  to 
unite  closely  is  due  to  the  repeated  emergence  of  the  humeral  head  forcing  them 
apart  before  union  is  complete.  The  defects  in  the  head  of  the  humerus  which 
have  been  found  at  autopsy  and  operation  have,  probably,  only  a  slight  and 
secondary  causal  importance,  while  the  fractures  of  the  greater  tuberosity  of 
the  humerus  sometimes  occurring  in  dislocations  of  the  shoulder  are  probably 
not  followed  by  recurrent  dislocations. 

Treatment. — Excisions  of  the  head  of  the  humerus  have  been  abandoned. 
Capsulorrhaphy  for  the  shortening  of  the  relaxed  anterior  portion  of  the  cap- 
sule has  given  excellent  functional  results.  Dr.  Dawbarn,  of  New  York, 
did  this  operation  in  my  clinic,  upon  a  city  fireman,  and  the  result  was  a 
perfect  success.  The  capsule  may  be  exposed  through  the  u.sual  resection 
incision  along  the  anterior  margin  of  the  deltoid.  This  may  be  modified  by 
an  additional  incision  outward  at  right  angles  to  the  first,  and  the  insertion 
of  the  pectoralis  major  may  be  partially  divided.  T.  Turner  Thomas  makes 
an  axillary  incision  along  the  inner  border  of  the  coracobrachialis,  passing 
between  this  muscle  and  the  axillary  vessels  and  nerves,  and  avoiding  par- 
ticularly the  circumflex  and  musculocutaneous  nerves.  The  subscapularis 
muscle  is  partially  divided  to  give  a  freer  exposure  of  the  capsule.  This  route 
exposes  the  site  of  the  original  tear  in  the  capsule  by  a  small  incision.  It 
avoids  division  of  the  deltoid  and  gives  dependent  drainage  if  drainage  is 
necessary. 

The  relaxed  pordon  of  the  capsule  may  be  shortened  by  taking  up  a  reef 
with  catgut  or  silk  sutures,  without  opening  and  exploring  the  joint  for  loose 
pieces  of  bone;  the  capsule  may  be  incised  transversely  to  its  longitudinal 
fibers  and  the  margins  of  the  incision  overlapped;  an  oval  piece  may  be  ex- 
cised and  the  edges  united  by  sutures;  or  the  margins  of  the  original  tear  may 
be  found  and  sutured  together. 

Dislocations  of  the  Elbow- joint. — Dislocations  of  the  elbow-joint  are 
not  infrequent,  and  they  are  commonest  in  children.     Both  bones  or  only  one 


Dislocation  of  Both  Bones  Forward  68i 

bone  of  the  forearm  may  be  dislocated,  and  the  dislocation  may  be  partial 
or  complete. 

Dislocation  of  Both  Bones  Backward. — The  causes  of  backward  dislo- 
cation of  both  bones  of  the  forearm  are  falls  upon  the  extended  hand  or  twists 
inward  of  the  ulna  (Malgaigne).  The  coronoid  process  lodges  in  the  olecranon 
fossa  of  the  humerus. 

Symptoms  oj  Backward  Dislocation.— In  complete  dislocation  of  both 
bones  of  the  forearm  the  olecranon  is  very  prominent  (Fig.  354)-  The  dis- 
tance between  the  point  of  the  olecranon  and  the  apex  of  the  inner  condyle  is 
notably  greater  than  on  the  sound  side;  the  forearm  is  flexed,  supinated,  and 
shortened;  the  lower  end  of  the  humerus  projects  in  front  of  the  joint,  below 
the  skin-crease;  the  head  of  the  radius  is  found  back  of  the  outer  condyle; 
and  there  are  the  general  symptoms  of  dislocation.  Fracture  of  the  coronoid 
rarely  occurs  with  backward  dislocation,  but  if  it  does  occur,  there  will  be  crepi- 
tus and  mobility.  Fracture  at  the  base  of  the  condyles  is  distinguished  from 
dislocation  of  both  bones  of  the  forearm  backward  by  the  following  points: 
in  fracture  there  are  found  the  ordinary  symptoms;    measurement  from  the 


Fig.  356.— Forward  dislocation  of  the  radius. 

condyles  to  the  styloid  processes  does  not  show  shortening;  there  is  no  altera- 
tion of  the  normal  relation  between  the  olecranon  process  and  the  condyles; 
and  the  projection  in  front  of  the  joint  Is  above  the  crease  of  the  bend  of  the 
elbow. 

Treatment  0}  Backward  Dw/oca^ion.— Reduction  must  be  effected  early 
in  dislocation  of  both  bones  of  the  forearm,  because  it  will  soon  become  im- 
possible, and  an  unreduced  dislocation  means  a  limb  without  the  powers  of 
flexion,  pronation,  and  supination.  The  surgeon  may  place  his  knee  in  front 
of  the  elbow-joint,  grasp  the  patient's  wrist,  press  upon  the  radius  and  ulna 
with  his  knee,  and  bend  the  forearm  with  considerable  force,  the  muscle 
pulhng  the  bones  into  place  (Sir  Astley  Cooper's  plan).  Forced  flexion, 
traction,  and  extension  may  be  tried  (Fig.  355).  Put  the  arm  in  Jones's  posi- 
tion for  two  weeks,  and  make  passive  motion  daily  after  the  first  few  days. 

Dislocation  of  Both  Bones  Forward.— The  cause  of  fonvard  disloca- 
tion of  both  bones  of  the  forearm  is  a  blow  on  the  olecranon  when  the  arm 
is  flexed.     It  is  an  unusual  accident. 

Symptoms  and  Treatment.— Tht  symptoms  of  forward  dislocation  of  both 
bones  of  the  forearm  are — the  forearm  is  flexed  and  lengthened;   some  slight 


682  Diseases  and  Injuries  of  Bones  and  Joints 

motion  is  possible;  the  olecranon  is  on  a  level  with  the  condyles  if  unfractured 
hence  its  prominence  is  gone;  the  humeral  condyles  are  felt  posteriorly,  and 
the  radius  and  ulna  are  felt  anteriorly.  The  treatment  of  this  injury  consists 
in  early  reduction,  which  is  accomplished  by  means  of  forced  flexion,  exten- 
sion, and  pressure,  placing  the  part  in  Jones's  position  for  two  weeks, 
and  making  passive  motion  daily  after  the  first  few  days. 

Lateral  dislocation  of  both  bones  of  the  forearm  is  usually  incomplete. 

Symptoms  and  Treatment  oj  Outward  Dislocation. — The  symptoms  of 
outward  dislocation  of  both  bones  of  the  forearm  are — the  forearm  is  flexed, 
fixed,  and  pronated;  the  joint  is  widened;  the  head  of  the  radius  projects  ex- 
ternally and  has  a  depression  above  it;  the  inner  condyle  projects  internally 
and  has  a  depression  below  it;  the  olecranon  is  nearer  than  normal  to  the 
external  condyle  and  further  than  normal  from  the  internal  condyle.  Reduc- 
tion is  efiected  by  extension  of  the  forearm  and  pressure  inward  upon  the 
head  of  the  radius.  Apply  an  ascending  spiral  reversed  bandage  of  the  fore- 
arm, a  figure-of-eight  bandage  of  the  elbow-joint,  and  a  sling.  Make  passive 
motion  after  a  few  days.     The  bandages  must  be  worn  for  two  weeks. 

Symptoms  and  Treatment  of  Inward  Dislocation. — In  dislocation  inward 
of  both  bones  of  the  forearm  the  position  of  the  forearm  is  the  same  as  that 
ui  dislocation  outward;  the  sigmoid  cavity  of  the  ulna  projects  internally,  and 
the  external  condyle  projects  externally.  Reduction  is  effected  by  extension 
of  the  forearm  and  pressure  outward  on  the  ulna,  subsequent  treatment 
being  the  same  as  that  employed  in  the  preceding  form. 

Dislocation  of  the  ulna  alone  is  very  rare,  and  can  take  place  only 
backward. 

Symptoms  and  Treatment. — Dislocation  of  the  ulna  alone  is  indicated 
bv  the  forearm  being  flexed  and  pronated.  The  head  of  the  radius  is  found 
in  place,  and  the  olecranon  projects  posteriorly.  The  treatment  of  this  injury 
is  the  same  as  that  for  dislocation  of  both  bones. 

Dislocation  of  the  Radius  Forward  (Fig.  356). — Dislocation  of  the 
radius  forward  is  the  commonest  form  of  dislocation  of  the  elbow.  This 
injury  is  caused  by  a  fall  upon  the  hand  with  the  forearm  in  pronation  and 
extension,  or  is  produced  by  blows  on  the  back  of  the  joint ;  forced  pronation 
alone  will  not  cause  it. 

Symptoms  and  Treatment. — The  symptoms  in  dislocation  of  the  radius 
fon\'ard  are — the  forearm  is  midway  between  pronation  and  supination,  and 
is  semiflexed;  attempts  to  increase  flexion  cause  the  radius  to  strike  against 
the  humerus  with  a  distinct  blow;  the  head  of  the  radius  is  felt  in  front  of 
the  outer  condyle  and  is  missed  from  its  proper  abode.  Reduction  is  effected 
by  flexion  over  the  knee,  extension,  and  manipulation.  The  subsequent  treat- 
ment is  Jones's  position  and  passive  motion.  Deformity  is  apt  to  recur 
after  reduction,  because  of  rupture  of  the  orbicular  ligament. 

Dislocation  of  the  radius  backward  is  caused  by  falls  on  the  hand 
or  by  blows  on  the  front  of  the  joint. 

Symptoms  and  Treatment. — Backward  dislocation  of  the  radius  is  indicated 
by  the  forearm  iDeing  slightly  fle.xed  and  fixed  in  pronation,  by  some  impair- 
ment of  flexion  and  extension,  and  by  the  head  of  the  radius  being  felt  behind 
the  outer  condyle.     Reduction  is  effected  by  flexion  over  the  knee,  extension, 


Backward  Dislocation  of  the  Wrist  683 

and  manipulation,  and  the  subsequent  treatment  is  the  same  as  that  given  for 
the  preceding  dislocation. 

Dislocation  of  the  radius  outward  is  very  rare.  In  this  injury  the 
head  of  the  radius  is  distinctly  felt.  Reduction  is  effected  by  extension  and 
pressure;  the  subsequent  treatment  is  the  same  as  that  for  the  above- 
mentioned  dislocations. 

Subluxation  of  the  Head  of  the  Radius. — This  name  is  given  to  an 
injury  which  is  very  frequent  in  children  between  two  and  four  years  of  age. 
It  results  from  traction  upon  the  hand  or  the  forearm,  and  often  arises  when 
the  nurse  or  the  mother  pulls  upon  a  child's  arm  to  save  it  from  a  fall  or  to 
lift  it  over  a  gutter.  Some  writers  hold  that  pronation  as  well  as  extension 
is  required  to  produce  the  injury;  many  surgeons  claim  that  extension 
and  adduction  are  the  causative  forces.  Hutchinson  asserts  that  supination 
may  cause  subluxation.     Bardenheuer  assigned  falls  as  causes. 

The  symptoms  are  very  characteristic.  The  history  points  to  the  injury. 
Pain,  and  often  a  click,  may  be  felt  in  the  wrist  at  the  time  of  the  accident. 
The  arm  hangs  by  the  side,  with  the  elbow-joint  slightly  flexed  and  the  forearm 
midway  between  pronation  and  supination.  Flexion  to  an  angle  of  less  than 
60°  and  complete  extension  are  resisted  and  are  very  painful,  but  movements 
between  60°  and  130°  are  free  and  painless.*  The  movements  of  the  wrist- 
joint  are  free  and  painless.  The  elbow-joint  presents  no  deformity.  Pressure 
over  the  head  of  the  radius  causes  pain.  Strong  pronation  is  painful;  strong 
supination  is  very  painful,  and  there  seems  to  be  a  mechanical  obstacle  to  its 
performance.  Forced  supination  develops  a  distinct  click  at  the  head  of 
the  radius,  and  causes  pronation  and  supination  to  become  natural  and  free 
from  pain.  The  condition  will  be  reproduced  if  the  parts  are  not  immobilized 
for  a  time.  The  nature  of  the  lesion  is  not  understood,  and  various  condi- 
tions have  been  thought  to  exist  by  different  observers.  Among  them  may 
be  mentioned  the  following:  a  slight  anterior  displacement  of  a  head  of  the 
radius ;  a  slight  posterior  displacement ;  locking  of  the  tuberosity  of  the  radius 
behind  the  inner  edge  of  the  ulna;  dislocation  of  the  triangular  cartilage  of 
the  wrist;  intracapsular  fracture  of  the  radial  head;  painful  paralysis  from 
nerve-injury;  displacement  by  elongation,  the  return  of  the  bone  being  pre- 
vented  by  collapse  of  the  capsule;  and  the  sHpping  up  of  the  margin  of  the 
orbicular  ligament  over  the  rim  of  the  head  of  the  radius. 

Treatment. — In  order  to  reduce  place  the  forearm  at  a  right  angle  to  the 
arm  and  make  forcible  supination.  Apply  an  anterior  angular  splint,  and 
have  it  worn  for  four  or  five  days,  or  put  the  part  in  Jones's  position  for  an 
■equal  period. 

Dislocations  of  the  wrist  are  very  uncommon  and  are  caused  by  falls 
•upon  the  hand. 

Backward  Dislocation  of  the  Wrist. — Symptoms. — The  deformity  in 
backward  dislocation  of  the  wrist  (Fig.  357,  a)  resembles  that  of  CoUes's 
fracture  (Fig.  357,  b).  The  fingers  are  flexed,  the  wrist  is  bent  backward, 
the  radius  projects  on  the  front  of  the  wrist,  the  carpus  projects  on  the  dorsal 
surface  of  the  forearm,  the  relation  of  the  styloid  process  of  the  radius  to  the 

*  See  the  instructive  article  by  W.  W.  Van  Arsdale,  in  the  Annals  of  Surgery,  vol 
ix,  1889. 


684 


Diseases  and  Injuries  of  Bones  and  Joints 


styloid  process  of  the  ulna  is  unaltered  (it  is  altered  in  Colles's  fracture), 
there  is  rigidity,  and  crepitus  is  absent. 

Forward  dislocation  of  the  wrist,  which  is  very  unusual,  is  caused  by 
a  fall  upon  the  back  of  the  hand. 

Symptoms  and  Treatment. — In  forward  dislocation  of  the  wrist  the  radius 
and  ulna  project  posteriorly  and  the  carpus  projects  in  front.  The  treatment 
in  both  of  these  dislocations  is  reduction  by  extension  and  manipulation,  the 
use  of  a  Bond  splint  for  ten  days,  and  the  employment  of  passive  motion 
after  five  or  six  days. 

Dislocation  at  the  inferior  radio-ulnar  articulation,  which  is  also 
very  common,  is  caused  by  twists. 

Symptoms  and  Treatment. — In  forward  dislocation  at  the  inferior  radio- 
ulnar articulation  the  forearm  is  pronated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  forms  a  projection  posteriorly.  In 
backward  dislocation  the  forearm  is  supinated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  projects  in  front.  Reduction  is  accom- 
plished by  extension  and  manipulation.  Two  straight  splints  (as  in  fracture 
of  both  bones)  are  to  be  applied  for  four  weeks,  and  passive  motion  is  to 
be  made  in  the  third  week. 

Dislocation  of  Individual  Carpal  Bones. — Pick  says  there  is  one  weak 
spot,  w^iich  is  "between  the  head  of  the  os  magnum  and  the  scaphoid  and 
semilunar  bones,"  and  the  os  magnum  may  be  forced  up.  This  lesion  is  called 
by  some  dislocation  of  the  os  magnum  backward.     Codman   and   Chase 


Fig.  357.— Deformity  in  dislocation  of  the  wrist  backward  (a)  and  in  Colles's  fracture  (b)  (Stimson). 

("Annals  of  Surgery,"  March  and  June,  1905)  regard  the  injury  as  really 
dislocation  0}  the  semilunar  forward,  a  dislocation  which  may  be  associated  with 
fracture  of  the  carpal  scaphoid.  The  injury  is  caused  by  forcible  overex- 
tension or  by  twisting  of  the  wTist.  According  to  Codman  and  Chase,  the  in- 
jury usually  occurs  in  men  between  thirty  and  forty,  results  from  violent  force, 
produces  severe  pain  immediately,  and  tenderness  and  ecchymosis  quickly  arise. 
On  examination  a  silver-fork  deformity  is  observed,  the  posterior  projection 
being  the  os  magnum,  this  projection  being  separated  from  the  radius  by  a 
groove  w^hich  marks  the  former  situation  of  the  dislocated  semilunar.  The 
dislocated  bone  is  felt  under  the  flexor  tendons  of  the  wrist,  the  palm  seems 
shorter  than  its  fellow,  the  fingers  are  partly  flexed,  active  or  passive 
motion  causes  pain,  and  the  .r-ray  exhibits  the  dislocated  bone  ("Annals  of 
Surgery,  "  March  and  June,  1905). 

Treatment.— P^ccor^mg  to  Codman  and  Chase,  recent  dislocations  (even 
after  the  fifth  week)  may  be  reduced  by  hyperextension  followed  by  hyper- 
flexion  over  "  the  thumbs  of  an  assistant  held  firmly  in  the  flexure  of  the  wrist 
or  the  semilunar"  ("Annals  of  Surgery,"  March  and  June,  1905). 


Dislocation  of  Metacarpophalangeal  Joint  of  Thumb  685 

If  bloodless  reduction  fails,  the  authors  advise  palmar  incision  and  re- 
duction, and  if  this  fails,  excision  of  the  bone.  If  in  excising  the  semilunar 
the  scaphoid  is  found  to  be  fractured,  the  proximal  part  of  the  entire  scaphoid 
must  also  be  removed. 

Dislocations  of  metacarpal  bones  are  uncommon.  The  first  metacarpal 
bone  is  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocations  of  the  metacarpal  bones  are 
■obvious  because  of  projection.  The  dislocations  are  reduced  by  extension 
and  manipulation,  a  straight  splint  and  large  pad  for  the  palm  are  applied 
(as  in  fracture  of  the  metacarpus),  and  the  splint  is  worn  for  three  weeks. 

Dislocations  at  the  metacarpophalangeal  articulations  are  uncom- 
mon. Backward  dislocation  is  the  most  common.  The  cause  is  a  fall  upon 
the  hand. 

Symptoms  and  Treatment. — Dislocated  metacarpophalangeal  articulations 
are  obvious.  Reduction  is  easily  effected  by  extension  and  manipulation, 
■except  in  the  case  of  the  thumb.     A  splint  must  be  worn  for  three  weeks. 

Dislocation  of  the  Metacarpophalangeal  Joint  of  the  Thumb. — 
In  this  dislocation  the  phalanx  usually  passes  backward.  In  some  cases  the 
long  flexor  of  the  thumb  gets  to  the  ulnar  side  of  the  head  of  the  metacarpal 
bone  and  hinders  reduction   (J.  Hutchinson,  Jr.,  in  "Brit.  Med.  Jour.," 


Fig.  358.— Levis's  splint  for  reducing  dislocation  of  phalanges. 


Fig.  359.— Levis's  splint  applied. 


Jan.  15,  1898).  The  chief  impediments  to  reduction,  as  demonstrated  by 
Farabeuf,  are  the  sesamoid  bones  and  glenoid  ligamxnt,  which  accompany  the 
base  of  the  phalanx  in  the  dislocation.  It  is  not  probable  that  the  catching  of 
the  metacarpal  bone  between  the  two  heads  of  the  flexor  brevis,  which  often 
happens,  is  an  important  impediment. 

Symptoms. — The  symptoms  of  backward  dislocation  are  as  follows:  The 
base  of  the  first  phalanx  rests  upon  the  metacarpal  bone;  the  head  of  the 
metacarpal  bone  projects  forward  and  buttonholes  the  muscles  of  the  thumb; 
the  first  phalanx  of  the  thumb  is  strongly  extended,  and  the  terminal  phalanx 
is  semiflexed.  The  symptoms  of  forward  dislocation  are  as  follows:  The 
base  of  the  first  phalanx  is  felt  in  the  palm,  and  the  head  of  the  metacarpal 
bone  is  felt  posteriorly. 


686  Diseases  and  Injuries  of  Bones  and  Joints 

Treatment. — In  treating  backward  dislocation  of  the  metacarpophalangeal 
joint  of  the  thumb  reduction  is  difficult.  Always  give  ether.  Keetley's 
directions  are  to  adduct  the  metacarpal  bone  into  the  palm  (this  relaxes  the 
flexor  muscles)  and  to  have  an  assistant  hold  it;  bend  the  thumb  strongly 
back,  extend,  pull  the  thumb  toward  the  fingers,  and  suddenly  flex.  To 
get  a  firm  enough  grasp  for  these  manipulations  use  the  apparatus  of  Char- 
riere  or  of  Levis  (Figs.  358,  359).  If  the  alcove  maneuvers  fail,  incise  freely  on 
the  dorsum  and  reduce.  Tenotomy  is  seldom  of  service.  After  reduction  of 
this  dislocation  a  splint  must  be  worn  for  three  weeks.  In  forward  dislocation 
reduction  is  easily  effected  by  strong  extension  and  forced  flexion.  A  splint  is 
to  be  worn  for  three  weeks. 

Dislocations  of  the  phalanges  may  be  complete  or  may  be  partial.  They 
are  commonest  between  the  first  and  second  phalanges. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious. 
In  reducing  such  dislocations  employ  extension  and  manipulation.  Use  a 
splint  for  one  week. 

Dislocations  of  the  Ribs  and  Costal  Cartilages. — The  ribs  may  be 
dislocated  from  the  vertebrae.  This  accident  is  seldom  uncomplicated,  and 
cannot  be  differentiated  from  fracture.  The  diagnosis  is  rarely  made,  and 
the  injury  is  treated  as  a  fracture.  The  ribs  may  be  dislocated  from  their 
cartilages,  one  or  more  ribs  being  displaced.  The  end  of  the  rib  forms  an 
anterior  projection,  there  is  a  depression  over  the  cartilage,  and  crepitus  is 
absent.  Treatment  is  the  same  as  that  employed  for  fractured  ribs.  The 
costal  cartilages  may  be  displaced  from  the  sternum,  forming  an  anterior 
projection  upon  this  bone.  Reduction  is  brought  about  by  placing  the 
patient  upon  a  table,  with  a  sand  pillow  between  the  scapulae,  pushing  back 
the  shoulders  and  chest,  and  forcing  the  cartilage  into  place.  The  dressings 
are  the  same  as  those  used  in  fractured  sternum.  The  cartilages  of  the 
lower  ribs  (sixth,  seventh,  eighth,  ninth,  and  tenth)  may  be  separated.  The 
inferior  cartilage  goes  forward  and  can  be  felt.  Pick  states  that  reduction 
is  brought  about  by  causing  the  patient  to  hold  the  chest  full  of  air  while 
efforts  are  made  to  push  the  cartilage  into  place.  The  injury  is  dressed  as 
are  fractured  ribs  (page  548). 

Dislocations  of  the  Sternum. — In  dislocations  of  the  body  of  the 
sternum  the  manubrium  is  separated  from  the  gladiolus.  The  injury  is  a 
rare  one,  is  usually  associated  with  fracture,  and  is  most  common  in  the 
young.  It  is  due  in  most  cases  to  violent  direct  force  inflicted  by  a  fall  or 
heavy  blow;  it  may  be  due  to  indirect  force  and  arose  in  one  case  of  acute 
tetanus.  The  symptoms  and  treatment  are  the  same  as  those  of  fracture 
(page  550).  Dislocation  of  the  ensiform  process  is  one  of  the  rarest  of 
injuries.  It  is  usually  due  to  direct  force,  but  Polaillon  reports  a  case  caused 
by  tight  lacing. 

Pelvic  dislocations  are  almost  always  complicated  with  fracture.  A 
pubic  bone  can  be  dislocated  by  falls  from  a  height  or  by  applying  violent 
force  to  the  acetabula.  The  dislocation  may  be  up  or  down,  front  or  back, 
and  it  may  damage  the  urethra  or  the  bladder.  The  patient  cannot  stand; 
there  are  great  pain  and  recognizable  deformity.  Treat  by  moulding  the- 
bones  into  place,  by  applying  a  pelvic  belt,  and  by  rest  in  bed  for  four  weeks. 


Dislocations  of  the  Femur 


687 


Dislocations  of  the  sacro-iliac  joint  are  produced  by  falls.  Movement  on  the 
part  of  the  patient  is  difficult  or  impossible;  there  is  violent  pain,  and  often 
paralysis  (from  pressure  upon  nerves).  In  dislocation  backward  there  is 
apparent  shortening  of  the  leg,  eversion  of  the  foot  exists,  and  the  ilium 
moves  posteriorly  and  upward.  In  dislocation  forward  the  anterior  supe- 
rior iliac  spine  projects  and  the  pelvis  is  broadened.  Sacro-iHac  dislocations 
are  reduced  by  holding  the  pelvis  firm  and  making  extension  with  a  pulley. 
The  patient  stays  in  bed  for  four  weeks  and  wears  a  pelvic  belt  as  in  fracture. 


Fig.  360. — Thyroid  dislocation  of  the  femur,  eight  weeks  after  the  accident.      Reduced  by 

open  section  (Rugh). 


Dislocations  of  the  Femur  (Hip-joint). — These  injuries  are  not  often 
encountered,  as  the  hip-joint  is  very  strong.  They  occur  in  young  adults.  In 
forcible  extension  the  head  of  the  femur  presses  against  the  capsule  of  the  joint, 
but  the  capsule  here  is  very  thick,  and  certain  muscles,  the  rectus,  psoas,  and 
iliacus,  are  pulled  tight  and  serve  to  strengthen  it.  The  head  of  the  bone 
cannot  go  directly  upward,  because  of  the  acetabulum  (Edmund  Owen).  The 
weak  point  of  the  acetabular  rim  is  below;  the  weak  part  of  the  capsule  is 
also  below;  hence  forced  abduction  is  apt  to  push  the  head  of  the  bone  through 
the  lower  part  of  the  capsule,  a  dislocation  occurring  primarily  into  the 
thyroid  foramen.     The   signs  of  the  dislocation  depend  upon   the  untorn 


688  Diseases  and  Injuries  of  Bones  and  Joints 

portion  of  the  capsule.  The  anterior  portion  of  the  capsule,  including  the  Y- 
ligament,  usually  escapes  laceration.  Vessels  are  rarely  injured.  Muscles  are 
often  torn.  In  some  cases  the  sciatic  nerve  is  lacerated,  bruised,  or  caught 
up  on  the  neck  of  the  femur  during  the  circumduction  of  attempted  re- 
ducdon.  Four  forms  of  hip-joint  dislocation  are  usually  described:  (i)  up- 
ward and  backward,  on  the  dorsum  of  the  ilium;  (2)  backward,  into  the 
sciadc  notch;  (3)  downward,  into  the  obturator  foramen;  and  (4)  inward, 
on  the  pubes. 

All  dislocations  are  primarily  inward  or  outward.  From  these  initial 
positions  the  head  may  be  shifted  to  any  region  about  the  socket  within  reach 
of  the  remnant  of  untorn  capsule  (Oscar  H.  Allis).  Allis  rejects  the  old 
classification  and    suggests  the  following: 

Low  thyroid,  ^ 

Mid-       "        VaU  present  abduction  and  outward  rotation. 
High      "       j 
Reversed  thyroid: 

Low  dorsal,  ~| 

Mid-      "       VAU  present  adduction  and  inward  rotation. 

High     "      J 

Dislocations  upon  the  dorsum  of  the  ilium  comprise  one-half  of  all 
hip-dislocations.  They  are  caused  by  a  fall  or  a  blow  when  the  limb  is  fle.xed 
and  abducted  (as  in  carrying  a  weight  upon  the  shoulder),  by  a  fall  upon 
the  knees  or  feet,  by  a  weight  striking  the  back  while  bending,  etc.  AUis  says 
rotation  inward  is  the  chief  element  in  their  production.  In  these  dislocations 
the  head  of  the  femur  goes  upward  and  backward,  rests  upon  the  ilium,  and 
is  always  above  the  tendon  of  the  obturator  internus  muscle.  These  disloca- 
tions are  secondary  to  thyroid  dislocation,  muscular  action  shifting  the  bone 
from  its  initial  seat  of  displacement. 

Signs. — Dislocation  on  to  the  dorsum  of  the  ilium  is  indicated  by  the 
following  symptoms:  the  buttock  appears  flat  and  broad;  the  great  trochanter 
is  above  Nelaton's  line  and  is  deeply  placed;  the  head  of  the  bone  can  be 
detected  in  its  new  situation ;  deep  pressure  in  front  of  the  joints  finds  a  hollow ; 
the  leg  is  shortened  by  about  two  or  three  inches,  as  a  rule;  the  fascia  lata  is 
relaxed;  in  some  thin  people  the  socket  can  be  outlined;  when  the  patient  is 
recumbent  the  injured  extremity  can  be  brought  to  the  perpendicular  without 
flexing  the  leg  (Allis) ;  the  knee  is  somewhat  flexed;  the  thigh  is  slightly  flexed, 
inwardly  rotated,  and  adducted  (Fig.  361)  (this  is  shown  by  the  fact  that 
the  axis  of  the  thigh  of  the  injured  side,  if  prolonged,  would  pass  through 
the  lower  third  of  the  sound  thigh) ;  when  the  capsule  is  extensively  lacerated 
(here  may  be  no  adduction  and  may  be  eversion  (Allis) ;  the  heel  is  raised, 
and  the  great  toe  of  the  foot  of  the  injured  side  rests  upon  the  front  of  the 
instep  or  the  ankle  of  the  sound  side;  rigidity  exists;  voluntary  movement  is 
impossible,  though  some  passive  motion  is  possible  in  the  direction  of  the 
deformity  (the  deformity  can  be  made  more  marked).  If  a  patient  is  re- 
cumbent and  the  knees  vertical,  the  foot  of  the  sound  extremity  is  free  of 
the  bed,  but  the  foot  of  the  injured  extremity  touches  the  bed  (AUis's  sign). 


Dislocation  into  the  Sciatic  Notch 


689 


Fig.  361.— Hip-joint 
dislocation  on  to  the 
dorsum    of    the     ilium 

(Cooper). 


Diagnosis. — Examine  iirst  without  anesthesia,  and  then  again  while  the 
patient  is  anesthetized.  The  A'-rays  are  valuable  in  diagnosis.  Dislocation  is 
distinguished  from  intracapsular  fracture  by  noting  the 
inversion,  the  great  shortening,  the  absence  of  crepitus, 
the  age  of  the  subject,  and  the  nature  of  the  force.  The 
nature  of  the  force,  the  inversion,  and  the  absence  of 
crepitus  mark  the  diagnosis  from  extracapsular  fracture. 

Treatment. — The  chief  obstacle  to  reduction  in  dis- 
location on  to  the  dorsum  of  the  ilium,  Bigelow  states, 
is  the  untorn  portion  of  the  capsule,  especially  the 
Y-ligament.  The  ilio-femoral,  Y,  or  Bigelow's  ligament 
resembles  an  inverted  Y,  arises  from  the  anterior  inferior 
spine  of  the  ilium,  is  inserted  into  the  anterior  intertro- 
chanteric line,  and  is  incorporated  into  the  front  of  the 
capsule.  To  reduce  a  dislocation  this  ligament  must  be 
relaxed  by  manipulation  or  be  torn  by  extension.  Man- 
ipulation makes  the  head  of  the  bone  retrace  its  steps 
over  the  same  route  it  took  in  emerging.  Give  ether; 
place  the  patient  supine  upon  a  mattress  on  the  floor ;  flex 
the  leg  on  the  thigh  (to  relax  the  hamstrings),  flex  the  thigh  on  the  pelvis;  in- 
crease the  adduction  over  the  middle  line ;  strongly  abduct ;  perform  external 
rotation  and  extension.  This  treatment  may  be  summed  up  as  flexion,  adduc- 
tion, external  circumduction,  and  extension;  or,  as  Pick  puts  it,  "bend  up,  roll 
out,  turn  out,  and  extend."  Allis's  advice  is  to  fix  the  pelvis  to  the  floor,  lift  the 
head  of  the  bone  to  the  level  of  the  socket,  rotate  outward  by  carrying  the 
leg  toward  the  pubis,  and  extend  the  femur.  If  extension  and  counter- 
extension  are  employed,  make  extension  in  the  axis  of  the  dislocated  limb 
and  obtain  counter-extension  by  a  perineal  band.  The  extension  band  is 
fastened  to  the  thigh  by  a  clove-hitch.  After  reduction  put  the  patient  to 
bed  and  use  sand-bags  (as  in  fracture  of  the  hip)  for  four  weeks.  We  may 
tie  the  knees  together  instead  of  using  the  sand-bags.  Passive  motion  is 
made  in  the  third  week.  The  pulleys  must  not  be  used  in  reduction.  They 
may  inflict  great  or  even  fatal  injury.  If  the  surgeon  fails  to  reduce  the 
deformity,  there  are  two  courses  open  to  him.  He  may  let  it  alone.  He 
may  operate.  If  he  lets  it  alone,  the  limb  will  become  ankylosed,  though 
probably  useful.  Allis  thinks  the  dorsal  region  will  be  the  best  place  to 
leave  it.  If  he  determines  to  operate,  he  must  recognize  that  tenotomy  is 
useless.  It  is  necessarj'  to  make  a  free  incision  in  order  to  restore  the 
bone. 

Dislocation  into  the  Sciatic  Notch. — In  this  dislocation  the  head  of 
of  the  bone  passes  backward  and  a  little  upward,  and  rests  upon  the  ischium 
at  the  margin  of  the  sciatic  notch  (not  in  the  notch),  below  the  tendon  of 
the  obturator  internus  muscle.  The  causes  are  the  same  as  those  given 
for  the  previous  dislocation. 

Signs. — The  signs  in  dislocation  into  the  sciatic  notch  are  like  those  of 
dislocation  upon  the  dorsum  of  the  ilium,  but  they  are  not  so  marked.  There 
are  flattening  and  broadening  of  the  hip;  ascent  of  the  trochanter  above 
Nelaton's  line;  shortening  to  the  extent  of  an  inch;  relaxation  of  the  fascia 
lata.  If  the  knee  of  the  injured  side  is  vertical,  the  sole  of  the  foot  touches 
44 


690 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  362. — Hip-joint 
dislocation  into  the 
sciatic  notch  (Cooper). 


the  bed.  Flexion,  inward  rotation,  and  adduction  e.xist,  but  the  axis  of  the 
femur  of  the  injured  side  passes  through  the  knee  of  the  sound  side,  and  the 
ball  of  the  great  toe  of  the  injured  side  rests  upon  the  great  toe  of  the  sound 
side  (Fig.  362),  Other  symptoms  are  identical  with  those  of  dislocation 
upon  the  dorsum  of  the  ilium,  but  are  less  pronounced. 
Allis's  signs  of  this  dislocation  are  of  value :  if,  with  the 
patient  recumbent,  the  thighs  are  brought  to  a  right  angle 
with  the  body,  shortening  on  the  affected  side  is  materi- 
ally increased;  if  the  dislocated  thigh  is  extended,  the 
back  arches  as  in  hip  disease. 

Diagnosis  and  Treatment. — The  signs  of  dislocation 
into  the  sciatic  notch  are  similar  to,  but  are  less  marked 
than,  those  of  dorsal  dislocation,  and,  being  a  backward 
dislocation,  the  reduction  and  treatment  are  the  same 
as  for  dislocation  backward  upon  the  dorsum  of  the 
ilium. 

Dislocation  Downward  into  the  Obturator  Fora- 
men.— Downward  dislocation  is  the  primary  position  of 
most  dislocations  of  the  hip,  the  bone  rarely  remaining  in 
the  th}Toid  foramen,  but  usually  mounting  up  as  a  result 
of  muscular  action  or  of  the  initial  violence.  The  cause  is  violent  abduction 
by  falls  or  by  stepping  from  a  moving  car. 

Signs. — Dislocation  downward  into  the  obturator  foramen  is  indicated 
by  flattening  of  the  hip;  the  head  of  the  bone  is  felt  in  its  new  position  and 
is  missed  from  the  acetabulum;  rigidity  exists;  passive  motion  is  only  possible 
in  the  direction  of  deformity,  and  that  to  a  slight  extent;  a  hollow  is  noted 
over  the  great  trochanter,  which  process  is  well  below  Nelaton's  line  and 
nearer  than  normal  to  the  middle  line.  The  gluteal 
crease  is  lower  than  is  the  crease  of  the  opposite  side; 
there  is  lengthening  to  the  extent  of  one  to  two  inches; 
the  body  is  bent  forward  by  the  traction  upon  the  psoas 
and  iliacus  muscles,  and  is  also  deviated  to  the  side,  thus 
causing  great  apparent  lengthening;  the  limb  is  ad- 
vanced partially  flexed  and  abducted,  and  the  foot  is 
pointed  straight  ahead  or  is  a  little  everted  (Fig.  363); 
when  the  patient  is  recuml)ent  extension  is  impossible, 
the  knees  cannot  be  pushed  together  without  great  pain, 
and  the  abductor  muscles  are  hard  and  rigid.  AUis' 
sign  is  absent.  Unreduced  dislocations  do  weU,  the 
patient  obtaining  a  very  useful  hip-joint  (Sedillot). 

Treatment. — In  treating  dislocation  downward  into 
the  obturator  foramen  give  ether  and  effect  reduction, 
if  possible,  by  manipulation,  and,  if  this  fails,  by  exten- 
sion. To  reduce  by  manipulation,  flex  the  leg  on  the  thigh  and  the  thigh  on  the 
pelvis,  and  then  perform,  in  the  following  order,  abduction,  internal  circum- 
duction, and  extension.  Allis's  rule  of  reduction  is  as  follows:  fix  the  pelvis  to 
the  floor;  pull  the  head  of  the  femur  outward  and  above  the  socket;  fix  the  head; 
push  the  knee  toward  sound  knee  and  extend  the  femur.  If  extension  is  made, 
make  traction  in  the  axis  of  the  Hmb  by  means  of  muslin  fastened  around  the 
thigh  by  a  clove-hitch.     Do  not  use  puUej's;  incise  rather  than  use  them. 


Fig.  363. — Hip-joint 
dislocation  into  the  ob- 
turator or  thyroid  fora- 
men (Cooper). 


Dislocation  with  Catching  up  of  Sciatic  Nerve 


691 


Dislocation  upon  the  pubis  is  a  ver\-  uncommon  accident.  The  head 
of  the  bone  usually  rests  just  internal  to  the  anterior  inferior  spine  of  the 
ihum.  The  primary  position  of  the  bone  is  in  the  thyroid  foramen;  the  pubic- 
dislocation,  when  it  occurs,  is  always  secondar}-,  and  is  due  to  the  initial  force 
and  to  muscular  action. 

Symptoms. — In  pubic  dislocation  the  head  of  the  bone  can  be  felt  and 
seen  in  its  new  position;  the  hip  is  flattened;  there  is  a  hollow  over  the  great 
trochanter,  this  process  being  found  below  the  anterior  superior  spine  of  the 
ilium;  there  is  shortening  to  the  extent  of  an  inch;  the  limb  is  in  abduction  with 
eversion  (Fig.  364),  and  the  knees  cannot  be  approximated  without  great  pain. 

Treatment. — In  the  treatment  of  pubic  dislocation  give  ether  and  employ 
manipulation  as  for  thyroid  dislocation.  If  this  fails,  employ  extension.  The 
limb  is  well  abducted,  extension  made  do-^niward  and  backward,  and  the 
head  of  the  femur  pulled  outward  "by  a  towel  around 
the  thigh,  just  beneath  the  groin"  (Keetley).  The  after- 
treatment  is  the  same  as  that  for  the  previous  forms. 

Anomalous  Dislocations  of  the  Hip. — In  supra- 
spinous dislocation  the  dislocation  of  the  hip  is  backward, 
the  head  of  the  femur  resting  upon  the  ilium  above  or 
even  anterior  to  the  anterior  superior  spine.  In  ischial 
dislocation  the  dislocation  is  downward  and  backward, 
the  head  of  the  femur  resting  on  the  ischial  tuberosity 
or  in  the  lesser  sciatic  notch.  Monteggia's  dislocation  is 
a  supraspinous  dislocation  with  eversion  of  the  limb.  In 
perineal  dislocation  the  head  of  the  femur  is  in  the  peri- 
neum. In  suprapubic  dislocation  the  head  of  the  femur 
passes  above  the  pubes.  In  subspinous  dislocation  the 
femoral  head  rests  on  the  horizontal  ramus  of  the  pubes. 

Dislocation  with  Catching  up  of  the  Sciatic  Nerve  during  Reduction. 
— This  accident  causes  severe  pain.  The  leg  is  tiexed  on  the  thigh  and  the 
thigh  is  flexed  on  the  pelvis.  .AJlis  tells  us  that  the  task  of  reduction  is  very 
unpromising.  We  must  strive  to  put  the  neck  of  the  femur  in  such  a  position 
that  the  nerve  will  "drop  oft","  and  yet  often  the  nerve  cannot  drop  off'  because 
it  is  held  by  adhesion  to  the  injured  muscles.  Allis  attempts  reduction  by 
the  following  plan; 

1.  Place  the  patient  upon  his  back  and  redislocate  the  femur. 

2.  Extend  the  thigh. 

3.  Flex  the  leg  on  the  thigh. 

4.  Turn  the  ankle  out  until  the  leg  is  horizontal  (this  causes  the  head 
of  the  bone  to  look  downward). 

5.  "Shake,  shock,  jar,  adduct,  and  abduct,"  to  disengage  the  nerve. 

6.  Rotate  into  socket  without  flexing  the  leg  (without  making  the  nerve 
tense). 

7.  If  this  fails,  make  an  incision  above  the  popliteal  space,  and  draw  the 
nerve  out  of  the  wound.  Detach  the  head  of  the  bone  from  its  entangle- 
ment and  rotate  it  into  the  socket.* 

*  Allis"  s  views  will  be  found  in  "An  Inquin'  into  the  Difficulties  Encountered  in  the 
Reduction  of  Dislocations  of  the  Hip."  By  Oscar  H.  Allis,  M.D.  This  highly  original  and 
valuable  treatise  received  the  Samuel  D.  Gross  prize  of  the  Philadelphia  Academy  of  Surgery 
in  1895. 


Fig.  364. — Dislocation 
on  pubis  (Cooper). 


692  Diseases  and  Injuries  of  Bones  and  Joints 

Dislocation  of  the  Head  of  the  Femur  with  Fracture  of  the  Shaft 
of  the  Bone. — We  may  incise  and  replace  and  wire  tlie  fragments.  We 
may  use  McBurney's  hooks  as  in  the  shoulder.  We  may  be  forced  to  do  a 
resection  of  the  head. 

Allis  maintains  that  it  is  possible  to  reduce  it  by  manipulation.  He 
states  that  the  upper  fragment  is  the  entire  lever,  and  the  lower  fragment 
"is  only  the  agent  through  which  we  apply  our  force."  The  fragments  are 
not  completely  separated,  but  are  connected  at  one  side  by  material  which 
is  "partly  periosteal,  partly  tendinous,  and  partly  muscular."  This  con- 
necting material  enables  us  to  make  traction  upon  the  upper  fragment,  but 
does  not  allow  "rotation,  circumduction,  and  leverage  through  the  agency 
of  the  lower  fragment."  Hence  "the  only  agency  at  our  command  is  trac- 
tion." If  the  dislocation  is  inward  (forward),  draw  the  head  outward  and 
have  an  assistant  make  direct  pressure  upon  the  head  of  the  bone.  If 
this  fails,  the  assistant  holds  the  head  of  the  bone  to  prevent  its  slipping 
into  the  thyroid  depression,  and  the  surgeon  makes  traction  inward  or 
inward  and  downward.  If  the  dislocation  is  outward  (backward),  make 
traction  directly  upward  to  lift  the  head  of  the  bone  to  the  level  of  the 
"socket,  and  try  to  place  the  head  over  the  socket  by  traction  obliquely 
upward  and  inward.  During  all  these  manipulations  an  assistant  presses 
upon  the  trochanter  to  prevent  the  head  of  the  bone  slipping  back.  Trac- 
tion is  now  made  downward  and  inward,  and  the  tightened  ligament  drags 
the  head  of  the  bone  into  place. 

Dislocations  of  the  Knee. — These  dislocations  are  rare.  There  are  four 
forms — forward,  backward,  inward,  and  outward.  They  may  be  complete 
or  incomplete;  the  commonest  dislocations  are  lateral.  The  cause  is  violent 
force,  such  as  a  fall,  or  in  jumping  from  a  moving  train,  or  in  being  caught 
by  the  foot  and  dragged. 

Dislocation  Forward  of  the  Knee-joint.— In  the  complete  form  of 
forward  dislocation  the  deformity  is  obvious.  The  limb  is  usually  extended, 
but  it  may  be  flexed.  Much  shortening  exists;  the  condyles  are  felt  posterior 
and  below;  the  head  of  the  tibia  is  felt  anterior  and  above;  the  patella  is 
movable  and  the  quadriceps  is  lax;  pressure  of  the  condyles  upon  the  con- 
tents of  the  popliteal  space  arrests  the  tibial  pulse  and  causes  edema  and 
intense  pain.  In  incomplete  dislocation  the  symptoms  are  identical  in  kind, 
but  are  less  pronounced. 

Treatment. — Compound  dislocation  of  the  knee-joint  often  demands  ex- 
cision or  amputation.  In  simple  dislocation  give  ether,  have  one  assistant 
extend  the  leg  while  another  makes  counter-extension  on  the  thigh,  and  the 
surgeon  pushes  the  bone  into  place.  Reduction  is  easy  because  of  liga- 
mentous laceration.  Place  the  limb  on  a  double  inclined  plane,  and  combat 
inflammation  by  the  usual  methods  (see  Synovitis,  page  625).  Begin  passive 
motion  in  the  third  week.  The  patient  must  wear  a  knee-support  for  months. 
If  the  popliteal  vessels  are  much  damaged,  gangrene  will  supervene  and 
amputation  will  be  demanded. 

Dislocation  Backward  of  the  Knee-joint. — In  the  complete  form  of 
knee-joint  dislocation  backward,  displacement  is  not  so  great  as  in  dislocation 
forward.     The  head  of  the  tibia  projects  posteriorly  and  above,  the  femoral 


Dislocations  of  the  Patella 


69; 


pig_255_(,l,l  ,li>lrK  alien  ot  ilir  patella  outward. 


condyles  anteriorly  and  below;  the  leg  is,  as  a  rule,  partly  flexed,  l.ul  it  may  be 
extended,  and  there  is  moderate  shortening.     In  incomplete  dislocation  the 

symptoms   are  less  marked. 

Treatment.— ThQ     treatment 

of  backward   dislocation    of  the 

knee-joint  is  the  same  as  for  for- 
ward dislocation. 

Dislocation  Outward  of  the 

Knee-joint.— Is  usually  incom- 
plete.    The   inner  tuberosity  of 

the  tibia  in  outward  dislocation 

lies  upon  the  outer  condyle  of  the 

femur  (Pick);  the  inner  condyle 

cf  the  femur  projects  internally; 

the    outer  tibial  tuberosity   and 

fibular  head  project  externally, 

the  former  having  a  depression 

below  it,  and  the  latter  above  it; 

the  leg  is  semiflexed,  but  shorten- 
ing is  absent. 

Dislocation  Inward  of  the 
Knee-joint.— Is  u-ually  incom- 
plete. The  outer  tuberosity  of 
the  tibia  in  inward  dislocation 
lies  upon  the  inner  condyle  of  the 

femur  the  outer  condvle  of  the  femur  forms  an  external  prominence,  and  the 
inner  tuberosity  of  the  iibia  forms  an  internal  prominence.  Pick  cautK^ns  us  not 
to  mistake  a  separation  of  the  lower  femoral  epiphysis  for  lateral  dislocation 
(the  former  is  reduced  easily,  the  deformity  tends  to  recur,  and  there  is  soft 

crepitus).  ,      ,  .  .  ^.    , 

Treatment.-ln  treating  lateral  dislocation  of  the  knee-joint,  ettect  ex- 
tension and  counter-extension  as  in  anteroposterior  dislocations.  The  leg 
is  moved  from  side  to  side  and  attempts  are  made  at  rotation.  The  after- 
treatment  is  the  same  as  that  for  anteroposterior  luxations. 

Dislocations  of  the  Patella.-Are  usually  acquired.  There  are  thirty- 
five  congenital  cases  on  record  (Bajardi).  There  are  three  forms:  outward, 
inward,  and  edgewise.  The  so-called  dislocation  upward  is  in  reahty^rupture 
of  the  Hgamentum  patellar  (page  732). 

Dislocation  outward  (Fig.  365)  may  be  due  to  muscular  action  or  to 
direct  force,  and  occurs  during  extension  of  the  leg.  It  occasionally  happens 
in  a  person  with  knock-knee.  If  dislocation  is  complete,  the  bone  hes  upon 
the  external  surface  of  the  external  condyle;  if  incomplete,  the  patella  rests 
upon  the  anterior  surface  of  the  external  condyle.  The  leg  is  extended,  flexion 
is  impossible,  and  attempts  at  flexion  produce  great  agony  In  the_  patient 
shown  in  Fig.  365,  flexion  became  possible  in  an  unreduced  dislocation,  but 
not  until  months  after  the  accident.  The  knee  is  wider  than  normal,  i  here 
is  a  hollow  in  front  of  the  joint.     The  bone  is  felt  in  its  new  position.         . 

Dislocation  inward  is  very  rare.  The  signs  are  like  those  of  disloca- 
tion outward,  except  that  the  pateUa  rests  upon  the  inner  condyle. 


694  Diseases  and  Injuries  of  Bones  and  Joints 

Treatment. — Give  ether.  Raise  the  body  upon  a  bed-rest,  and  flex  the 
thigh.  Grasp  the  patella  and  depress  the  margin  which  is  farthest  from  the 
center  of  the  joint  (Pick) .  The  muscles  pull  the  bone  into  place.  Immobilize 
for  three  weeks,  and  then  begin  passive  motion.  Incision  may  be  necessary 
in  order  to  effect  reduction. 

Dislocation  of  the  Patella  Edgewise. — The  patella  rotates  vertically, 
one  edge  resting  between  the  condyles.  As  a  rule,  the  outer  border  is  in  the 
intercondyloid  notch  (Pick).  This  condition  is  produced  by  direct  force 
when  the  extremity  is  partly  flexed.  Twisting  and  muscular  action  have 
been  assigned  as  causes.     The  condition  is  obvious  at  a  glance. 

Treatment. — Give  ether.  Pick  recommends  "sudden  and  forcible  bend- 
ing of  the  knee."  In  some  cases  the  bone  can  be  pushed  into  place,  the 
limb  being  extended  and  flexed  as  in  the  reduction  of  a  lateral  dislocation. 
In  some  cases  incision  will  be  necessary. 

Dislocation  of  the  Semilunar  Cartilages  of  the  Knee-joint  {the 
Internal  Derangement  0}  Hey;  Subluxation  of  the  Knee-joint).  The  condi- 
tion was  described  by  Hey  of  Leeds  in  1803.  The  interarticular  cartilages  of  the 
knee-joint  are  attached  in  front  of  and  behind  the  tibial  spine,  and  the  convex- 
ity of  each  cartilage  is  attached  to  the  edge  of  the  corresponding  tibial  tuberosity 
by  means  of  the  coronary  ligament.  The  internal  cartilage  is  fastened  to  the 
internal  lateral  ligament  and  has  a  moderate  freedom  of  movement.  The 
outer  cartilage  is  not  connected  with  the  internal  lateral  ligament  and  is  not  freely 
movable.  It  has  been  stated  that  the  outer  cartilage  is  more  frequently  dislo- 
cated than  the  inner,  but  modern  experience  indicates  that  this  is  not  true,  and 
that  the  internal  cartilage  is  the  one  most  apt  to  suffer.  In  17  cases  operated 
upon  by  Barker,  the  internal  cartilage  was  involved  in  every  case  ("Lancet," 
Jan.  4,  1902).  Those  persons  whose  occupations  force  them  to  pass  con- 
siderable time  upon  their  knees  are  predisposed  to  this  accident  (Annandale). 
The  derangenient  of  the  cartilage  is  usually  caused  by  a  sudden  external  ro- 
tation of  the  tibia,  while  the  knee-joint  is  in  partial  flexion;  for  instance,  when 
the  patient  stumbles  over  an  obstacle,  the  knee-joint  being  partially  flexed,  the 
tibia  is  twisted  outward.  When  the  joint  is  flexed,  a  normal  cartilage  moves 
backward,  and  when  it  is  extended,  moves  forward  again.  When  the  cartilage 
is  thrown  out  by  the  sudden  eversion  and  flexion  of  the  tibia,  it  is  caught  and 
does  not  move  into  place  readily  when  the  leg  is  extended.  The  tear  takes 
place  in  the  direction  of  the  fibers  of  the  cartilage. 

Symptoms. — The  indications  of  interarticular  cartilage  displacement  are 
a  sudden,  violent,  sickening  pain  in  the  knee,  which  may  be  so  severe  as  to 
cause  the  patient  to  fall  to  the  ground.  The  knee  is  in  a  position  of  fixed 
semiflexion.  Further  flexion  is  possible,  but  extension  is  impossible.  In 
some  cases  the  patient  can  voluntarily  make  further  flexion;  in  others,  the 
pain  is  so  severe  that  he  either  cannot  or  will  not  do  it;  but  increase  of  flexion 
can  be  obtained  by  passive  motion.  The  joint  is,  however,  blocked  both  to 
passive  and  to  voluntary  extension.  Attempts  at  passive  motion  are  pro- 
ductive of  fierce  pain.  If  either  cartilage  is  displaced  away  from  the  tibial 
spine,  a  prominence  may  be  found  on  one  or  the  other  side  of  the  knee-joint. 
If  the  displacement  takes  place  toward  the  tibial  spine,  a  prominence  may 
be  found  on  one  side  of  the  ligament  of  the  patella.  Subluxation  is  rapidly 
followed  by  inflammation  of  the  synovial  membrane  of  the  joint  and  of  the 
cartilages   themselves;   and   swelling  quickly   masks   the  projection   of  the 


Dislocations  of  the  Fibula  695 

cartilage.  This  accident  is  frequently  mistaken  for  the  blocking  of  the  joint 
by  a  floating  cartilage;  but  a  dislocated  cartilage  always  remains  in  the  same 
position,  and  a  loose  cartilage  changes  its  position  from  time  to  time  (Turner). 
Loose  bodies  in  a  joint  produce  pain  of  a  shifting  character,  and  interference 
with  both  flexion  and  extension,  or  with  either  flexion  or  extension  in 
an  irregular  way  (Cotterill).  In  regard  to  the  diagnosis,  Cotterill  points 
out  that  in  a  sprain  of  the  joint  extension  is  not  painful,  Ijut  flexion  is  inter- 
fered with;  whereas,  in  the  dislocation  of  a  cartikige  of  the  joint,  flexion  is 
still  possible,  but  extension  cannot  be  carried  out  ("Lancet,"  Feb.  22,  1902). 

Treatment. — I  have  used  with  satisfaction  to  reduce  a  displaced  internal 
semilunar  cartilage  a  method  described  by  Henry  W.  Jacob  ("Brit.  Med.  Jour.," 
March  7,  1908).  It  is  not  followed  by  severe  synovitis  unless  the  patient 
has  walked  or  has  made  repeated  efforts  to  reduce  the  displacement,  and  as 
it  is  a  painless  method  ether  is  not  required.     Jacob  describes  it  as  follows: 

"The  patient  lies  on  a  bed  or  couch,  the  surgeon  standing  on  the  outer  side 
of  the  Hmb  affected,  with  his  face  toward  the  patient's  foot;  the  patient  then 
raises  his  leg  off  the  couch  in  the  semiflexed  condition,  the  surgeon  grasps  the 
patient's  leg  in  both  hands,  and  using  his  own  thigh  as  a  fulcrum,  by  means  of  a 
steady  pulHng  movement  draws  the  patient's  leg  outward  while  the  surgeon's 
thigh  keeps  the  patient's  femur  in  a  fixed  position;  directly  this  movement  is 
effected  the  patient  must  steadily  extend  the  hmb,  and  the  displaced  cartilage 
will  probably  go  back  with  a  slight  click;  if  the  first  movement  of  extension  is 
not  successful  the  maneuver  must  be  repeated  without  any  hurry  or  unnecessary 
force,  and  after  a  few  attempts  the  cartilage  can  usually  be  felt  to  slip  in  with- 
out pain  or  inconvenience." 

In  treating  dislocation  of  a  semilunar  cartilage  of  the  knee  it  is  customary 
to  give  ether  and  reduce  by  forced  flexion  and  external  rotation.  Exten- 
sion becomes  possible  if  the  cartilage  is  freed.  During  these  maneuvers  an 
assistant  endeavors  to  push  any  projection  of  cartilage  into  place.  After 
reduction  apply  a  splint  for  two  weeks  and  combat  inflammation  by 
proper  remedies  (see  Synovitis);  then  begin  passive  motion.  At  the  end  of 
two  weeks  apply  a  firm  knee-cap  made  of  leather  and  let  the  patient  get  about 
on  crutches.  After  a  couple  of  weeks  the  crutches  can  be  laid  aside.  As 
recurrence  of  the  displacement  is  usual,  the  patient  should  wear  a  knee-cap 
during  the  day  for  many  months.  A  partial  tear  may  entirely  heal  when 
thus  treated  by  rest  and  support;  an  extensive  tear  will  not,  although  even 
in  such  cases  a  useful  but  somewhat  stiff  joint  may  be  obtained.  If  it  is 
found  impossible  to  unlock  the  blocked  joint,  or  if  the  tear  is  extensive 
and  redislocation  is  prone  to  occur,  an  operation  is  advisable.  The  joint 
is  opened  and  the  loose  cartilage  is  pushed  into  place  and  held  by  stitches  or 
the  loosened  portion  is  excised. 

Dislocations  of  the  Fibula:  Dislocation  at  the  Superior  Tibio- 
fibular Articulation. — This  injury  is  rare.  The  head  of  the  fibula  may  go 
forward  or  backward.  The  causes  are  direct  force  and  violent  adduction  of 
the  foot  with  abduction  of  the  knee  (Bryant). 

Symptoms. — After  dislocation  of  the  fibula  the  position  is  one  of  semiflexion 
of  the  knee,  voluntary  extension  and  flexion  being  impaired  or  lost.  A 
distinct  movable  projection  is  readily  noticed  in  front  or  behind,  which  is 
found  to  be  continuous  with  the  fibula.  There  is  a  depression  over  the 
normal  position  of  the  head  of  the  fibula. 


6g6  Diseases  and  Injuries  of  Bones  and  Joints 

Treatment. — In  treating  dislocation  of  the  fibula  bend  the  knee  to  relax 
^he  biceps,  and  proceed  to  push  the  bone  into  place.  Put  a  compress  over 
the  head  of  the  fibula,  apply  a  bandage,  and  put  the  limb  on  a  double  in- 
clined plane  for  three  weeks.  At  the  end  of  this  time  put  a  lacing  knee- 
support  upon  the  knee  and  let  the  patient  up.  Displacement  being  liable 
to  recur,  a  knee-cap  must  be  worn  for  a  year. 

Dislocations  of  the  Ankle-joint. — These  injuries  are  not  unusual. 
Fracture  is  a  frequent  complication.  There  are  five  forms  of  ankle-joint 
dislocation — outward,  inward,  forward,  backward,  and  upward. 

Lateral  dislocations  of  the  ankle-joint  are  either  outward  or  inward, 
and  may  be  complete  or  incomplete.  In  these  dislocations  the  astragalus 
rotates.  In  incomplete  dislocations  "there  is  no  great  separation  of  the 
trochlear  surface  of  the  astragalus  from  the  under  surface  of  the  tibia,  but 
the  outer  or  inner  margin  of  this  surface  is  brought  into  contact  with  the 
articular  surface  of  the  tibia,  and  the  whole  foot  presents  a  lateral  twist" 
(Pick).     The  causes  of  these  dislocations  are  twists  of  the  joint. 

Symptoms. — Incomplete  outward  dislocation  of  the  ankle-joint  is  known 
as  Pott's  fracture  (see  page  620).  Complete  outward  dislocation,  in  which 
the  articular  surface  of  the  astragalus  is  completely  displaced  outward  from 
the  articular  surface  of  the  tibia,  and  which  condition  is  associated  with  a 
fracture  of  the  fibula  and  separation  of  the  inferior  tibiofibular  articulation, 
is  known  as  Diipuytren's  jracture.  In  incomplete  dislocation  the  foot  goes 
outward  and  upward,  the  fibula  is  fractured,  and  the  tibiofibular  ligaments 
are  torn  off.  In  Dupuytren's  fracture  the  ankle  is  broad,  the  inner  malleolus 
projects  and  looks  lower  than  natural,  the  outer  malleolus  ascends  with  the 
foot,  the  foot  rotates  outward,  and  crepitus  can  be  detected.  In  inward  dis- 
location which  is  associated  with  fracture  of  the  inner  malleolus  there  is 
inversion,  the  outer  malleolus  projects,  and  crepitus  can  be  detected.  In 
incomplete  separation  the  symptoms  are  similar,  but  are  not  so  marked. 

Treatment. — In  treating  a  case  of  dislocation  of  the  ankle-joint  the  de- 
formity is  reduced  by  flexing  the  leg  on  the  thigh  and  the  thigh  on  the  pelvis; 
;'an  assistant  makes  counter-extension  from  the  knee;  the  surgeon  makes 
extension  from  the  foot,  and  at  the  same  time  rocks  the  astragalus  into  place. 
Dupuytren's  fracture  is  treated  in  the  same  manner  as  Pott's  fracture  (page 
621).  Dislocation  inward  is  treated  in  a  fracture-box  for  the  same  period  as 
Pott's  fracture. 

Anteroposterior  dislocations  of  the  ankle-joint  are  rare.  The  cause 
is  the  catching  of  the  foot  in  jumping  or  falling — direct  violence.  In  disloca- 
tion forward  the  foot  is  lengthened,  the  heel  is  not  conspicuous,  the  tibia  and 
fibula  project  against  the  tendo  Achillis,  and  the  relation  of  the  malleoli  to 
the  tarsus  is  altered.  In  incomplete  dislocation  the  symptoms  are  similar, 
but  less  pronounced.  In  dislocation  backward  the  foot  is  shortened,  the 
tibia  and  fibula  project  in  front,  the  heel  is  prominent,  and  the  relation  be- 
tween the  malleoli  and  the  tarsus  is  altered.  In  incomplete  dislocation  the 
symptoms  are  similar,  but  less  marked. 

Treatment. — In  anteroposterior  dislocation  of  the  ankle-joint,  reduce  as 
in  lateral  dislocations.  Sometimes  the  tendo  Achillis  must  be  cut.  Apply 
a  plaster-of-Paris  dressing,  and  let  it  be  worn  for  two  weeks;  then  begin 
passive  motion,  and  let  the  patient  wear  side-splints  for  a  week  longer. 

Dislocation  upward  of  the  ankle-joint,  or  Nelaton's  dislocation,  is 


Subastiagaloid  Dislocation  697 

a  very  rare  injury.  The  astragalus  is  wedged  between  the  widely  separated 
tibia  and  fibula.  This  dislocation  is  usually  associated  with  fracture.  The 
cause  is  a  fall  upon  the  feet  from  a  great  height. 

Symptoms. — Upward  dislocation  of  the  ankle-joint  is  indicated  by  the 
widening  of  the  ankle  and  by  the  flattening  of  the  foot.  The  malleoli  are 
nearly  on  a  level  with  the  plantar  surface  of  the  foot,  and  there  is  absolute 
rigidity. 

Treatment. — In  treating  upward  dislocation  of  the  ankle-joint  give  ether, 
and  try  to  reduce  by  powerful  extension  and  counter-extension.  Treat  the 
injury  afterward  in  the  same  manner  as  an  anteroposterior  luxation. 

Dislocation  of  the  Astragalus. — The  astragalus  may  be  displaced  from 
the  bones  of  the  leg  and  at  the  same  time  be  separated  from  the  rest  of  the 
tarsus.  The  displacement  may  be  forward,  backward,  outward,  inward,  or 
rotary. 

Dislocation  of  the  astragalus  forward  or  backward  is  caused  by  falls 
or  twists. 

Symptoms. — In  forward  dislocation  the  astragalus  projects  strongly;  there 
is  shortening  of  the  foot,  and  the  malleoli  approach  the  plantar  aspect  of  the 
foot;  the  foot  is  deviated  to  one  side  or  to  the  other,  and  there  is  absolute 
rigidity  of  the  ankle-joint.  In  incomplete  luxations  the  symptoms  are  similar, 
but  less  marked.  This  dislocation  may  be  obliquely  forward.  In  backward 
dislocation  of  the  astragalus  the  foot  is  not  deviated  to  either  side;  the  astragalus 
projects  between  the  malleoli  and  above  the  os  calcis,  and  the  tendo  Achillis 
is  stretched  over  the  projection.  Rigidity  is  absolute.  This  dislocation  mav 
be  obliquely  backward. 

Lateral  and  Rotary  Dislocations  of  the  Astragalus. — Lateral  dis- 
locations of  the  astragalus  are  rare,  are  always  compound,  and  are  always 
associated  with  fracture.  In  rotary  dislocation  the  astragalus  remains  in 
its  normal  habitat  after  rotating  on  its  own  axis,  either  horizontal  or  vertical. 
The  causes  of  rotary  dislocation  are  twists  of  the  foot  when  it  is  at  a  right 
angle  to  the  leg  (Barwell).  The  symptoms  of  rotary  dislocations  are  obscure. 
There  is  rigidity,  but  sometimes  portions  of  the  astragalus  may  be  made  out* 

Treatment  oj  Dislocations  of  the  Astragalus. — In  treating  astragalus  dis- 
location reduce  under  ether  by  flexing  the  knee  to  relax  the  gastrocnemius, 
extending  the  foot,  and  pushing  the  bone  into  place.  It  may  be  necessary 
to  cut  the  tendo  Achillis.  After  reduction  put  up  the  foot  and  leg  in  a  plaster- 
of-Paris  dressing  for  two  weeks,  and  then  begin  passive  motion  and  apply 
side-sphnts,  which  are  to  be  worn  for  one  week  more.  If  reduction  fails, 
support  the  limb  on  splints,  combat  inflammation,  and  endeavor  to  bring 
about  union  between  the  dislocated  bone  and  the  tissues.  Often,  in  un- 
reduced dislocation,  the  skin  sloughs  over  the  projecting  bone.  Excision 
is  demanded  the  moment  sloughing  is  seen  to  be  inevitable.  Cases  of  com- 
pound dislocation  of  the  astragalus  require  immediate  excision. 

Subastragaloid  Dislocation. — This  condition-  is  a  separation  of  the 
astragalus  from  the  os  calcis  and  scaphoid,  without  separation  from  the  bones 
of  the  leg.  Pick  states  that  the  usual  classification  for  these  dislocations 
is  forward,  backward,  inward,  and  outward,  but  that  the  displacement  is, 
as  a  rule,  oblique,  the  foot  passing  backward  and  outward  or  backward  and 
inward.     The  cause  is  twisting. 


698  Diseases  and   Injuries  of  Bones  and  Joints 

Symptoms. — In  subastragaloid  dislocation  the  astragalus  projects  on  the 
dorsum;  the  foot  is  everted  in  outward  dislocation  and  inverted  in  inward 
dislocation;  the  relation  of  the  malleoli  to  the  astragalus  is  unaltered;  the 
ankle-joint  is  not  absolutely  rigid;  the  foot  "is  shortened  in  front  and  is 
elongated  behind"  (Pick). 

Treatment. — To  treat  subastragaloid  dislocation  make  extension  in  the 
direction  opposite  to  that  of  the  displacement.  In  dislocation  of  the  tarsus 
backward  fix  a  bandage  around  the  foot,  on  a  level  with  the  heads  of  the 
metatarsal  bones,  which  bandage  the  surgeon  ties  around  his  shoulders. 
The  surgeon  puts  one  knee  in  front  of  the  ankle  and  thus  fixes  the  leg,  raises 
himself  up  to  make  extension  upon  the  tarsus,  and  moulds  the  bone  into 
position.  Tenotomy  may  be  necessary.  After  reduction  apply  a  plaster- 
of-Paris  dressing  and  have  it  worn  for  three  weeks.  The  ankle-joint,  fortu- 
nately, is  not  involved,  and  stiffness  of  this  articulation  need  not  be  appre- 
hended. If  reduction  is  impossible,  take  the  same  course  as  in  luxations  of 
the  astragalus. 

Dislocations  of  the  other  tarsal  bones  are  very  rare.  Single  bones 
may  be  dislocated,  or  the  luxation  may  occur  at  the  mediotarsal  articulation. 

Symptoms  and  Treatment. — Projection  is  an  obvious  symptom  in  disloca- 
tion of  the  other  tarsal  bones.  The  treatment  is  to  reduce  by  extension  and 
moulding,  the  part  being  put  up  in  plaster-of-Paris  dressing  for  two  weeks. 

Dislocations  of  the  metatarsal  bones  are  rare. 

Symptoms  and  Treatment. — Shortening  of  the  toes  and  projection  of  the 
dislocated  bone  are  symptoms  of  dislocation  of  the  metatarsal  bones.  To 
treat  these  dislocations  reduce  by  extension  under  ether  and  put  up  in  a 
plaster-of-Paris  dressing  for  two  weeks.  If  reduction  fails,  the  functions  of 
the  foot  will  not  be  much  impaired. 

Dislocations  of  the  phalanges  are  very  rare.  The  lirst  phalanx  of 
the  big  toe  is  the  one  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious. 
The  treatment  is  by  reduction  as  in  dislocations  of  the  thumb.  Immobilize 
for  two  weeks. 

Operations  upon  Bones  and  Joints. 
Osteotomy. — By  the  term  osteotomy  the  modern  surgeon  means  literally 
the  sectioning  of  a  bone  for  the  purpose  of  straightening  a  limb  ankylosed 


Fig.  366. — Adams's  large  saw. 

in  a  bad  position,  correcting  a  bony  deformity,  or  amending  a  vicious  union 
of  a  fracture.  In  a  linear  osteotomy  the  bone  is  transversely  or  obliquely 
divided  at  one  spot;  in  a  cuneijorm  osteotomy  a  wedge-shaped  portion  of 


Osteotomy  for  Genu  Valgum,   or  Knock-knee 


699 


bone  is  removed.  The  operation  of  osteotomy  may  be  performed  with  a 
saw  (Fig.  366)  or  with  an  osteotome.  The  saw  creates  dust,  draws  much 
air  into  the  wound,  and  lacerates  the  tissues  to  a  considerable  degree. 
Most  surgeons  prefer  the  chisel  or  the  osteotome.  The  osteotome  slopes 
down  to  a  point  from  each  side  (Fig.  367);  the  chisel  is  .straight  on  one 
side  and  on  the  other  is  bevelled  to  a  point. 


Fig.  367. — Osteotome. 


Fig.  368. — Rawhide  mallet. 


Osteotomy  for  Genu  Valgum,  or  Knock-knee  (Macewen's  Operation, 
Fig.  369). — In  this  operation  the  instruments  required  are  the  scalpel,  hemo- 
static forceps,  osteotomes  of  several  sizes,  a  mallet  (Fig.  368),  and  a  sand- 
bag wrapped  in  an  aseptic  towel. 

Operation. — The  patient  lies  upon  his  back,  being  rolled  a  little  toward 
the  diseased  side.     The  leg  of  the  diseased  side  is  partly  flexed  upon  the 
thigh  and  the  thigh  upon  the  pelvis,  and  the  extremity  is  laid  upon  its  outer 
surface,   the   sand-bag    being 
pushed  between  the  extremity 
and  the  bed,  opposite  to  the 
site  of  section.     The  flexion  of 
the  knee  relaxes  the  popliteal 


Fig.  369.— Osteotomy  of  the  right 
femur  in  a  case  of  knock-knee  :  a  b, 
Epiphyseal  line;  c,  section  of  Mac- 
ewen  ;  d  e,  section  of  Ogston. 


Fig.  370.— Macewen's  operation  for  genu  valgum. 
The  chisel  is  held  in  the  line  for  striking  with  a  mal- 
let ;  the  arrow  shows  the  direction  in  which  the  chisel 
is  levered  up  and  down  so  as  to  make  a  wide  gap  in 
the  bone  (after  Barker). 


vessels  and  saves  them  from  injury.  The  surgeon,  if  operating  on  the  right 
leg,  stands  outside  of  that  extremity;  if  operating  on  the  left  leg,  he  stands 
opposite  the  left  hip  (Barker).  The  knife  is  inserted  into  the  tissues  and  car- 
ried to  the  bone  at  the  inner  side  of  the  knee,  just  in  front  of  the  adductor 
tubercle  of  the  inner  condyle  and  on  a  level  with  the  upper  border  of  "  the 
patellar  articular  surface  of  the  femur"  (Barker).  An  incision  is  made 
upward  one  inch  in  length,  in  the  direction  of  the  axis  of  the  femur.  At 
the  lower  angle  of  this  wound  an  osteotome  is  inserted  and  the  blade  after 


700  Diseases  and  Injuries  of  Bones  and  Joints 

insertion  is  turned  to  a  right  angle  with  the  shaft  of  the  femur,  half  an 
inch  above  the  epiphysis  (Fig.  369).  The  osteotome  is  struck  several  times 
with  a  mallet;  the  handle  is  moved  several  times  toward  and  from  the  body, 
so  as  to  widen  the  cut  in  the  bone  (Fig.  370);  the  osteotome  is  again  struck 
with  the  mallet  several  times;  it  is  again  moved  toward  and  from  the  body, 
and  this  process  is  continued  until  the  bone  is  cut  two-thirds  through.  If 
the  osteotome  becomes  tightly  fixed,  it  should  be  withdrawn  and  a  smaller 
one  introduced.  In  the  soft  bone  of  a  young  child  this  to-and-fro  movement 
of  the  chisel,  if  carefully  executed,  is  not  hable  to  break  the  instrument.  In 
dense  bone  it  may  break  the  instrument;  hence,  when  doing  an  osteotomy 
in  dense  bone,  the  osteotome  is  moved  to  and  fro  across  the  limb  and  slight 
downward  pressure  upon  the  handle  will  to  a  great  extent  prevent  binding. 
When  the  bone  is  cut  two-thirds  through,  the  osteotome  is  withdrawn,  a  piece 
of  wet  antiseptic  gauze  is  held  over  the  wound,  and  the  surgeon  fractures 
the  femur  by  strong  adduction.  The  wound  is  neither  sutured  nor  drained, 
but  is  dressed  antiseptically,  the  entire  extremity  is  wrapped  in  cotton,  and  a 
plaster-of-Paris  dressing  is  applied  and  carried  up  to  the  groin.  The  dress- 
ing may  be  removed  in  two  weeks,  and  the  patient  may  subsequently  be 
treated  with  sand-bags,  as  for  an  ordinary  fracture  of  the  thigh,  but  with- 
out extension.     This  operation  is  scarcely  ever  fatal. 

Ogston's  Operation  (Fig.  369). — In  this  operation  the  internal  condyle  is 
sawed  off  obliquely  with  an  Adams  saw — a  proceeding  which  permits  the 
straightening  of  the  knee.  The  objection  to  the  procedure  is  that  it  opens 
the  knee-joint,  and  that  this  cavity  fills  up  more  or  less  with  a  mixture  of 
blood  and  bone-dust.     Macewen's  operation  is  decidedly  the  safer. 

Osteotomy  for  a  Bent  Tibia. — In  this  operation  the  instruments  required 
are  the  same  as  those  used  in  the  above  operation.  The  tibia  is  divided 
transversely  or  obliquely  (linear  osteotomy),  or  a  wedge-shaped  piece  is 
removed  (cuneiform  osteotomy).  The  oblique  incision  is  the  best.  If  the 
convexity  of  the  tibial  curve  is  inward,  cut  the  bone  from  above  downward 
and  from  in  front  backward;  if  the  curve  is  forward,  section  the  bone  from 
above  downward  and  from  within  outward.  The  fibula  need  rarely  be  inter- 
fered with.  After  the  osteotomy  the  limb  is  treated  just  as  it  would  be  for 
a  fracture. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — This  operation  is 
performed  in  order  to  allow  straightening  of  a  limb  that  has  undergone  bony 
ankylosis  in  a  faulty  or  an  inconvenient  position.  In  some  cases  an  attempt 
is  made  to  obtain  a  movable  joint,  but  in  most  cases  the  surgeon  must  be 
satisfied  with  an  ankylosis  in  extension.  Osteotomy  may  be  performed 
through  the  neck  of  the  femur  or  through  the  shaft  of  the  femur  below  the 
trochanters. 

Osteotomy  through  the  neck  of  the  femur  is  performed  (i)  with  a 
saw  (Adams's  operation)  or  (2)  with  an  osteotome. 

I.  Adamses  Opcraiion  (Fig.  371). — In  this  operation  the  instruments  re- 
quired are  a  scalpel,  hemostatic  forceps,  a  long,  blunt-pointed  tenotome, 
and  an  Adams  saw. 

Operation. — The  patient  lies  upon  his  sound  hip;  the  surgeon  stands  upon 
the  side  to  be  operated  upon,  and  back  of  the  patient.  The  knife  is  entered 
a  finger's  breadth  above  the  great  trochanter,  is  pushed  in  until  it  strikes 


Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint  701 

the  neck  of  the  bone,  is  then  carried  across  the  front  of  and  at  a  right  angle 
with  the  neck,  and  is  withdrawn,  enlarging  the  wound,  in  the  soft  parts 
as  it  emerges,  to  the  extent  of  an  inch.  The  saw  is  then  introduced  and 
the  neck  of  the  femur  is  entirely  divided.  After  the  osteotomy  dress  the 
wound  antiseptically  and  place  the  extremity  straight.  To  straighten  the 
limb  it  may  be  found  necessary  to  cut  contracted  tendons  and  fascial  bands. 
After  securing  extension  and  applying  dressings  use  the  weight-extension 
apparatus  and  the  sand-bags.  Begin  passive  movements  from  the  start  if 
a  movable  joint  is  desired;  few  patients  can  tolerate  the  pain  necessary  to 
bring  this  about.  If  it  is  determined  to  aim  for  a  stiff  joint,  treat  the  case 
as  an  intracapsular  fracture  would  be  treated. 

2.  With  an  Osteotome. — The  instruments  required  in  this  operation  are 
the  same  as  those  used  for  genu  valgum.  A  sand-bag  is  not  needed.  The 
position  of  the  patient  is  the  same  as  that  in  Adams's  operation.  An  incision 
one  inch  long  is  made,  starting  just  above  the  great  trochanter,  ascending 
in  the  axis  of  the  femoral  neck,  and  reaching  to  the  bone.  An  osteotome 
is  introduced,  is  turned  to  a  right  angle  with  the  neck 
of  the  bone,  and  is  struck  with  a  mallet  until  the  bone  ^  f\^ 

is  completely  divided.     (It  is  not  to  be  divided  partially  ^/XX,    \J 

and  then  broken.)     The  after-treatment  is  the  same  as  [  /"^^ 

that  for  Adams's  operation.     The  operation  with   the  1  \ 

osteotome  is  to  be  preferred  to  that  by  the  saw.  \  / 

Osteotomy  of  the  Shaft  of  the  Femur  below  the 
Trochanters  (Gant's  Operation). — In  this  operation 
(Fig.  371)  the  saw  may  be  used,  but  the  osteotome  is  to 
be  preferred.  The  instruments  employed  are  the  same 
as  those  used  for  Adams's  operation,  plus  an  osteotome. 

Operation. — The  position  in  Gant's  is  hke  that  in  Fig.  37i.-Osteot- 

Adams's  operation.  A  longitudinal  incision  one  inch  ^l"^  Ihe°"^femur:"''A^ 
long  is  made  upon  the  outer  aspect  of  the  femur  and  Adams's  operation;  b, 
on  a  level  with  the  lesser  trochanter.  The  osteotome  is  Gant's  operation. 
inserted  and  the  bone  is  completely  divided  below  the 
lesser  trochanter.  The  after-treatment  is  the  same  as  that  for  Adams's  oper- 
ation. Gant's  operation  is  the  best  method  for  correcting  faulty  position  in 
bony  ankylosis,  and  Adams's  operation  can  only  be  employed  in  those  cases 
where  the  femur  still  has  a  neck  which  is  practically  unchanged. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — This  operation 
is  performed  for  bony  ankylosis  of  a  knee  in  a  position  of  flexion.  The 
instruments  employed  are  the  same  as  those  used  for  genu  valgum. 

Operation. — The  patient  lies  upon  his  back  with  his  thighs  flat  upon  the 
bed,  the  legs  hanging  over  the  end  of  the  bed.  The  surgeon  stands  on  the 
patient's  right  side.  Just  above  the  patellar  articular  surface  upon  the  femur 
a  transverse  incision  is  made,  one  inch  in  length  and  reaching  to  the  bone. 
The  osteotome  is  introduced  and  the  bone  is  cut  nearly  through.  The  leg 
is  then  forcibly  extended.  It  must  not  be  extended  too  violently,  or  the 
popliteal  vessels  may  be  injured.  In  cases  where  the  structures  of  the  pop- 
liteal space  are  tense,  the  leg  must  not  be  brought  at  once  into  extension, 
but  this  position  should  be  attained  gradually  by  means  of  weights.     The 


702  Diseases  and   Injuries  of  Bones  and  Joints 

wound   is   dressed   aseptically,  and    the   extremity  is  placed  upon  a  double 
inclined  plane  and  is  treated  as  for  fracture  near  the  knee-joint. 

Osteotomy  for  vicious  union  of  a  fracture  is  performed  in  case  of 
angular  deformity,  and  is  carried  out  in  the  same  manner  as  are  the  above 
procedures.  It  is  best,  when  possible,  to  enter  the  osteotome  upon  the  con- 
cavity of  the  bent  bone,  so  that  the  periosteum  will  not  rupture  when  extension 
is  made,  and  the  patient  will  in  consequence  gain  a  longer  limb. 

Osteotomy  for  Hallux  Valgus, — In  this  operation  a  linear  osteotomy  is 
made  through  the  neck  of  the  metatarsal  bone  of  the  great  toe,  the  toe  is 
forcibly  adducted,  and  a  splint  is  applied  to  the  inside  of  the  foot  and  the 
toe. 

Osteotomy  for  Talipes  Equinovarus. — The  instruments  required  in 
this  operation  are  a  scalpel,  hemostatic  forceps,  a  narrow,  blunt-pointed 
saw,  special  directors,  bone-cutting  forceps,  sequestrum  forceps,  and  scissors. 
Operation  (after  Barker). — The  patient  lies  upon  his  back,  the  thigh  is 
semiflexed,  the  knee  is  bent,  and  the  sole  of  the  foot  rests  upon  the  table. 
The  surgeon  stands  to  the  right  side  if  it  is  the  right  limb  which  is  to  be 
operated  upon,  or  to  the  left  side  if  it  is  the  left  limb.  The  surgeon  feels 
for  the  outer  surface  of  the  cuboid  bone,  and  cuts  away  from  over  the  latter 
a  piece  of  skin  corresponding  in  size  with  the  bone-wedge  intended  to  be 

removed  (this  piece  of  skin  must  include  the 
bursa  which  forms  in  these  cases).  The  foot 
is  then  turned  outward,  the  astragaloscaphoid 
articulation  is  located,  and  over  this  an  incision 
is  made  "from  the  lower  to  the  upper  dorsal 
Fig.  372— Davy's  director  (Pye).  border  of  the  scaphoid  bone"  (Barker),  reach- 
ing through  the  skin  only;  the  foot  is  placed 
again  in  the  first  position,  all  the  soft  parts  are  raised  from  off  the 
superior  surface  of  the  tarsus,  and  a  triangular  surface  corresponding 
with  the  base  of  the  wedge  to  be  removed  is  cleared;  a  "kite-shaped" 
director  (Fig.  372)  is  passed  into  the  external  wound  and  projected 
from  the  internal  wound;  the  saw  is  pushed  through  the  groove  of  the 
director  nearest  the  toes,  and  is  made  to  cut  through  the  tarsus,  from  the 
dorsum  to  the  sole,  at  right  angles  to  the  metatarsal  bones;  the  saw  is 
pushed  through  the  groove  of  the  director  nearest  the  ankle,  and  is  made  to 
cut  from  the  dorsum  to  the  sole,  at  right  angles  to  the  long  axis  of  the  cal- 
caneum;  the  wedge-shaped  piece  of  bone  is  grasped  with  sequestrum  forceps 
and  cut  out  with  scissors,  with  bone  forceps,  or  with  a  blunt  bistoury.  The 
wound  is  well  irrigated,  the  foot  is  straightened,  the  internal  wound  is  sewed 
up,  the  external  wound  is  sutured  except  at  its  lowest  portion,  where  a 
drainage-tube  is  to  be  retained  for  twenty-four  hours,  and  the  wound  is 
dressed  antiseptically.  The  foot  is  put  up  in  plaster  or  upon  a  Davy  splint. 
Osteotomy  for  Talipes  Equinus. —  This  operation  is  described  by  Mr. 
Davy,  who  devised  it,  as  follows:*  "Taking  the  line  of  the  transverse  tarsal 
joint  as  a  guide,  on  the  outer  and  inner  sides  of  the  foot,  and  immediately 
over  the  joint,  two  wedge-shaped  pieces  of  skin  are  removed,  equal  in  extent 
to  the  amount  of  bone  demanded.  The  soft  structures  are  freed  on  the 
dorsum  of  the  foot  in  the  way  previously  described;  but,  as  the  base  of  the 

*  Barker's  "Manual  of  Surgical  Operations." 


Operative  Treatment  of  Recent  Fractures  703 

osseous  wedge  for  equinus  cases  is  at  the  dorsum  and  its  apex  at  the  sole, 
the  parallel  wire  director,  instead  of  the  kite-shaped  varus  one,  is  used.  The 
saw  is  successively  inserted  in  its  grooves,  and  by  keeping  in  mind  the  idea 
of  a  keystone  a  clean  wedge  of  bone  is  cut  out  from  the  dorsum  to  the  sole 
of  the  foot."  The  wedge  is  extracted,  and  the  foot  is  straightened  and  is 
put  uj)  in  plaster  of  Paris  or  is  placed  on  a  Davy  sj)lint. 

Operative  Treatment  of  Recent  Fractures.— We  have  learned  from 
skiagraphs  that  the  common  treatment  by  splints  usually  results  in  more  or  less 
permanent  displacement.  In  many  cases  this  does  not  interfere  with  function; 
in  some  cases  it  does.  There  is  much  impairment  of  function  after  a  fracture 
of  the  patella  with  wide  separation  of  the  fragments,  and  after  a  fracture  of  a 
long  bone  with  marked  angulation  or  with  decided  overlapping  of  the  frag- 
ments. The  most  perfect  results  are  obtained  by  operation,  exposure  of  the 
fragments,  correction  of  deformity,  while  we  see  the  fragments  and  fixation. 
Practically  all  surgeons  agree  that  for  fracture  of  the  patella  and  for  fracture  of 
the  olecranon  treatment  by  operation  gives  the  best  results.  All  compound 
fractures  require  operation.  In  a  fracture  of  a  long  bone  with  incomplete 
reduction  or  with  a  deformity  which  recurs  in  spite  of  splinting,  operation  should 
be  performed.  In  most  fractures  of  long  bones  perfect  apposition  of  the 
fragments  is  not  obtained,  although  we  may  think  it  has  been.  The  x-rays 
illustrate  the  error  and  we  often  find  it  on  incision.  Bloodgood  points  out 
that  in  fractures  near  joints  there  is  great  difficulty  in  reduction  and  little 
evidence  of  deformity.  Oblique  fractures  of  the  upper  third  of  the  femur 
should  be  operated  upon  because  of  the  difficulty  or  impossibility  of  reduction 
by  any  other  method. 

In  some  cases  of  fracture  of  the  bones  of  the  forearm  operation  is  indicated 
to  preserve  pronation  and  supination.  If  the  ends  of  the  fragments  do  not 
grate  when  they  are  apparently  in  contact  and  are  rubbed  to  and  fro,  it  means 
that  some  of  the  soft  parts  are  caught  between  them  and  operation  is  necessary 
in  order  to  remove  the  intervening  tissue.  If  this  is  not  done  there  will  be 
non-union  or  delayed  union.  Many  comminuted  fractures  should  be  treated 
directly  after  incision  of  the  soft  parts.  If  an  important  nerve  or  blood-vessel 
has  been  divided,  operation  is  required  for  that  reason.  During  the  operation 
the  seat  of  fracture  should  be  exposed  and  the  fragments  fixed.  In  a  fracture 
of  the  neck  of  the  femur  in  a  youth  or  a  person  of  middle  age  the  fragments 
should  be  nailed  together,  otherwise  there  will  probably  be  much  lameness. 
Many  fractures  of  the  clavicle  should  be  exposed  by  incision  and  wired. 
This  should  always  be  done  when  sharp  ends  endanger  or  have  wounded 
vessels. 

Some  cases  of  fracture  of  the  humerus  near  the  elbow  and  some  cases  of 
fracture  of  the  surgical  neck  of  that  bone  require  operation.  Most  cases  of 
fracture  with  dislocation  require  it. 

In  any  case  of  fracture,  if  it  seems  that  non-operative  treatment  will  fail 
to  give  a  good  functional  result,  operation  should  be  advised  if  it  is  not  contra- 
indicated  by  the  condition  of  the  patient. 

There  is,  of  course,  some  risk  in  treatment  by  incision  and  it  is  only  justi- 
fiable in  competent  hands  and  amid  proper  surroundings.  It  can  never 
be  routine  treatment  and  will  never  be  extensively  employed  outside  of  a  hospi- 
tal.    The  occasional  operator  should  look  to  it  with  less  confidence  than  does 


704 


Diseases  and  Injuries  of  Bones  and  Joints 


the  daily  operator.     If  infection  should  occur  it  will  be  a  catastrophe  and  may 
cause  death,  hence,  perfect  asepsis  is  imperatively  required. 

Bone  fragments  may  be  held  together  by  wiie,  nails,  screws,  plates,  bone 
ferrules,  chromic  catgut,  clamps,  etc.,  according  to  the  needs  of  the  case. 
As  a  general  thing  silver  wire  is  used,  but  it  has  defects.  It  fails  to  retain  frag- 
ments in  rigid  apposition  and  unless  very  thick  wire  is  used  it  is  liable  to  break. 
Silver  wire  was  used  for  this  purpose  in  1 775  by  Lapeyode  and  Sicre  of  Toulouse 
(Geo.  W.  Guthrie,  "Amer.  Medicine,"  March  7,  1903).  In  most  cases  I 
prefer  the  silver  plate  perforated  for  short  silver  screws  as  employed  by  Prof. 
Halsted.  This  gives  rigid  fixation  and  the  screws  do  not  project  from  the 
wound.     The  plate  is  not  removed  unless  it  causes  trouble. 

After  operation  there  must  be  careful  fixation  by  splints  or  plaster  of  Paris, 
the  circulation  must  be  guarded  and  maintained,  massage  should  be  used,  and 
passive  movements  instituted  as  in  a  case  treated  without  incision. 

If  rigid  fixation  of  the  fragments  was  secured,  repair  takes  place  with  very 
little  callous  formation. 

Recent  Transverse  Fracture  of  the  Patella, — (See  page  612.) 
Bone=grafting,  or  Transplantation.— (See  page  508.) 
Operative  Treatment  of  Ununited  Fracture.— The  instruments 
required  in  this  operation  are  a  scalpel,  hemostatic  forceps,  dissecting  forceps, 


Fig.  374.— Brainard's  diills  with  Wyeth's  adjustable  handles. 


retractors,  Allis's  dissector,  an  awl  or  special  drill  (Figs.  373,  374),   chisels, 
a  mallet,  a  fine  saw,  hon-jaw  forceps,  and  silver  wire. 

In  operating,  incise  longitudinally  down  to  the  seat  of  fracture,  retract 
the  periosteum  from  the  bone,  drill  the  bones  before  cutting  them,  chisel 
away  the  material  of  imperfect  union,  saw  through  each  bone  end  far  enough 
from  the  seat  of  fracture  to  reach  sound  tissue,  pass  large  silver  wires  through 
the  holes  (this  wire  should  be  one-tenth  inch  in  diameter  for  the  femur,  one- 
sixteenth  inch  for  the  patella,  etc.)  (Fig.  377),  twist  the  wires  a  fixed  number 
of  times  (two  complete  turns)  in  the  direction  that  the  hands  of  a  watch 
move  (this  is  Keen's  direction.  In  case  removal  of  the  wires  should  be 
demanded  later  we  know  how  to  untwist  them),  sever  the  ends  of  the 
wires,  and  hammer  their  stems  against  the  bones.  The  wires  may  never 
require  removal.  Dress  the  part  as  a  recent  fracture.  Various  plans 
besides  wiring  have  been   employed   in   ununited   fracture.     Gussenbauer's 


Ununited  Fractures  of  the  Femoral  Neck 


705 


clamp  is  used  by  some.  Clayton  Parkhill's  bone-clamp  is  a  very  useful 
appliance,  and  holds  the  fragments  firmly  in  contact  (Fig.  255).  Menard 
and  Lannelongue  inject  a  i  :  10  solution  of  chlorid  of  zinc  between  the  frag- 
ments and  around  their  ends,  and  then  immobilize  the  parts.  Some  sur- 
geons unite  the  fragments  with  kangaroo-tendon  instead  of  wire  (suturing  of 
bone) ;  others  use  nails  of  bone  or  ivory;  others  use  screws.  Senn  asserts  that 
the  above  methods  will  not  hold  fragments  in  contact  if  these  fragments  have 
a  tendency  to  become  displaced.  Senn  fastens  the  bones  together  by  hollow 
cylinders  of  decalcified  bone  or  ivory,  the  cylinders  being  perforated  in  many 
places  (bone  ferrules).  The  soft  parts  are  sutured,  no  drain  is  used,  and  the 
limb  is  encased  in  plaster  of  Paris. 

Ununited  Fractures  of  the  Femoral  Neck. — Loreta  did  the  first  suc- 
cessful operation  for  this  condition  about  seventeen  or  eighteen  years  ago. 
The  operation  is  not  adapted  to  the  aged,  but  should  certainly  be  employed  in 
youths  and  middle-aged  individuals  if  the  general  condition  of  the  patient  or 


Fig.  375- 


-Method   of  securing  screw  of  Freeman's  apparatus   in  fracture  of  neck  of  femur;  the 
wooden  plates  embracing  screws  (Freeman,  in  "Annals  of  Surgery,"  Oct.,  1904). 


some  particular  diseased  state  does  not  forbid,  and  if  pain  is  severe  and  disability 
is  pronounced. 

Leonard  Freeman  advises  an  anterior  incision  beginning  below  and  ex- 
ternal to  the  anterior  superior  iliac  spine  and  extending  downward,  external  to 
the  sartorius,  for  3  or  4  inches  ("Annals  of  Surg.,"  Oct.,  1904).  When  the 
fragments  are  exposed,  the  connective  tissue  between  them  is  cut  away  by 
means  of  scissors,  the  surfaces  of  the  fragments  are  freshened  with  a  chisel  or 
a  curet,  oozing  is  arrested  by  pressure  and  hot  water,  and  loose  osseous  splinters 
are  removed  (Freeman).  Some  surgeons  have  fixed  the  fragments  together 
by  nails,  screws,  or  pegs  of  bone  or  ivory,  access  to  the  trochanter  being  best  ob- 
tained for  this  purpose  by  making  a  second  incision  over  the  outer  portion 
of  that  bony  process.  As  Freeman  points  out,  however,  the  head  is  often  so 
very  soft  that  none  of  these  apphances  will  obtain  fixation. 

Freeman  has  devised  a  clamp  for  this  purpose  (Figs.  375,  376).  An  addi- 
tional incision  is  made  over  the  trochanter  and  holes  are  bored  for  the  clamp 
45 


■o6 


Diseases  and  Injuries  of  Bones  and  Joints 


screws,  one  hole  being  drilled  "through  the  base  of  the  trochanter,  the  exter- 
nal fragment  of  the  neck,  and  into  the  head  of  the  bone"'  ("Annals  of  Sur- 
gery," Oct.,  1904).  The  wound  is  closed,  dressings  are  applied,  and  extension 
is  made  on  a  long  side  splint,  a  pad  being  placed  beneath  the  trochanter  to 
prevent  the  disposition  to  pass  backward,  which  movement,  if  it  occurs,  v^ill 
cause  external  rotation  of  the  limb  and  separation  of  the  fragments.  In  about 
eight  weeks  the  extension  is  removed  and  the  patient  is  allowed  about  on 
crutches.  Dr.  H.  Augustus  Wilson  has  succeeded  by  nailing  the  fragments 
together.  He  gets  such  a  patient  up  on  crutches  in  two  weeks  ("Amer.  Jour. 
Orthopedic  Surger}^"  Jan.,  1908). 

In  Freeman's  case  the  screws  were  removed  in  two  weeks  because  of  infec- 
tion of  the  cancellous  tissue.  A  similar  condition  arose  in  Da\ns's  case  in 
which  two  steel  drills  were  used. 

According  to  Freeman,  14  operations  for  ununited  fracture  of  the  femoral 
neck  are  on  record  ("Annals  of  Surgen,-,"  Oct.,  1904).  Four  of  these  cases 
were  done  by  G.  G.  Daxis.  Cobb  finds  six  additional  cases  and  reports  one 
of  his  own  (Farrar  Cobb,  in  "Boston  Med.  and  Surg.  Jour.,"  May  10.  1906). 
Dr.  H.  Augustus  Wilson  has  collected  36  cases  of  direct  fixation  of  old  intra- 
capsular fractures  ("Amer.  Jour.  Orthopaedic  Surg.,"  Jan.,  1908). 

Ununited  Fracture  of  Patella. — An  incision  is  made  in  the  long  axis  of 


Fig.  376. — Completed  screw  and  clamp  of  Freeman's  apparatus    for  fixation  of  fracture  of  neck 
of  femur  (Freeman,  in  "Annals  of  Surgery,"  Oct.,  1904). 

the  limb,  over  the  middle  of  the  space  between  the  fragments,  from  well  above 
the  upper  fragments  to  well  below  the  lower  piece;  this  incision  divides  all  the 
soft  parts.  The  soft  parts  are  retracted,  but  the  periosteum  is  undisturbed; 
each  fragment  is  bored  (Fig.  378,  i)  in  one  or  two  places;  the  surfaces  of  the 
fragments  are  cut  square  through  sound  bone  with  a  saw;  all  old  reparative 
material  is  cut  away;  the  wires  are  passed  through  the  perforations,  twisted, 
cut  oflF,  and  hammered  down  (Fig.  378,  2).  If  the  bone  fragments  cannot  be 
approximated,  it  may  become  necessan,^  to  incise  the  muscle  around  and  above 
the  patella  or  partially  to  separate  the  tuberosity  of  the  tibia  and  bend  this  proc- 
ess upward.  A  small  drain  is  inserted  above  the  bone,  the  wound  is  sutured, 
aseptic  dressings  are  applied,  and  the  limb  is  put  upon  a  Macewen  splint. 


Aspiration  of  Joints 


70? 


Fig.  377. — Wiring  of  bones  for  ununited 
fracture  :  a  a.  Sawn  surfaces  approximated  after 
removal  of  old  material  which  was  interposed 
between  the  fragments ;  b  b^  b  b,  perforations 
drilled  completely  across  the  bone ;  c,  c,  wires 
ready  for  twisting. 


Treves's  Operation  for  Caries  of  the  Lumbar  and  Last  Dorsal 
Vertebrae. — The  instruments  required  are  a  scalpel,  hemostatic  forceps, 
grooved  director,  an  Allis  dissector,  sequestrum  forceps,  curet  sj)Oons,  and  a 
sand-bag.     We  will  describe  the  operation  as  performed  on  the  right  loin. 

Operation. — The  patient  lies  upon  his  left  side,  with  the  knfees  drawn  up 
and  a  sand-bag  under  the  left  loin.  The  surgeon  stands  behind  the  patient 
(Barker).  An  incision  is  made  at  the  outer  border  of  the  erector  spinas  mass, 
reaching  from  the  last  rib  to  the  iliac  crest  and  going  down  at  once  to  the  lum- 
bar fascia.  The  lumbar  aponeurosis  is  opened,  the  erector  spinas  muscle  is  re- 
tracted inward,  and  the  anterior  portion 
of  the  erector  spinse  sheath  is  incised. 
The  quadratus  lumborum  muscle  is  next 
cut,  and  then  the  anterior  leaflet  of  the 
lumbar  aponeurosis  is  slit.  The  ab- 
scess is  thus  reached  and  opened  and 
tuberculous  pus  flows  out.  The  cav- 
ity is  carefully  irrigated.  The  abscess 
cavity  is  irrigated  wnth  quantities  of 
warm  corrosive  sublimate  solution 
(i :  5000).  The  cavity  is  filled,  the  fluid 
is  allowed  to  flow  out,  its  exit  being 
aided  by  pressure  in  front  and  changes 
of  posture;  the  cavity  is  filled  again, 
and  so  on,  and,  after  all  loose  debris 
is  removed,  the  bodies  of  the  vertebrje  are  carefully  examined  with 
the  finger  and  diverticula  are  opened.  Loose  pieces  of  bone  are, 
removed  with  spoons  or  forceps,  and  cavities  are  thoroughly  but  lightly  cureted, 
as  in  some  places  the  wall  is  very  thin.     By  means  of  properly  shaped  spoons 

carious  bone  can  be  removed  even  from  the 
anterior  surface  of  the  column  (Treves). 
Thus  the  wall  of  the  abscess  is  completely 
removed.  Finally  all  debris  is  washed  out 
by  irrigation  with  mercurial  solution;  any 
mercurial  solution  which  might  remain  is 
washed  out  with  warm  water  or  salt  solution, 
and  the  interior  of  the  cavity  is  wiped  dry. 
At  this  stage  most  operators  introduce  iodoform 
emulsion.  Whether  or  not  this  is  done,  "  the 
wound  is  closed  by  a  series  of  silkworm-gut 
sutures,  passed  sufficiently  deep  to  include  the 
greater  part  of  the  muscular  and  tendinous 
structures  with  the  skin"  (Treves's  "Opera- 
tive Surgery"). 

Aspiration  of  Joints.— In  certain  cases 
of  joint-effusion  from  inflammation,  tubercu- 
lous or  otherwise,  and  sometimes  in  hemor- 
rhage  into  a  joint,    it    is    desirable    to   re- 
move   the    fluid   by   aspiration.      The   pneumatic  aspirator    is    used    (Fig. 
379)-       The     trocar  and  cannula    are     thoroughly    asepticized    and    the 
joint  is  prepared  as  for  a  set  operation.     The  needle  is  entered  at  a  surface 


Fig.  378.— Wiring  of  the  patella: 
I,  Fragments  cut  and  cleaned  and 
the  wires  passed;  2,  wires  twisted 
and  hammered  down  upon  the  bone 
(after  Barker). 


7o8 


Diseases  and  Injuries  of  Bones  and  Joints 


free  from  vessels.  The  directions  for  using  an  aspirator  are  as  follows: 
insert  the  stopper  firmly  into  a  strong  bottle  (preferably  a  clear  glass  one), 
then  attach  the  short  elastic  hose  to  the  stopcock  B  of  the  tube  projecting 
from  the  stopper,  and  attach  the  other  end  of  the  same  elastic  hose  to  the 
exhausting  or  inward-flowing  chamber  of  the  pump.  Next  attach  one  end 
of  the  longer  elastic  hose  to  the  stopcock  A  projecting  from  the  stopper 
and  the  other  end  to  the  needle.  Care  should  be  taken  that  all  the  fittings 
or  attachments  are  placed  firmly  into  their  respective  places.  Now  close  the 
stopcock  A  and  open  the  stopcock  B.  By  giving  from  thirty-five  to  fifty  strokes 
of  the  pump  a  sufficient  vacuum  can  be  produced  to  fill  with  the  fluid  from 
the  joint  a  bottle  holding  from  a  pint  to  a  quart.  After  having  formed  the 
vacuum,  close  the  stopcock  B,  and  insert  the  needle  in  the  joint.  When 
the  stopcock  A  is  opened,  suction  through  the  needle  draws  the  fluid  from 
the  joint.  The  trocar  may  also  be  used  to  inject  antiseptic  agents.  After 
the  completion  of  aspiration  the  part  is  dressed  antiseptically  and  the  ex- 
tremity is  put  at  rest  upon  a  splint. 

Excisions  of  Bones  and  Joints. — The  ancients  practised  excision 
and  resection  for  compound  dislocations  and  fractures.  The  operation  was 
first  formally  advised  as  a  substitute  for  amputation  in  joint  disease  by  Mr. 


Fig.  379.— Aspirator  and  injector. 

Park  in  1782.  The  terms  excision  and  resection  are  usually  employed  as 
synonymous,  but  such  a  use  is  not  strictly  accurate.  According  to  Professor 
Ashhurst,  the  term  excision  means  "  the  removal  of  an  offending  part  without 
that  total  ablation  of  the  affected  portion  of  the  body  which  is  implied  by  the 
term  amputation.  Hence  we  speak  of  excisions  of  tumors,  of  joints,  of  the  eye- 
ball, etc."  Resection  has  a  more  restricted  meaning;  it  signifies  "an  opera- 
tion which  takes  away  a  middle  portion  and  brings  the  ends  together  again, 
and  is  thus  in  strict  surgical  language  limited  to  partial  excisions  of  the 
long  bones"  (International  Encyclop.  of  Surgery,  edited  by  John  Ashhurst, 
Jr.).  Excision  of  a  joint  is  the  removal  of  the  articular  portions  of  the 
bones  of  the  joint,  and  also  the  cartilage  and  synovial  membrane.  In 
the  hip-joint  and  shoulder-joint  only  the  head  of  the  long  bone  may  be  re- 
moved, and  not  the  articular  surfaces  of  both  bones.  In  partial  excision  of  a 
long  bone  excision  (resection)  for  bone  disease  enough  bone  is  known  to  have 


Erasion,  or  Arthrectomy  709 

been  removed  only  when  the  remaining  bone  bleeds.  Complete  excision  of 
a  bone  is  the  removal  of  an  entire  bone.  Partial  excision  or  resection  is  the 
removal  of  a  portion  only  of  a  bone.  Excision  is  a  conservative  operation 
which  often  averts  amputation. 

Excision  may  be  performed  by  the  open  method,  in  which  tlie  periosteum 
is  not  preserved,  or  it  may  be  performed  by  the  subperiosteal  method,  in 
which  the  periosteum  is  carefully  separated  by  a  rugine  and  the  capsular 
ligament  is  preserved.  Arthrectomy,  or  erasion,  is  the  excision  of  the  dis- 
eased synovial  membrane  and  ligament,  and  also  small  foci  of  disease  of  bone 
and  cartilage. 

Excision  may  be  employed  for  compound  dislocation,  and  in  compound 
dislocations  of  the  elbow  and  the  shoulder  it  is  usually  performed.  Ex- 
cisions for  compound  dislocations  in  other  large  joints  are  very  dangerous; 
they  are  rarely  attempted  in  battle-field  practice,  and  are  to  be  avoided  even 
in  civil  practice  unless  the  patient  is  young  and  vigorous  and  every  advantage 
can  be  given  him  during  the  operation  and  convalescence.  Excision  for 
deformity  is  rarely  performed  except  upon  the  hip,  the  knee,  and  the  shoulder, 
and  these  excisions  must  not  be  employed  if  the  patient's  condition  leads 
one  to  fear  the  result  of  a  protracted  convalescence.  Excision  of  the  elbow, 
however,  is  usually  a  safe  operation.  In  excising  for  deformity  always  con- 
sider the  patient's  trade  and  the  demands  of  habitual  position  which  it  makes 
upon  him.* 

Excision  is  largely  employed  for  joint-disease,  especially  for  tuberculous 
joints.  Bell  states  that  attempts  to  preserve  the  limb  without  excision  are 
more  justifiable  in  the  lower  than  in  the  upper  limbs,  because  operation 
in  the  lower  extremity  is  more  dangerous  than  in  the  upper,  and  because 
a  cure  without  operation  in  the  lower  limbs,  if  this  cure  can  be  brought  about, 
gives  as  good  a  result  as  a  cure  by  excision.  In  the  upper  extremities  the 
danger  from  operation  is  less  than  is  the  danger  from  waiting.  In  a  young 
subject  an  excision  may  remove  the  epiphysis,  and  thus  lead  to  permanent 
shortening,  which  is  productive  of  less  inconvenience  and  deformity  in  the 
arm  than  in  the  leg.  The  great  danger  of  excision  operations  is  that  the 
section  may  be  made  through  cancellous  bony  tissue;  hence  disastrous  sup- 
puration, phlebitis,  myelitis,  septicemia,  or  pyemia  may  follow;  further,  in 
excision  the  cut  is  often  made  through  diseased  tissue,  and  a  protracted  con- 
valescence is  often  inevitable.  Amputation  is  effected  through  healthy  tissue, 
and  the  convalescence  is  short.  Excision,  however,  when  successful,  gives 
the  patient  a  very  useful  limb. 

Erasion,  or  Arthrectomy. — Erasion  is  the  complete  removal  of  diseased 
synovial  membrane,  Hgaments,  etc.  This  operation  seeks  to  remove  a  depot 
of  infection  in  an  early  stage  of  tuberculous  synovitis,  and  it  possesses  the 
conspicuous  merit  of  not  interfering  with  the  epiphysis.  The  term  erasion 
is  also  used  to  designate  the  operation  of  removing  healthy  synovial  mem- 
brane, ligaments,  etc.,  for  the  purpose  of  producing  fixation  of  a  flail  joint 
due  to  infantile  paralysis.  Erasion  is  oftenest  practised  upon  the  knee- 
joint.  The  instruments  required  are  a  scalpel,  hemostatic  forceps,  dis- 
secting forceps,  toothed  forceps,  volsellum,  scissors,  bone-gouges,  curets,  and 
an  Esmarch  apparatus. 

Erasion  of  the  Knee-joint. — The  patient    lies  upon  his  back;  the  leg  is 

*  Joseph  Bell,  in  his  "  Manual  of  Surgical  Operations." 


7IO 


Diseases  and  Injuries  of-  Bones  and  Joints 


flexed  with  the  sole  of  the  foot  planted  upon  the  table,  and  an  Esmarch  ban- 
dage'is  applied  at  a  point  well  up  on  the  thigh.  The  surgeon  stands  to  the 
right  of  the  patient.  The  incision  is  begun  in  the  mid-line  of  the  thigh  (on 
the  side  opposite  to  that  occupied  by  the  surgeon),  about  three  inches  above 
the  patella;  it  is  carried  down  across  the  ligament  of  the  patella  and  up  to 
a  correspondilig  point  on  the  opposite  side  of  the  thigh.  This  incision 
goes  down  to  the  bone;  .the  flap  is  turned  up  and  the  joint  exposed;  the 
knee-joint  is  strongly  flexed,  and  the  synovial  membrane  and  diseased  liga- 
ments are  dissected  away  with  scissors  and  forceps,  great  care  being  taken 
that  the  posterior  ligaments  (which,  fortunately,  are  rarely  implicated  early 


Fig.  380.  Fig.  381. 

Fig.  380. — i-io,  Amputations  (Joseph  Bell):  i,  of  lower  third  of  forearm  (Teale's)  ;  2,  at  shoulder- 
joint  by  large  postero-external  flap  (second  method)  ;  3,  at  shoulder-joint  by  triangular  flap  from  del- 
toid (third  method) ;  4,  5,  through  tarsus  (Chopart's)  ;  6,  7,  at  knee-joint ;  8,  by  single  flap  (Garden's) ; 
9,  10,  of  thigh  (Teale's).     a,  excision  of  hip  ;  b,  of  ankle-joint  (Hancock's  incision). 

Fig.  381.— 1-18,  Amputations  (Joseph  Bell)  :  i,  amputation  at  wrist-joint  (dorsal  incision) ;  2,  at 
wrist-joint  (palmar  incision)  ;  3,  at  forearm  (dorsal  incision)  ;  4,  at  forearm  (palmar  incision)  ;  5,  at 
elbow-joint  (anterior  flap)  ;  6,  at  arm  (Teale's)  ;  7,  at  shoulder-joint  (first  method) ;  8,  9,  of  metatarsus 
(Hay's);  10,  11,  at  ankle  (Syme's)  ;  12,  13,  of  leg,  posterior  flap  (Lee's)  ;  14,  at  knee-joint  (Garden's)  ; 
15,  of  thigh  (B.  Bell's)  ;  16,  of  thigh  (Spence's)  ;  17,  of  thigh  in  middle  third  ;  18,  at  hip-joint,  a,  ex- 
cision of  wrist  (radial  incision)  ;  b,  of  wrist  (ulnar  incision). 


in  the  case)  are  not  divided  and  that  the  contents  of  the  popliteal  space  remain 
intact.  After  removing  the  diseased  ligaments  and  synovial  membrane  the 
cartilage  is  examined  and  any  diseased  portion  is  removed.  The  bone  is 
then  examined  and  any  tuberculous  foci  are  gouged  away.  Any  exposed  ves- 
sels are  ligated.  The  wound  is  irrigated  with  salt  solution,  the  extremity  is 
straightened,  and  the  ends  of  the  ligamentum  patellae  are  sutured,  a  drain- 
age-tube  is  inserted  at  each  angle  of  the  wound,  the  skin  is  sutured,  and  anti- 
septic or  sterile  dressings  are  applied.  The  limb  is  placed  upon  a  posterior 
splint  for  a  few  days,  then  the  drainage-tubes  are  removed,  the  dressings 
are  changed,  and  a  plaster-of-Paris  cast  is  applied,  trap-doors  being  cut  on 


Excision   of  the  Shoulder-joint 


711 


each  side,  and  the  joint  is  kept  immobile  for  two  or  three  weeks.  This  oper- 
ation is  only  suited  to  early  cases  in  which  the  lesion  involves  chiefly  or  purely 
the  synovial  membrane  and  hgaments,  and  in  these  cases  it  frequently  gives 
a  good  result,  some  ca])acity  for  motion  being  not  unusually  preserved. 

Excision  of  the  Shoulder-joint. — In  the  shoulder-joint  partial  excision 
is  often  performed,  the  head  of  the  humerus  being  removed  and  the  glenoid 
oeing  undisturbed;  but  some  patients  require  complete  excision,  the  entire 
glenoid  depression,  as  well  as  the  head  of  the  humerus,  being  removed  by 
the  surgeon.     Excision  of  the  shoulder-joint  is  made,  if  possible,  an  intra- 


Fig.  382.  Fig.  2,>^i. 

Fig.  382 — 1-9,  Amputations  (Joseph  Bell) :  i,  of  arm  by  double  flaps  ;  2,  at  shoulder-joint ;  3,  at 
ankle-joint  by  internal  flap  (Mackenzie's)  ;  4,  5,  of  leg  just  above  the  ankle-joint  (Syme's)  ;  6,  7,  below 
the  knee  (modified  circular)  ;  8,  through  condyles  of  femur  (Syme's)  ;  9,  at  lower  third  of  thigh 
(Syme's).     a,  excision  of  head  of  humerus;  b,  of  knee-joint  (semilunar  incision). 

Fig.  383. — i-S,  Amputations  (Joseph  Bell)  :  i,  at  elbow-joint  (posterior  flap)  ;  2,  at  shoulder-joint, 
posterior  incision  (first  method)  ;  3,  at  ankle-joint  (Mackenzie's)  ;  4,  through  condyles  of  femur 
(Syme's)  ;  5,  at  lower  third  of  thigh  (Syme's)  ;  6,  at  knee  (posterior  incision)  ;  7,  of  thigh  (Spence's); 
8,  at  hip-joint,  a-c,  Excisions  :  a,  excision  of  shoulder-joint  (deltoid  flap)  ;  B,  of  shoulder-joint  (pos- 
terior incision)  ;  c,  of  elbow-joint  (H-shaped  incision)  ;  D,  of  elbow-joint  (linear  incision)  ;  e,  of  hip- 
joint  (Gross's) ;  f,  of  os  calcis  ;  g,  of  scapula. 


capsular  operation,  the  capsule  being  opened,  but  the  capsular  attachment 
to  the  anatomical  neck  of  the  humerus  not  being  interfered  with.  In  ad- 
vanced cases,  however,  the  capsular  attachment  must  be  destroyed.  Ex- 
cision of  the  shoulder- joint  is  seldom  performed  in  civil,  but  is  a  common 
operation  in  military  practice;  it  is  performed  for  gunshot-wounds,  com- 
pound dislocations,  tuberculous  disease,  and  tumors  of  the  head  and 
upper  portion  of  the  humerus.  The  instruments  required  are  a  scalpel,  an 
Adams  saw  and  a  metacarpal  saw,  an  osteotome  or  chisel,  a  mallet,  an  AUis 
dissector,  a  periosteum-elevator,  hemostatic  forceps,  dissecting  forceps,  toothed 
forceps,  lion-jawed  forceps,  sequestrum  forceps,  metal  retractors,  curets,  and 
cutting  bone  forceps. 


712  Diseases  and   Injuries   of  Bones  and  Joints 

Operation  by  Anterior  Incision. — The  patient  lies  supine;  a  pillow  is  placed 
beneath  the  shoulders,  and  a  sand  pillow  is  put  beneath  the  shoulder  to  be 
operated  upon.  The  arm  is  held  to  the  side  with  the  outer  condyle  forward 
and  the  bicipital  groove  inward  (Barker's  directions).  The  surgeon  stands 
by  the  affected  side.  An  incision  three  or  four  inches  in  length  is  made  from 
just  external  to  the  coracoid  process  of  the  scapula,  running  straight  down  the 
humerus  (Fig.  382,  a).  This  incision  divides  the  border  of  the  deltoid  muscle 
and  brings  into  sight  the  long  head  of  the  biceps.  The  tendon  of  the  biceps 
is  retracted  inward,  unless  it  is  diseased,  in  which  case  it  is  resected.  The 
knife  is  carried  up  the  groove  and  opens  the  capsule  of  the  joint.  The  peri- 
osteum is  lifted  from  the  neck  of  the  bone  while  an  assistant  rotates  the 
elbow  to  make  the  muscles  tense.  In  some  places,  if  the  periosteum  tears, 
muscular  insertions  must  be  cut  with  a  knife.  The  head  of  the  bone  is 
sawn  off  while  the  bone  is  in  place,  or  the  elbow  is  strongly  pulled  back, 
and  the  head  of  the  bone  is  forced  out  of  the  wound,  and  is  then  sawn  off 
at  the  point  required.  In  ordinary  cases  only  the  articular  head  is  removed;  in 
other  cases  the  section  is  made  just  above  the  surgical  neck;  in  yet  others 
a  portion  of  the  shaft  must  also  be  cut  away.  If  the  glenoid  cavity  is  found 
slightly  diseased,  the  dead  bone  must  be  removed  by  the  chisel  and  mallet  or 
by  the  cutting  forceps.  If  the  cavity  is  seriously  diseased,  the  entire  glenoid 
should  be  removed.  Scrape  away  all  damaged  tissue;  hgate  bleeding  points; 
irrigate  the  wound  with  corrosive  sublimate  solution ;  swab  it  out  with  a  solution 
of  chlorid  of  zinc  (gr.  xx  to  3J) ;  dust  with  iodoform;  close  the  upper  portion 
of  the  wound  and  insert  a  drainage-tube  in  the  lower  angle;  dress  the  wound 
antiseptically;  place  a  small  pad  in  the  axilla;  apply  the  second  roller  of 
Desault;  and  put  the  patient  in  bed  with  a  pillow  under  the  affected  shoul- 
der. In  seven' days  the  hand-sling  is  substituted  for  the  bandage,  and  with 
the  elbow  hanging  free  the  patient  is  permitted  to  get  up  and  is  advised  to 
move  his  arm  frequently.  Drainage  is  maintained  until  the  wound  is  well 
healed  from  the  bottom.  Great  hmitation  of  movement  inevitably  follows 
a  shoulder-joint  resection. 

Excision  by  the  deltoid  flap  is  performed  when  the  head  of  the  bone  is 
much  enlarged  (as  by  a  tumor)  or  when  the  tissues  are  thick  and  indurated. 
The  deltoid  flap  is  in  the  shape  of  a  U  or  is  semilunar  (Fig.  383,  a).  Raising 
this  flap  exposes  the  head  of  the  bone  most  satisfactorily.  Bell  states  that 
when  the  glenoid  cavity  is  chiefly  involved  the  incision  should  be  posterior 
(Fig.  ?,H  B). 

Senn's  Method. — Senn  has  recently  described  *  an  incision  which  does 
not  damage  any  important  vessels,  muscles,  tendons,  or  nerves,  and  which 
is  followed  by  good  functional  results.  A  semilunar  skin-flap  is  formed, 
the  incision  running  from  the  coracoid  process  to  the  posterior  border  of 
the  axillary  space.  The  flap  is  turned  up,  exposing  the  upper  half  of  the 
deltoid  muscle.  The  acromion  is  sawn  off  and  turned  down  with  the  attached 
deltoid.  The  capsule  is  now  freely  exposed;  it  is  opened,  and  either  arthrec- 
tomy  or  excision  is  performed,  according  to  conditions.  In  closing  the 
wound  it  is  not  necessary  to  bore  the  acromion  and  pass  silver  wires  to  join 
the  fragments;  it  is  enough  to  suture  the  periosteum  with  catgut. 

Excision  of  the  Elbow-joint. — This  operation  is  performed  for  wounds, 

*  Phila.  Med.  Jour.,  Jan.   i,  1898. 


Excision  of  the  Wrist-joint 


713 


faulty  ankylosis,  and  chronic  articular  disease.  Excision  must  be  complete. 
Endeavor  to  make  a  sub{)eriosteal  resection;  this  maintains  the  shape  of  the 
articulation  and  gives  the  best  chance  for  a  movable  joint.  The  instruments 
used  are  the  same  as  those  for  the  shoulder,  plus  a  Butcher  saw. 

Operation. — The  patient  is  "supine,  but  inclining  to  the  sound  side,  the 
affected  arm  being  held  almost  vertical,  with  the  forearm  iiexed  and  nearly 
horizontal"  (Barker).  The  incision  is  made  on  the  posterior  surface  of  the 
joint.  A  single  posterior  incision  is  usually  employed  (Fig.  383,  d).  An 
incision  is  made  a  little  internal  to  the  long  axis  of  the  olecranon,  beginning  two 
inches  above  and  terminating  two  inches  below  the  tip  of  the  olecranon.  This 
incision  goes  down  to  the  bone,  and  throughout  the  entire  operation  the  surgeon 
must  guard  and  shield  the  ulnar  nerve.  The  periosteum  and  soft  parts  are 
well  separated;  the  olecranon  is  sawn  off;  forced  t^exion  exposes  the  joint- 
cavity  freely,  and  enables  the  surgeon  to  lift  the  periosteum  and  soft  parts 
from  the  humerus;  the  humerus  is  sawn  through  at  the  beginning  of  its 
condyloid  processes;  the  radius  and  ulna  are  cleared  and  are  sawn  at  a  level 
below  that  of  the  base  of  the  coronoid  process  of  the  ulna.  Diseased  tissues 
are  cut  and  scraped  away;  the  wound  is  irrigated,  sutured,  drained,  and 
dressed.  In  some  cases  an  H -shaped  incision  is  employed  (Fig.  383,  c),  but 
the  cicatrix  of  a  transverse  cut  will  limit  flexion  of  the  limb. 

After  excision  of  the  elbow  the  patient  is  put  to  bed  and  the  arm  is  laid 
upon  a  pillow,  the  elbow  being  placed  midway  between  a  right  angle  and 
complete  extension,  the  forearm  being  placed  midway  between  pronation 
and  supination.  No  sphnt  is  used,  as  a  rule.  Esmarch  used  the  splint 
shown  in  Fig.  384.      The  aim  in  treatment  is  to  obtain  a  freely  movable 


Fig.  384. — Esmarch's  splint  for  the  treatment  of  a  limb  after  excision  of  the  elbow-joint. 


joint.  Passive  motion  is  begun  in  one  week,  at  which  time  the  patient  gets 
up.  The  hand  is  carried  in  a  shng  for  a  time  after  healing  of  the  wound  is 
complete. 

Excision  of  the  Wrist-joint. — Bell  states  that,  whatever  method  of 
excision  is  chosen,  three  cardinal  rules  must  be  borne  in  mind:  (i)  remove 
all  the  diseased  bone,  including  the  portions  of  the  radius,  ulna,  carpus, 
and  metacarpus  which  are  covered  with  cartilage;  (2)  interfere  with  the 
tendons  to  the  least  possible  degree;  and  (3)  begin  passive  motion  of  the 
fingers  very  early.  Many  surgeons  prefer  the  simple  gouging  away  of  dis- 
eased foci  and  the  scraping  of  sinuses  instead  of  a  formal  resection  of  the 
wrist,  amputation  being  employed  in  severe  cases  or  when  scraping  fails 


714  Diseases  and  Injuries  of  Bones  and  Joints 

after  several  trials.     Formal  excision  is  not  frequently  performed,  and  the 
results  cannot  be  regarded  as  very  favorable. 

Lister's  Open  Method  of  Excision. — The  instruments  required  in  this 
operation  are  the  same  as  those  used  for  any  resection.  Break  up  adhesions 
as  completely  as  possible  by  forcible  movements.  Apply  a  tourniquet  or  an 
Esmarch  apparatus.  The  patient  lies  upon  his  back,  the  arm  and  the  fore- 
arm being  brought,  from  stage  to  stage,  into  the  most  desirable  positions. 
Begin  an  incision  over  the  middle  of  the  dorsum  of  the  radius,  on  a  level 
with  the  styloid  process;  carry  it  downward  in  the  direction  of  the  inner 
edge  of  the  articulation  of  the  thumb  with  its  metacarpal  bone,  and  when 
the  knife  reaches  the  radial  side  of  the  second  metacarpal  bone  alter  the 
direction  of  the  incision  and  carry  it  downward  in  the  long  axis  of  the  meta- 
"carpal  bone  to  about  its  middle  (Fig.  381,  a).  This  is  known  as  the  radial 
incision,  and  the  only  tendon  divided  is  that  of  the  extensor  carpi  radialis 
brevior  muscle.  The  tissues  upon  the  radial  aspect  of  the  incision  are  dis- 
sected up,  the  tendon  of  the  extensor  carpi  radialis  longior  muscle  is  divided 
at  its  point  of  insertion  (Bell),  and  all  the  soft  structures  are  retracted  out- 
ward, exposing  the  trapezium,  which  is  cut  off  from  the  rest  of  the  carpus, 
but  which  is  left  in  place,  as  its  removal  at  this  stage  endangers  the  radia" 
artery  (Barker).  By  extending  the  hand  the  tendons  are  loosened  and  the 
carpus  is  cleared  in  the  direction  of  the  ulnar  border  of  the  hand. 

Another  incision  is  made,  starting  upon  the  inner  surface  of  the  wrist, 
two  inches  above  !he  articular  surface  of  the  ulna,  and  midway  between 
the  ulna  and  the  flexor  carpi  ulnaris  tendon.  This  incision,  which  is  known 
as  the  ulnar  incision,  is  carried  down  until  it  is  opposite  the  middle  of  the 
fifth  metacarpal  bone  in  the  palm  (Fig.  381,  b).  "The  dorsal  lip  of  this 
incision  is  raised"  (Bell),  and  the  extensor  carpi  ulnaris  tendon  is  divided 
and  dissected  from  its  depression,  but  is  not  separated  from  the  integument. 
The  extensor  tendons  are  lifted;  the  ligaments  upon  the  dorsum  and  sides  of 
the  wrist-joint  are  cut;  the  flexor  tendons  are  raised  from  the  carpal  bones; 
the  pisiform  bone  is  cut  from  the  carpus,  but  is  not  yet  removed;  and  the 
unciform  process  of  the  unciform  bone  is  cut  with  forceps.  The  anterior 
radiocarpal  ligament  is  divided,  the  carpometacarpal  articulations  are  cut 
through,  and  the  carpus  is  pulled  out  with  bone-forceps.  The  ends  of  the 
radius  and  ulna  are  forced  out  of  the  ulnar  incision.  All  that  portion  of 
the  ulna  which  is  crusted  with  cartilage  is  to  be  removed,  the  saw-cut  is  to 
be  oblique,  and  the  base  of  the  styloid  process  is  to  be  left  behind.  A  thin 
section  is  to  be  sawn  from  the  radius,  and  the  tendon-grooves  are  not  to  be 
impinged  upon.  The  articular  surface  of  the  ulna  is  cut  away  with  pliers 
(Bell).  If  foci  of  disease  are  discovered  beyond  these  points,  they  are  to 
be  gouged  out.  The  ends  of  the  metacarpal  bones  are  sawn  off,  and  their 
articular  facets  are  cut  away  by  means  of  pHers.  The  trapezium  is  dissected 
out,  the  end  of  the  first  metacarpal  bone  is  sawn  off  and  its  facet  is  cut  away 
with  pliers,  and  a  portion  of  the  pisiform  bone  is  removed  (the  entire  bone 
being  removed  if  it  be  diseased).  The  wound  is  irrigated,  vessels  are  tied, 
the  radial  incision  is  closed,  the  ulnar  incision  is  partly  closed,  a  drainage- 
tube  is  inserted  by  way  of  the  ulnar  incision,  the  wounds  are  dressed  anti- 
septically,  and  the  Esmarch  apparatus  is  taken  off.  The  forearm  and  hand 
are  placed  upon  a  spHnt  which  immobilizes  the  wrist  and  leaves  the  fingers 


Excision   of  the   Hip-joint 


715 


semiflexed.  Passive  motion  of  the  fingers  is  begun  after  thirty-six  hours. 
The  sphnt  is  worn  for  many  months,  until  the  wrist-joint  is  immobile  and 
solid.     Esmarch  uses  the  splint  shown  in  Fig.  3^5- 

Excision  of  Metacarpal  Bones  and   of  Phalanges.— Excision  of  a 

metacarpal  bone,  except  in   cases  of  necrosis  with  the  formation  of  large 


Fig.  385.— Esmarch's  interrupted  splint  applied. 


quantities  of  new  bone,  usually  leaves  a  useless  finger;  hence  amputation  is 
preferred  usually  to  excision.  This  rule  does  not  apply  to  the  metacarpal 
bone  of  the  thumb,  which  is  occasionally  resected.  The  incision  for  this 
operation  is  made  upon  the  dorsum,  and  is  straight.  Excision  of  the  proximal 
phalanx  of  the  thumb  is  sometimes  performed.  Excision  for  disease  is  rarely 
performed  upon  the  finger-joints,  amputation 
being  preferred,  though  the  operation  is  some- 
times undertaken  for  compound  dislocation.  In 
the  metacarpophalangeal  joint  of  the  thumb  ex- 
cision, if  it  can  be  performed,  is  preferred  to  am- 
putation. The  incision  for  resection  of  this  joint 
is  placed  upon  the  radial  aspect. 

Excision  of  the  Hip-joint. — Some  sur- 
geons advocate  this  operation;  others,  notably 
Marsh,  are  emphatically  opposed  to  it.  Excision 
should  be  performed  in  the  early  stage  of  tuber- 
culous disease  f/  less  radical  treatment  has  failed. 
In  this  stage  the  usual  position  of  the  Hmb 
is  one  of  fle.xion,  abduction,  and  eversion.  In 
cases  of  long  duration,  especially  where  dislo- 
cation exists,  excision  is  an  easy  and  a  compara- 
tively safe  operation;  in  recent  cases  it  is  diffi- 
cult and  carries  with  it  decided  dangers,  but  the 
peril  of  delay  may  be  greater  than  the  peril  of 
an  early  resection.  In  cases  of  hip  disease  with 
involvement  of  the  acetabulum  the  mortality  is 
50  per  cent.,  whether  operation  is  or  is  not  at- 
tempted. Excision  is  performed  especially  for  tuberculous  disease  and  for 
gunshot-injuries.     The  instruments  required  are  those  used  for  other  excisions. 

Operation  by  Anterior  Incision  (Eig-  386)  (Barker's  Operation). — In  this 
operation  the  patient  is  supine,  with  the  thighs  extended  as  thoroughly  as 
circumstances  permit.     The  surgeon  stands  to  the  right  of  the  patient.     An 


Fig.  386. — Excision  ui  the  hip- 
joint  :  A,  Gluteus  muscle;  b,  tensor 
vaginae  femoris  muscle;  c,  sar- 
torius  muscle  ;  D,  anterior  incision. 


7i6  Diseases  and   Injuries  of  Bones  and  Joints 

incision  is  begun  half  an  inch  below  and  half  an  inch  external  to  the  anterior 
superior  iliac  spine,  and  it  is  carried  downward  and  a  little  inward  for  about 
three  inches  (Fig.  386,  d).  If  dislocation  exists,  the  incision  must  not  be 
so  long.  This  incision  is  carried  at  once  deeply  between  the  muscles,  and 
the  capsule  of  the  joint  is  opened.  The  neck  of  the  bone  is  divided  from 
its  upper  surface  downward  with  a  saw  or  an  osteotome,  and  without  dis- 
locating the  bone  through  the  wound  by  forcible  extension  and  eversion. 
The  head  of  the  bone  is  removed.  All  tuberculous  foci  must  be  scraped  away, 
and  the  flushing  gouge  is  used  upon  tuberculous  areas  of  the  acetabulum. 
All  sinuses  should  be  thoroughly  scraped.  Bleeding  is  arrested,  the  wound 
is  irrigated  with  normal  salt  solution,  mopped  out  with  chlorid  of  zinc 
solution,  and  dusted  with  iodoform.  A  drainage-tube  is  inserted  at  the 
lower  angle  of  the  incision,  and  the  upper  portion  of  the  cut  is  closed. 
The  wound  is  dressed  antiseptically.  Extension  is  made  with  the  extension 
apparatus  until  healing  has  obtained  good  headway,  when  a  double  Thomas's 
splint  is  applied,  so  that  the  patient  can  be  taken  out  daily  in  the  air  and 
sunlight.  As  a  rule,  rigid  ankylosis  results  from  resection  of  the  hip,  but 
occasionally  a  joint  results  with  a  small  range  of  movement. 

Operation  by  Lateral  Incision  (Langenbeck's  Operation). — In  this  opera- 
tion a  straight  incision  two  inches  long  is  made  in  the  direction  of  the  axis 
of  the  femur,  and  passing  downward  from  the  apex  of  the  great  trochanter. 
From  the  beginning  of  this  incision  a  curved  incision  is  carried  toward  the 
head  of  the  bone,  the  convexity  of  the  curve  being  backward  (Fig.  380,  a). 
Bell  advises  the  use  of  the  saw  after  bringing  the  head  of  the  bone  into  the 
wound  by  abduction  and  eversion  of  the  thigh.  Barker  applies  the  saw  with 
the  bone  in  situ,  and  strongly  opposes  wrenching  the  bone  out  of  the  incision, 
because  of  the  danger  of  peeling  off  the  periosteum,  which  peeling,  if  it  takes 
place,  favors  necrosis. 

Incision  oj  Gross. — In  Gross's  operation  a  seinilunar  flap  is  made  with 
the  convexity  backward  (Fig.  383,  e). 

Excision  of  the  Knee-joint.— In  this  operation  a  complete  excision 
should  be  performed,  and  the  patella  ought  to  be  removed.  This  operation 
is  performed  for  tuberculous  disease,  some  compound  fractures  and  com- 
pound dislocations,  and  some  cases  of  angular  ankylosis,  but  it  is  rarely 
employed  for  gunshot-injuries,  amputation  being  usually  preferable.  The 
instruments  required  are  the  same  as  those  for  the  shoulder,  plus  Butcher's 
saw. 

Operation  by  Anterior  Semilunar  Flap. — The  patient  lies  upon  his  back, 
and  the  joint,  if  not  ankylosed  in  extension,  should  be  semiflexed.  The 
surgeon  stands  to  the  right  side.  An  incision  is  made  which  at  once  opens 
the  joint.  The  incision  begins  at  one  condyle  and  reaches  the  other  con- 
dyle by  a  curve  which  passes  through  the  ligamentum  patella;  midway 
between  the  tuberosity  of  the  tibia  and  the  inferior  margin  of  the  patella 
(Fig.  382,  b).  The  flap  is  dissected  up,  the  knee  is  thrown  into  forced 
flexion,  the  lateral  ligaments  and  crucial  ligaments  are  cut,  and  the 
end  of  the  femur  is  well  cleared.  The  blade  of  Butcher's  saw  is 
passed  beneath  the  bone,  which  is  sawn  from  below  upward  (Ashhurst). 
The  end  of  the  tibia  is  cleared  and  a  portion  is  sawn  off.  If,  after 
sawing,   diseased  foci   are  discovered,   another  section  can  be  sawn  off  or 


Excision   of  the  Ankle-joint 


717 


the  foci  can  be  gouged  away.  Ashhurst,  who  has  had  a  vast  experience 
with  this  operation,  insists  that  in  sawing  through  the  femur  the  natural 
obhquily  of  the  bone  must  be  borne  in  mind  and  the  section  must  be  made 
in  "a  hne  parallel  to  that  of  the  free  surface  of  the  condyles."  If  the  section 
is  made  transverse  to  the  axis  of  the  femur,  "the  limb,  after  adjustment, 
will  be  found  to  be  markedly  bowed  outward."  The  same  surgeon  says 
that  the  epiphyseal  line  is  somewhat  higher  on  the  front  than  it  is  on  the 
back  of  the  femur,  and  in  consequence  the  following  rule  is  formulated  for 
section  of  the  condyles:  the  section  of  the  condyles  should  be  "in  a  plane 
which,  as  regards  the  axis  of  the  femur,  is  oblique  from  behind  forward, 
from  below  upward,  and  from  within  outward. "  Ashhurst  advocates  section 
of  the  tibia  "in  a  plane  transverse  to  the  long  axis  of  the  bone,  with  a  slight 
anteroposterior  obliquity,  so  as  to  correspond  with  that  of  the  section  of 
the  condyles, "  and  he  further  says  that  the  patella  must  be  removed,  whether 
it  is  diseased  or  not,  and  quotes  Peniere's  observations  to  the  effect  that 
excision  of  the  patella  diminishes  the  risk  of  death  one-third,  and  its  retention 
doubles  the  probabihty  of  an  amputation  becoming  necessary  in  the  future. 


Fig.  387. — Watson's  plaster-of-Paris  swing-splint. 


After  removing  the  patella  the  diseased  synovial  membrane  is  clipped 
away  with  scissors  and  all  sinuses  and  diseased  territories  are  well  curetted. 
The  posterior  ligament  of  the  joint  is  not  removed  unless  it  is  diseased;  its 
retention  prevents  displacement  and  guards  the  popliteal  space.  In  children 
the  fragments  should  be  wired  together;  in  adults  this  need  not  be  done. 
After  hemostasis,  irrigate,  dust  with  iodoform,  insert  a  drainage-tube,  suture, 
dress  antiseptically,  and  adjust  the  limb  upon  Price's  splint  or  Ashhurst's 
bracketed  wire  splint.  In  some  cases  tenotomy  is  required  to  permit  ex- 
tension. Instead  of  the  bracketed  sphnt,  a  long  fracture-box  may  be  used. 
If  the  femur  tends  to  project  anterior  ly,  use  an  anterior  splint.  If  there 
be  a  tendency  to  outward  bowing,  adopt  Ashhurst's  expedient  of  carrying 
a  strip  of  adhesive  plaster  around  the  outside  of  the  limb  and  fastening  it 
to  the  inner  side  of  the  sphnt.  The  splint  is  kept  on  until  bony  union  is 
complete,  as  in  this  operation  a  movable  joint  is  never  sought.  Many  sur- 
geons use  a  plaster-of-Paris  splint,  which  is  employed  until  the  parts  have 
become  firm  and  solid  (Fig.  387). 

Excision  of  the  Ankle-joint. — This  operation  is  performed  chiefly  for 
gunshot-wounds,  compound  dislocations,  and  in  some  cases  of  tuberculous 


7i8  Diseases  and  Injuries  of  Bones  and  Joints 

joint-disease.  Excision  of  the  ankle  is  an  operation  which  is  seldom  per- 
formed. The  instruments  used  are  the  same  as  those  employed  for  any 
resection. 

Operation  (Hancock's  Method). — In  this  operation  the  patient  lies  upon 
his  back,  the  foot  rests  upon  its  inner  side,  and  the  surgeon  stands  to  the 
outer  side  of  the  damaged  limb.  Begin  an  incision  just  behind  and  two 
inches  above  the  external  malleolus,  and  carr\'  it  across  the  front  of  the  joint 
to  a  corresponding  point  above  and  behind  the  internal  malleolus  (Fig.  380, 
b);  this  incision  goes  only  through  the  skin,  and  the  flap  thus  marked  out 
is  reflected.  ''  Cut  down  upon  the  external  malleolus,  carrying  the  knife 
close  to  the  edge  of  the  bone  both  behind  and  below  the  process,  dislodge 
the  peronei  tendons,  and  divide  the  external  lateral  ligaments"  (Joseph  Bell). 
Cut  the  fibula  one  inch  above  the  malleolus  by  means  of  phers;  divide  the 
tibiofibular  ligament;  turn  the  foot  upon  its  outer  side;  dissect  from  their 
habitat  back  of  the  inner  malleolus  the  tendons  of  the  posterior  tibial  and 
the  common  flexor  of  the  toes;  carry  the  knife  around  the  inner  malleolus, 
close  to  the  bony  edge;  separate  the  internal  lateral  ligament,  and  dislocate 


Fig.  388. — Volkmann's  dorsal  splint  for  excision  of  the  ankie. 

the  lower  end  of  the  tibia  through  the  wound  by  turning  the  sole  of  the  foot 
downward;  saw  off  the  lower  end  of  the  tibia  and  the  articular  process  of 
the  astragalus,  sawnng  away  from  the  tendo  Achillis,  and  remove  the  frag- 
ments with  bone  forceps.  Cut  away  diseased  s}Tiovial  membrane,  and  curet 
all  sinuses  and  tuberculous  areas.  Arrest  bleeding,  irrigate,  and  drain.  Sew 
up  the  wound,  insert  a  tube  at  the  ou,ter  angle,  and  cause  it  to  emerge  at  the 
inner  angle.  Apply  antiseptic  dressings,  and  put  up  the  foot  in  fixed  dress- 
ing or  in  splints  at  a  right  angle  to  the  leg  (Fig.  388).  In  Langen beck's 
operation  the  excision  is  subperiosteal.  If,  in  an  excision  of  the  ankle-joint, 
the  astragalus  is  found  extensively  diseased,  remove  the  entire  bone. 

Excision  of  the  Os  Calcls. — In  caries  hmited  to  the  os  calcis  most 
surgeons  prefer  to  gouge  away  the  dead  bone,  leaving  the  periosteum  and, 
if  possible,  a  shell  of  healthy  bone,  and  draining  thoroughly.  Others  advo- 
cate excision  in  some  cases.  Extensive  disease  limited  purely  to  the  os  calcis 
is  rare,  and  most  surgeons  advise  gouging  for  limited  caries,  and  Syme's 
amputation  in  the  event  6f  the  disease  extending  beyond  the  periosteum  of 
reaching  adjacent  bones. 

Operation  by  Subperiosteal  Method. — In  this  operation  the  position  as- 


Excision  of  the  Scapula  7^9 

sumed  by  the  patient  is  supine  with  the  leg  extended  and  the  foot  resting 
on  its  inner  side.  The  incision,  which  cuts  the  tendo  Achillis  and  reaches 
the  bone  at  once,  is  begun  at  the  upper  border  of  the  os  calcis  and  the  inner 
margin  of  the  tendo  Achillis,  and  is  taken  outward  and  horizontally  forward 
to  a  point  in  front  of  the  calcaneocuboid  articulation  (Fig.  383,  f).  A  ver- 
tical incision  is  begun  near  the  forward  termination  of  the  initial  incision,  is 
carried  across  the  outer  edge  and  plantar  surface  of  the  foot,  and  terminates  at 
the  external  margin  of  the  inner  surface  of  the  os  calcis.  Some  surgeons  carry 
the  vertical  incision  a  little  upward,  toward  the  dorsum.  The  periosteum 
is  entirely  stripped  with  an  elevator,  the  os  calcis  is  removed,  the  cavity  is 
packed  with  iodoform  gauze,  the  wound  is  stitched,  a  drain  is  inserted  pos- 
teriorly, and  the  foot  is  dressed  antiseptically,  is  placed  at  a  right  angle  to 
the  leg,  and  plaster-of-Paris  is  applied,  trap-doors  being  cut  for  drainage. 

Astragalectomy,  or  excision  of  the  astragalus,  is  seldom  performed. 
Astragalectomy  is  employed  occasionally  for  relapsed  and  inveterate  cases 
of  club-foot.  The  indications  are  pointed  out  by  Willard  (''Internationa. 
Clinics,"  vol.  iii,  12th  series):  "  (i)  Adults  w-ith  great  bony  deformitv;  (2) 
neglected  children  of  five  to  fifteen  years,  who  have  markedly  distorted  theii 
tarsi  by  locomotion;  (3)  relapsed  cases  which  have  resisted  the  milder  forms 
of  operation,  or  which  have  been  neglected  by  parents  after  previous  opera- 
tion; (4)  only  occasionally,  young  children  in  whom  from  infancy  the  bones 
of  the  foot  have  been  exceedingly  rigid  and  unyielding,  and  where  there  is 
practically  but  little  motion  either  at  the  ankle-joint  or  in  the  tarsus." 

Operation  by  the  Subperiosteal  Plan. — Barker  advises  an  incision  going 
at  once  to  the  bone,  from  the  "tip  of  the  external  malleolus  forward  and 
a  Uttle  inward,  curving  toward  the  dorsum  of  the  foot."  The  foot  is  ex- 
tended and  turned  inward,  the  periosteum  is  lifted,  the  astragalus  is  re- 
moved, and  the  wound  is  treated  and  the  foot  is  dressed  as  is  done  in 
excision  of  the  os  calcis. 

Excision  of  the  Metatarsophalangeal  Articulation  of  the  Great 
Toe. — In  this  operation  make  a  lateral  incision  and  cut  off  or  saw^  off  the 
proximal  end  of  the  first  phalanx  and  the  distal  third  of  the  first  metatarsal 
bone. 

Excision  of  the  Metatarsal  Bone  of  the  Great  Toe  (Butcher's  Method). 
— In  this  operation  a  lateral  straight  incision  is  made,  the  periosteum  is 
elevated,  and  the  shaft  is  sawn  from  each  extremity  and  removed. 

Excision  of  the  clavicle  may  be  required  for  dislocation,  caries, 
necrosis,  gunshot-wound,  tumor  of  this  bone,  as  a  preliminary  to  hgation 
of  the  artery  and  vein  in  certain  cases  of  amputation  at  the  shoulder- 
joint,  or  in  cases  of  removal  of  the  entire  upper  extremity.  In  excision  of 
the  clavicle  the  position  of  the  patient  is  the  same  as  that  for  ligation  of  the 
third  part  of  the  subclavian  artery  (page  479).  An  incision  is  made  down 
to  the  bone,  from  the  sternoclavicular  joint  to  the  acromioclavicular  articu- 
lation. If  the  case  is  suitable,  the  periosteum  is  stripped  and  the  bone  is 
sawn  and  removed;  if  not,  the  bone  is  sawn  and  each  half  is  separately  dis- 
articulated. The  wound  is  sutured  and  dressed,  and  the  limb  is  put  up  in 
a  Velpeau  bandage. 

Excision  of  the  Scapula. — Complete  excision  of  the  scapula  is  usually 
performed   for  tumors.     Partial   excision  requires   no  detailed   description. 


720  Diseases  and  Injuries  of  Bones  and  Joints 

In  excision  of  the  scapula  the  patient  hes  upon  his  sound  side.  Treves 
suggests  the  following  incisions:  one  outside  the  vertebral  border  of  the 
scapula,  from  its  superior  to  its  inferior  angle;  another  from  over  the  acro- 
mioclavicular joint,  along  the  acromion  process  and  spine  of  the  scapula, 
to  meet  the  first  incision.  Syme  used  an  incision  carried  transversely  inward 
from  the  acromion  process  to  the  vertebral  border  of  the  scapula,  and  another 
cut  directly  downward  from  the  center  of  the  first  incision  (Fig.  383,  g).  In 
the  method  of  Treves  *  the  upper  flap  is  reflected  and  the  trapezius  muscle 
is  divided;  the  lower  flap  is  reflected  and  the  deltoid  muscle  is  divided.  The 
patient's  hand  is  placed  on  the  sound  shoulder;  the  muscles  of  the  vertebral 
border  are  divided,  the  posterior  scapular  artery  is  tied,  and  while  the  vertebral 
border  of  the  scapula  is  pulled  toward  the  surgeon,  the  serratus  magnus 
muscle  is  cut,  the  upper  border  of  the  shoulder-blade  is  cleared,  and  the  supra- 
scapular artery  is  tied.  The  hand  is  now  brought  down  to  the  side;  the 
acromioclavicular  joint  is  disarticulated;  the  conoid  and  trapezoid  ligaments 
are  divided;  the  muscles  of  the  coracoid  process  are  cut;  the  capsule  is  incised, 
with  the  supraspinatus  and  infraspinatus,  the  subscapularis,  and  the  scap- 
ular origins  of  the  biceps  and  triceps  muscles;  and  finally  the  teres  major 
and  minor  muscles  are  divided,  the  subscapular  artery-  is  tied,  and  the  bone 
is  removed.  The  wound  is  stitched,  a  drain  is  introduced,  and  antiseptic 
dressings  are  applied.  The  patient  lies  upon  his  back  until  heahng  is  well 
under  way,  when  the  arm  is  placed  in  a  sling.  The  drainage-tube  may  be 
removed  in  twenty- four  hours. 

Excision  or  Resection  of  a  Rib  (Fig.  494). — In  caries  the  gouge  and  ron- 
geur may  remove  the  disease.  In  other  cases  excision  is  performed.  In  this 
operation  the  patient  lies  upon  his  sound  side  unless  the  operation  is  performed 
for  empyema,  in  which  case  he  lies  on  his  back  or  only  partly  on  the  sound  side. 
(See  Empyema,  Operation  for.)  The  surgeon  faces  the  patient.  INIake  an 
incision  down  to  the  bone,  in  the  long  axis  of  the  rib.  The  periosteum,  if  not 
diseased,  is  lifted  from  the  bone,  and  the  intercostal  artery  is  lifted  out  of  the 
way  with  the  periosteum  and  is  thus  saved  from  being  cut.  After  dividing  the 
bone  beyond  the  limits  of  disease,  remove  it.  During  the  sawing  a  metal  re- 
tractor is  held  beneath  the  rib,  between  the  rib  and  the  periosteum.  It  is  better 
to  saw  it  than  cut  it  with  ordinar}^  biting  forceps,  because  the  latter  splinter  the 
bone.  The  author  usually  uses  a  forceps  known  as  a  costotome,  which  cuts  the 
rib  without  splintering.  If  the  periosteum  is  diseased,  remove  it  after  tying  the 
intercostal  artery.  It  should  be  removed  in  a  case  of  empyema,  otherwise  bone- 
formation  may  interfere  with  drainage.  In  empyema,  after  removing  the 
periosteum,  open  into  the  pleural  cavity,  allow  pus  to  flow  out  slowly,  remove 
fibrinous  masses,  employ  a  finger  to  feel  if  there  are  adhesions  and  if  the  lung 
will  probably  expand,  and  insert  a  drainage-tube.  In  resection  for  rib  disease 
curet  sinuses  and  pack  with  iodoform  gauze  for  some  days.  Sew  up  the  wound 
except  at  one  end.  Dress  antiseptically  and  apply  a  binder.  (See  Operations 
upon  the  Chest  and  Estlandei's  Operation.) 

In  removing  a  cemical  rib  make  an  incision  along  the  posterior  edge  of 
the  sternocleidomastoid,  avoid  the  pleura,  subclavian  vessels,  and  brachial 
plexus,  and  remove  the  periosteum  with  the  rib  in  order  that  the  bone  will 
not  be  reproduced. 

Complete  Excision  of  One-half  of  the  Upper  Jaw. — The  whole  upper 

*Treves's  "Manual  of  Operative  Surgery." 


Preliminary  Closure  of  the  External  Carotid  Artery  721 


Fig.  389. — A  B,  Incision  of  the 
soft  parts  preliminary  to  excision  of 
the  upper  jaw  ;  CD  E,  incision  of  soft 
parts  preliminar>'  to  excision  of  the 
lower  jaw. 


jaw  has  been  removed,  but  in  what  follows  only  resection  of  one-half  the 
jaw  will  be  described.  This  operation  is  performed  for  malignant  tumors 
of  the  superior  maxillary  bone  or  its  antrum.  Up  to  1826,  at  which  time 
Lizars,  of  Edinburgh,  suggested  the  operation,  tumors  of  the  antrum  were 
treated  by  scraping  them  away  with  a  sharp  spoon.  Gensoul,  of  Lyons,  in 
1827  performed  the  first  operation  for  resection  of  the  upper  jaw.  This  ope- 
ration is  not  justifiable,  except  as  a  palhative  measure,  if  the  orbit  is  invaded, 
if  the  skin  and  subcutaneous  tissues  are  infil- 
trated, or  if  the  disease  extends  widely  beyond 
the  superior  maxillary  and  palate  bones.  The 
instruments  required  are:  a  mouth-gag;  scal- 
pels; strong  scissors;  tracheotomy  tubes; 
dissecting,  toothed,  and  hemostatic  forceps; 
bone-cutting,  lion-jaw, sequestrum, and  tooth- 
extracting  forceps;  a  volsella;  a  narrow- 
bladed  saw;  a  chisel  and  maUet;  a  perios- 
teum-elevator; a  spatula  or  metal  retractor; 
PaqueUn's  cautery;  sponges  which  are  tied 
to  sticks;  needles,  curved  and  straight,  large 
and  small ;  silk  and  catgut  ligatures ;  silkworm- 
gutsutures;andHorsley'santisepticbone-wax. 
Preliminary  Closure  of  the  External 
Carotid  Artery. — Some  surgeons  hgate  the 
external  carotid  artery  or  compress  it  tem- 
porarily. In  a  number  of  excisions  of  the 
upper  jaw  I  have  always  found  the  hemorrhage  readily  controllable  as  soon 
as  the  bone  is  removed,  and  have  never  felt  it  necessary  to  resort  to  prehmi- 

nary  hgation  or  compression. 

Operation  by  Median  Incision. — The  patient, 
whose  face  has  been  shaved,  is  placed  in  the  Tren- 
delenburg position,  thus  avoiding  the  possible  need 
of  instant  tracheotomy.  The  surgeon  stands  to  the 
right  side  of,  and  faces,  the  patient.  The  incisor 
tooth  on  the  diseased  side  is  pulled  out.  The 
incision,  which  is  kno'rni  as  Weber's  incision  (Fig. 
389,  hne  A  b),  is  begun  half  an  inch  below  the 
inner  canthus  of  the  eye,  and  is  carried  along  the 
side  of  the  nose,  around  the  ala  of  the  nose,  by 
the  margin  of  the  nostril,  and  through  the  middle 
of  the  Up.  "WTiile  the  lip  is  being  incised  the 
assistant  arrests  hemorrhage  by  grasping  the  cor- 
ners of  the  mouth,  and  after  the  Hp  is  divided, 
the  coronary  arteries  are  at  once  ligated.  Some 
operators  approach  the  mucous  membrane  cau- 
tiously and  ligate  the  vessels  before  opening  the 
cavity  of  the  mouth.  The  upper  portion  of  the 
wound  having  been  compressed  by  another  as- 
sistant during  these  manipulations,  pressure  is  now 
removed  and  bleeding  points  are  ligated.  Another 
incision  is  now  carried  outward  from  the  beginning  of  the  first  incision,  along 
4b 


Fig.  390. — I,  Excision  of  the 
upper  jaw  :  a  b,  Section  of  the 
nasal  process ;  b  c,  section  of 
the  orbital  plate  ;  d,  section  of 
the  malar  bone  and  orbital 
plate  ;  e,  section  of  the  alveo- 
lus and  hard  palate.  2,  Ex- 
cision of  the  lower  jaw  :  G,  Sec- 
tion of  the  inferior  maxillary ; 
H,  section  of  the  ramus  in  par- 
tial resection. 


722  Diseases  and   Injuries  of  Bones  and  Joints 

the  orbital  margin  to  well  over  the  malar  bone.  The  flap  is  lifted  from  the 
periosteum,  and  the  bleeding  from  the  infraorbital  artery  and  the  small 
vessels  is  restrained  by  pressure.  The  nasal  cartilage  is  separated  from  the 
bone,  and  the  nasal  process  of  the  superior  maxillary  is  sawn  (line  A  b,  Fig. 
390).  The  orbital  periosteum  is  lifted  up,  and  the  orbital  plate  is  cut  with 
forceps  from  the  saw-cut  in  the  superior  maxillary  bone  to  the  sphenomaxillary 
fissure  (line  B  c.  Fig.  390).  The  malar  bone  is  sawn  or  is  bitten  through 
about  its  center,  the  cut  running  into  the  sphenomaxillary  fissure  and  taking 
a  downward  and  outward  direction  (line  CD,  Fig.  390).  The  soft  parts 
covering  the  hard  palate  are  incised  in  the  median  line,  a  corresponding 
incision  is  made  along  the  floor  of  the  nose  near  the  septum,  and  the  soft 
palate  is  separated  from  the  hard  palate  by  a  transverse  cut.  The  saw  is 
introduced  through  the  nose,  and  ij^e  palate  is  sawn  (line  e,  Fig.  390).  The 
upper  jaw-bone  is  grasped  with  Fergusson's  lion-jaw  forceps  and  removed, 
the  removal  being  aided  by  the  use  of  the  scissors  and  bone-cutters;  the 
latter  are  used  to  separate  the  upper  jaw  from  the  pterygoid  process  (Treves). 
Every  vessel  that  can  be  seen  is  tied,  and  severe  bleeding  from  bone  is  arrested 
by  antiseptic  wax.  Oozing  is  controlled  by  hot  water  and  pressure  or  by 
Paquelin's  cautery.  Examine  carefully  to  see  if  all  the  diseased  area  is 
removed;  if  it  is  not,  use  the  gouge,  scissors,  chisel,  and  saw  until  healthy 
tissue  is  reached.  The  wound  is  packed  with  iodoform  gauze,  and  the  end 
of  the  strip  is  so  placed  as  to  be  accessible  through  the  mouth.  The  wound 
is  sutured  (the  mucous  membrane  of  the  lip  must  be  stitched,  as  well  as  the 
skin)  and  is  dressed  antiseptically  (the  eye  being  protected  by  aseptic  gauze), 
and  a  crossed  bandage  of  the  angle  of  the  jaw  is  applied. 

Excision  of  One-half  of  the  Lower  Jaw. — In  some  rare  instances 
the  entire  inferior  maxillary  bone  is  removed.  The  lesions  necessitating 
removal  of  the  lower  jaw  are  of  the  same  nature  as  cause  us  to  remove  the 
upper  jaw.  The  instruments  required  for  removal  of  the  lower  jaw  are 
those  used  for  excision  of  the  upper  jaw,  plus  a  metacarpal  saw  (having  a 
movable  back). 

In  this  operation  the  patient  is  placed  in  the  same  position  as  for  excision 
of  the  upper  jaw,  the  chin  having  been  previously  shaved.  A  vertical  cut 
is  made  through  the  chin-tissue,  starting  below  the  margin  of  the  Hp  and 
reaching  to  below  the  border  of  the  jaw  (c  D,  Fig.  389).  From  the  point  D 
an  incision  is  carried  outward  below  the  border  of  the  jaw  and  then  back 
of  the  ramus,  as  shown  in  the  line  D  E  (Fig.  389).  Treves's  advice  is  to  carry 
this  incision  down  to  the  bone,  except  at  the  line  of  the  facial  artery,  at  which 
point  it  must  go  through  the  skin  only.  The  facial  artery  is  now  to  be  sought 
for,  tied  in  two  places,  and  divided.  The  periosteum  is  lifted  from  the 
external  surface  of  the  bone,  from  the  symphysis  outward.  Hemorrhage  is 
arrested.  The  buccal  mucous  membrane  is  cut  from  the  alveolus.  A  lateral 
incisor  tooth  is  pulled,  and  the  bone  is  sawn  in  the  line  G  (Fig.  390).  The 
bone  is  grasped  in  a  lion-jaw  forceps  and  is  drawn  outward.  The  mylo- 
hyoid insertion  is  cut;  the  internal  pterygoid  muscle  is  cut  or  the  periosteum 
at  this  spot  is  lifted;  the  inferior  dental  artery  is  cut  and  tied;  the  jaw  is  pulled 
down;  the  insertion  of  the  temporal  muscle  upon  the  coronoid  process  is 
cut  away;  and  the  external  pterygoid  muscle  is  divided.  The  capsule  of 
the  joint  is  opened,  and  the  bone  is  separated  from  the  ligaments  which  still 


"Opercttion   for  Congenital   Dislocation   of  Hip  7^3 

hold  it  in  place.  Bleeding  is  arrested,  the  wound  is  sutured,  a  tube  is  intro- 
duced in  the  posterior  portion  of  the  wound  and  retained  for  twenty-four 
hours,  and  antiseptic  dressings  and  a  Gibson  or  a  Barton  bandage  are  applied. 
Partial  excisions  of  the  alveolus  may  be  performed  through  the  mouth  by 
means  of  chisels  and  rongeur  forceps,  and  Wyeth  has  thus  removed  half  of 
the  jaw,  but  if  any  considerable  part  of  the  body  of  the  jaw  is  to  be  removed, 
it  is  usually  best  to  make  an  incision  below  the  inferit^r  maxillary. 

Barker's  Operation  for  Dislocation  of  the  Semilunar  Cartilages 
of  the  Knee-joint.* — Begin  the  incision  over  the  ligament  of  the  patella, 
half  an  inch  above  the  articular  surface  of  the  tibia,  and  carry  it  in  a  curve 
downward  and  outward  to  the  anterior  edge  of  the  internal  lateral  ligament. 
The  periosteum  should  be  divided  by  the  cut.  This  incision  forms  a  flap 
the  lower  edge  of  which  is  half  an  inch  below  the  border  of  the  articular 
surface  of  the  tibia.  The  flap  is  lifted  until  the  cartilage  is  seen  "under 
the  attachment  of  the  meniscus,  which  if  partially  attached  will  rise  with 
the  flap  until  its  under  surface  is  seen."  If  partially  torn  anteriorly  it  is 
stitched  to  periosteum  by  a  few  silk  sutures.  The  periosteum  is  then  stitched 
in  place,  no  drain  is  used,  the  joint  is  immobilized,  and  for  one  week  ice  is 
kept  upon  the  part.  If  the  meniscus  is  found  completely  separated  and 
curled  up,  it  may,  if  the  injury  was  recent,  be  reduced.  If  the  injury  was  old 
and  if  the  cartilage  is  shrunken,  it  should  be  completely  cut  away  (Barker). 

Operation  for  Congenital  Dislocation  of  Hip. — Lorenz's  Bloodless 
Method  oj  Reduction. — The  method  of  reducing  by  manipulation  a  congenital 
dislocation  of  the  hip  was  devised  by  Paci  and  modified  and  improved  by 
Lorenz.  It  has  long  been  known  that  reduction  is  easy  at  birth,  because 
an  acetabulum,  though  probably  a  shallow  one,  exists  and  the  head  of  the 
bone  is  not  firmly  held  in  its  new  situation.  In  an  older  child  the  problem 
is  far  more  difficult,  because,  even  if  reduction  is  effected,  the  acetabulum 
may  be  extremely  shallow  o*r  absent,  and  redislocation  may  readily  occur. 
Lorenz  aims  to  effect  thorough  reduction  and  then  fixes  the  limb  in  abduction 
for  months,  so  that  the  acetabulum  will  deepen  and  the  bone  will  become 
firm  in  its  proper  socket.  This  operation  is  rarely  successful  in  children 
over  six  years  of  age.  The  child  is  anesthetized  and  an  attempt  is  made  to 
draw  the  femoral  head  on  to  a  line  with  the  acetabulum.  If  the  child  has 
never  walked,  this  is  readily  accomplished.  If  it  has  walked,  the  procedure 
may  be  very  difficult,  and  it  may  be  necessary  to  make  extension  with  a 
fillet  fastened  above  the  knee,  and  counter-extension  with  a  screw  and  a 
perineal  band.  The  drawing  down  of  the  head  is  made  easier  by  stretch- 
ing and  massaging  the  adductor  muscles.  The  next  step  is  to  strongly  flex 
the  thigh,  rotate  it  a  trifle  internally,  and  then  abduct  it  while  flexion  is  main- 
tained. This  causes  the  head  of  the  femur  to  pass  around  the  posterior  mar- 
gin of  the  acetabulum  and  frequently  produces  reduction.  "  Full  abduction 
being  kept  up,  the  thigh  is  rotated  out,  thus  forcing  the  head  of  the  femur 
more  firmly  into  the  socket"  (see  the  description  of  the  Lorenz  method  in 
J.  Jackson  Clarke's  "  Orthopaedic  Surgery").  The  strongly  abducted  limb  is 
put  up  in  plaster-of-Paris.  In  about  three  months  the  plaster  is  removed,  the 
abduction  is  diminished,  the  plaster  is  reapplied  and  is  retained  for  another 
three  months.     During  the  continuance  of  immobilization  of  the  hip,  the  child 

*  "Lancet,"  Jan.  4,  1902. 


724  Diseases  and  Injuries  of  Bones  and  Joints 

walks  about,  with  the  knees  bent.  When  the  plaster  is  finally  removed,  ma- 
nipulation, massage,  and  exercise  strengthen  the  muscles  and  give  freedom  to 
the  joint.  In  a  double  dislocation  one  joint  can  be  cured  before  the  other  is 
operated  upon,  or  both  may  be  operated  upon  at  the  same  seance.  In  double 
dislocation  plaster  must  be  worn  more  than  six  months.  The  Lorenz  opera- 
tion is  safe  when  applied  to  very  young  children,  but  has  elements  of  danger 
which  increase  with  the  years  of  the  subject.  A  patient  may  suffer  grave 
lacerations  of  muscles  and  ligaments,  and  even  vessels  and  nerves.  Death 
may  result  from  shock,  and  extensive  deep-seated  hemorrhage  may  occur. 
In  fact,  it  is  a  mistake  to  call  it  a  bloodless  method.  The  blood  flows,  though 
we  do  not  see  it.  An  untrained  man  may  do  fearful  mischief  by  this  opera- 
tion, and  it  should  only  be  attempted  by  a  very  skilful  manipulator  and  upon 
properly  selected  cases,  when  it  is  a  very  successful  procedure.     I  am  satisfied 


Fig.  391.- — Lorenz  method      Unilateral  congenital  dislocation  of  hip  (reduced).     Cast  applied 

with  leg  in  "  frog  position." 

that,  except  in  the  case  of  a  very  young  child,  in  whom  reduction  is  easy,  one 
who  performs  the  Lorenz  operation  should  be  something  more  than  skilful 
and  experienced.  He  should  be  physically  strong,  so  that  traction  and  ab- 
duction will  be  powerful  and  steady.  A  weak  man  will  jerk,  will  throw  his 
weight  upon  the  part,  and  will  be  apt  to  tear  structures  instead  of  stretching 
them.     Sudden  forcible  movements  are  apt  to  break  the  bone. 

Hofjd's  Operation. — The  instruments  used  are  the  same  as  for  a  resec- 
tion. Make  the  external  incision  of  Langenbeck  to  open  the  joint  (page  716). 
The  capsule  is  incised  at  its  insertion  into  the  neck,  and  the  periosteum  and 
muscles  are  lifted  from  the  great  trochanter.  Hoffa  claims  that  in  children 
less  than  five  years  of  age  the  head  of  the  bone  can  be  readily  replaced  into 
the  acetabulum  by  flexing  the  thigh  and  making  direct  pressure  upon  the 
head  of  the  bone.  After  replacing  the  femoral  head  it  is  held  in  place  while 
an  assistant  extends  the  leg  in  order  to  stretch  the  muscles.  In  children  over 
five  years  of  age  cut  the  muscles  which  spring  from  the  ischial  tuberosity  and 
also  the  adductors  with  a  tenotome;  cut  the  fascia  lata  and  muscles  which  arise 
from  the  anterior  superior  iliac  spine  by  incision;  open  the  joint  and  liberate 


Operation  for  Congenital  Dislocation  of  Hip  725 

the  head  of  the  bone;  remove  the  Hgamentum  teres;  scrape  out  the  acetabulum, 
removing  "cartilage,  fat,  and  considerable  spongy  tissue"  (Tubby);  and  re- 
place the  head  of  the  bone  in  the  acetabulum.  The  limb  is  maintained  in 
inversion,  abduction,  and  extension  for  several  weeks,  when  it  is  straight- 
ened. Massage  and  passive  motion  are  begun  in  the  fifth  week.  The  patient 
now  gets  about,  wearing  an  apparatus  for  many  weeks.  This  apparatus  per- 
mits the  head  of  the  bone  to  move  in  the  socket,  but  prevents  redislocation. 

Lorenz^s  Operation. — This  is  a  modification  of  Hoifa's.  The  muscles 
inserted  into  the  greater  and  the  lesser  trochanter  are  not  cut ;  the  sartorius, 
the  hamstrings,  and  the  external  portion  of  the  fascia  lata  are  cut  (Tubby). 

The  incision  of  Lorenz  is  longitudinally  from  the  anterior  superior  spine. 
Another  incision  is  carried  inward  from  this  at  the  level  of  the  lesser  trochanter. 
The  capsule  is  opened  by  a  crucial  cut;  the  acetabulum  is  enlarged;  the  head 
of  the  bone,  if  it  remains,  is  inserted  into  the  acetabulum;  if  there  is  no  true 
head,  a  new  one  is  formed  and  inserted  into  the  cavity.  The  limb  is  im- 
mobilized in  a  position  of  moderate  abduction.  Massage  and  passive  motion 
are  begun  in  the  fifth  week,  and  are  continued  for  months.* 

*I  have  drawn  upon  the  very  lucid  description  of  these  operations  in  A.  H.  Tubby's 
treatise  upon  "  Deformities." 


726         Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursse 


XX.   DISEASES  AND    INJURIES  OF  MUSCLES,  TENDONS,  AND 

BURS/E. 

Myalgia,  or  muscular  rheumatism,  is  a  painful  disorder  of  the 
voluntary  muscles  and  of  the  fibrous  and  periosteal  areas  where  they  are 
attached.  The  term  "muscular  rheumatism"  is  not  strictly  correct.  It  is 
possible  that  in  some  cases  the  muscular  structure  is  inflamed,  but  it  is  certain 
that  in  many  cases  the  pain  is  distinctly  neuralgic.  Muscular  rheumatism 
may  be  due  to  cold  and  wet,  to  over-exertion  and  strain,  to  acute  infectious 
disorders,  to  syphilis,  to  chronic  intoxications  (lead,  mercury,  and  alcohol), 
and  to  disturbances  of  the  circulation.  Gouty  and  rheumatic  persons  are 
especially  predisposed,  men  being  more  liable  to  the  disease  than  women. 
The  disease  is  usually  acute,  but  it  may  be  chronic. 

Symptoms. — Muscular  rheumatism  is  apt  to  come  on  suddenly.  The 
pain,  which  may  be  very  acute  and  lancinating  or  may  be  dull  and  aching, 
is  in  some  cases  constantly  present;  in  other  cases  it  is  awakened  only  by 
muscular  contraction,  and  it  is  frequently  reheved  by  pressure,  though  there 
is  often  some  soreness.  The  skin  above  the  muscle  is  sometimes  tender 
to  light  pressure.  The  disease  usually  lasts  for  a  few  days,  but  it  tends  to 
recur.     There  is  little,  if  any,  fever. 

Lumbago  is  myalgia  of  the  muscles  of  the  loins.  Rheumatic  torticollis  is 
myalgia  of  the  muscles  of  the  neck.  Usually  one  side  of  the  neck  is  attacked. 
The  chin  is  turned  from  the  afiFected  side  and  the  neck  is  stiff.  Pleurodynia 
is  myalgia  of  the  intercostal  muscles.  The  pain  is  very  severe,  is  aggravated 
by  deep  respiration,  by  coughing,  and  by  yawning,  there  may  be  tenderness, 
and  the  patient  tries  to  limit  chest-movement.  In  intercostal  neuralgia  the 
p>ain  is  limited,  is  not  constant,  but  occurs  in  distinct  paroxysms,  and  is 
linked  with  the  presence  of  the  tender  spots  of  \'alleix.  Pleurodynia  lacks 
the  physical  signs  of  pleurisy.  Cephalodynia  is  myalgia  of  the  muscles  of 
the  scalp.  The  muscles  of  the  shoulder,  upper  dorsal  region,  abdomen,  and 
extremities  may  also  be  attacked  by  myalgia.  Myalgia  must  not  be  confused 
with  the  pains  of  locomotor  ataxia. 

Treatment. — Remo\e  any  obvious  cause.  Treat  any  existing  diathesis, 
such  as  gout  or  rheumatism.  Rest  is  of  the  first  importance.  For  lumbago, 
put  the  person  to  bed.  For  pleurodynia,  strap  the  side  of  the  chest.  A 
hypodermatic  injection  of  morphin  and  atropin  into  the  affected  muscles  at 
once  aUays  the  pain,  and  a  deep  injection  of  distilled  water  is  sometimes 
curative.  Relief  may  be  afforded  by  painting  the  surface  with  30  drops  of 
a  mixture  of  equal  parts  of  guaiacol  and  glycerin  and  covering  the  painted 
area  with  cotton.  The  introduction  of  four  or  five  aseptic  needles  into  the 
muscles,  and  their  retention  for  a  few  minutes,  sometimes  acts  most  favor- 
ably. Ironing  the  skin  above  the  painful  muscles  with  a  very  warm 
iron,  a  piece  of  flannel  being  interposed,  is  a  useful  domestic  remedy. 
Vigorous  rubbing  of  the  area  with  a  piece  of  ice  allays  the  pain.  Hot  poultices 
do  good.  If  the  pain  is  widely  diffused,  alters  its  seat,  or  is  very  obstinate, 
order  hot  baths  or  Turkish  baths  and  administer  diuretics.  In  chronic  cases 
employ  blisters  or  counter-irritation  by  the  cautery,  give  iodid  of  potassium 
and  nux  vomica,  and  have  the  patient  take  a  Turkish  bath  every  week.     The 


Tumors  of  the  Muscles  727 

constant  electric  current  finds  advocates.  In  an  ordinary  severe  case  order 
a  hot  bath,  put  the  patient  to  bed  with  a  hot-water  bag  over  the  part,  and 
administer  10  grains  of  Dover's  powder;  the  next  morning  order  to  be  taken 
four  times  daily  a  capsule  containing  5  grains  of  salol  and  3  grains  of  phenac- 
etin,  until  the  pain  disappears.  Citrate  of  potassium,  citrate  of  lithium, 
chlorid  of  ammonium,  or  the  salicylate  of  colchicin  may  be  ordered  instead 
of  salol  and  phenacetin. 

Infective  myositis  is  a  wide-spread  inflammation  of  the  voluntary 
muscles,  due  to  an  unknown  infective  cause.  It  is  a  disorder  accompanied 
by  pain  and  stiffness,  by  cutaneous  edema,  and  by  various  paresthesias. 
Myositis  resembles  trichinosis,  and  is  distinguished  from  it  only  by  spearing 
out  a  bit  of  muscle  and  examining  it  microscopically.  Occasionally  diffuse 
suppuration  occurs. 

Ordinary  myositis  arises  from  injuries,  from  syphilis,  or  from  rheu- 
matism, and  it  presents  the  usual  inflammatory  symptoms.  Contraction 
and  adhesions  may  follow.  I  operated  upon  a  case  of  myositis  of  the  rectus 
abdominis  in  a  boy  of  eight.  There  was  a  large  mass  Uke  a  full  bladder. 
There  had  not  been  an  attack  of  typhoid  and  there  was  not  hereditary  syph- 
iUs.  Caseation  existed.  The  condition  was  possibly  tuberculous,  although 
no  baciUi  were  found. 

Treatment  of  Myositis. ^Infective  myositis  is  treated  by  anodynes,  stim- 
ulants, nutritious  food,  hot  applications,  and  rest.  If  pus  forms,  it  should  be 
evacuated.  Rheumatic  myositis  calls  for  the  administration  of  the  salicylates, 
the  alkahes,  or  salol.  SyphiHtic  myositis  is  treated  with  mercury  and  iodid 
of  potassium.  The  remedies  employed  for  myalgia  are  used  in  traumatic 
myositis. 

Hypertrophy  of  the  muscles  may  arise  from  their  increased  use.  In 
pseudohypertrophic  paralysis  the  bulk  of  the  muscle  is  greatly  augmented, 
but  it  contains  less  muscle-structure  and  more  fat  or  connective  tissue. 

Atrophy  of  the  muscles  arises  from  want  of  use,  from  injury,  from 
continuous  pressure,  from  interference  with  the  blood-supply,  from  disease  of 
the  nerves  or  their  centers,  or  from  lead-poisoning. 

Degeneration  of  Muscles.— The  muscles  may  undergo  granular 
degeneration,  waxy  degeneration,  fatty  degeneration,  and  calcareous  degen- 
eration, and  may  become  pigmented. 

Local  Ossification  and  Myositis  Ossificans.— It  is  not  unusual 
for  a  small  portion  of  bone  to  form  in  the  periosteal  insertion  of  a  muscle 
which  is  subjected  to  frequent  strain.  In  persons  who  ride  many  hours  a 
day  there  not  infrequently  develops  the  "rider^s  bone,'^  which  is  an  area 
of  ossification  in  the  adductor  muscles  of  the  thigh.  Myositis  ossificans,  a 
wide-spread  ossification  of  the  muscles,  is  a  rare  disorder  the  cause  of  which 
is  unknown,  and  which,  if  not  congenital,  at  least  begins  in  early  hfe.  In 
some  cases  a  traumatic  origin  seems  probable.  It  is  seen  more  often  among 
males  than  females.  Columns  of  inflammatory  swelling  and  induration 
slowly  develop,  each  column  running  in  the  direction  of  the  muscular  fibers, 
and  ossification  of  the  indurated  columns  takes  place.  It  is  stated  that  the 
thumbs  and  great  toes  shorten  (J.  Jackson  Clarke's  "Orthopaedic  Surgery"). 

Tumors  of  the  Muscles.— Primary  tumors  of  the  muscles  are  rare. 
Among  those   which   may  occur  are  sarcoma,   fibroma,   Upoma,   osteoma, 


728         Diseases  and  Injuries  of  ^luscles.  Tendons,  and  Bursae 

angioma,  myxoma,  and   enchondroma.     Most    cases  of   supposed  primary 
sarcoma  of  muscle  are  in  reality  cases  of  syphiloma  (Esmarch). 

Syphilis  may  cause  inflammation.  Gummata  may  form,  or  gumma- 
tous infiltration  may  take  place. 

Trichinosis  or  trichiniasis  is  a  disease  due  to  the  embryos  of  the 
trichina  spiralis.  The  disease  originates  from  eating  meat  which  con- 
tains the  trichinae  and  has  been  insufiiciently  cooked.  These  nematodes 
are  carried  into  the  intestine,  there  to  develop  and  multiply.  In 
from  seven  to  nine  days  a  horde  of  embryos  develop  in  the  bowel,  and  leave  the 
alimentary  canal  by  passing  through  the  peritoneum  or  by  means  of  the  blood, 
and  finally  reach  the  connective  tissue  of  the  muscles.  From  the  connective 
tissue  the  embryos  migrate  into  the  primitive  muscle-fibers,  where  they  dwell 
and  enlarge.  Myositis  develops,  and  in  the  course  of  five  or  six  weeks  the 
parasites  become  encapsuled  and  develop  no  further.  The  cyst-walls  may 
calcify  and  the  worms  may  become  calcified,  or  may  live  for  years.  The  eating 
of  infected  meat  is  not  inevitably  followed  by  the  disease,  and  a  few  embryos 
lodged  in  muscle  may  cause  no  symptoms. 

Symptoms. — The  symptoms  of  trichinosis  often  appear  in  a  day  or  two 
after  eating  infected  meat.  The  symptoms  of  acute  gastro-intestinal  catarrh 
or  of  cholera  morbus  are  common,  but  in  some  cases  no  gastro-intestinal 
manifestations  usher  in  the  disease.  In  from  seven  to  fourteen  days  after 
the  infected  meat  is  eaten  the  migration  of  the  parasites  develops  obvious 
symptoms.  A  chill  may  be  noted;  there  is  usually  fever;  muscular  pain, 
tenderness,  swelling,  and  stiffness  are  complained  of.  This  condition  may 
be  wide-spread.  Involvement  of  the  muscles  of  mastication  interferes  with 
chewing;  of  the  larynx,  wdth  talking  and  respiration;  of  the  intercostals 
and  diaphragm,  with  respiration.  Skin-edema  and  itching  are  marked.  In 
some  cases  delirium  exists.  The  writer  saw  in  the  Philadelphia  Hospital  one 
fatal  case  which  was  mistaken  for  erysipelas  because  of  the  high  fever,  the 
delirium,  and  the  edematous  redness  of  the  face  and  neck.  Dyspnea  is 
frequent.  Mild  cases  get  well  in  a  week  or  two;  severe  cases  may  last  many 
weeks.  The  mortality  varies  in  different  epidemics  from  i  to  30  per  cent. 
(Osier).  The  diagnosis  is  made  by  spearing  out  a  piece  of  muscle,  which  is 
then  examined  for  trichinae  under  a  microscope;  or  the  worms  may  perhaps  be 
detected  in  the  feces  by  means  of  a  pocket-lens.  In  a  case  under  the  care 
of  the  author,  in  St.  Joseph's  Hospital,  there  was  no  record  of  any  attack  of 
gastro-intestinal  disturbance  and  the  first  manifestation  was  enlargement 
of  the  calf  of  the  left  leg.  In  most  cases  of  trichinosis  there  is  eosinophilia, 
but  in  the  author's  case,  previously  referred  to,  eosinophilia  was  not  present. 

Treatment. — To  treat  trichinosis  employ  purgatives  (senna  and  calomel) 
early  in  the  case,  and  give  glycerin,  and  also  santonin  or  filix  mas.  WTien 
muscular  invasion  has  taken  place,  sedatives,  hypnotics,  nourishing  diet, 
and  stimulants  are  indicated. 

Ischemic  Myositis,  or  Volkmann's  Contracture  {Volkmann's  par- 
alysis; Ischemic  paralysis;  Ischemic  muscular  atrophy  with  contractures 
and  paralysis,  Fergusson  calls  it). — It  is  occasionally  noticed,  particularly 
in  children,  after  prolonged  fixation  of  the  forearm,  especially  after  pro- 
longed fixation  of  the  elbow-joint  by  some  appliance  that  impedes  the 
freedom  of  circulation  in  the  part.     Contracture  of  the  fingers  occurs  and  per- 


Ischemic  Myositis,  or  Volkmann's  Contracture  729 

haps  rigidity  and  flexion  of  tiie  wrist.  In  1875  Volkmann  described  severe 
contractures  of  the  hand  observed  in  some  cases  as  a  result  of  the  use  of  tight 
bandages  to  hold  s])lints  in  place  in  treating  fractures  of  the  arm.  He  believed 
that  the  condition  was  due  to  deprivation  of  arterial  blood,  that  the  muscles 
perished  for  want  of  oxygen,  and  that  rigor  mortis  occurred.  He  pointed  out 
that  paralysis  and  contracture  occur  simultaneously,  whereas,  in  primary 
nerve  lesion  paralysis  precedes  contracture.  The  condition  may  come  on 
after  the  application  of  an  Ivsmarch  band,  after  a  severe  injury  in  the  neigh- 
borhood of  the  elbow-joint,  may  follow  ligation  of  the  main  artery  of  a  limb, 
venous  embolism,  venous  thrombosis  from  injury  or  infectious  disease,  Ray- 
naud's disease,  or  exposure  to  cold.  One  of  Jones'  cases  followed  a  rapidly 
developing  traumatic  myositis  ossificans;  two  followed  crushes;  in  one  an 
elastic  tourniquet  had  been  kept  on  a  child's  arm  to  prevent  bleeding  after  an 
operation  for  webbed  fingers;  in  one  pad  pressure  had  been  maintained  for 
twenty-four  hours  to  check  bleeding  ("Am.  Jour.  Orthop.  Surg.,"  April,  1908). 
There  are  two  forms,  one  due  to  almost  complete  arterial  ischemia,  lasting  for 
several  hours  at  least;  another  due  to  interference  with  venous  return.  Volk- 
mann's contracture  is  due  to  a  muscular  degeneration,  infiltration,  induration, 
and  contraction,  the  result  of  marked  and  prolonged  arterial  ischemia  or  inter- 
rupted venous  return,  and  it  is  frequently  spoken  of  as  ischemic  myositis  (Dud- 
geon, "Lancet,"  Jan.  11,  1902).  In  some  cases  distinct  neuritis  with  paralysis 
also  exists.  One  characteristic  of  ischemic  contracture  is  the  rapidity  with 
which  it  comes  on.  Dudgeon  points  out  that  in  half  a  day,  or  even  in  less 
time  in  some  cases,  the  symptoms  appear,  these  symptoms  being  paralysis 
of  the  part  with  contracture.  Pain  is  unusual,  unless  the  nerves  are  ser- 
iously involved.  In  some  cases  the  fingers  and  hand  swell  and  become  dis- 
colored. The  absence  of  pain  frequently  prevents  the  recognition  of  the 
condition;  therefore,  the  causative  spHnt  or  bandage  pressure  may  be  main- 
tained for  days  after  the  trouble  has  become  serious.  When  the  splints  and 
bandages  are  removed  and  the  forearm  is  examined,  there  is  almost  alw^ays 
tenderness  over  the  muscles  and  the  nerve-trunks;  and  in  the  majority  of 
cases  in  which  a  splint  was  the  cause,  a  portion  of  the  skin  will  have  sloughed. 
Dudgeon  points  out  the  characteristic  position  of  the  deformity,  as  follows: 
When  the  wrist  is  extended,  the  metacarpophalangeal  joints  are  also  extended; 
but  the  interphalangeal  joints  of  the  fingers  and  the  terminal  joint  of  the 
thumb  are  so  strongly  bent  that  the  tips  of  the  fingers  touch  the  palm,  and  this 
position  cannot  be  corrected  by  any  justifiable  amount  of  force.  As  soon  as 
the  wrist-joint  is  bent  to  a  right  angle,  the  interphalangeal  joints  can  readily 
be  extended.  In  a  very  severe  case  the  wrist  itself  will  become  markedly 
flexed,  and  it  will  be  impossible  to  extend  it.  The  forearm  is  usually  semi- 
flexed and  the  hand  pronated.  The  ulceration  or  sloughing  so  frequently 
present  is  called  a  splint-sore.  There  is  always  marked  induration  about 
a  splint-sore.  The  flexor  muscles  themselves  are  indurated  and  usually 
wasted.  The  condition  of  sensation  depends  upon  the  state  of  the  nerves  of 
the  part.  When  neuritis  is  absent,  sensation  will  be  normal;  but  in  accord- 
ance with  the  amount  of  neuritis  and  degeneration  there  will  be  hyperesthesia, 
partial  anesthesia,  or  complete  anesthesia.  A  curious  feature  of  these  cases 
that  is  dwelt  upon  by  Dudgeon  and  commented  upon  by  Turner  is  the  fact 
that  in  young  children  there  is  a  cessation  of  growth  of  the  bone.     Robert 


73©        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

Jones  ("Am.  Jour.  Orthop.  Surg.,"  April,  1908)  reports  that  19  cases  out  of  40 
were  associated  with  fracture.  In  13  of  the  19  cases  there  was  pronounced 
malunion. 

Treatment. — The  old  view  of  this  condidon  was  that  it  is  practically  hope- 
less. Anderson  and  Dudgeon,  however,  maintain  that  restoration  may  usually 
he  obtained,  the  treatment  consisting  in  regular,  active  motion,  passive  move- 
ment, massage,  and  electricity.  Forcible  extension  under  ether  is  of  no  benefit 
whatever. 

Jones'  plan  of  treatment  is  very  beneficial  (''Am.  Journ.  Orthop.  Surg.," 
April,  1908). 

Operadve  procedures  on  arms  that  necessarily  have  deficient  circulation  are 
hazardous,  and  Jones  has  discondnued  all  operative  correction  and  rehes  upon 
purely  mechanical  and  manipulative  routine,  as  follows: 

Five  splints  are  cut  out  of  zinc,  tin,  or  sheet  wire,  to  fit  each  finger  and  thumb. 
The  wrist  is  forcibly  flexed  and  held  while  each  finger  is  separately  splinted.     It 


Fig.  392. — Rugh's  splint  for  Volkfnann's  contracture. 


will  be  observed  that  in  the  fully  flexed  position  of  the  wrist  the  fingers  are  all 
relaxed. 

When  the  finger  splints  have  been  applied  the  wrist  is  released,  and  the 
patient  is  directed  to  systematically  extend  the  carpophalangeal  joints.  In  a 
few  days  the  second  splinting  may  usually  be  employed  by  embMding  the 
entire  hand  to  the  WTist  and  the  already  splinted  fingers  in  plaster  of  Paris, 
while  the  \ATist  is  again  flexed.  Several  days  are  devoted  to  systematic  volun- 
tary efforts  at  extension  of  the  hand  in  a  similar  manner  employed  for  the 
metacarpophalangeal  joints. 

The  third  splinting  embraces  that  already  employed  and  in  addition  em- 
braces the  wrist  in  the  fullest  extension  possible,  which  in  a  few  days  may  be 
increased  until  full  extension  is  obtained.  The  latter  position  of  full  exten- 
sion of  wrist,  hand,  and  fingers  is  maintained  for  some  weeks  until  all  con- 
tractible  elasticity  has  disappeared. 


Strains  731 

It  is  usually  observed  that  when  the  hand  can  be  held  in  hyperextension 
without  tendency  to  relapse,  the  circulation  will  almost  invariably  improve  and 
the  fingers  resume  their  normal  function  and  appearance  except  in  cases  of 
nerve  destruction.  Jones  has  found  that  in  many  cases  where  the  nerves  had 
lost  their  function  during  contractu^e,  the  extension  of  the  hand  was  the  start- 
ing-point of  recovery. 

R.  H.  Sayre  ("  Volkmann's  Ischemic  Paralysis  and  Contracture,  Am.  Jour. 
Orthop.  Surg.,"  Nov.,  1908,  p.  221)  advocates  the  Jones  method  in  all  cases, 
inasmuch  as  cutting  operations  may  be  employed  later  when  the  results  of 
Jones'  treatment  are  not  entirely  satisfactory.  The  improvement  in  the  cir- 
culation and  function  obtained  by  the  Jones  method  will  make  the  operative 
field  more  capable  of  rapid  recovery. 

In  a  persistent  and  long-continued  case  an  operation  may  be  necessary. 
The  operation  may  consist  in  dividing  in  the  forearm  the  flexor  muscles  of  the 
fingers,  as  advised  by  Davies  Colley,  and  then,  at  a  later  period,  dividing  the 
flexor  tendons.  The  objection  to  his  procedure  is  that  it  destroys  the  capacity 
to  flex  the  fingers  for  all  time.  Another  suggestion  has  been  to  excise  a  piece 
from  both  the  radius  and  the  ulna,  and  wire  the  fragments  together.  The 
best  surgical  treatment  is  probably  exposing  the  nerves,  separating  them  from 
adhesions,  stretching  them,  and  then  doing  tendon-lengthening,  but  this  should 
not  be  done  until  all  the  improvement  possible  to  secure  by  conservative  treat- 
ment has  been  obtained  by  at  least  three  months  of  effort. 

Wounds  and  Contusions  of  the  Muscles. — Wounds  of  muscles  may 
be  either  opeti  or  subcutaneous.  In  a  longitudinal  wound  the  edges  lie  close 
together,  and  hence  drainage  must  be  provided  for  by  the  surgeon.  In  a 
transverse  wound  the  edges  separate  widely,  and  catgut  stitches  must  be 
inserted.  Contusions  of  muscles,  like  contusions  of  other  tissues,  vary  in 
extent  and  in  severity.  There  are  pain  (which  is  increased  by  attempts  to 
use  the  muscle),  loss  of  function,  swelling  beneath  the  deep  fascia,  and  dis- 
coloration, which  may  appear  at  once  because  of  superficial  damage  from 
the  initial  injury,  or  which  may  appear  in  dependent  parts  after  many  days 
by  gravitation  of  the  blood  and  the  blood-stained  serum.  As  a  result  of 
contusion,  suppuration,  inflammation,  or  atrophy  may  arise. 

Treatment. — In  a  longitudinal  wound,  drain;  in  a  transverse  wound, 
suture  the  muscle.  The  further  indications  in  wounds  and  contusions  of 
muscles  are  to  obtain  rest  by  means  of  spHnts  and  to  secure  relaxation.  Limi- 
tation of  swelling  is  secured  by  bandaging.  Inflammation  is  combated 
first  by  cold  and  lead- water  and  laudanum;  later  by  iodin,  blue  ointment, 
ichthyol,  and  intermittent  heat.  To  prevent  loss  of  function,  employ,  as 
soon  as  the  acute  symptoms  subside,  massage,  passive  motion,  and  stimulat- 
ing liniments,  and,  later  in  the  case,  electricity  (galvanism  if  the  reactions  of 
degeneration  exist;  faradism,  if  absent). 

Strains. — A  muscular  strain  is  a  stretching  of  a  muscle  with  a  small 
amount  of  rupture.  It  is  caused  by  traction  in  the  long  axis  of  the  muscle. 
The  muscle  becomes  swollen,  tender,  stiff,  weak,  and  sore,  and  attempts 
at  motion  produce  sharp  pain.  A  strain  of  a  tendon  is  a  trivial  or  partial 
rupture.  It  leads  to  the  development  of  acute  thecitis,  with  fluid  swell- 
ing and  pseudocrepitation.  Strains  are  common  in  the  deltoid,  the  ham- 
string  muscles,   the   back,   the   calf,    the   biceps,  and    the   great   pectoral. 


732         Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

Strain  of  the  psoas  muscle  causes  pain  on  voluntary  flexion  of  the  thigh,  and  is 
associated  with  tenderness  in  the  iliac  fossa.  Strain  of  the  right  psoas  may 
be  mistaken  for  appendicids,  but  it  lacks  the  intense  local  tenderness,  the  ab- 
dominal rigidity,  and  the  constitutional  symptoms.  '^ Lawn-tennis  arm" 
is  a  strain  of  the  pronator  radii  teres  muscle.  "'Rider's  leg"  is  a  strain  of  the 
adductor  muscles  of  the  thigh.  A  strain  of  the  long  head  of  the  biceps  flexor 
cubiti  produces  the  condition  called  by  ball  players  a  "glass  arm."  A  strain 
may  be  the  only  injury,  or  may  be  associated  with  some  other  condition  (frac- 
ture of  bone,  dislocation,  sprain,  contusion,  etc.).  A  strain  may  be  followed 
by  periostitis  at  the  point  of  insertion  of  tlie  muscle.  Atrophy  of  the  muscle 
occasionally  follows  a  strain. 

A  strained  muscle  is  usually  rigid,  is  tender,  and  pains  greatly  when  an 
attempt  is  made  to  use  it.  The  skin  over  it,  especially  over  its  point  of  inser- 
tion, is  usually  tender. 

A  strain  of  the  back  is  a  very  common  accident  which  is  often  associated 
with  sprains  of  the  vertebral  articulations.  There  is  great  pain  when  the 
patient  voluntarily  straightens  up.  If  the  vertebral  ligaments  are  not  damaged , 
the  patient  can  be  straightened  by  passive  motion  without  pain.  The  skin 
is  tender  in  certain  areas.  The  muscles  are  often  rigid.  There  may  be 
unilateral  rigidity.  In  a  back  injury  make  a  careful  examination  to  be  sure 
no  damage  has  been  inflicted  upon  the  vertebrae  or  cord. 

Treatment. — Relaxation  by  suitable  position;  rest  by  the  use  of  splints 
or  by  putting  the  patient  to  bed;  bandages  for  compression;  hot  fomentations 
or  a  hot-water  bag,  and  ichthyol.  As  soon  as  acute  symptoms  subside  employ 
frictions  and  massage.  If  there  is  much  pain  after  a  strain,  administer  Dover's 
powder,  or  even  morphin. 

Rupture  of  Muscles  and  Tendons. — Rupture  of  a  muscle  is  an- 
nounced by  a  sudden  and  violent  pain  and  by  loss  of  funcdon,  arising  dur- 
ing powerful  muscular  contraction  or  strong  traction  in  the  long  axis  of  a 
muscle.  The  rupture  may  be  announced  by  a  clearly  audible  snap  (A.  Pearce 
Gould).  A  distinct  gap  is  felt  between  the  ends;  great  pain  develops  on  move- 
ment; there  are  tenderness,  loss  of  power,  and  swelling.  Rupture  may  be 
followed  by  atrophy,  as  is  a  contusion.  Among  the  muscles  which  occasion- 
ally rupture  we  may  mention  the  quadriceps,  biceps,  triceps,  deltoid,  plan- 
taris,  etc. 

Rupture  of  the  biceps  flexor  cubiti  or  its  tendon  is  not  very  common; 
72  cases  have  been  collected  (W.  W.  Keen,  in  "Annals  of  Surgery,''  May, 
1905).  It  is  much  more  common  in  men  than  in  women.  Loos's  table  of 
66  cases  contains  records  of  only  2  women  (Doane,  in  "Jour,  of  American 
Med.  Assoc,"  May  16,  1908).  The  rupture  may  be  where  the  muscular 
belly  passes  into  the  lower  tendon,  through  the  muscular  belly,  in  the  mus- 
cular part  passing  either  to  the  long  or  short  head,  or  at  the  part  where  the  mus- 
cular belly  joins  the  long  or  short  head.  The  tendon  of  the  long  head  may  be 
torn  through  or  the  long  head  may  be  torn  from  the  glenoid  cavity.  The 
muscular  portion  is  far  more  often  injured  than  the  tendinous.  In  rupture 
of  the  muscle  belly  a  part  of  the  muscle,  in  rupture  of  the  long  head  the  entire 
mu.scle,  becomes  soft  and  relaxed.  In  rupture  of  the  belly  there  is  a  gap 
between  the  two  portions  and  each  portion  causes  a  lump.  In  rupture  of 
the  tendon  there  are  not  two  lumjjs  with  a  gap  between,  but  there  will  be  a 


Rupture  of  Muscles  and  Tendons  733 

single  muscular  lump.  In  rupture  of  the  long  head  the  muscular  belly  is 
much  nearer  the  elbow  than  in  health  (Figs.  393  and  394).  If  rupture  takes 
place  at  the  lower  part  of  the  belly,  the  muscle  passes  toward  the  shoulder. 
Rupture  of  the  long  head  of  the  biceps  allows  the  humerus  to  pass  somewhat 
forward  and  upward. 


Fig.  393.— Author's  case  of  rupture  of  the  long  head  of  the  biceps. 

Flexion  with  the  forearm  supinated  is  much  less  powerful  than  flexion 
with  the  forearm  pronated  {Hater's  sign). 

In  a  case  of  my  own  in  the  Blockley  Hospital  the  accident  had  occurred 
while  carrying  a  heavy  bucket.  Forearm  flexion  was  possible,  but  slow, 
feeble,  partial,  and  incomplete.  On  flexion  the  short  head  contracted,  but  the 
muscular  "bunch"  of  the  belly  was  nearer  the  elbow  than  normally.  Rup- 
ture of  the  plantaris  muscle  {coup  de  jouet;  lawn-tennis  leg)  is  an  injury  which 
is  frequently  not  diagnosticated.  It  occurs  during  exercise  (walking,  bicy- 
cling, jumping,  playing  tennis)  or  is  first  complained  of  after  exercise.  It 
produces  sudden  pain  in  the  middle  of  the  calf,  swelling,  and  often  ecchymosis 
and  inability  to  walk  except  with  a  rigid  ankle  and  everted  toes.  Rupture 
of  the  quadriceps  extensor  femoris  tendon  results  occasionally  from  force  which 
in  other  cases  fractures  the  patella.  The  rupture  is  just  above  the  patella. 
The  patient  cannot  extend  the  thigh  and  cannot  walk  or  stand  and  there  is 
severe  pain.  A  gap  can  be  felt  just  above  the  patella,  unless  it  is  hidden  by 
synovial  effusion,  and  the  muscle  is  bunched  above. 

Treatment. — In  limited  rupture  treat  as  a  severe  strain.  In  treating 
extensive  rupture  of  an  important  muscle,  when  the  ends  are  widely  separated, 
expose  by  a  septic  incision,  unite  the  divided  ends  with  sutures  of  chromicized 
catgut  (Fig.  100),  and  sew  up  the  skin  with  silkworm-gut.  Treat  the  part  in 
any  case  by  rest  and  relaxation  and  combat  inflammation  by  appropriate 
means.  Passive  motion  and  massage  are  employed  as  soon  as  union  is  firm. 
In  rupture  of  the  quadriceps  extensor  femoris,operation  should  be  undertaken, 


734        Diseases  and. Injuries  of  Muscles,  Tendons,  and  Bursce 

because  mechanical  treatment  gives  frequently  a  bad  result  and  confines  the 
patient  to  bed  for  weeks.  Rnptuye  of  the  biceps  requires  incision  and  suture. 
In  a  case  in  the  Blockley  Hospital  (Figs.  393  and  394)  I  operated  and  found 
that  the  long  head  with  a  portion  of  periosteum  had  been  torn  off  from  the 
glenoid  cavity.  A  portion  of  the  upper  end  of  the  tendon  was  cut  away 
and  the  tendon  was  fastened  to  the  short  head  by  splitting  and  suture.  Nine 
months  later  the  result  was  perfect  (Keen,  in  "Annals  of  Surgery,"  May, 
1905).  Rupture  of  the  plantaris  is  treated  at  first  by  rest  in  a  posterior  splint 
and  compression  and  later  by  massage  and  the  use  of  an  elastic  bandage. 
The  patient  is  allowed  to  walk  with  a  cane  in  one  week,  but  does  not  raise 
the  heel  for  several  weeks. 

Hernia  of  Muscles.— When  a  tear  takes  place  in  a  muscular  sheath, 
a  portion  of  the  muscle  protrudes.  The  treatment  is  incision,  extirpation  of 
the  protruding  mass  of  muscle,  and  suturing  of  the  muscle  wound  and  of  the 
sheath. 


Fig.  394.— Author's  case  of  rupture  of  the  long  head  of  the  biceps. 

Contractions  of  muscles  may  result  from  injury,  from  joint  disease, 
from  malposition  of  parts  (as  in  old  dislocation  or  torticollis),  or  from  diseases 
of  the  nervous  system.  The  treatment  in  some  cases  is  sudden  extension, 
in  other  cases  gradual  extension,  tenotomy,  or  myotomy.  Macewen  recom- 
mends the  making  of  a  number  of  V-shaped  incisions  in  the  muscle.  In 
some  cases  of  spasmodic  contraction  nerve-stretching  is  of  value. 

Dislocations  of  Muscles  and  Tendons.— The  long  head  of  the  biceps 
is  oftenest  displaced.  The  flexor  carpi  ulnaris,  the  peroneus  brevis,  the 
peroneus  longus,  the  tibialis  posticus,  the  sartorius,  the  plantaris,  the  quad- 
riceps extensor  femoris,  and  the  extensors  back  of  the  wrist  may  be  dislocated. 
What  is  known  as  dislocation  of  the  latissimus  dorsi,  a  condition  in  which 
that  muscle  no  longer  lies  upon  the  angle  of  the  scapula,  is  not  a  dislocation, 
but  a  paralysis.  Most  of  these  accidents  are  associated  with  chronic  joint- 
disease  or  with  fracture,  but  displacement  may  exist  as  a  solitary  injury. 
Dislocation  of  the  long  head  of  the  biceps  may  occur  tolerably  early  in  the 
progress  of  rheumatoid  arthritis  of  the  shoulder- joint,  and  the  displaced 
tendon  may  be  absorbed. 

Symptoms. — After  dislocation  of  a  tendon  the  muscle  of  the  tendon  can 
still  contract,  but  it  acts  at  a  disadvantage;  thus  the  corresponding  joint 
exhibits  partial  loss  of  function.  The  displaced  tendon  can  be  felt,  and  a 
hollow  exists  where  it  normally  resides. 

When  the  muscle  contracts,  the  tendon  is  felt  to  slip  from  its  groove. 
When  the  tendon  of  the  biceps  is  dislocated,  the  head  of  the  bone  passes 
forward  (so-called  subluxation  of  the  humerus). 

Treatment. — In  tendon-dislocation  reduction  is  easy,  but  the  displace- 


Palmar  Abscess  735 

ment  is  apt  to  recur  because  of  laceration  of  the  sheath.  The  treatment 
usually  advised  is  to  effect  reduction  by  relaxation  of  the  limb  and  manipula- 
tion of  the  tendon,  to  place  the  part  upon  a  splint  so  that  the  muscle  belonging 
to  the  tendon  will  be  relaxed,  and  to  apply  pressure  over  the  point  of  injury. 
This  treatment  generally  fails,  and  if  the  tendon  does  not  become  firmly 
anchored  in  its  proper  situation  in  four  weeks,  we  should  operate.  In  some 
tendons  it  is  enough  to  incise,  freshen  the  edges  of  the  torn  sheath,  and  sew 
up  with  kangaroo-tendon  or  chromicized  catgut.  In  a  tendon  lying  in  a  long 
groove  make  a  halter  for  the  tendon  by  incising  the  periosteum  and  suturing 
it  over  the  tendon.*  Passive  movements  are  begun  at  the  end  of  the  first 
week.  Even  if  the  tendon  will  not  remain  reduced,  a  useful  joint  will  be 
obtained. 

Wounds  of  Tendons. — Subcutaneous  wounds  of  tendons  are  usually 
inflicted  by  the  surgeon,  and  they  heal  well.  Open  wounds  require  rigid 
antisepsis  and  suturing  of  the  tendon.  In  wounds  of  the  wrist  especially 
always  suture  the  tendons  (Fig.  loi),  and  be  sure  to  bring  the  proper  ends 
into  apposition. 

Rupture  of  Tendons. — A  violent  muscular  effort  may  rupture  a  tendon, 
and  as  the  accident  occurs,  a  snap  may  often  be  heard.  The  symptoms  are 
sudden  pain  and  loss  of  power,  fullness  of  the  associated  muscle  from  retrac- 
tion, and  absolute  inabihty  to  bring  the  tendon  into  action.  A  gap  may  often 
be  felt  in  the  tendon. 

Treatment. — The  best  procedure  in  treating  rupture  of  a  tendon  is 
exposure  by  incision  and  the  introduction  of  sutures.  Some  surgeons  relax 
the  parts  and  apply  splints. 

Thecitis,  or  tenosynovitis,  is  inflammation  of  the  sheath  of  a  tendon. 

Acute  thiecitis  may  arise  from  a  contusion,  from  a  wound,  from  repeated 
overaction  in  working  or  while  engaged  in  some  sport,  from  rheumatism, 
from  gonorrhea,  from  pyogenic  infection,  from  influenza,  from  the  continued 
fevers,  or  from  syphilis.  In  early  s)T3hiHs  certain  tendon-sheaths  may  rapidly 
develop  effusion  because  of  hyperemia  of  the  sheaths  (Taylor) . 

Symptoms. — In  nonsuppurative  cases  of  thecitis  the  symptoms  are 
pain,  swelhng,  tenderness,  and  moist  crepitus  along  the  tendon-sheath,  due 
to  inflammatory  roughening.  The  crepitus  disappears  as  the  swelhng  in- 
creases, but  it  reappears  as  the  swelling  diminishes.  In  suppurative  cases 
{phlegmon  of  the  tendon-sheaths)  the  symptoms  are  great  swelling,  pulsatile 
pain,  dusky  discoloration,  inflammation  spreading  up  the  tendon-sheaths, 
and  often  the  constitutional  symptoms  of  sepsis. 

Treatment. — In  treating  non-suppurative  thecitis,  employ  splints  and 
apply  locally  iodin,  blue  ointment,  or  ichthyol,  and  administer  suitable  reme- 
dies to  combat  any  causative  constitutional  disease.  In  the  suppurative  form 
make  free  incisions,  irrigate,  drain,  dress  with  hot  antiseptic  fomentations,  and 
employ  Bier's  method  (page  116).     (See  Felon,  page  740.) 

Palmar  Abscess. — We  mean  by  this  term  an  abscess  beneath  the 
palmar  fascia  and  not  a  superficial  collection  of  pus.  Palmar  abscess  may 
arise  after  wounds,  abrasions,  burns,  or  inflammations  of  the  skin  of  the 
palm.  A  thecal  abscess  in  a  flexor  tendon  of  a  finger  travels  rapidly  upward 
and  may  produce  a  palmar  abscess.  A  thecal  abscess  of  either  the  index, 
*  Walsham's  case  of  dislocation  of  the  peroneus  longus,  Brit.  Med.  Jour.,  Nov.  2,  1895. 


736        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

ring,  or  middle  finger  is  usually  arrested  at  the  lower  end  of  the  palm, 
but  suppurative  thecitis  of  the  thumb  or  the  little  finger  conducts  pus 
along  the  tendon  sheath  and  up  the  arm  (Fig.  396).  If  the  theca  ruptures, 
pus  is  diffused  over  the  palm.  It  produces  great  swelling  of  the  hand  and 
fingers,  the  dorsum  being  swollen  as  well  as  the  palm.  The  fingers  become 
flexed  and  rigid.  Violent  pulsatile  pain  and  decided  constitutional  disturb- 
ance exist.  Discoloration  is  late  in  appearing.  Adjacent  lymph-glands 
enlarge.  Palmar  abscess  is  a  most  serious  affection.  The  pus  may  dissect 
up  all  the  structures  of  the  palm,  may  pass  between  the  bones  and  reach 
the  dorsum,  or  may  pass  beneath  the  anterior  annular  ligament  into  the 
connective-tissue  planes  of  the  forearm.  In  some  cases  it  leaves  a  clawed, 
stiff,  and  useless  hand. 

Treatment. — A  palmar  abscess  demands  radical  treatment  at  the  earliest 
possible  moment;  delay  will  be  responsible  for  stiff  and  contracted  fingers  and 
hyperesthetic  skin,  resulting  in  a  damaged  and  perhaps  a  useless  hand.  The 
patient  should  be  placed  under  the  influence  of  ether.     The  incision  is  made 


Fig.  395. — Tuberculous  thecitis  (compound  ganfjlion). 

in  the  line  of  the  metacarpal  bone  and,  if  possible,  below  the  palmar  arches. 
A  line  transverse  with  the  web  of  the  thumb  is  below  the  })almar  arches.  In 
an  incision  above  this  fine  try  not  to  cut  either  arch;  but  if  one  be  cut,  at 
once  take  means  to  arrest  the  hemorrhage  (page  450).  In  a  severe  case  it 
may  be  necessary  to  make  several  palmar  incisions,  to  open  the  tendon-sheaths 
on  the  flexor  surface  of  the  forearm  above  the  wrist,  and  to  make  counter- 
openings  in  the  back  of  the  hand,  and  it  is  sometimes  necessary  to  introduce 
tubes,  and  drain  through  and  through  the  hand.  After  operation  apply  hot 
antiseptic  fomentations  and  put  the  part  upon  a  splint.  Bier's  passive  hy- 
peremia is  very  useful.  When  granulaticjns  begin  to  form,  dry  dressings 
are  substituted  for  the  hot  moist  dressing.  It  may  be  necessary  to  give  mor- 
phin  for  pain,  and  stimulants  may  be  needed.  There  is  great  danger  of  stiff- 
ness of  the  fingers  occurring,  the  tendons  becoming  adherent  to  their  sheaths. 
Hence  passive  movements  are  inaugurated  as  soon  as  granulations  begin  to 
form. 

Chronic  thecitis  may  follow  acute  thecitis,  but  may  be  due  to  injury, 
to  rheumatism,  to  gummatous  infiltration,  to  rheumatoid  arthritis,  or  to 
tuberculous  inflammation  of  a  tendon-sheath.  Chronic  thecitis  is  commonest 
in  the  tendons  of  the  fingers,  the  ankles,  and  the  knees;  it  may  spread  to  a 
joint  or  it  may  arise  from  a  tuber^.ulnus  joint.  This  condition  causes  very 
little  pain.     In  ordinary  non-tuberculous  thecitis  the  part  is  weak,  tender, 


Ganglia 


737 


painful,  and  stiff,  crepitates  on  motion,  and  is  swollen.  In  tuberculous 
thee  His  there  is  at  first  distention  of  the  tendon-sheath  with  serum.  The 
serum  contains  rue,  riziform,  or  melon-seed  bodies,  and  the  wall  of  the  ten- 
don-sheath is  here  and  there  thickened  and  caseating.  Later  in  the  case  the 
interior  of  the  tendon-sheath  becomes  lined  with  tuberculous  granulations  and 
a  tuberculous  abscess  may  form.  Rice  bodies  are  sometimes  fibrinous  masses, 
are  sometimes  pieces  of  separated  and  dead  recently  formed  fibrous  tissue,  and 
are  sometimes  masses  of  proliferating  cells.  In  these  tuberculous  cases  the 
swelling  is  firm  or  doughy  when  due  to  granulation  tissue,  but  is  fluctuating 
when  due  to  fluid.  Grating  is  marked.  Tubercle  bacilli  are  present  in  the 
fluid  or  in  the  granulation  tissue.  Tuberculous  thecitis  is  most  conmion 
about  the   ATist.  constituting  the  so-called  compound  ganglion  (Fig.  395). 

Treatment. — Tuberculous  cases  are  treated  as  follows:  If  there  is  a  fluid 
effusion  and  no  rice  bodies,  make  a  small  incision,  wash  out  with  salt  solution, 
introduce  some  iodoform  emulsion,  and  close 
the  wound.  In  cases  in  which  there  are  rice 
bodies,  open  the  sheath,  evacuate  the  con- 
tents, scrape  the  walls  thoroughly,  inject  with 
iodoform  emulsion,  and  close  the  wound. 
(If  the  annular  ligament  requires  di\ision, 
stitch  it  before  closing  the  wound — Fig. 
411,)  In  cases  with  extensive  thickening 
apply  an  Esmarch  bandage,  make  a  large 
incision,  and  remove  all  infected  tissue  from 
the  sheath,  around  the  sheath,  and  from  the 
tendon.  In  tuberculous  thecitis  Bier's 
method  (page  249)  may  be  of  service  and  so 
may  the  .v-rays.  In  ordinary  traumatic  the- 
citis use  for  the  first  few  days  rest  associated 
with  applications  of  ichthyol.  Later  employ 
hot  and  cold  douches,  massage  and  passive 
movements,  strapping  of  the  part,  inunctions 
of  ichthyol,  and  the  hot-air  bath.  If  effusion 
is  persistent  or  rice  bodies  e.xist.  make    an 


Fig.  396. — Palmar  synovial  sheaths 
(vaginse  tendinum),  normal  adult  type 
(Poirier  and  Charpy). 


In  s}-phihtic  cases  admin- 


incision  and  scrape  the  interior  of  the  ten 
don-sheath.     In  rheumatic  cases  give  anti- 
rheumatic remedies  and  employ  the  hot-air  bath, 
ister  mercur}"  and  iodid  of  p)otassium. 

Ganglia. — In  connection  with  tendon-sheaths  and  joints  simple  ganglia 
may  develop.  They  are  small,  tense,  round  swellings,  which  are  firm,  grow 
progressively  though  slowly,  are  painless  when  uninflamed,  and  contain  a  fluid 
of  the  appearance  and  consistence  of  glycerin-jelly  (Bowlby).  Ganglia  are 
commonest  upon  the  dorsum  of  the  wrist  and  they  occur  especiallv  in  those 
who  constantly  use  the  wrist  muscles.  GangUa  are  occasionally  seen  on  the 
dorsum  of  the  foot.  Paget  states  that  a  simple  ganglion  is  due  to  cystic  de- 
generation of  a  s^-no^ial  fringe  inside  a  tendon-sheath,  and  that  the  fluid  of 
the  ganglion  does  not  communicate  with  the  fluid  of  the  tendon-sheath.  Other 
pathologists  have  maintained  that  a  simple  ganghon  is  a  hernia  of  s}Tio\ial 
membrane  through  a  rent  in  a  tendon-sheath,  all  communication  between  the 


47 


738        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 


herniated  part  and  the  tendon-sheath  being  soon  obliterated.  The  belief  is 
now  general  that  a  ganglion  is  due  to  cystic  degeneradon  of  an  area  of  con- 
nective tissue  adjacent  to  a  joint  or  a  tendon,  this  area  of  tissue  hanng  been 
rendered  extremely  cellular  by  traumatism.  A  number  of  minute  cysts 
form  and  they  coalesce  into  one  cyst.  The  cyst  may  form  a  secondary  com- 
munication \\-ith  the  interior  of  a  tendon-sheath  or  joint.  Ganglia  occasionally 
diminish  in  size  or  even  disappear  spontaneously.  Compound  ganglion  is  an 
old  name  f()r  tuberculous  thecitis. 

Treatment. — A  ganglion  is  treated  by  aseptic  puncture  with  a  tenotome, 
evacuation,  scarification  of  the  walls,  antiseptic  dressing,  and  pressure.     An 


F'g-  397- — Ganglion  of  extensor  tendon-sheaths  of  the  wrist. 

old-time  method  of  treatment  was  subcutaneous  rupture  brought  about  by 
striking  with  a  hea\T  book.  Duplay  treats  a  ganglion  by  injecting  a  few 
drops  of  iodin  through  a  hj-podermatic  needle.  The  cyst  is  not  evacuated 
before  injection.  The  parts  are  dressed  antiseptically,  and  cure  is  obtained 
in  one  week.  Recurrent  gangha,  ver\'  large  ganglia,  and  ganglia  with  very 
thick  contents  should  be  dissected  out. 

Felon,  or  whitlow,  is  a  \dolent,  rapidly  spreading  pyogenic  inflamma- 
tion of  a  finger  or  a  toe  which  resembles  cellulitis,  and  which  is  sometimes 
followed  by  gangrene  of  the  soft  parts  or  by  necrosis  of  bone  (Fig.  39S).  As 
a  rule,  an  injur}-  precedes  the  whitlow — an  abrasion  of  the  surface  which 
admits  pus-organisms  or  a  contusion  which  creates  a  point  of  least  resist- 
ance. The  commonest  seat  of  a  felon  is  the  last  digit  of  a  finger  or  the 
thumb.  An  abrasion  of  the  surface  at  this  point  absorbs  pus-organisms  and 
the  superficial  l}-mphatics  carry  the  bacteria  directly  inward,  the  micro- 
organisms lodging,  it  may  be,  in  the  skin,  in  the  subcutaneous  tissues,  in  the 
tendon-sheath,  or  beneath  the  periosteum.  The  perpendicular  direction  of 
the  fibers  of  the  subcutaneous  tissue  favors  this  passage  inward. 

Felons  are  ven,-  rare  in  infants,  but  may  occur  in  children.  Women  are 
more  Uable  to  them  than  are  men.  The  fingers  are  much  more  prone  to 
infection  than  are  the  toes,  because  they  are  more  exposed  to  injur>\  Several 
fingers  may  be  attacked  at  once  or  successively  in  persons  of  dilapidated 
constitution.  WTiitlow^  is  most  apt  to  occur  and  is  most  severe  in  persons 
broken  down  by  disease,  alcoholism,  overwork,  or  worr}-.  In  certain  cases 
of  neuritis  painless  suppuration  may  arise.  In  s\Tingomyelia  painless  felons 
are  common,  and  they  are  apt  to  be  associated  with  necrosis  of  bone.     Pain- 


Deep  Felons 


739 


less  and  destructive  whitlows  constitute  a  characteristic  part  of  Morvan's 
disease. 

There  are  two  forms  of  felons,  the  superficial  and  the  deep. 

Superficial  Felons. — One  form  of  superficial  felon  is  between  the  cuticle 
and  the  true  skin  and  is  rarely  followed  by  involvement  of  deeper  parts.  The 
infection  is  in  the  skin.  The  point  of  infection  becomes  dark  red,  swollen, 
painful,  and  tender.  The  epidermis  is  lifted  up  into  a  pustule  by  the  sero-pus 
which  forms,  and  a  considerable  area  may  be  attacked  before  the  spread  of  the 
process  is  arrested.  The  commonest  form  of  superficial  felon  is  subcutaneous 
suppuration,  the  pus  collecting  in  the  fibro-fatty  pad  at  the  palmar  surface 
of  the  last  digit  (G.  B.  Mower  WTiite,  in  "Brit.  Med.  Jour.,"  Feb.  24,  1906). 
This  form  often  spreads  deeply.  If  the  subcutaneous  tissues  only  are  involved, 
the  s}Tnptoms  are  those  of  an  ordinary  celluHtis.  There  is  severe  pain,  increased 
by  motion,  pressure,  and  a  dependent  position.  Swelling  and  discoloration 
are  early  and  marked.   Pus 

forms    within     forty-eight      r- ^ 

hours.  Paronychia,  or 
"ring  around,"  is  a  cellu- 
litis starting  at  the  end  or 
side  of  the  digit,  and  in- 
volving the  parts  around 
and  below  the  nail.  The 
pus-organisms  obtain  en- 
trance by  means  of  an  ab- 
rasion, a  puncture,  or  an 
ulcerated  "step-mother." 
In  paronychia  pain  is  throb- 
bing and  violent;  is  in- 
creased by  motion,  pres- 
sure, or  a  dependent  posi- 
tion; the  skin  is  dusky  red, 
but  the  swelling  is  slight. 
In  about  forty-eight  hours 
pus  forms  in  the  superficial 
parts,  the  epidermis  being 

lifted  into  pustules  or  blebs,  and  pus  may  also  form  under  the  nail 
of  the  nail  or  the  entire  nail  may  be  lost. 

If  the  tendon-sheath  becomes  involved  as  well  as  the  subcutaneous  tissue, 
the  s}-mptoms  are  those  of  suppurative  thecitis,  with  more  marked  discoloration 
of  the  skin. 

Deep  Felons  (Fig.  398). — There  are  two  forms  of  deep  felon.  One  is  a 
thecal  abscess  involving  the  flexor  tendon-sheath,  arising  secondarily  to 
subcutaneous  suppuration  and  spreading  widely.  In  suppurative  thecitis  of 
the  three  middle  fingers  the  process  seldom  reaches  the  palm;  in  suppurative 
thecitis  of  the  theca  of  the  thumb  or  Httle  finger  the  pus  may  pass  above  the  wrist 
and  a  true  palmar  abscess  may  form  (Fig.  396).  Another  form  is  suppuration 
beneath  the  periosteum.  This  form  is  the  so-called  hone  felon.  It  is  occasion- 
ally primary,  but  more  often  arises  secondarily  to  suppurative  thecitis  or  to  sub- 
cutaneous suppuration.     In  some  cases  a  deep  felon  involves  most  of  the  struc- 


Fig.  398. — Deep  felon,  with  sloughing- of  soft  parts  and  necrosis 
of  bone. 


A  portion 


740        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursa 


tares  of  the  finger  (periosteum,  bone,  tendon,  tendon-sheath,  and  cellular  tissue), 
and  may  destroy  the  digit  or  the  finger.  The  bacteria  causative  of  a 
deep  felon  are  lodged  in  the  deeper  parts.  The  pain  is  agonizing,  entfi-ely 
preventing  sleep,  pulsatile  in  character,  associated  with  excruciating  tender- 
ness, greatly  aggravated  by  motion  or  a  dependent  position,  and  often  extend- 
ing up  the  hand  and  forearm.     The  skin  is  dusky  red  and  edematous,  and 

the  part  is  enormously  swollen.  Pus  forms 
quickly;  diffuse  cellulitis  may  arise;  slough- 
ing of  the  tendon  and  subcutaneous  tissue  may 
take  place;  necrosis  of  one  or  more  bones  may 
ensue,  and  in  some  cases  gangrene  of  the  finger 
follows. 

In  deep  whitlow  lymphangitis  of  the  fore- 
arm and  arm  is  not  unusual,  adenitis  of  the  axil- 
lary glands  is  common,  and  almost  always 
there  is  fever.  In  superficial  felon  consti- 
tutional symptoms  are  shght  or  absent,  and 
lymphangitis  and  adenitis  arise  in  a  minority 
of  cases. 

Treatment. — In  a  subcuticular  felon,  after 
cleansing,  soften  the  parts  well  in  an  antiseptic 
fluid  and  then  pare  off  the  cuticle  with  a  very 
sharp  knife.  This  plan  of  A\Tiite's  is  an  excel- 
lent one;  it  gives  vent  to  pus  and  prevents  the 
inoculation  of  the  deeper  tissues  which  may 
follow  incision.  In  subcutaneous  suppuration 
incise  the  abscess,  but  be  careful  not  to  open  the  tendon-sheath  or  perios- 
teum, as  this  would  diffuse  infection  (White,  in  "Brit.  Med.  Jour.," 
Feb.  24,  1906).  In  neither  of  the  above  instances  is  it  necessary  to 
give  an  anesthetic.  After  operating  the  parts  must  be  irrigated,  dressed  with 
hot  antiseptic  fomentations,  the  hand  must  be  placed  upon  a  sphnt,  and 
Bier's  passive  hyperemia  is  to  be  induced  daily.  In  a  deep  felon  I  am  convinced 
that  we  should  operate  immediately.  Allay  tension  and  prevent  pus-forma- 
tion by  early  incision.  Do  not  waste  dme  with  poultices;  to  wait  means 
agonizing  pain,  sleepless  nights,  constitutional  involvement,  and,  perhaps, 
sloughing  of  tendons  or  death  of  bone.  Incision  and  drainage  constitute 
the  treatment,  but  incision  conducted  in  a  particular  manner.  I  have  only 
lately  learned  how  to  treat  a  deep  felon.  I  formerly  treated  all  cases  by  incisions 
down  to  the  bone  alongside  of  the  tendon  (Fig.  399)  and  was  frequently  disap- 
pointed by  a  spread  of  the  suppuration  in  spite  of  incisions,  by  necrosis  of  bone, 
or  by  extensive  sloughing  of  tendons.  A  few  months  ago  I  obtained  new  fight 
upon  this  subject  from  an  article  on  "Whitlow, "  by  G.  B.  Mower  White  ("Brit. 
Med.  Jour.,"  Feb.  24,  1906).  I  immediately  put  in  practice  the  common- 
sense  suggestions  in  this  valuable  article  and  have  seen  a  surprising  improve- 
ment in  results.  The  chief  points  in  White's  plan  of  treatment  are  as  follows: 
To  plunge  a  knife  through  an  area  of  infection  into  a  tendon-sheath  if  that 
sheath  is  not  infected  will  lead  to  infection,  and  the  way  to  be  sure  whether 
it  is  or  is  not  infected  is  to  look  through  a  carefully  made  incision  and  see. 
After  careful  sterilization,  anesthetize,  drain  the  extremitv  of  blood  by  ele- 


Fig.  399.— I,  z.and  3,  Incisions 
for  felon  of  finger  and  for  ordinary 
suppuration;  4,  palmar  incision. 


Bursitis  741 

vation,  and  apply  an  Esmarch  hand  to  the  arm.  This  enables  us  to  see  what 
we  arc  doing.  Make  an  incision  hy  the  side  of  the  tendon-sheath  (Fig.  3Q9), 
slowly  and  carefully,  and  on  reaching  it  see  if  it  is  distended.  If  in  doubt,  insert 
a  hypodermatic  needle  and  withdraw  fluid.  If  we  get  turbid  serum,  the  theca 
is  infected.  If  the  theca  is  not  infected,  do  not  open  it  but  incise  the  subperi- 
osteal area  of  suppuration  if  it  exists.  If  the  theca  is  infected,  remember  that  this 
infection  has  surely  ascended  more  or  less,  and  we  must  not  only  open  at  the  lower 
point,  but  must  also  incise  at  the  upper  point.  Do  not  incise  the  theca  over  the 
length  of  the  tendon,  as  sloughing  will  follow.  If  one  of  the  three  middle 
fingers  is  involved,  incise  the  distal  end  of  the  theca  and  also  the  proximal  end 
over  the  head  of  a  metacarpal  bone  in  the  mid-line,  wash  from  opening  to 
opening,  and  drain.  If  the  theca  of  the  thumb  or  little  finger  is  involved,  open 
distally  and  then  proximally  above  the  wrist.  To  reach  the  proximal  end  of 
the  theca  of  the  thumb  cut  at  the  radial  side  of  the  tendon  of  the  flexor  carpi 
radiahs.  Also  open  the  palmar  sac  of  the  flexor  longus  pollicis,  making  the  cut 
along  the  inner  border  of  the  outer  head  of  the  flexor  brevis  pollicis. 

To  reach  the  proximal  end  of  the  theca  of  the  little  finger  begin  an  incision 
at  the  upper  margin  of  the  annvilar  ligament  and  carry  it  up  along  the  inner 
border  of  the  flexor  sublimis.  Retract  the  tendons  and  pus  will  usually 
be  found  between  the  tendons  of  the  superficial  and  deep  flexor.  Look  beneath 
the  profundus  tendons  for  the  bursa  and  open  it.  Then  open  the  palm  by  an 
incision  in  the  line  of  the  axis  of  the  ring-finger.  Thus  three  openings  are  made 
in  either  case,  and  the  theca  can  be  thoroughly  washed  and  drained.  If 
either  the  thumb  or  little  finger  bursa  is  found  infected,  the  other  must  be 
exposed  and  examined,  as  they  usually  communicate  at  their  proximal  ends 
or  a  communication  may  form  as  a  result  of  suppuration.  Rupture  of  either 
bursa  may  diffuse  pus  widely.  White,  in  order  to  prevent  secondary  hem- 
orrhage, ligates  the  radial  artery  in  two  places  and  removes  ij  inches  of  it 
(if  operating  on  the  thumb  bursa);  and  ligates  the  superficial  arch  and 
removes  i  inch  of  it  (if  operating  on  the  palmar  expansion  of  the  little  finger 
theca).  These  arterial  ligations  seem  a  serious  and  perhaps  unnecessary 
addition  to  the  operation  and  I  have  not  practised  them.  After  thorough 
irrigation  apply  antiseptic  fomentations,  splint  the  extremity,  and  induce 
.Bier's  passive  hyperemia  daily.  If  the  patient  cannot  sleep,  give  morphin. 
See  that  the  bowels  are  moved  once  a  day.  Give  quinin,  iron,  and  milk-punch. 
As  soon  as  granulations  begin  to  form,  use  dry  dressings  and  make  passive 
motion  daily.  If  bone  undergoes  necrosis,  let  it  loosen  and  then  remove  it. 
Amputation  is  sometimes  necessary. 

Bursitis  is  inflammation  of  a  bursa.  Acute  bursitis  arises  from  strain 
or  from  traumatism.  The  symptoms  of  acute  bursitis  are  pain,  limited 
swelling,  moist  crepitus,  fluctuation,  and  discoloration  in  the  anatomical 
position  of  a  bursa.  In  chronic  bursitis  there  is  intermittent  pain,  tender- 
ness, and  progressive,  fluctuating  swelling.  Bursitis  of  the  retrocalcaneal 
bursa  {Alberfs  disease)  is  a  painful  aflfection  which  is  often  overlooked.  It 
is  rather  common  in  storekeepers  who  rise  often  on  the  toes  to  reach  shelves, 
in  motormen  who  use  a  foot  gong,  in  street-car  conductors,  and  clerks  who 
stand  at  desks.  It  may  follow  gonorrhea.  Walking  causes  great  pain 
in  the  heel.  Raising  up  on  the  toes  is  exceedingly  painful.  It  is  usually 
associated  with  flat-foot.     In  these  cases  osteophytes  often  form  within  the 


742        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursas 


bursa.  There  are  numerous  bursae  about  the  hip.  Some  anatomists  count 
twenty-one.*  The  two  most  important  bursae  and  the  ones  usually  affected 
are  the  iliac  and  the  deep  bursa  over  the  great  trochanter,  f  Inflammation 
of  the  iliac  or  ilio-psoas  bursa  produces  swelling  below  Poupart's  ligament, 
which  swelling  is  tense,  but  exhibits  fluctuation  on  careful  examination. 
Often  the  swelling  attains  large  size.  In  some  cases  the  sac  can  be  emptied 
by  pressure,  the  fluid  passing  into  an  adjacent  bursa  or  into  the  joint.  The 
swelling  is  beneath  the  femoral  artery  and  consequently  lifts  that  vessel 
(F.  B.  Lund,  in  "Boston  Med,  and  Surg.  Jour.,"  Sept.  25, 1902).  The  enlarge- 
ment often  presses  on  the  anterior  crural  nerve  and  causes  spasmodic  pain 
throughout  the  nerve's  trajectory.  The  limb,  according  to  Zuelzer,  is  usually 
slightly  flexed,  abducted  and  rotated  outward,  and  movement  in  an  opposite 
direction  causes  pain.  Inflammation  of  the  bursae  about  the  hip  may  produce 
symptoms  resembling  those  of  incipient  coxalgia,  but  in  bursitis  the  symptoms 
do  not  remit,  as  in  hip-disease.     lUo-psoas  bursitis  occasionally  results  from 

gonorrhea.  The  bursa  is  sometimes 
involved  in  joint-disease.  In  inflam- 
mation of  the  iliac  bursa  flexion  is 
not  so  marked  as  in  coxalgia,  and  the 
trochanter  is  never  above  Nelaton's 
line.  In  inflammation  of  the  deep 
trochanteric  bursa  the  position  is  the 
same  as  in  iliac  bursitis,  and  resem- 
bles that  of  coxalgia.  In  coxalgia, 
however,  there  is  pain  on  pressure 
upon  the  front  of  the  joint  or  directly 
on  the  trochanter  or  on  tapping  the 
sole  of  the  foot.  These  manipula- 
tions do  not  cause  pain  in  bursitis 
(Zuelzer).  In  inflammation  of  the 
gluteal  hurscB  there  is  moderate  pain 
back  of  the  thigh  and  knee,  which 
disappears  when  the  patient  is  at  rest;  there  are  a  marked  limp,  limitation 
of  motion,  and  an  area  of  deep  fluctuation  in  the  buttock  (Brackett). 

It  is  difficult  to  differentiate  between  inflammation  of  a  deep  bursa  and 
synovitis;  indeed,  in  bursitis  the  joint  is  apt  to  be  secondarily  affected.  This 
difficulty  is  especially  vexatious  in  distinguishing  between  joint-injury  and 
injury  of  the  bursa  beneath  the  deltoid.  Suppuration  may  take  place  in  a 
bursa.  Direct  force  may  rupture  a  bursa.  The  bursa  beneath  the  deltoid 
is  frequently  ruptured.  When  this  accident  happens,  there  are  pain,  marked 
swelling,  a  large  area  of  moist  crepitus,  and  later  extensive  discoloration 
from  blood.  Chronic  bursitis  may  follow  acute  bursitis,  or  the  disease  may 
be  chronic  from  the  start.  It  may  be  due  to  tuberculosis.  Bursae  particu- 
larly apt  to  become  tuberculous  are  those  about  the  hip,  the  subdeltoid,  the 
olecranon,  the  prepatellar,  and  the  retrocalcaneal.  In  tuberculous  bursitis 
during  the  first  stage  the  bursa  is  distended  with  fluid,  due  to  oversecretion , 
the  walls  are  thickened  here  and  there,  and  perhaps  contain  caseous  foci  and 

*Synnestvedt,  of  Sweden. 

t  Zuelzer  in  Zeit  f.  Chir.,  vol.  1. 


Fig.  400. — Olecranon  bursitis. 


Bursitis 


743 


rice  bodies  are  found  in  the  bursal  fluid.    In  a  more  advanced  stage  the  bursal 
wall  is  lined  with  caseating  granulation  tissue  and  the  bursa  may  become  a 


Fig.  401. — Housemaids'  knee. 


Fig.  402. — Bursitis  of  left  olecranon  bursa  of  three  years'  duration. 


tuberculous  abscess,  the  walls  may  give  way  with  diffusion  of  the  process, 
or  mixed  infection  with  pyogenic  organisms  miay  occur.     In  some  cases  of 


744        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

tuberculous  bursitis  tending  to  cure  the  bursal  walls  become  enormously 
thickened  by  fibrous  tissue.  The  symptom  of  chronic  bursitis  is  swelling 
with  little  or  no  pain  unless  acute  inflammation  arises.  Chronic  bursitis  of 
the  subhyoid  bursa  is  known  as  Boyer's  cyst. 

Treatment. — Acute  bursitis  is  treated  by  rest,  pressure,  and  the  apph- 
cation  of  iodin,  blue  ointment,  or  ichthyol.  If  the  swelling  persists,  aspirate 
and  apply  pressure,  or  incise  the  sac  and  remove  it  partly  or  completely. 
If  pus  forms,  incise,  paint  the  interior  of  the  sac  with  pure  carbolic  acid, 
and  pack  with  iodoform  gauze.  Chronic  bursitis  may  be  cured  by  the  use 
of  pressure  and  the  application  of  blue  ointment,  and  with  treatment  of 


Fig.  403. — Diagram  from  a  frozen  section.  Notice  the  deltoid  and  its  origin,  from  the 
edge  of  the  acromion.  Notice  the  subdeltoid  or  subacromial  bursa  with  its  roof  made  by 
the  under  surface  of  the  acromion  and  by  the  fascia  beneath  the  upper  portion  of  the 
deltoid.  Its  base  is  on  the  greater  tuberosity  and  the  tendon  of  the  supraspinatus,  which 
separates  it  like  an  interarticular  fibrocartilage  from  the  true  joint  (Codman). 

any  causative  diathesis,  but  most  cases  require  Incision  and  packing.  A 
ruptured  bursa  is  treated  as  an  acute  bursitis.  In  bursal  tuberculosis  the 
best  treatment  is  excision.  If  we  are  dealing  with  a  very  deep  bursa,  the 
proper  treatment  is  incision,  scraping  with  a  sharp  spoon,  mopping  with 
carbolic  acid,  and  packing  with  iodoform  gauze. 

Bursitis  of  the  subacromial  bursa  has  been  considered  by  A.  E. 
Codman  ("Boston  Med.  and  Surg.  Jour.,"  Oct.  22  and  29,  Nov.  5,  12,  19,  and 
26,  and  Dec.  3,  1908),  who  points  out  that  the  deltoid  and  the  subacromial 
bursa  are  one  and  the  same  thing.  When  the  arm  is  abducted,  the  entire 
bursa  is  subacromial;  when  it  is  adducted,  a  large  portion  of  the  bursa  is 
subdeltoid.  Codman  describes  three  types  of  condidons  associated  wath 
inflammation  of  this  bursa,  first:  The  acute,  or  spasmodic  t}'pe,  in  which 


Bursitis  of  the  Subacromial  Bursa 


745 


there  is  local  tenderness  on  the  point  of  the  shoulder,  just  below  the  acro- 
mion process  and  outside  the  bicipital  groove.  In  some  cases  Uawbarn 
has  shown  that  the  tender  point,  which  is  the  base  of  the  bursa,  disappears 
under  the  acromion  when  the  arm  is  abducted.  Codman  goes  on  to  show 
that  in  attempting  abduction  about  ten  degrees  of  motion  can  be  obtained 
without  moving  the  scapula.  Then  the  scapula  is  locked  by  spasm  and 
moves  with  the  humerus.  This  spasm  may  be  temporary  in  mild  cases. 
Sometimes  pain  prevents  the  patient  from  voluntarily  raising  the  arm,  though 
't  may  be  raised  by  passive  motion.  The  pain  may  run  down  the  outer  side 
of  the  arm,  even  into  the  hand;  the  patient  frequently  locates  the  pain  about 
the  insertion  of  the  deltoid,  and  may  be  able  to  note  swelling  of  the  bursa. 

Codnian  describes  type  two,  the  subacute  or  adherent  type,  in  which 
there  are  adhesions  between  the  roof  and  floor  of  the  bursa  and  a  definite 
mechanic    hindrance   to  abduction  and  external   rotation.      There  may  or 


Fig.  404. — Showing  incision  used  for  demonstration  of  the  bursa  (Codman). 

may  not  be  local  tenderness,  but  Dawbam's  sign  is  absent,  owing  to  the 
presence  of  the  adhesions.  Abduction  is  limited  to  such  a  great  degree  that, 
as  a  rule,  the  tuberosity  will  not  pass  beneath  the  acromion.  Any  movement 
in  abduction  beyond  ten  degrees  causes  the  scapula  to  move.  The  pain  is 
located  as  in  type  one,  and  frequently  also  passes  into  the  neck.  In  some 
cases  it  is  very  severe. 

Codman's  third  form  is  the  chronic  or  non-adherent.*  In  this  the  full 
arc  of  motion  is  retained,  but  motion  is  painful.  The  bursa  is  thickened 
and  irregular.  There  may  or  may  not  be  local  tenderness;  and  if  this  is 
present,  one  will  find  Dawbam's  sign.  Abduction  and  external  rotation  are 
limited  little,  if  at  all,  but  at  some  point  during  abduction  there  is  severe 
tenderness,  which  disappears  as  soon  as  the  tuberosity  passes  beneath  the 
acromion.  The  scapula  does  not  accompany  the  motions  of  the  humerus. 
There  is  often  considerable  pain  after  motion. 

Codman  points  out  that  the  prognosis  in  type  one  is  very  favorable  if 
treatment  is  correct.      In  type  two  the  disability,  even  without  treatment, 


746        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

seldom  lasts  more  than  two  years.  He  says  that  even  severe  or  adherent- 
cases,  if  there  are  no  secondary  contractures  in  the  forearm  muscles,  will 
recover  in  from  one  to  two  years.      In  infective  cases  the  prognosis  is  far 


Fig.  405. — Showing  the  abduction  splint  in  position,  the  patient  standing.  It  is  held 
by  a  figure-of-8  bandage,  which  crosses  behind  the  shoulders  and  by  a  belt  about  the  hips. 
The  arm  is  at  rest  (Codman). 

Description  of  Splint. — The  frame  of  the  splint  which  I  use  is  made  of  iron  wire  (diameter, 
^  inch),  stiff  enough  to  maintain  its  form  and  to  carry  the  weight  of  the  arm  securely. 
Sufficient  cotton  wadding  to  thoroughly  pad  it  is  bandaged  over  it  and  the  whole  covered 
with  cotton  or  linen  cloth.  The  general  shape  is  shown  in  the  photograph.  It  should  be 
just  long  enough  to  extend  from  the  axilla  to  the  seat  of  the  chair  on  which  the  patient  sits. 
It  is  best  held  in  position  by  a  belt  around  the  pelvis  and  a  figure-of-8  flannel  bandage  about 
the  shoulders  crossing  back  of  the  neck.  A  pad  should  be  placed  in  the  opposite  axilla  to 
prevent  excoriation  of  the  skin  by  the  bandage. 

During  the  first| twenty-four  hours  and  afterward,  if  worn  at  night,  the  arm  should  also 
be  lightly  bandaged  to  the  projecting  part  of  the  splint.  Additional  security  is  given  by 
the  application  of  a  swathe,  which  may  be  pinned  to  the  bandage  of  the  axilla. 

When  properly  adjusted  it  is  perfectly  comfortable.  Unless  it  is  comfortable  it  is  use- 
less.    The  use  of  the  splint  is  not  essential  and  is  even  harmful  if  not  skilfully  cared  for. 


worse  than  in  traumatic  cases.     In  chronic  cases,  in  which  the  arc  of  mobility 
is  not  affected,  the  prognosis  is  fairly  good. 

Treatment. — Acute  cases  of  subacromial  bursids  should  be  treated  by 
keeping  the  arm  abducted.  Monks  suggests  that  the  patient  may  sit  by  a 
table,  the  arm  being  abducted  and  placed  upon  a  pillow  that  is  on  the  table. 


Bunion 


747 


This  relaxes  the  short  rotators  and  the  deltoid,  and  keej)S  the  base  of  the 
bursa  from  being  in  contact  with  the  acromion  (Codman).  At  night  Cod- 
man  j)laces  the  arm  on  a  pillow,  with  its  long  axis  at  right  angles  with  the 
patient's  body  as  he  lies  recumbent.  If  the  patient  has  to  get  about,  he  may 
use  a  sling  most  cautiously.  He  should  take  the  arm  out  from  time  to  time 
and  rest  it  on  a  table.  Massage  should  be  used  about  the  bursa,  but  not 
directly  over  it.  In  the  more  severe  cases  with  adhesions  one  may  employ 
massage,  passive  and  active  movements,  baking,  forcible  movement  and 
manipulation  under  an  anesthetic,  followed  by  fixation  in  the  yjosition  of 
abduction,  or  perhaps  incision  of  the  bursa  with  division  of  the  adhesions 
or  excision  of  the  subdeltoid  portion  of  the  bursa  (Codman) .  In  the  cases 
in  which  there  is  irregularity  of  the  surface  of  the  bursa,  one  should  excise 
and  remove  the  thickened  folds  or  other  irregularities. 

Housemaids'  knee  (Fig.  401)  is  thickening  and  enlargement  of  the 
prepatellar  bursa,  the  result  of  intermittent  pressure.  In  effusion  into  the  knee- 
joint  the  fluid  is  behind  the  patella  and  the  bone  floats  up;  in  housemaids' 
knee  the  fluid  is  above  the  bone  and  the  osseous  surface  can  be  felt  beneath  it. 
"Miners'  elbow"  (Fig.  402^,  which  is  a  condition  similar  to  house- 
maids' knee,  affects  the  olecranon  bursa. 

"Weavers'  bottom"  is  enlargement  of  the  bursa  over  the  tuberosity 
of  the  ischium.  A  biursa  which  is  simply  thickened  and  enlarged  rarely  gives 
rise  to  annoyance;  but  when  it  inflames,  as  it  is  apt  to  do,  it  causes  the  ordi- 
nary symptoms  of  bursitis. 

Treatment  of  Special  Forms. — 
Some  few  cases  of  housemaids'  knee 
may  be  cured  by  rest  and  blistering,  but 
in  most  cases  it  is  necessary  to  incise 
and  pack  with  iodoform  gauze.  In 
enlargement  of  the  bursa  beneath  the 

Kgamentum  patellae,  if  rest  and  blister- 
ing fail  to  cure,  aspirate  or  incise.     In 

enlargement  of  the  bursa  beneath  the 

tendon  of  the  semimembranosus  and 

also    in    "weavers'    bottom"   and    in 

"miners'  elbow,"  incise  and  pack.     In 

operating  for  ilio-psoas  bursitis  I  fol- 
low Lund's  advice  and  make  a  vertical 

incision  below  Poupart's  ligament,  and 

between    the    anterior    crural    nerve 

and  the   femoral  artery.      The  fibers 

of  the  ilio-psoas  muscle  are  separated 

and  the  bursa  is  opened  and  drained. 

Some    few    cases     of     retrocalcaneal 

bursitis  recover  after  rest,   but    most 

of  them  require  incision  and  drainage. 

If    osteophytic    formations    exist,  the 

bony  stalactites  must  be  removed  by 

means  of  the  rongeur.     Flat-foot,  if  it  exists,  is  treated  by  a  support  (page  759). 
Bunion. — A  bunion  is  a  bursa  due  to  pressure,  and  it  is  most  commonly 

situated  above  the  metatarsophalangeal  articulation  of  the  great  toe,  but  is 


Fig.  406. — Enlargement  of  the  deep  infra- 
patellar bursa,  chronic,  and  the  result  of 
traumatism  (Pattersoa). 


748        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursas 

occasionally  seen  over  the  joint  of  another  toe.  When  the  big  toe  is  pushed 
toward  the  other  toes  by  ill-fitting  boots,  a  bunion  forms.  When  a  bunion  is 
not  inflamed,  it  may  cause  but  little  trouble;  but  when  it  inflames,  the  bursa 
enlarges  and  the  parts  become  hot,  tender,  and  exceedingly  painful.  Sup- 
puration may  occur  and  pus  may  invade  the  joint,  and  the  bone  not  unusu- 
ally becomes  diseased. 

Treatment.— In  treating  a  bunion  the  patient  must  wear  shoes  that  are 
not  pointed,  that  have  the  inner  border  straight,  and  that  have  rounded 
toes  (Jacobson).  For  a  mild  case  a  bunion-plaster  gives  comfort.  Sayre 
advises  the  use  of  a  linen  glove  over  the  digits,  the  phalanges  being  drawn 
inward  by  a  piece  of  elastic  webbing,  one  end  of  which 
is  fastened  to  the  glove  and  the  other  end  to  a  piece  of 
strapping  from  the  heel.  A  special  apparatus  may  be 
worn  (Fig.  407).  In  many  cases  osteotomy  of  the  first 
phalanx  or  of  the  first  metatarsal  bone  is  required;  in 
some  cases  excision  of  the  joint  is  necessary;  in  others 
amputation  must  be  performed.  Charles  Mayo  has 
operated  on  65  cases  successfully.  He  removes  the  head 
of  the  metatarsal  bone  and  \vith  it  two-thirds  of  the  hy- 
Fig.  407.— Bigg's  ap-  pertophy  on  the  inner  side,  and  turns  the  bursa  into 
paratus  for  bunions.  the  joint  area  in  front  of  the  bone.  He  sutures  this  bursa 
in  place  and  now  has  a  synovial  membrane  for  a  joint 
which  becomes  satisfactorily  movable  ("Annals  of  Surgery,"  August,  igo8). 
When  the  bursa  is  not  inflamed,  but  only  thickened,  bUsters  should  be  em- 
ployed over  it,  or  there  should  be  applied  tincture  of  iodin,  ichthyol,  or  mer- 
curial ointment.  When  the  bursa  inflames,  ichthyol  ointment  is  applied,  and 
intermittent  heat  by  foot-baths  gives  relief.  Suppuration  demands  imme- 
diate incision  and  antiseptic  dressing.  If  an  ulcerated  bunion  does  not  heal 
by  antiseptic  dressing,  stimulate  it  with  nitrate  of  silver  and  dress  it  with 
unguent,  hydrarg.  nitrat.  (i  part  to  7  of  cosmolin).  Jacobson  recommends 
skin-grafting  for  some  cases. 

Operations  upon  Muscles  and  Tendons. 

Tenotomy  is  the  cutting  of  a  tendon.  It  may  be  open  or  subcutaneous, 
the  open  operation  being  preferred  in  dangerous  regions. 

Open  Division  of  the  Sternocleidomastoid  Muscle  for  Wry=» 
neck. — Subcutaneous  tenotomy  for  wry-neck  has  been  largely  abandoned. 
It  is  not  only  more  unsafe  than  the  open  operation,  but  it  never  completely 
divides  all  the  contracted  band. 

The  instruments  required'  consist  of  a  scalpel,  dissecting  forceps,  hemo- 
static forceps,  scissors,  needles,  ligatures,  etc.  The  patient  is  placed  recum- 
bent, the  chin  being  drawn  more  than  is  habitual  toward  the  opposite  side. 

A  transverse  incision  is  made  over  the  muscle  about  one-fourth  of  an 
inch  above  the  clavicle.  The  superficial  parts  are  divided,  the  muscle  is 
exposed  and  sectioned,  bleeding  is  arrested,  and  the  skin  is  sutured.  Avoid 
the  anterior  jugular  vein,  which  is  underneath  the  muscle,  and  also  the  exter- 
nal jugular,  which  is  close  to  the  outer  edge  of  the  muscle.  Mikulicz  advo- 
cates the  removal  of  almost  the  entire  muscle,  leaving,  however,  the  upper 
and  posterior  portion  where  the  spinal  accessory  nerve  passes.     After  ope- 


Subcutaneous  Fasciotomy  of  the  Plantar  Fascia  749 

ration  for  wry-neck  support  the  head  with  sand-l)ags  or  a  plaster-of -Paris 
dressing  until  healing  occurs,  and  then  inaugurate  motions,  active  and  passive. 

Subcutaneous  Tenotomy  of  the  Tendo  Achillis. — This  operation 
is  performed  for  club-foot,  in  which  the  heel  is  raised.  The  tendon  is  cut 
about  one  inch  above  its  point  of  insertion.  The  instrument  used  for  the 
first  puncture  is  a  sharp  tenotome.  The  patient  lies  upon  his  back,  "with 
his  body  rolled  a  httle  toward  the  affected  side"  (Treves),  the  foot  being 
placed  upon  its  outer  side  on  a  sand-pillow.  The  surgeon  stands  to  the 
outer  side.  The  tendon  is  rendered  moderately  rigid,  and  a  sharp  tenotome, 
with  its  blade  turned  upward,  is  inserted  along  the  anterior  border  of  the 
tendon  until  the  surgeon's  finger  feels  the  knife  approaching  the  outer  side. 
The  sharp-pointed  instrument  is  withdrawn  and  a  blunt-pointed  tenotome 
is  inserted  in  its  place.  The  tendon  is  drawn  into  rigidity,  and  the  surgeon 
turns  the  blade  of  his  knife  toward  the  tendon,  places  his  finger  over  the  skin, 
and  saws  toward  his  finger.  The  tendon  gives  way  with  a  snap.  Treves 
states  that  a  beginner  is  apt  not  to  push  the  knife  far  enough  toward  the 
outside,  or  he  may  in  the  first  puncture  push  the  knife  through  the  tendon; 
in  either  case  the  tendon  is  not  completely  cut.  The  little  wound,  which  is 
covered  with  a  bit  of  gauze,  will  be  entirely  closed  in  forty-eight  hours.  In 
club-foot  cases  after  tenotomy  some  surgeons  at  once  correct  the  deformity 
and  immobilize  the  limb  in  plaster;  some  partially  correct  the  deformity  and 
apply  plaster  for  one  week,  at  which  time  they  remove  the  plaster,  correct 
the  deformity  further,  reapply  the  plaster,  and  so  on;  other  surgeons  do  not 
attempt  correction  of  the  deformity  until  the  cut  tendon  has  begun  to  unite, 
when  they  gradually  stretch  the  new  material. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Anticus 
Muscle. — The  tendon  is  divided  about  one  and  a  half  inches  above  its  point 
of  insertion.  It  can  be  made  tense  by  extending  and  abducting  the  foot. 
The  sharp-pointed  tenotome  is  entered  upon  the  outside  of  the  tendon,  and 
is  passed  well  around  it.  The  blunt-pointed  tenotome  is  used  to  cut  the  tense 
tendon. 

Subcutaneous  Tenotomy  of  the  Tendons  of  the  Peroneus  Lon= 
gUS  and  Brevis  Muscles. — These  two  tendons  are  cut  together  back  of  the 
external  malleolus,  and  one  and  a  half  inches  above  the  tip  of  the  malleolus, 
so  as  to  avoid  the  synovial  sheath  (Treves).  The  patient  lies  upon  the  sound 
side,  the  outer  aspect  of  the  deformed  foot  being  upward  and  the  inner  aspect 
of  the  ankle  of  the  deformed  side  resting  upon  a  sand-pillow.  A  sharp  teno- 
tome is  introduced  close  to  the  fibula,  and  is  carried  around  the  loose  tendons. 
A  blunt-pointed  tenotome  is  now  introduced,  its  edge  is  turned  toward  the 
tendons,  and  these  structures  are  cut  as  they  are  made  tense. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Posticus 
Muscle. — This  tendon  is  sectioned  above  the  point  where  its  synovial 
sheath  begins;  that  is,  above  the  internal  annular  ligament  (Treves).  The 
tendon  is  made  tense  and  the  pointed  knife  is  entered  above  the  base  of  the 
inner  malleolus.  The  knife  is  entered  just  back  of  the  inner  edge  of  the 
tibia,  and  is  carried  around  the  muscle  and  is  kept  close  to  the  bone.  The 
tendon  is  sectioned  with  a  blunt  knife. 

Subcutaneous  Fasciotomy  of  the  Plantar  Fascia.— The  con- 
tracted bands  are  discovered  by  motions  which  render  them  tense,  and  they 


75©        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursse 

are  divided  just  in  front  of  the  attachments  to  the  os  calcis.  The  sharp 
knife  passes  between  the  skin  and  fascia  at  the  inner  side  of  the  sole  of  the 
foot.  The  fascia  is  cut  from  without  inward  by  the  blunt-pointed  tenotome. 
It  is  usually  necessary  to  section  the  fascia  at  more  than  one  point. 

Tendon=suture  and  Tendon=Iengthening.— The  instruments  re- 
quired in  these  operations  are  an  Esmarch  apparatus;  curved  needles,  and 
needle-holder;  chromicized  gut,  kangaroo-tendon,  or  silk  for  an  ordinary  case, 
silver  wire  for  a  suppurating  wound.  In  performing  tendon-suture  make  the 
part  aseptic  and  bloodless.  It  is  wise  to  apply  a  rubber  bandage  on  the 
proximal  side,  the  bandage  being  applied  centrifugally,  forcing  the  proximal 
end  of  the  tendon  into  view  (Haegler).  If  searching  for  the  proximal  end  of  a 
flexor  of  the  finger,  flex  the  injured  finger,  and  hyperextend  the  adjoining 
fingers  (FiHget).  If  this  expedient  fails,  enlarge  the  incision,  or,  what  is 
better,  make  a  large  flap  in  the  skin.  After  finding  the  ends  approximate 
them,  being  sure  the  proper  ends  are  brought  into  contact;  stitch  them  to- 
gether with  a  continuous  suture  or  with  one  of  the  sutures  shown  in  Fig. 
408,  1,2,  and  3.  In  a  suppurating  wound  suture  by  silver  wire  should  be 
tried,  though  it  usually  fails.  After  suturing,  remove  the  Esmarch  apparatus, 
arrest  bleeding,  close  the  wound  and  dress  it  antiseptically,  relax  the  parts, 
and  place  the  limb  on  a  splint.  If,  after  suturing,  there  is  much  tension, 
stitch  the  cut  tendon  above  the  sutures  to  an  adjacent  tendon,  and  apply 
a  splint,  the  finger  which  was  injured  being  flexed,  the  others  being  extended. 


B— 1 


L 


1 


Fig.  408. — Tendon-sutures:   i,  Of  Le  Fort;    2,  of 
Le  Dentu  ;  3,  of  Lejars. 


Fig.  409. — Anderson's  method  of  tendon- 
lengthening. 


If  only  the  distal  end  of  the  tendon  can  be  found,  graft  it  upon  the  nearest 
tendon  with  a  like  anatomical  course  and  function.  When  a  tendon  has 
been  sutured,  begin  gentle  massage  in  two  weeks.  Positive  passive  motion 
is  begun  in  three  or  four  weeks.  In  old  injuries,  when  the  ends  cannot  be 
brought  into  apposition,  lengthen  one  end  or  both  ends,  either  by  the  method 
of  Anderson  (Fig.  409)  or  by  the  method  of  Czerny  (Fig.  410).  Dr.  J.  Neely 
Rhoads  ("Med.  News,"  Nov.  28,  189 1)  suggested  that  slight  lengthening 
could  be  accomplished  by  "cutting  half  through  the  tendon  at  different 
levels  and  from  opposite  sides,  leaving  some  longitudinal  fibers  to  slip  on 
each  other,  thus  gaining  slight  elongation"  (H.  Augustus  Wilson,  in  "Inter- 
national Chnics,"  vol.  i,  4th  series).  Poncet  makes  several  zigzag  incisions 
on  each  side  of  the  tendon,  and  when  the  tendon  is  pulled  upon  it  elongates 
decidedly.  Hibbs's  method  is  shown  in  Fig.  412.  One  of  these  methods  of 
lengthening  may  be  used  if  there  is  deformity  from  tendon-contraction.. 


Tendon- transplantation  751 

If  the  tendon  cannot  be  lengthened  sufl&ciently,  make  a  bridge  of  catgut  from 
one  end  of  it  to  the  other,  or  graft  in  another  tendon  from  one  of  the  lower 
animals,  or  graft  the  distal  end  to  a  tendon  of  like  function  {tendon-grafting) . 

The  annular  ligament  is  sutured  as  shown  in  Fig.  411. 

Tendon=transplantation. — This  operation  is  usually  said  to  have 
been  devised  by  Nicoladoni  in  1882;  as  a  matter  of  fact,  Duplay  did  the  ope- 
ration in  1876.  endeavoring  to  secure  function  in  an  arm  rendered  powerless 
by  an  injun-  (Eltings,  in  ''Albany  Med.  Annals,"  April,  1902). 

The  first  American  surgeon  to  do  the  operation  was  Parrish,  of  New  York, 
who  in  1892  transplanted  tendons  in  a  case  of  club-foot.     In  some  cases  in 


Fig.  41a — Czemy's  method  of  tendon-length-  Fig.  411.— Method  of  suturing  the  annnlar 

ening.  ligament  of  the  wrist. 

which  a  muscle  has  been  paralyzed  surgeons  have  divided  the  tendon  of  the 
paralyzed  muscle  and  have  united  its  distal  end  with  the  tendon  of  a  normal 
muscle,  the  normal  tendon  being  split  to  receive  it.  It  has  also  been  stated 
that  when  a  muscle  or  the  tendon  of  a  muscle  is  sutured  to  a  paralyzed  antag- 
onistic muscle,  the  transplanted  structure  will  actually  execute  the  functions 
of  the  paralyzed  muscle.  For  instance,  a  flexor,  when  so  transplanted,  may 
become  an  extensor  and  act  under  the  mental  impulse  of  extension;  a  pronator 
may  become  a  supinator  (H.  A.  Wilson  in  "American  Med.,"  April  8,  1905). 
These  principles  have  been  utilized  when  some  or  many  of  the  muscles  of  a 
limb  have  been  paralyzed,  the  tendon  of  an  unparalyzed  muscle  or  the  tendons 
of  an  unparalyzed  group  of  muscles  being  fastened  to  the  tendons  of  the  par- 
alyzed muscle.  It  has  been  shown  that  the  success  of  this  procedure  depends 
upon  the  accuracy  of  diagnosis,  the  division  of  secondary  contractures,  the 
correction  of  existing  deformities,  and  careful  after-treatment.     (See  the  article 


Fig.  412. — Hibbs's  method  of  tendon-lengthening. 

by  Dr.  J.  Hilton  Waterman,  in  "Med.  News,"  July  12,  1902.)  In  a  paralysis 
of  the  lower  extremity,  as  Goldthwait  points  out,  the  sartorius  usually  retains 
power,  and  it  may  be  advisable  in  such  a  case  to  divide  the  sartorius  and 
suture  its  upper  end  to  the  quadriceps  above  the  patella.  A  strip  of  the  tendo 
AchiUis  may  be  grafted  upon  the  peronei  in  certain  cases.  An  artificial  tendon 
may  be  made  of  silk,  the  silk  being  passed  from  the  sound  to  the  paralyzed 


752  Orthopedic  Surgery 

tendon  (Lange);  the  silk  eventually  becomes  surrounded  by  fibrous  tissue. 
Strands  of  silkworm  gut  may  be  used  for  the  same  purpose  (Kummell).  The 
operation  of  tendon-transplantation  is  occasionally  of  distinct  benefit,  but  I 
agree  with  Ridlon,  and  am  not  usually  sanguine  of  results.  Ridlon  wisely 
reminds  us  that  in  such  cases  much  good  may  perhaps  result  from  the  proper 
use  of  braces,  tenotomy,  and  hand  stretching,  followed  by  prolonged  reten- 
tion in  plaster,  the  patient  using  his  Umb  actively. 

Ridlon  points  out  that  most  brace  treatment  is  not  curative  because  it 
only  aims  to  prevent  deformity  developing,  and  tenotomy  and  stretching 
fail  because  they  only  seek  to  remove  existing  deformity.  The  object  should 
be  some  restoration  of  function.  This  is  often  obtained  by  following  Thomas's 
direction  and  "posturing"  the  Hmb  so  as  to  permit  structural  shortening  of 
the  paralyzed  muscles  and  then  fixing  them  for  months. 


XXI.    ORTHOPEDIC  SURGERY. 

This  branch  of  surgery  formerly  dealt  onl}-  with  the  treatment  of  de- 
formities by  means  of  mechanical  apphances,  but  of  recent  years  its  domain 
has  been  enlarged  to  include  the  treatment,  surgical  and  mechanical,  of 
deformities,  contractures,  and  many  joint-diseases. 

Torticollis  (wry=neck)  is  a  condition  in  which  contraction  of  certain  of 
the  neck-muscles  causes  an  alteration  in  the  position  of  the  head.  The  disease 
is  one-sided;  the  sternocleidomastoid  is  the  muscle  chiefly  involved,  though 
the  trapezius,  the  splenius,  and  other  muscles  sometimes  suffer.  Acute  torti- 
colHs,  which  is  rare,  is  a  temporary  condition,  and  results  from  cold  or  from 
injury  (see  Myalgia).  Chronic  torticollis  may  be  congenital  (due  to  injury 
before  birth  or  during  birth),  may  be  due  to  nerve-irritation,  to  an  assumed 
attitude  because  of  eye-defect,  to  polio-encephalitis  (Golding  Bird),  to  in- 
flammation of  the  glands  or  to  disease  of  the  vertebrae,  and  it  may  be  inter- 
mittent, but  is  usually  persistent.  The  muscle  stands  out  in  bold  outhne,  the 
head  is  turned  to  the  opposite  side,  the  ear  of  the  disordered  side  is  turned 
toward  the  shoulder,  the  chin  is  thrown  forward,  and  spinal  curvature  may 
arise.  The  corresponding  side  of  the  face  atrophies.  There  is  no  pain.  In 
many  cases  the  head  may  be  restored  to  its  normal  position  by  passive  move- 
ment or  by  voluntary  effort,  but  it  at  once  returns  to  its  habitual  position. 
MikuHcz  asserts  that  torticolHs  is  a  chronic  fibrous  myositis,  due  often  to 
compression  during  labor.  He  further  says  that  the  lesion  known  as  hema- 
toma of  the  sternomastoid,  which  occasionally  follows  labor,  is  not  hematoma, 
but  thickening  due  to  myositis.  D'Arcy  Power  reported  the  autopsy  on  a 
child  one  month  of  age.  The  sternomastoid  muscle  contained  a  fibrous 
mass,  the  result,  Power  believes,  of  a  hemorrhage  into  the  muscle  prior  to  birth 
("Med.  Chir.  Trans.,"  vol.  Ixxvi).  Power,  Clutton,  and  Owens  have  all  traced 
cases  of  hematoma  of  the  sternomastoid  from  early  infancy  to  the  time  when 
tenotomy  was  required  for  torticollis.  W.  W.  Richardson  ("Surg.  Gynec. 
and  Obstet.,"  1906)  beheves  that  interstitial  myositis  is  always  present,  but 
doubts  the  causal  influence  of  the  lateral  position  of  the  head  in  utero.  In 
some  cases  hereditary  influence  is  evident.     One  woman  gave  birth  success- 


Treatment  of  Torticollis  753 

ively  to  seven  wry-necked  children  (Xove-Jusserand  and  Vianny,  in  "Revue 
D'Orthop.,"  1906).  In  spasmodic  wry-neck  the  muscle  is  thrown  repeatedly 
into  clonic  contracdons.  In  congenital  torUcollis  the  muscle  and  the  cervical 
fascia  are  shortened,  and  the  muscle  does  not  relax  under  the  influence  of  an 
anesthetic.  In  torticollis  due  to  rheumatism  and  reflex  causes  the  tonically 
contracted  muscle  relaxes  when  the  patient  is  anesthetized. 

Symptoms. — Congenital  wry-neck  is  due  to  central  nen-ous  disease,  to 
spinal  deformity,  or  to  injury  during  birth,  and  in  this  form  the  sternomastoid 
is  shortened,  hardened,  and  atrophied.  It  may  not  be  noticed  for  some 
years  because  of  the  short  neck  of  infancy.  It  is  associated  with  a^sym- 
metrical  development  of  the  face,  and  is  almost  invariably  upon  the  right 
side.  Spasmodic  wry-neck  may  present  tonic  spasm  only,  intermittent  spasm 
alone,  or  both  may  appear  alternately.  It  sometimes  arises  in  those  whose 
occupation  demands  frequent  rotation  of  the  head,  but  more  often  no  such 
cause  can  be  discovered.  It  is  probably  a  disease  of  the  cortical  area  which 
presides  over  rotation  of  the  head.  (See  article  by  C.  A.  Hamann,  in  "Buft'alo 
Med.  Jour.,"  Dec,  1901.)  It  is  a  disease  especially  of  adults;  in  women  it  is 
often  linked  with  hysteria.  Pahl  ("California  State  ^led.  Soc.,"  1906) 
analyzed  68  reported  cases.  Men  and  women  appeared  equally  liable,  it 
was  most  frecjuent  between  the  ages  of  twenty  and  thirty,  and  the  right  side  was 
affected  in  twice  as  many  cases  as  the  left  side.  The  exciting  cause  may  be  a 
cold,  a  blow,  or  a  mental  storm;  the  predisposing  cause  is  the  neurotic  tempera- 
ment. It  may  be  due  to  enlarged  glands,  to  carious  teeth,  or  to  eye-strain. 
In  some  rare  cases  bilateral  spasm  occurs,  the  head  being  pulled  backward 
and  the  face  being  turned  upward.  Clonic  spasms  may  come  on  unannounced, 
or  they  may  be  preceded  by  pain  and  stiffness;  the  head  can  he  held  still  for  a 
moment  only;  there  is  sometimes  pain,  always  fatigue,  but  during  sleep  the 
contractions  cease.  The  attack  will  probably  pass  away,  but  \vill  almost 
certainly  recur. 

Treatment. — Congenital  wTy-neck  is  treated  by  myotenotomy  through 
an  open  incision  in  a  line  parallel  to  and  just  below  the  clavicle.  The  flaps 
are  raised,  access  is  free  to  both  origins  of  the  muscle,  the  muscle  is  readily 
divided,  the  wounds  in  the  skin  and  fascia  are  closed.  This  incision  leaves 
a  trivial  scar.  After  operation  plaster  of  Paris  is  used  to  secure  fixation  and 
fixation  is  maintained  from  four  to  eight  weeks.  Early  operation  favors  the 
establishment  of  muscular  co-ordination  before  the  development  of  perma- 
nent bony  deformity  of  the  vertebrae.  Some  surgeons  cut  the  scalene  muscles 
as  well  as  the  sternocleidomastoid.  Gerdes  Rowland  lengthens  the  sterno- 
mastoid and  carefully  sutures  it  ("Practitioner,"  Sept.,  1908).  The  old  sub- 
cutaneous myotenotomy  should  be  abandoned,  as  aseptic  incision  enables 
the  surgeon  to  see  and  to  feel  all  the  contracted  bands  of  fascia,  muscle, 
and  tendon,  and  to  avoid  vital  structures  (page  748).  In  spasmodic  wry- 
neck there  is  a  fair  chance  of  recovery.  Pahl's  table  (Ibid.)  shows  that  out  of 
68  cases,  28  recovered,  17  were  improved,  and  11  were  not  improved  by  treat- 
ment. Results  in  12  were  not  stated.  Treat  the  neurotic  temperament  and 
remove  any  ob\ious  irritation  (eye-strain,  carious  teeth,  enlarged  glands). 
Drugs  usually  are  practically  useless,  although  Chas.  S.  Potts  reported  a  cure 
after  the  hypodermatic  use  of  atropin.     The  rest  cure  is  sometimes  beneficial. 


754  Orthopedic  Surgery 

Tenotomy  is  not  to  be  employed.  In  1890  Mayo  Collier  suggested  ligation  of 
the  spinal  accessory  nerve  with  silver  wire.  In  persistent  cases  stretch  or 
divide  and  exsect  a  part  of  the  spinal  accessory  nerve  (Keen).  To  reach  this 
nerve,  make  an  incision  along  the  posterior  edge  of  the  sternocleidomastoid 
muscle,  find  the  nerve  as  it  emerges  from  under  the  middle  of  the  muscle, 
about  one  and  a  half  inches  below  the  tip  of  the  mastoid  process,  retract  the 
muscle  at  this  point,  and  remove  at  least  one  inch  of  nerve.  Neurectomy  of 
the  spinal  accessory  nerve  paralyzes  the  sternocleidomastoid  muscle,  in  spite 
of  the  fact  that  that  muscle  has  also  a  nerve-supply  from  the  cervical  nerves. 
The  paralysis  is  followed  by  atrophy,  and  if  the  spasm  affected  the  sterno- 
mastoid  muscle  only,  the  operation  will  cure  the  case.  Unfortunately,  other 
muscles  are  usually  involved,  and  cure  will  only  be  obtained  by  performing 
neurectomy  on  the  nerves  which  innervate  the  affected  muscles.  For  the  treat- 
ment of  rheumatic  wry-neck,  see  Myalgia  (page  726). 

Dupuytren's  contraction  is  a  contraction  of  the  palmar  fascia,  of  its 
digital  prolongations,  and  of  the  fibers  joining  the  fascia  and  skin.  Fixed 
contraction  of  one  or  more  fingers  occurs.  The  ring-finger  and  the  little  finger 
most  often  suffer,  but  any  finger  or  the  thumb  may  be  involved.  The  condi- 
tion may  be  symmetrical.  It  is  far  more  common  in  men  than  in  women. 
The  disease  arises  oftenest  in  men  beyond  middle  age,  but  is  sometimes  met 
with  in  youths.  The  cause  of  this  disease  is  unknown;  some  refer  it  to  gout 
or  rheumatism  or  osteo -arthritis;  others  to  traumatism,  syphihs,  organic 
nervous  diseases,  arteriosclerosis,  reflex  irritation,  or  neuritis.  In  one-ft)urth 
of  the  cases  heredity  seems  to  be  influential.  If  due  to  traumatism,  the  right 
hand,  should  suffer  most  frequently;  but  it  occurs  in  the  left  hand  nearly  as 
often  as  in  the  right  (P.  Jansen,  in  "Arch.  f.  klin.  Chir.,"  Bd.  Ixvii,  H.  4). 
Jansen  examined  specimens  from  7  cases  and  found  connective-tissue  hyper- 
trophy and  circulatory  disturbance,  the  contraction  being  a  result  of  the 
above-named  processes. 

Symptoms. — Dupuytren's  contraction  is  indicated  by  a  small  hard  lump 
or  crease  which  appears  over  the  palmar  surface  of  the  metacarpophalangeal 
joint.  This  nodule  grows  and  the  corresponding  finger  is  gradually  pulled 
down.  In  some  cases  the  tip  of  the  finger  is  forced  against  the  palm.  The 
skin  becomes  dimpled  or  puckered. 

Treatment.— Fibrolysin,  which  is  a  soluble  combination  of  thiosinamin 
and  salicylate  of  sodium,  has  been  used  hypodermatically  in  Dupuytren's  con- 
traction and,  it  is  claimed,  with  success  (Schwalbach).  In  treating  Dupuy- 
tren's contraction  subcutaneous  multiple  incisions  may  be  made,  the  tense 
fascia  and  the  fasciocutaneous  fibers  being  cut.  The  finger  is  straightened 
and  is  placed  upon  a  straight  splint,  which  is  worn  continuously  for  a  week 
or  ten  days  and  is  worn  at  night  for  at  least  a  month.  A  more  satisfactory 
operation  is  that  of  Keen.  Keen  divides  the  skin  by  a  V-shaped  cut,  the  base 
of  the  V  being  downward,  lifts  up  the  flap,  and  dissects  out  the  contracted 
tissue.  A  cure  is  most  certain  to  be  obtained  by  Lexer's  radical  operation. 
This  surgeon  excises  the  entire  aponeurosis  and  considerable  portions  of  the 
palmar  skin  adherent  to  the  aponeurosis.  In  order  to  cover  this  wound  it 
may  be  necessary  to  slide  a  pedunculated  flap  into  the  raw  surface. 

Syndactylism  (webbed  fingers)  is  always  congenital,  and  may  persist 


Trigger-finger  or  Jerk-finger 


755 


through  several  generations.  Simple  incision  of  the  web  is  useless;  the 
operation  to  be  performed  is  that  of  Agnew  or  of  Diday  (Figs.  413,  414). 

In  Agnew's  operation  a  flap  of  skin  from  the  dorsum  is  inserted  between 
the  fingers  and  sutured  in  place. 

In  Diday's  operation  a  flap  is  taken  from  the  dorsal  surface  and  another 
flap  is  raised  from  the  palmar  surface,  and  each  flap  is  sutured  to  the  finger 
from  which  it  springs. 

Polydactylism  (supernumerary  digits)  is  always  congenital,  is 
often  hereditary,  and  is  usually  symmetrical.  There  may  be  an  incomplete 
digit,  or  there  may  be  an  entire  and  well-developed  finger  or  toe  with  a  meta- 
carpal or  metatarsal  bone.  The  connection  to  the  metacarpus  or  meta- 
tarsus may  be  by  a  fibrous  pedicle  .only.  If  the  digit  is  complete,  with  a 
metacarpal  bone,  no  operation  is  required ;  if  it  is  incomplete  or  is  ill-developed, 
it  should  be  removed. 

Tngger=finger  or  Jerk=finger  '(Lock=finger,  Snapping=finger). 
— The  patient  can  usually  close  the  fingers,  but  on  trying  to  open  them 
one  finger  remains  closed.  It  can  be  opened  by  grasping  it  with  the  other  hand, 
but  flies  open  with  a  snap,  like  opening  a  knife  (Abbe).     In  some  cases  two 


Fig.  413.— Agnew's  operation  for  webbed 
fingers  (Pye). 


Fig.  414. — Diday's  operation  for  webbed 
fingers  (Pye). 


fingers  are  involved.  In  a  reported  case  (Frederick  Grifflth,  "Annals  of 
Surgery,"  1904)  the  ring  and  middle  fingers  of  the  left  hand  locked  at  the 
knuckle-joints  on  attempting  flexion.  The  locking  occurred  when  about  one- 
third  the  amount  of  flexion  necessary  to  grasp  an  object  was  achieved.  By 
bending  the  fingers  with  the  other  hand  unlocking  was  accomplished  and 
flexion  was  finished  voluntarily.  In  attempting  extension  blocking  occurred 
at  the  same  point  and  unlocking  was  accompUshed  in  the  same  manner.  In 
most  cases,  but  not  in  all,  there  is  pain  when  locking  occurs.  The  condition 
is  gradual  in  onset.  Trigger-finger  is  often  associated  with  rheumatism  (in 
52  cases  out  of  121,  according  to  Necker) .  It  is  said  by  Tubby  to  be  due  to  en- 
largement of  the  flexor  tendon,  or  to  contraction  of  the  groove  in  the  trans- 
verse ligament  in  the  palm.  It  may  be  due  to  a  ganghon,  enchondroma,  or 
tenosynovitis.  Traumatism  or  irritation  may  produce  it.  The  tendon-sheath 
may  be  thickened  or,  according  to  Marcano,  there  may  be  a  nodule  on  the 
tendon  which  rubs  against  the  sesamoid  bone.  It  may  result  from  occupa- 
tion. 

Treatment.  — If  a  ganglion,  a  loose  cartilage,  or  a  tendon  nodule  exists, 
treat  by  excision.  A  sesamoid  bone  may  be  excised.  If  there  is  inflammation, 
use  massage  an  J  counter-irritation.  If  there  is  no  obvious  cause,  put  a  com- 
press over  the  tunnel  in  the  ligament  and  apply  a  splint. 


756 


Orthopedic  Surgery 


JVlallet=finger. — This  is  called  also  drop-f,nger  and  rupture  of  the 
extensor  tendon.  It  is  due  to  a  blow  in  the  direction  of  flexion  when  the 
finger  is  extended.  It  is  supposed  to  be  due  partly  to  stretching  and  partly 
to  rupture  of  the  extensor  tendon  at  the  point  at  which  it  is  the  posterior 
ligament  of  the  distal  interphalangeal  joint.  Abbe  has  shown  that  baseball 
players  are  liable  to  a  condition  which  is  the  reverse  of  this,  in  which  the 
last  phalanx  is  dislocated  backward.  Drop-finger  is  treated  by  incision 
and  suture  of  the  tendon  to  the  periosteum. 

Genu  valgum  (knock=knee)  resuhs  from  an  unnatural  growth  of  the 
internal  condyle,  causing  the  shaft  of  the  femur  to  curve  inward  and  the 
internal  lateral  ligament  of  the  knee-joint  to  stretch,  the  knees  coming  close 
together  and  the  feet  being  widely  separated.  This  deformity  is  usually 
noted  when  the  child  begins  to  walk,  but  it  may  not  appear  until  puberty 

or  even  long  after.  Knock- 
knee  may  arise  from  rickets, 
from  an  occupation  demand- 
ing prolonged  standing,  or 
from  flat-foot.  It  may  occur 
in  one  knee  or  in  both  knees. 
Treatment. — Mild  rachi- 
tic cases  of  knock-knee  may 
remain  in  slight  deformity, 
or  may  get  well  from  im- 
provement of  the  general 
health.  In  ordinary  cases 
simply  treat  the  rickety  con- 
dition. The  patient  is  for- 
bidden to  stand  or  to  walk, 
and  the  limb,  after  being  put 
as  straight  as  can  be,  is  fixed 
on  an  external  splint  and  a 
pad  is  put  over  the  inner  con- 
dyle. Later  in  the  case 
plaster-of-Paris  is  used. 
Some  surgeons  prefer  to  im- 
mobilize while  the  leg  is  flexed 
to  a  right  angle  with  the  thigh.  In  a  severe  case  the  surgeon  can  immobil- 
ize after  forcibly  straightening  (causing  an  epiphyseal  separation)  or  after 
the  performance  of  osteotomy  (page  699) .  Osteotomy  is  preferable  to  frac- 
ture by  a  mechanical  appliance  (osteoclasis). 

Genu  varum  (bow=legS)  is  the  opposite  of  knock-knee.  Usually  both 
legs  are  bowed  out,  the  knees  being  widely  separated,  the  tibiae  and  femora, 
as  a  rule,  being  curved,  and  the  feet  being  turned  in.  This  disease  in  early 
life  is  due  to  rickets,  the  weight  of  the  body  producing  the  deformity.  In 
older  people  incurable  bow-legs  may  arise  from  arthritis  deformans. 

Treatment. — Some  mild  cases  of  genu  varum  recover  as  a  result  of 
improvement  in  the  heaUh.  Ordinary  cases  are  treated  by  braces,  by  plaster- 
of-Paris  bandages,  and  by  attention  to  the  general  health.  When  the  bones 
have  hardened  in  severe  deformity,  osteotomy  is  necessary. 

Club=hand  (Fig.  415). — A  congenital  deformity  in  which  the  hand  devi- 


Fig.  415.— Club-hand. 


Talipes 


757 


ates  from  the  normal  relation  to  the  forearm.  It  is  usually  associated  with 
other  deformities.  In  some  cases  the  radius  and  possibly  some  of  the  carpal 
bones  are  absent. 

Treatment. — By  massage  and  passive  motion,  by  immobilization,  by 
tenotomy  or  osteotomy. 

Talipes  (club=foot)  is  a  permanent  deviation  of  the  foot  into  deformity. 
There  are  several  forms.  Talipes  equinus  (Fig.  416)  is  a  confirmed  extension; 
talipes  calcaneus  (Fig.  417)  is  a  confirmed  flexion;  talipes  varus  is  a  confirmed 
adduction  and  inversion;  and  talipes  valgus  is  a  confirmed  abduction  and 
aversion.  Two  of  these  forms  may  be  combined,  as  in  talipes  equino-varus 
(Fig.  418,  tahpes  equino- valgus,  talipes  calcaneo- varus,  and  talipes  cal- 
caneo-valgus.  The  causes  of  talipes  are  congenital  or  acquired.  The  con- 
genital form  is  due  to  persistence  of  the  fetal  form  of  the  foot.  Acquired 
cases  may  arise  from  infantile  paralysis,  from  spastic  contractions,  from 
cicatrices,  from  traumatisms,  from  arrest  of  bony  growth  following  upon  the 
inflammation  of  bone,  or  from  hysterical  contractures. 


Fig.  416.— Talipes 
equinus  (Albert). 


Fig.  417.— Talipes  cal- 
caneus (Albert). 


Fig.  41  fS.— Double  equino-varus  ("American  Text- 
book of  Surgery"). 


Talipes  equinus  is  rarely  congenital.  In  this  condition  the  patient  walks 
upon  the  toes  and  cannot  bring  the  heel  to  the  ground. 

Talipes  Calcaneus. — The  patient  walks  upon  the  heel  and  cannot  bring 
the  toes  to  the  ground.  The  true  form  is  seen  in  congenital  cases,  the  flexors 
of  the  foot  being  shortened,  and  the  tendo  Achillis  being  lengthened. 

Talipes  varus  is  rarely  met  with  without  equinus.  In  this  condition  the 
patient  walks  on  the  outer  edge  of  the  foot. 

Talipes  valgus  is  met  with  in  flat-foot.  The  patient  walks  on  the  inner 
edge  of  the  foot. 

Talipes  equino-varus. — The  heel  is  raised  and  the  patient  walks  upon  the 
outer  edge  of  the  foot.     This  is  the  usual  congenital  form. 

Talipes  equino-valgus  is  very  rarely  congenital.  The  heel  is  raised  and 
the  patient  walks  upon  the  inner  side  of  the  foot. 

Talipes  calcaneo-varus  is  a  combination  of  calcaneus  and  varus. 

Talipes  calcaneo-valgus  is  a  combination  of  calcaneus  and  valgus. 

Treatment. — In  congenital  cases  the  condition  is  usually  manifest  on 
both  sides,  and  is  nearly  always  tahpes  equino-varus.  Congenital  club-foot 
should  be  treated  in  infancy,  and  when  a  restoration  to  position  can  be  effected 
by  the  hands  of  the  surgeon,  is  treated  by  plaster-of-Paris  bandages.  If 
a  child  has  begun  to  walk,  it  may  still  be  possible  to  correct  the  deformity 


75^  Orthopedic  Surgery 

eventually  by  manipulations,  by  plaster-of-Paris  bandages,  or  by  club-foot 
shoes,  but  most  cases  require  tenotomy  of  the  tendo  Achillis  before  the  appli- 
cation of  the  shoe  or  the  plaster.  The  club-foot  shoe  may  do  good  service, 
but  in  many  instances  it  is  painful  and  is  not  so  efficient  as  plaster-of-Paris. 
In  severe  cases,  before  applying  the  plaster,  the  patient  is  given  ether;  the 
surgeon  cuts  the  tendons  of  the  anterior  and  posterior  tibial  muscles,  the 
plantar  fascia,  and  the  tendo  Achillis,  in  the  order  named,  and  forcibly  corrects 
the  deformity.  In  old  cases,  with  alteration  in  the  shape  of  the  bones,  cunei- 
form osteotomy,  or  the  removal  of  the  cuboid  or  other  tarsal  bones,  may 
be  indicated.  In  these  cases  Phelps  advises  an  open  transverse  division  of 
all  rigid  planter  soft  parts.  Buchanan  employs  subcutaneous  division  of 
all  resistant  structures.  Occasionally  in  relapsed  and  inveterate  cases 
<isiragalectomy  is  performed.  It  is  seldom  practiced  upon  young  children, 
(See  page  719.)  In  some  cases  of  tahpes  calcaneus  shortening  of  the  tendo 
Achillis  is  advised;  but  such  an  operation  is  only  of  temporary  value,  as 
stretching  occurs  after  two  years  or  more.  In  tahpes  due  to  infantile  paral- 
ysis the  operative  treatment  is  the  same,  but  we  should 
not  immobihze  in  plaster  but  rather  in  some  apparatus 
which  can  easily  be  removed  to  permit  the  use  of  massage 
and  electricity.  In  paralytic  cases  tendon-transplantation 
is  occasionally  employed.  This  consists  in  dividing  the 
,  '  ^^  tendon  of  the  paralyzed  muscle  and  attaching  its  distal 
;  '  '  '  end  to  the  adjacent  tendon  of  a  healthy  muscle.  (For 
rj;  full  consideration  see  a  work  on  orthopedic  surgery.) 

^^  \^'  Pes  planus  (flat=foot)  is  a  condition  in  which  there 

^  ''is  loss  of  the  arch  of  the  foot,  due  to  muscular  paralysis 

anormatlo^TLtuI  °^  Hgamentous  weakness,  to  prolonged  standing,  or'  to 
and  of  a  flat  foot-sole  trauma.  Flat-foot  is  especially  apt  to  occur  in  rickets. 
(B)  (Albert).  Spurious    flat-joot,    or   hiflammatory    flat-foot,    occurs    in 

Pott's  fracture  and  in  inflammation  of  the  ankle-joint 
or  of  the  tendon  of  the  peroneus  longus  muscle.  Paralytic  flat-foot  is 
seen  after  infantile  paralysis.  Static  flat-foot  is  due  to  disproportion 
between  the  body  weight  and  the  support  of  that  weight.  All  children 
are  born  with  pronated  feet;  the  arch  usually  begins  to  form  soon 
after  birth,  but  in  some  individuals  it  never  forms.  Flat-foot,  according  to 
de  Vlaccos,  is  thus  produced:  If  we  suppose  a  straight  line  prolonged  down- 
ward from  the  center  of  the  leg,  most  of  the  astragalus  and  os  calcis  will 
be  external  to  it;  hence  the  body  weight  presses  on  the  inner  side  of  the 
foot,  and  tends  to  flatten  the  arch  and  cause  outward  rotation,  tendencies 
which  are  antagonized  by  the  flexors  of  the  toes  and  by  the  tibialis  posticus 
muscle.  The  os  calcis  is  pronated  and  is  pushed  to  the  side,  the  astragalus 
moves  after  the  os  calcis,  and  the  ligaments  are  stretched  ("Rev.  de  Chir.," 
Aug.,  1901).  Pes  planus  is  productive  of  much  pain  upon  standing  or  walking; 
in  fact,  the  individual  may  be  completely  crippled.  Pain  is  quickly  relieved 
upon  sitting  down.  \A'alking  upon  the  toes  is  not  painful.  A  marked  flat- 
foot  can  at  once  be  recognized  by  wetting  the  sole  of  the  patient's  foot  with 
a  colored  fluid  and  causing  him  to  step  firmly  upon  a  piece  of  paper  (Fig. 
419,  A,  b).  Beginning  flat-foot  cannot  be  thus  recognized  and  is  frequently 
overlooked,  the  patient  being  treated  for  gout  or  rheumatism.  Even  a  slight 
case  can  be  detected  by  carefully  observing  the  inner  surface  of  the  foot. 


Pes  Planus 


759 


When  weight  is  placed  upon  it,  it  is  seen  to  descend  as  the  arch  falls.  A 
more  accurate  method  is  measurement,  to  find  the  middle  of  the  foot.  In  fiat- 
foot  the  extremity  is  lengthened.  Golding-Bird  points  out  that  the  middle  of  the 
normal  foot  is  the  point  of  articulation  of  the  inner  cuneiform  and  the  metatar- 
sal bone  of  the  great  toe.  In  flat-foot  the  greatest  change  is  in  the  posterior  half 
of  this  line.  The  e.xtent  to  which  the  posterior  measurement  exceeds  the  ante- 
rior is  the  degree  of  flat-foot.     The  excess  may  reach  three-fourths  of  an  inch. 

Treatment. — In  paralytic  flat-foot,  which  arises  from  infantile  paralysis, 
employ  exercise,  electricity,  and  massage.  To  maintain  a  correct  position  of 
the  ankle  and  to  facilitate  normal  muscular  action, 

apply   suitable   braces.     In   some  cases  of  para-    ^  1 

lytic  flat-foot  it  is  advisable  to  permanently  stift'en 
the  ankle-joint  by  operation.  Operation  is  not 
indicated  before  the  twelfth  year,  because  during 
the  earUer  years  of  life  union  will  probably  fail  to 
occur.  Goldthwait  removes  the  cartilage  from 
the  articular  surfaces  of  the  astragalus,  calcaneus, 
tibia,  and  malleoh,  and  seeks  to  obtain  permanent 
bony  ankylosis.  In  static  flat-foot  it  has  long  been 
customary  to  advise  rest  in  bed  for  two  weeks,  and 
then  exercise  for  several  hours  a  day  to  increase 
the  arch.  The  usually  recommended  exercise 
has  been  to  rise  upon  the  toes  again  and  again, 
the  patient  resting  for  a  time  after  each  seance  of 
exercise  by  sitting  tailor-fashion  with  the  legs 
crossed  under  him.  Massage  is  ordered  and  a 
shoe  is  made  containing  a  piece  of  steel  so  ar- 
ranged as  to  raise  the  arch  of  the  foot.  The 
patient's  general  health  is,  of  course,  attended  to. 

Orthopedic  surgeons  have  come  to  regard  this 
philosophical  and  improper. 

In  static  flat-foot  it  is  essential  to  understand  that  a  flat-foot  may  be  a 
fully  functionating  foot,  free  from  pain  and  disabihty,  and,  therefore,  not  a  sub- 
ject for  treatment.  For  convenience,  flat-foot  is  divided  into  rigid  and  flex- 
ible. Either  form  may  or  may  not  be  painful.  The  pain  of  flat-foot  is  usually 
the  result  of  excessive  use.  It  must  be  differentiated  from  Albert's  disease, 
achillodynia,  metatarsalgia,  osteophytes  on  the  under  surface  of  the  os  calcis, 
and  Raynaud's  disease.  Rigid  flat-foot  can  be  made  flexible  by  manipu- 
lative measures  or  by  the  employment  of  H.  Augustus  Wilson's  flat-foot  cor- 
rection screw  (see  Fig.  421).  This  apparatus  pulls  down  on  the  posterior 
part  of  the  os  calcis  and  the  distal  extremities  of  the  metatarsal  bones  and 
pushes  up  beneath  the  tarsus.  The  force  employed  is  very  great  and  much 
care  should  be  exercised  when  it  is  used  upon  a  patient  under  anesthesia 
It  is  preferable  to  use  it  without  ether,  relying  upon  the  patient  to  state  when  the 
pressure  becomes  unendurable.  A  flexible  flat-foot  is  capable  of  restoration  of 
the  lost  muscular  control  by  apphed  physical  culture.  Each  toe  and  then 
the  foot  muscles  should  be  developed  to  the  maximum,  so  that  the  muscular 
control  of  the  foot  becomes  almost  as  good  as  the  muscular  control  of  the  hand. 

It  was  formerly  customary  to  prescribe  various  forms  of  steel  plates  to 
correct  the  broken-down  arch,  but  orthopedic  surgeons  are  discouraging  their 


Fig.  420. — -Y-ray  of  hammer- 
toe. 


usual  treatment  as  un- 


760  Orthopedic  Surgery 

use,  as  they  destroy  the  muscular  control  of  the  foot,  and  by  weakening  the  foot 
render  it  susceptible  to  sprains  and  other  injuries.  When  necessity  demands 
the  employment  of  arch  supporters,  they  should  be  used  exactly  like  splints 
for  fractures.  They  should  be  kept  on  constantly,  day  and  night,  for  the  short- 
est possible  time  and  laid  aside  as  quickly  as  possible.  Three  weeks  is  entirely 
too  long  for  them  to  be  used  continuously,  as  in  that  Ume  they  are  capable 
of  causing  such  muscle  wasting  that  months  may  be  required  to  obtain 
muscular  re-establishment.  In  cases  of  tiat-foot  that  are  incajjable  of  muscu- 
lar reconstruction,  H.  Augustus  Wilson  ("Amer.  Medicine,"  2^Iay  6,  1905,  p. 
725)  advocates  the  employment  of  the  method  de\ised  by  Prof.  Dr.  E. 
Miiller  ("Central,  f.  Chir.,"  January  10,  1903,  p.  40)  for  paralytic  valgus. 
It  consists  of  an  arthrodesis  of  the  astragaloscaphoid  joint,  and  transplanta- 
tion of  the  tendon  of  the  extensor  proprius  hallucis  into  a  hole  drilled  free 
from  above  downward  through  the  scaphoid.  Fixation  in  plaster  of  Paris 
in  an  overcorrected  position  for  four  weeks  almost  invariably  results  in  full 


Augustus  Wilson's  flat-foot  correction  screw. 


correction  and  normal  function.  The  anterior  dbial  tendon  is  supplemented 
in  its  action  by  the  transplanted  tendon.  Toe  drop  does  not  occur  because 
the  lesser  extensor  of  the  big  toe  assumes  unusual  power  in  raising  the  toe. 

Gleich  shortens  the  foot  and  raises  the  arch  by  sawing  through  the  os  caicis 
and  fastening  the  posterior  part  of  this  bone  at  a  lower  level.  Trendelenburg 
ad\ises  supramalleolar  osteotomy.  This  operarion  permits  of  adduction  and 
the  adducted  foot  should  be  put  up  in  an  immovaljle  dressing  of  plaster  of 
Paris.  Ogston  resects  the  astragaloscaphoid  joint.  Golding-Bird  and  Davy 
remove  the  scaphoid  bone.  Stokes  removes  a  wedge-shaped  piece  from  the 
head  and  neck  of  the  astragalus. 

Pes  cavus  (hollow  foot)  is  an  increase  in  the  arch  of  the  foot,  due,  pos- 
sibly, according  to  Golding-Bird,  to  paralysis  of  the  peronei  muscles.  When 
the  peronei  muscles  are  paralyzed,  the  adductors  act  unopposed,  and  sec- 
ondary contraction  of  the  plantar  fascia  occurs.  Certain  it  is  that  a  con- 
tracted plantar  fascia  is  the  chief  obstacle  to  correction.  In  many  cases  the 
cause  is  the  wearing  of  shoes  which  are  too  short  for  the  feet.  The  pressure 
made  upon  the  toes  causes  spasm  of  the  plantar  flexors  and  this  spasm,  per- 
mits the  fascia  to  contract. 


Metatarsalgia  761 

Treatment. — A  shoe  is  worn  containing  a  plate  of  steel  in  the  sole,  and 
pressure  is  applied  over  the  instep.  Tenotomy,  division  of  the  plantar  fascia, 
or  excision  of  bone  may  be  recjuired.  In  paralytic  cases  apply  electricity 
and  massage  to  the  paralyzed  muscles. 

Hallus  valgus,  or  varus,  a  displacement  of  the  great  toe  outward  or 
inward,  may  occur  in  the  young,  but  it  is  most  frequent  in  old  persons,  espe- 
cially old  women.  It  arises  often  from  wearing  pointed  shoes,  shoes  that 
are  too  short,  or  high  heels,  but  may  be  due  to  gout  or  to  rheumatic  gout. 
In  many  cases  an  exostosis  forms  in  the  inner  portion  of  the  distal  end  of 
the  metatarsal  bone.  In  hallux  valgus  a  bunion  (bursa)  is  apt  to  form  over 
the  metatarsophalangeal  joint  and  it  may  inflame  or  ulcerate. 

Treatment. — An  arrangement  may  be  worn  to  straighten  the  toe  and 
to  protect  the  bunion  (Fig.  407).  The  prominent  and  hypertrophied  inner 
portion  of  the  head  of  the  metatarsal  bone  may  be  removed  by  means  of  a 
chisel,  osteotomy  may  be  performed  upon  the  metatarsal  bone,  the  joint 
may  be  excised,  or  amputation  may  be  required.  H.  A.  Wilson  advocates 
lateral  excision.  By  means  of  bone-forceps  he  cuts  away  that  part  of  the 
distal  extremity  beyond  the  phalanx,  and  with  a  chisel  removes  the  remaining 
sharp  line  edge.  He  places  the  phalanx  in  normal  position  and  holds  it  so 
for  two  weeks  ("Am.  Jour.  Orthopedic  Surgery,"  Jan.,  1906). 

Hanimer=toe  (Figs.  420  and  422)  is  a  condition  in  which  there  is  flexion 
of  one  or  more  toes  at  the  first  interphalangeal  joint.  Shattuck  shows  that 
this  condition  is  due  to  contraction  of  "  the  plantar  fibers  of  the  lateral  ligaments 
of  the  joint."*  This  disease  usually  begins  in  youth  and  may  be  congenital. 
A  bunion  is  apt  to  form,  and  the  joint  may  become  dislocated. 

Treatment. — Terrier's  plan  of  treatment  consists  in  making  a   dorsal 
flap,  removing  a  bursa  if  one  is  found,  dividing  the  extensor  tendon,  opening 
the  articulation,  removing  each  articular  surface  with  cutting  forceps,  suturing 
the  soft  parts,   and  applying  a  plantar  splint  for  two 
weeks. f     Some    surgeons  excise   the  joint.      Probably 
amputation  of  the  toe  is  the  best  treatment. 

Metatarsalgia  (Morton's  Disease)  .—This  disease 
was  first  described  by  Dr.  Thomas  G.  Morton,  of  Phila- 
delphia, in  1876.  It  is  a  painful  condition  of  the  foot,  Fig.  422.— Hammer-toe. 
due  to  jamming  of  a  nerve  between  the  heads  of  the  fourth 
and  fifth  metatarsal  bones.  The  head  of  the  fifth  metatarsal  bone  is,  by 
lateral  pressure,  forced  against  and  below  the  neck  of  the  fourth  metatarsal, 
and  as  a  result  the  superficial  branch  of  the  external  plantar  nerve  and  its 
two  digital  branches  are  squeezed.  It  is  usually  associated  wath  flat-foot. 
Pain  is  produced  by  walking,  and  the  suffering  may  be  so  severe  that  the 
patient  is  obliged  to  sit  down  at  once.  When  the  shoe  is  removed  and  the 
foot  is  rested,  the  pain  soon  abates.  The  pain  is  felt  on  the  outer  and  inner 
sides  of  the  little  toe,  the  outer  side  of  the  fourth  toe,  and  about  the  head 
of  the  fifth  and  the  neck  of  the  fourth  metatarsal  bones.  Pain  can  be  devel- 
oped by  grasping  the  foot  in  the  hand  and  squeezing  it.  If  flat-foot  exists, 
there  is  also  pain  due  to  this  trouble. 

Treatment. — Mild  cases  may  be  cured  occasionally  by  wearing  well- 
fitting  shoes  and  employing  massage.     Some  cases  require  a  brace.     Severe 
cases  demand  resection  of  the  fourth  metatarsophalangeal  joint,  or  amputa- 
*  American  Text-Book  of  Surgery.  fRev.  de  Chir.,  July,  1895, 


762 


Orthopedic  Surgery 


tion  of  the  fourth  toe,  and  with  it  the  head  of  the  fourth  metatarsal  bone. 
Graham,  of  Washington,  has  cured  cases  by  excising  a  portion  of  the  super- 
ficial branch  of  the  external  plantar  nerve. 

Coxa  Vara  and  Coxa  Valga.— Coxa  vara  {incurvation  or  infraction  of 
the  neck  of  the  femur)  is  a  disease  characterized  by  bending  of  the  neck  of  the 
femur,  the  femoral  neck  being  depressed  below  its  normal  obtuse  angle  with  the 
shaft,  the  hip-joint  being  perfectly  healthy,  and  the  condition,  as  a  rule,  being 
unilateral,  but  sometimes  bilateral.  This  condidon  was  described  by  Miiller 
in  1889.  Coxa  vara  is  first  noticed,  as  a  rule,  between  the  thirteenth  and 
twentieth  years,  and  the  commonly  accepted  view  has  been  that  the  deformity 
is  rachitic,  but  Kredel  has  reported  two  congenital  cases.*  Traumatic  coxa 
vara  may  follow  impacted  fracture  of  the  neck  of  the  femur  in  a  child.  An 
individual  with  coxa  vara  develops  a  limp,  and  grows  tired  after  shght  ex- 
ertion, but  there  is  no  swelling,  no  tenderness,  and  little  or  no  pain.  Shorten- 
ing after  a  time  becomes  apparent,  and  the  great  trochanter  can  be  detected 
above  Nelaton's  line.  The  extremity  is  adducted,  and  usually  rotated  out- 
ward. Abduction  is  Hmited.  In  some  cases  in  which  there  is  joint  irrita- 
tion all  joint  motions  may  be  distinctly  limited. 

In  a  bilateral  case  there  is  lordosis,  but  shortening  may  not  be  detected 
because  both  legs  are  the  same  length.  Each  great  trochanter,  however,  is 
above  Nelaton's  Hne. 

Coxa  valga  is  a  condition  in  which  the  angle  of  the  neck  to  the  shaft  of 
the  femur  is  more  obtuse  than  normal.  The  neck  may  assume  a  position  in 
line  with  the  long  axis  of  the  shaft.  It  occurs  particularly  in  children  who 
have  had  infantile  palsy,  but  it  may  be  congenital,  may  occur  in  rickets  and 
osteomalacia,  and  after  a  prolonged  period  of  disease  of  a  limb.  The  patient 
has  pain  and  a  limp,  the  extremity  is  lengthened,  abducted,  and  in  external 
rotation  there  is  limitation  of  adduction  and  the  trochanter  is  flattened.  Coxa 
valga  is  usually  unilateral,  but  may  be  bilateral. 

The  differential  diagnosis  in  coxa  vara  and  coxa  valga  is  often  very  difficult, 
and  the  accompanjing  table  will  materially  aid  in  contrasting  the  conspicuous 
features  of  the  various  conditions  wath  which  these  two  deformities  of  the  neck 
of  the  femur  may  be  confounded: 


Hip 

Infantile 

Congenital 

Psoas 

Coxa  Vara 

Knee   Dis- 

Disease. 

Paralysis. 

Dislocation. 

Abscess. 

OR  Valga. 

ease. 

Age. 

Four  to  six. 

Four  to  six. 

Any  age. 

Four  to  six. 

Anv  age. 

Four  to  six. 

Onset. 

Insidious. 

Sudden. 

From  birth. 

Insidious. 

Childhood. 

Insidious. 

Pain. 

Referred      to 
knee. 

None. 

None. 

Referred      to 
abdomen. 

None. 

Referred  from 
knee. 

History. 

TB. 

Inflammatory 
disease. 

Limp      from 
birth. 

TB. 

Limp. 

TB. 

Posture. 

Flexion, 
abduction, 
external     ro- 
tation. 

Uncontrolled . 

Shortening. 

Flexion, 
adduction, 
external     ro- 
tation. 

Great 
trochanter 
higher. 

Knee  fle.xed. 

Muscular  rigid- 

Present in  all 

.\bsent . 

Absent. 

In  one  direc- 

None. 

About  knee. 

ity. 

directions. 

tion. 

Temperature. 

I  degree  high. 

Normal. 

Normal. 

I  degree. 

Normal. 

I  degree. 

Local       tender- 

In  hip. 

None. 

None. 

In  spine. 

None. 

In  knee. 

Night  cries. 

Present. 

Absent . 

Absent. 

Present. 

Absent. 

Present. 

Tendency        to 

Yes. 

No. 

No. 

Yes. 

No 

Yes. 

abscess. 

A'-rr\y, 

Diseased 

Atrophy. 

Alteration   in 

Normal  hip. 

.Alteration  in 

Normal  hip. 

focus  in  hip. 

joint. 

neck  angle. 

focus  in  knee. 

*Centralbl.  f.  Chir.,  Oct.  17,  1896. 


Neuritis,  or  Inflammation  of  a  Nerve  763 

The  x-rays  show  the  deformed  bone  in  either  coxa  vara  or  coxa  valga. 

Treatment.  — In  coxa  vara,  as  long  as  bending  is  j)rogressing,  employ  rest. 
When  the  bone  hardens,  it  may  be  necessary  to  perform  osteotomy  l)elow  the 
trochanters.  In  coxa  valga  (Jaleazzi  performs  osteotomy  through  the  neck 
of  the  femur  and  allows  the  trochanter  to  ascend. 

Flail=jointS. — After  an  attack  of  infantile  paralysis  involving  the 
entire  lower  extremity  of  each  side  the  limbs  become  limp  and  swing  flail- 
like when  the  extremity  is  made  to  move,  and  the  joints  are  much  relaxed. 
In  such  cases  the  psoas  and  iliacus  muscles  are  never  completely  paralyzed, 
and  the  aim  of  the  surgeon  is  to  utilize  these  muscles  in  enabling  the  patient 
to  walk.  In  many  cases  the  application  of  apparatus  is  sufficient.  In  others 
ankylosis  may  be  established  in  the  ankles  and  knees  by  operation.  If 
ankylosis  is  established  in  these  joints,  the  psoas  and  iliacus  muscles  become 
able  to  move  the  legs. 


XXII.  DISEASES  AND  INJURIES  OF  NERVES. 

Diseases  of  Nerves. 

Neuritis,  or  inflammation  of  a  nerve,  may  be  limited  or  be 
widely  distributed  {multiple  neuritis).  The  first-mentioned  form  will  here 
be  considered.  The  causes  of  neuritis  are  traumatism,  wounds,  overaction 
of  muscles,  gout,  rheumatism,  syphilis,  fevers,  and  alcoholism. 

Symptoms. — The  symptoms  of  neuritis  are  as  follows:  excessive  pain, 
usually  intermittent,  in  the  area  of  nerve-distribution.  The  pain  is  worse 
at  night,  is  aggravated  by  motion  and  pressure,  and  occasionally  diffuses 
to  adjacent  nerve-areas  or  awakens  sympathetic  pains  in  the  opposite  side 
of  the  body.  The  nerve  is  very  tender.  The  area  of  nerve-distribution 
feels  numb  and  is  often  swollen.  Early  in  the  case  the  skin  is  hyperesthetic; 
later  it  may  become  anesthetic.  The  muscles  atrophy  and  present  the 
reactions  of  degeneration;  that  is,  the  muscles  first  cease  to  respond  to  a 
rapidly  interrupted,  and  next  to  a  slowly  interrupted,  faradic  current;  faradic 
excitability  diminishes,  but  galvanic  excitability  increases.  When,  in  neuritis, 
faradism  produced  no  contraction,  a  slowly  interrupted  galvanic  current 
which  is  so  weak  that  it  would  produce  no  movement  in  the  healthy  muscle 
causes  marked  response  in  the  degenerated  muscle.  In  health  the  most 
vigorous  contraction  is  obtained  by  closing  with  the  —  pole;  in  degenerated 
muscles  the  most  vigorous  contraction  is  obtained  by  closing  with  the  -\-  pole. 
When  voluntary  power  returns,  galvanic  excitability  declines;  but  power 
is  often  nearly  restored  before  faradic  excitability  becomes  manifest  (Buzzard). 

Treatment. — The  treatment  of  neuritis  consists  of  rest  upon  splints 
and  the  use  of  an  ice-bag  early  in  the  case  and  a  hot-water  bag  later.  Blisters 
over  the  course  of  the  nerve  are  of  value,  especially  in  traumatic  neuritis. 
Massage  and  electricity  must  be  used  to  antagonize  degeneration.  A  descend- 
ing galvanic  current  allays  pain  to  some  extent.  Deep  injections  of  chloro- 
form or  cocain  may  allay  pain.  Treat  the  patient's  general  health,  especially 
any  constitutional  disease  or  causative  diathesis.  The  salicylate  of  ammo- 
nium or  phenacetin  may  be  given  internally.  In  some  cases  nerve-stretching 
is  advisable. 


764 


Diseases  and  Injuries  of  Nerves 


Neuralgia  is  manifested  by  violent  paroxysmal  pain  in  the  trajectory  of 
a  nerve.  This  disease,  unless  it  is  exceedingly  severe  and  persistent,  is  treated, 
as  a  rule,  by  the  physician.  Injections  of  alcohol  or  osmic  acid  into  the  nerve 
may  secure  relief  or  cure.     If  neuralgia  is  due  to  adhesions  about  the  nerve 

or  to  the  pressure  of  scar  or  callus, 
these  conditions  should  be  amended 
surgically.  There  is  some  e\-idence 
that  neuralgia  arises,  at  least  occa- 
sionally, from  dilatation  of  the  vessels 
of  the  sheath  and  subsequent  edema 
and  exudation.  If  this  be  the  case 
cure  may  follow  opening  the  sheath 
and  separating  adhesions  between 
the  sheath  and  nerve  (Robert  M. 
Simon,  in  "Brit.  Med.  Jour.,"  April 
10,  1909).  Neuralgia  of  stumps  and 
scars  is  a  surgical  condition,  and  is 
due  to  neuromata,  or  entanglement 
of  nerve-filaments  in  a  cicatrix. 
Tic  douloureux  and  other  intract- 
able neuralgias  require  careful  re- 
moval of  any  cause  of  reflex  irri- 
tation. Causal  reflex  irritation  may 
arise  from  disease  of  the  stomach, 
eyes,  teeth,  uterus,  nose,  throat,  etc. 
Tic  douloureux  has  been  treated  by 
removal  of  the  Gasserian  ganglion; 
intracranial  neurectomy  of  the  sec- 
ond and  third  divisions;  division  of 
the  sensory  root;  removal  of  Meckel's 
ganglion;  ligation  of  the  common 
carotid  artery;  neurectomy  of  termi- 
nal branches  of  the  fifth  nerve;  di\'i5ion  of  motor  nerves;  injections  of  osmic 
acid  (page  779);  injections  of  alcohol;  massive  doses  of  strychnin  (Dana)  and 
purgatives  (Esmarch).  The  distribution  of  the  fifth  nerve,  the  seat  of  pain  in 
tic  douloureux,  is  shown  in  Fig.  423. 

Treatment  of  Neuralgia  of  Stumps. — Excise  the  scar;  find  the  bulbous 
end  of  the  nerve  and  cut  it  off.  Senn  tells  us  to  section  the  nerve  by  V-shaped 
cuts,  the  apex  of  the  V  being  toward  the  body,  and  to  suture  the  flaps  together. 
Senn's  method  will  prevent  recurrence.  In  some  cases  reamputation  is 
performed.  In  entanglement  of  a  nerve  in  a  scar  remove  a  portion  of  the 
nerve  above  the  scar  and  also  the  neuroma  in  the  scar. 


Fig.  423. — Distribution  of  the  cutaneous  sensi- 
tive nerves  upon  the  head :  o;«a,  0W?,  The  occipit. 
maj.  and  minor  (from  the  N.  cervical.  II  and  III) ; 
am,  N.  auricular  magn.  (from  N.  cervic.  Ill) ;  cs, 
N.  cervical,  superfic.  (from  N.  cervic.  Ill);  V\, 
first  branch  of  the  fifth  {so,  N.  supraorbit.;  st.  N. 
supratrochl. ;  z/,  N.  infratrochl. ;  f,  X.  ethmoid.; 
/,  N.  lachrymal.)  ;  ^o,  second  branch  of  the  fifth 
(sm,  K.  subcutan.  malse  seu  zygomaticus) ;  I3, 
third  branch  of  the  fifth  (at,  X.  auriculo-tempor. ; 
b,  N.  buccinator;  m,  X.  mental.);  B,  posterior 
branches  of  the  cervical  nenes  (Seeligmuller). 


WOUXDS   .\XD    IXJURIES    OF    NeRVES. 

Section  of  Nerves  (as  from  an  incised  wound) . —After  nerve-section 
sensation  and  motor  power  are  lost  at  once.  The  entire  peri[)heral  portion  of 
the  nerve  degenerates  and  ceases  structurally  to  be  a  nerve  in  a  few  weeks, 
but  after  many  months,  or  even  years,  the  nen'e  may  regenerate.  The  proxi- 
mal end  degenerates  only  in  the  portion  immediately  adjacent  to  the  section; 


Section  of  Nerves  765 

it  rapidly  regenerates,  and  if  it  does  not  adhere  to  the  peripheral  segment 
a  bulb  or  enlargement  composed  of  fibrous  tissue  and  small  nerve-fibers  forms 
just  above  the  line  of  section;  this  bulb  adheres  to  the  perineural  tissues. 
The  entire  distal  end  degenerates,  but  new  axis-cylinders  form  in  this  segment 
by  proliferation  of  the  nuclei  on  the  sheath  of  Schwann.  Union  of  a  divided 
nerve  is  brought  about  by  the  projection  of  axis-cylinders  from  the  proximal 
end  or  from  each  end  and  the  fusion  of  these  cylinders.  The  nearer  the  two 
ends  are  to  each  other,  the  better  the  chance  of  union.  When  a  nerve  has  been 
divided  and  has  not  been  sutured,  abolition  of  function  may  be  permanent 
or  restoration  may  occur.  Sensation  may  return  in  from  six  weeks  to  several 
months.  Motor  power  may  never  return.  If  it  does  return  it  will  do  so  long 
after  sensory  restoration.  Restoration  of  motor  power  requires  from  twelve 
weeks  to  three  and  one-half  years.  It  is  seldom  noted  before  six  months. 
The  return  is  always  slow  (John  B.  Muqjhy,  in  "Surg.  G}Tiec.,  and  Obstet.," 
April,  1907).  Failure  of  return  means  that  the  ends  are  separated  by  a  wide 
interval  or  that  fascia  is  interfused  between  them.  In  some  recorded  cases 
motion  and  sensation  have  returned  xdth  great  rapidity,  due,  some  have  said, 
to  anastomoses  with  adjacent  nerves.  ^lurphy  shows  that  when  restoration 
begins,  trophic  energy  returns  even  before  sensation^  and  ^^■hen  trophic  energy- 
returns  the  blueness  and  coldness  of  the  Umb  lessen. 

The  nerve-fibers  which  convey  impressions  of  cutaneous  pain  and  of  ex- 
treme heat  and  cold  regenerate  far  more  rapidly  than  those  which  subsen'C 
sensations  of  light  touch  and  slight  degrees  of  heat  and  cold. 

The  investigations  of  Head  and  others  show  that  restoration  does  not  begin 
at  the  normal  area  and  spread  from  there  over  the  anesthetic  area,  but  that  the 
reverse  is  the  case.  It  begins  from  the  confines  of  the  anesthetic  area  and 
spreads  toward  the  normal  part. 

General  Symptoins. — Immediately  after  nerve-section  vasomotor  paral- 
ysis comes  on,  and  for  a  few  days  the  paralyzed  part  presents  a  temperature 
higher  than  normal.  It  then  becomes  blue  and  cold.  Pronounced  changes 
occur  in  the  trajectory  of  a  divided  nerve.  The  muscles  degenerate,  atrophy, 
and  shorten,  and  develop  the  reactions  of  degeneration.  When  union  of  the 
nerve  occurs,  the  muscles  are  restored  to  a  normal  condition.  If  the  nerve 
contains  sensory  fi^bers,  complete  anesthesia  (to  touch,  pain,  and  temperature) 
usually  follows  its  dinsion;  but  if  a  part  is  supplied  by  another  nen-e  as  well  as 
by  the  di\dded  one,  anesthesia  u^ill  not  be  complete.  Trophic  changes  arise 
in  the  paralyzed  parts.  Among  these  changes  are  muscular  atrophy;  glossy 
skin;  cutaneous  eruptions;  ulcers;  dry  gangrene;  painless  felons;  falling  of  the 
hair;  brittleness,  furro\\'ing,  or  casting  off  of  the  nails;  joint-inflammations; 
and  ankylosis.  The  diagnosis  as  to  which  nerve  is  cut  depends  upon  a  study 
of  the  distribution  of  motor  and  sensory  paralysis.* 

A  curious  fact  that  was  pointed  out  by  Letievant  is  that  after  division  of  a 
nerve  blunt  pressure  may  be  appreciated  over  the  entire  analgesic  area.  This 
phenomena  was  long  thought  to  be  due  to  nerve  anastomoses,  the  sensory  areas 
from  dillerent  nerves  overlapping.  The  explanation  now  given  is  founded  on 
Sherrington's  demonstration  that  the  motor  branches  of  a  mixed  ner\'e  carry 
sensory  fibers  through  muscles  and  tendons,  and  Head's  proof  that  certain 
afferent  fibers  convey  impressions  of  deep  sensibility  as  produced  by  pressure- 
*  See  Bowl  by  on  "  Injuries  of  Nerves." 


766  Diseases  and  Injuries  of  Nerves 

The  Symptoms  of  Division  of  Nerves. — Brachial  Plexus. — If  one 
or  more  cords  of  the  bracliial  plexus  are  divided,  motor  paralysis  and  anes- 
thesia appear  in  the  limb,  the  extent  of  the  paralysis  and  the  area  of  the  anes- 
thesia depending  upon  the  cord  or  cords  involved.  It  should  be  remembered 
that  the  inner  cord  of  the  brachial  plexus  gives  origin  to  the  ulnar  nerve;  the 
inner  and  outer  cords  give  branches  which  fuse  to  form  the  median  nerve. 
The  posterior  cord  gives  origin  to  the  subscapular,  the  circumflex,  and  the 
musculospiral  nerves.  The  outer  cord  gives  origin  to  the  external  anterior 
thoracic  and  the  musculo-cutaneous,  as  well  as  to  the  outer  trunk  of  origin 
of  the  median. 

Evulsion  0}  the  brachial  plexus  is  sometimes  efifected  by  an  injury,  when 
the  arm  is  not  lost.  Algernon  T.  Bristow  ("Annals  of  Surgery,"  Sept.,  1902) 
reports  3  cases  of  this  rare  injury,  and  has  collected  24  undoubted  instances. 
One  of  his  own  cases  was  operated  upon  the  third  day  after  the  accident.  In 
this  case  there  was  complete  paralysis  of  the  upper  extremity,  with  the  excep- 
tion of  the  sensory  area  of  the  intercostohumeral  and  the  circumflex  nerves. 
The  accident  had  been  inflicted  by  the  patient's  forearm  becoming  entangled 
in  a  rope,  which  was  pulled  upon  by  a  steam  winch.  On  reaching  the  hos- 
pital he  felt  severe  pain,  referred  to  the  arm.  There  was  much  swelling  in 
the  inner  portion  of  the  subclavian  triangle,  the  left  pupil  was  contracted, 
and  it  seemed  likely  that  the  nerves  had  been  evulsed  close  to  the  interverte- 
bral foramina.  From  the  fact  that  sensation  was  preserved  in  the  skin  of 
the  convexity  of  the  shoulder  down  to  the  insertion  of  the  deltoid,  Bristow 
concluded  that  some  fibers  of  the  posterior  cord  of  the  plexus  had  escaped 
division;  but  when  the  operation  was  performed,  this  conclusion  was  found 
to  be  erroneous.  An  incision  was  made,  and  it  was  found  that  the  plexus 
had  given  way  at  the  point  where  the  four  cervical  nerves  and  the  last  dorsal 
unite  to  form  the  three  trunks.  In  order  to  reach  the  lower  ends,  it  was 
necessary  to  saw  the  clavicle  and  divide  the  two  pectoral  muscles;  and  the 
torn  ends  of  the  nerve-trunks  were  found  underneath  the  clavicle.  Suturing 
was  performed.  The  ends  of  the  sawn  clavicle  were  sutured  together,  the 
wound  was  closed  and  dressed,  and  the  arm  was  put  up  in  Sayre's  dressing. 

This  article  of  Bristow's  is  of  extreme  interest.  He  discusses  the  injury  to 
the  sympathetic  and  the  reason  that  sensation  was  preserved  over  the  area 
usually  supplied  by  the  circumflex.  After  the  performance  of  this  operation 
sensation  over  the  entire  upper  arm  returned.  We  agree  with  Bristow  that 
after  such  an  injury  early  operation  is  the  only  thing  that  offers  any  prospect 
of  the  return  of  function.  It  may  be  necessary  to  perform  nerve  anastomosis, 
uniting  the  end  of  the  distal  segment  of  a  divided  trunk  with  an  undivided 
trunk.  1  myself  once  operated  upon  a  patient  that  had  developed  paralysis, 
motor  and  sensory,  after  violent  stretching  of  the  arm.  In  the  Hght  of  Bris- 
tow's case  I  assumed  that  evulsion  of  the  plexus  had  probably  taken  place. 
Incision  disclosed  the  fact  that  the  plexus  was  intact,  but  was  surrounded  with 
dense  scar-tissue.  This  tissue  was  removed,  so  as  to  loosen  the  nerves;  but 
I  have  lost  track  of  the  patient,  and  do  not  know  the  result.  My  patient  was 
operated  upon  many  months  after  the  injury.  It  is  weU  to  bear  in  mind  that 
in  an  injury  of  the  supraclavicular  division  of  the  brachial  plexus  there  will 
probably  be  palsy  of  the  great  serratus  muscle. 

Murphy  points  out  that  an  injury  above  the  clavicle  will  involve  the  cir- 


The  Symptoms  of  Division  of  Nerves  767 

cumflex  and  musculospiral — that  as  the  great  pectoral  is  supphed  from 
l)oth  the  external  and  internal  cords  of  the  plexus,  complete  paralysis  of  the 
great  y)ectoral  proves  that  both  cords  are  involved  and  that  unimpaired  move- 
ments of  the  (haphragm  on  the  side  of  the  lesion  (observed  with  the  fluorosco[)e) 
show  that  the  cords  of  the  plexus  are  not  divided  within  the  foramina,  but 
well  outside  of  them  (John  B.  Murphy,  in  "Surg.,  Gynec,  and  Obstet.,"  April, 
1907). 

Brachial  Birth  Palsy. — It  has  been  pointed  out  by  Clark,  Taylor,  and 
Prout  ("Am.  Jour.  Med.  Sciences, "  Oct.,  1905)  that  brachial  birth  palsy  results 
from  tension  on  the  nerve-trunks  by  overstretching  during  delivery,  the  nerve- 
sheath  first  rupturing  and  then  the  nerve-fibers.  When  the  sheath  ruptures 
hemorrhage  occurs,  fibrous  tissue  forms,  and  the  scar  presses  on  the  intact, 
slightly  stretched,  or  actually  lacerated  nerve  and  prevents  repair.  The 
authors  tell  us  that  the  fifth  cervical  root  first  gives  way,  then  the  sixth,  and 
so  on  down  the  plexus  if  there  is  sufficient  force.  In  the  mild  cases  the  fifth 
root  alone  suffers.  They  call  it  brachial  birth  palsy,  or  laceration  palsy,  and 
sum  up  the  symptoms  in  a  severe  case  as  follows:  The  arm  hangs  powerless; 
abduction  at  the  shoulder  is  impossible  because  of  deltoid  and  supraspinatus 
palsy;  the  forearm  is  extended  and  flexion  is  impossible  because  of  biceps, 
brachialis  anticus,  and  supinator  longus  palsy;  palsy  of  supinator  brevis  and 
biceps  causes  pronation  of  hand;  there  is  inward  rotation  of  the  humerus 
because  of  palsy  of  the  supraspinatus,  infraspinatus,  and  teres  minor. 

Brachial  birth  palsy  is  manifest  soon  after  its  infliction  by  evidences  of 
pain  on  handling  the  extremity,  the  pain  being  due  to  neuritis  (authors  above 
quoted).  Medical  treatment  is  relied  on  for  one  year,  and  then,  if  improve- 
ment is  not  manifest,  operation  is  indicated  (page  786) . 

Posterior  {Long)  Thoracic  Nerve.- — Division  of  this  nerve  causes  paralysis 
of  the  serratus  magnus  muscle,  which  is  made  evident  by  eversion  from  the 
thorax  and  rotation  of  the  scapula  when  the  arm  is  taken  forward  {wing-like 
scapula).  In  paralysis  of  this  muscle  the  arm  cannot  be  raised  above  the 
horizontal. 

Suprascapular  Nerve. — Division  of  this  nerve  produces  some  anesthesia 
over  the  scapula  and  paralysis  of  the  supraspinatus  and  the  infraspinatus 
muscles.  The  supraspinatus  is  but  an  adjuvant  to  the  deltoid  and  palsy  of 
it  is  not  manifestly  disabling.  Palsy  of  the  infraspinatus  renders  external 
rotation  of  the  humerus  impossible,  and  writing  becomes  most  difficult  because 
the  pen  cannot  be  moved  along  the  paper.  Sewing,  too,  is  greatly  interfered 
with. 

Circumflex  Nerve. — Division  of  the  circumflex  nerve  produces  paralysis 
of  the  deltoid  muscle,  so  that  it  becomes  impossible  to  lift  the  arm  to  a  right 
angle  with  the  body.  There  is  some  shght  retention  of  power  in  the  anterior 
fibers,  which  are  suppHed  by  the  anterior  thoracic  nerve.  The  skin  over  the 
lower  part  of  the  muscle  is  usually  anesthetic. 

Musculocutaneous  Nerve. — Division  of  this  nerve  produces  paralysis  of 
the  biceps  and  of  the  brachialis  anticus  muscles  (paralysis  of  the  forearm 
flexors) .  This  palsy  becomes  especially  evident  when  the  forearm  is  supinated, 
because  in  this  position  the  supinator  longus  can  no  longer  act  as  a  flexor  of  the 
elbow.  There  is  anesthesia  of  the  radial  side  of  the  forearm  anteriorly  and 
posteriorly. 


768 


Diseases  and  Injuries  of  Nerves 


The  Musculospiral  or  Radial  Nerve. — Division  of  this  nerve  high  up  near 
the  plexus  causes  paralysis  of  the  extensor  muscles  of  the  elbow  and  the 
wrist,  of  the  supinators,  and  of  the  long  extensors  of  the  thumb  and  fingers. 
When  divided  near  the  middle  of  the  humerus,  the  triceps  usually,  but  not 
invariably,  escapes.  If  the  injury  is  below  the  branch  going  to  the  supinator 
longus,  that  muscle  will  escape;  otherwise  it  will  become  paralyzed.  The 
extensor  palsy  causes  wrist-drop  and  loss  of  the  power  of  extending  the  first 
phalanges  of  the  fingers  and  thumb;  and,  as  Gowers  has  pointed  out,  flexion 
is  reduced  to  one-third  of  the  normal,  the  flexors  having  lost  power  "from 
the  loss  of  antergic  support."  As  a  rule,  in  musculospiral  palsy  there  is  loss 
of  supination.  Sensibility  is  sometimes  greatly  affected,  and  sometimes 
very  sHghtly.  If  the  injury  is  above  the  level  of  the  musculospiral  groove 
there  will  be  anesthesia  in  the  area  supplied  by  the  sensory  fibers  of  the  nerve 


Fig.  424.— Paralysis  of  musculospiral  nerve 
after  fracture  of  the  humerus  ("wrist-drop"); 
but  when  fingers  ha\e  been  flexed  into  palm,  a, 
they  can  be  extended,  b,  at  first  interphalaugeal 
joints  by  lumbricals  and  interossei,  which  are 
supplied  by  the  ulnar  and  median  nerves 
(Erichsen). 


Fig.  425. — Distribution  of  sensory  nerves 
on  the  backs  of  the  fingers  :  r,  Musculospiral 
or  radial  nerve ;  ?/,  ulnar  nerve;  ;«,  median 
nerve  (Krause). 


(Fig.  429).  If  the  nerve  is  injured  in  the  musculospiral  groove  there  are  seldom 
sensory  disturbances.  Anesthesia  rarely  occurs  in  the  upper  arm  in  any  case, 
and  even  after  an  injury  in  the  groove  the  hand  sensation  may  be  normal  or 
nearly  so.  Fig.  424  shows  the  position  of  the  parts  in  musculospiral  palsy  and 
Figs.  425  and  429  the  sensory  distribution  of  the  nerve. 

The  Median  Nerve. — After  division  of  the  median  nerve  there  is  paralysis 
of  the  pronators;  the  flexor  carpi  radialis;  the  finger  flexors,  except  the  ulnar 
portion  of  the  deep  flexor;  the  abductors,  and  the  flexors  of  the  thumb;  and 
the  two  radial  lumbricales.  The  forearm  can  be  placed  in  a  position  midway 
between  pronation  and  supination;  but  further  pronation  cannot  be  volun- 
tarily effected.  In  executing  flexion  of  the  wrist  a  strong  deviation  toward  the 
ulnar  side  takes  place.  The  thumb  is  in  a  position  of  extension  and  abduction, 
and  cannot  be  brought  into  apposition  with  the  finger-tips.  The  second 
phalanges  of  the  fingers  cannot  be  flexed  on  the  first,  and  the  distal  phalanges 
of  the  first  and  second  fingers  cannot  be  voluntarily  flexed.  The  corresponding 
phalanges  of  the  third  and  fourth  fingers  can  be  flexed,  this  being  accomplished 
by  the  unparalyzed  ulnar  half  of  the  deep  flexor.  Flexion  of  the  first  pha- 
langes is  still  possible,  as  it  is  accomplished  by  means  of  the  interossei.     The 


The  Symptoms  of  Division  of  Nerves 


769 


extensor  action  of  the  interossei  muscle  upon  the  middle  and  distal  phalanges, 
being  unopposed,  may  eventually  cause  subluxation.  The  sensory  distri- 
bution of  the  median  nerve  is  shown  in  Figs.  425,  426,  427,  and  429.  It  is 
the  sensory  nerve  of  the  radial  side  of  the  palm,  the  front  of  the  thumb,  the 
first  and  second  fingers  and  half  of  the  third  finger,  and  the  back  of  the  last 


Fig.  42(5. — Sectiou  of  median  nerve;  areas 
of  anesthesia  (heavy  shading)  and  of  dyses- 
thesia (light  shading)  on  palmar  surface  of 
hand  (Bowlby). 


Fig.  427. — Section  of  median  nerve;  re- 
gions of  anesthesia  and  dysesthesia  on  dorsal 
surface  of  hand  (Bowlby). 


phalanx  of  the  index  and  the  middle  finger  (Gowers).  The  sensory  changes 
after  median  paralysis  are  quite  variable — sometimes  wide-spread  and  com- 
plete, at  other  times  trivial,  and  occasionally  absent.  Gowers  says  that 
if  there  is  anesthesia  it  is  usually  of  the  palmar  surface,  and  may  also  occur 
on  the  dorsal  aspect  of  the  ends  of  the  first  two  fingers. 


Fig.  428. — Division  of  ulnar  nerve. 

The  Ulnar  Nerve. — When  the  ulnar  nerve  is  divided,  there  is  paralysis  of 
the  flexor  carpi  ulnaris,  of  the  ulnar  portion  of  the  deep  flexor,  of  the  muscles 
of  the  little  finger,  of  the  abductor  pollicis,  and  of  the  inner  end  of  the  flexor 
brevis  pollicis  (Gowers).  It  becomes  impossible  to  adduct  the  thumb,  and 
the  majority  of  the  movements  of  the  little  finger  are  abolished.  Flexion  of 
the  fingers  is  impossible  at  the  first  joints,  and  extension  is  impossible  at  the 
49 


770 


Diseases  and  Injuries  of  Nerves 


other  joints;  but,  as  Gowers  points  out,  the  loss  is  shghter  in  the  first  two 
fingers  than  in  the  others,  because  the  lumbricales  of  the  first  two  fingers  are 
supphed  by  the  median  nerve.  Interosseal  flexion  is  impossible,  and  the 
opponents  of  the  interossei,  acting  without  normal  antagonism,  contract  and  pro- 


ike 

Anterior  surface.  Posterior  surface. 

Fig.  429.— Distribution  of  the  cutaneous  nerves  to  the  shoulder,  arm,  and  hand.  The  region  of 
the  N.  radialis  is  represented  by  the  unbroken  hatched  line,  that  of  the  N.  ulnaris  by  the  broken 
hatched  lines,  a.  Anterior,  b,  posterior  surface ;  sc,  Nn.  suprascapular  (plexus  cervicalis) ;  ax, 
chief  branch  of  N.  axillar.;  cps,  cpi,  Nn.  cutanei  post.  sup.  and  inf.  (from  N.  radialis)  ;  ra,  terminal 
branches  of  N.  radialis;  cm,  cf,  Nn.  cutanei  medius  (also  to  the  plexus)  and  lateralis  (chiefly  to  the 
N.  medianus);  cp,  N.  cutan.  palmar.,  N.  rad. ;  cmd,  N.  cutan.  medialis  ;  7He,  N.  medianus;  u,  N. 
ulnaris;  epu,  N.  cutan.  palm,  ulnaris  (Henle). 


duce  what  is  known  as  claw-hand  (Figs.  428  and  43°)  -  a  condition  in  which  the 
first  i)halanges  are  overextended  and  the  others  are  flexed.  The  sensory 
loss  in  ulnar  paralysis  is  extremely  variable.  The  sensory  distribudon  is 
to  the  ulnar  side  of  the  hand,  both  back  and  front,  involving  the  htUe  finger, 
the  ring-finger,  and  the  ulnar  half  of  the  middle  finger  (Figs.  425,  429,  and  431), 


The  Symptoms  of  Division  of  Nerves 


77T 


Lumbar  Plexus. — The  lumbar  plexus  suppUes  the  cutaneous  svirface  of  the 
lower  portion  of  the  abdomen,  of  the  front  and  the  sides  of  the  thigh,  and  of 
the  inner  portion  of  the  leg  and  foot  (Fig.  432).  It  innervates  the  flexors  and 
adductors  of  the  hip-joint,  the  extensors  of  the  knee,  and  the  cremaster 
muscle.  The  branches  sent  to  the  leg  are  the  obturator  and  the  anterior 
crural  nerves. 

Sacral  Plexus. — The  sacral  plexus  supplies  the  extensors  and  rotators  of 
the  hip,  the  knee-flexors,  and  all  the  muscles  of  the  foot;  also  the  skin  of  the 
gluteal  region,  the  back  of  the  thigh,  the  outer  portion  and  the  posterior  part 


Fig.  430 — Paralysis  of  ulnar  nerve  from  wound  at  A  ;  contracture  of  common  extensor  with  pMSSterior 
luxation  of  first  phalanges  ;  B,  head  of  metacarpal  bone  (Duchenne). 


Fig.  431. — Showing  sensory  loss  and  ordinary  position  in  injuries  of  the  ulnar  nerve  (Bowlby). 


of  the  lower  leg,  and  most  of  the  foot  (Gowers)  (Fig.  432).  Its  chief  branches 
are  those  to  the  external  rotators  of  the  hip — the  gluteal  nerve,  the  small 
sciatic,  and  the  great  sciatic. 

The  Anterior  Crural  Nerve. — When  this  nerve  is  divided,  the  extensor 
muscles  of  the  knee  are  paralyzed.  The  psoas  muscle  is  not  affected,  even  if 
the  nerve  is  divided  within  the  abdomen;  but  high  division  may  produce 
paralysis  of  the  iliacus  muscle.  In  anterior  crural  palsy  the  skin  is  anesthetic 
over  ahnost  the  entire  thigh,  the  inner  surface  of  the  leg  and  foot,  and  the  inner 
sides  of  the  first  and  second  toes  (Fig.  432). 


772 


Diseases  and  Injuries  of  Nerves 


The  Obturator  Nerve. — In  obturator  palsy  the  adductor  muscles  of  the 
thigh  are  paralyzed,  and,  in  consequence,  the  patient  is  unable  to  cross  one 

leg  over  the  other.  Gowers 
points  out  that  external  rota- 
tion of  the  thigh  is  also  inter- 
fered with. 

The  Superior  Gluteal  Nerve. 
— The  division  of  this  nerve 
paralyzes  the  gluteus  medius 
and  the  gluteus  minimus  mus- 
cles, and  there  is  "loss  of  ab- 
duction and  circumduction  of 
the  thigh"  (Gowers). 

The  Small  Sciatic  Nerve. 
— Division  of  this  nerve  para- 
lyzes the  gluteus  maximus  mus- 
cle and  produces  anesthesia 
of  the  upper  half  of  the  calf  of 
the  leg  and  of  the  middle  third 
of  the  back  of  the  thigh  (Gowers) 
(Fig.  432). 

The  Great  Sciatic  Nerve. — 
If  this  nerve  is  dinded  near 
the  sciatic  notch,  there  is  a 
paralysis  of  the  flexor  mus- 
cles of  the  leg.  These  mus- 
cles, as  Gowers  points  out,  are 
also  extensors  of  the  hip.  There 
is  Hkewise  paralysis  of  all  the 
muscles  below  the  knee.  If, 
however,  the  injur}^  is  below  the 
upper  third  of  the  thigh,  there 
is  no  paralysis  of  the  flexors  of 
the  leg.  If  the  nerve  is  damaged 
on  a  level  below  the  small  sci- 
atic, there  is  anesthesia  of  the 
outer  portion  of  the  leg,  of  the 
sole  of  the  foot,  and  of  most  of 
the  dorsum   of  the  foot  (Fig. 

432)- 

The      Extenuil      Popliteal 

Nerve. — When    this    nerve    is 

damaged,  there  is  paralysis  of 

the  tibialis  anticus  muscle,  the 

extensor  longus  digitorum,  the 

extensor  bre\'is  digitorum,  and 

the  peronei;    and   the  patient  is  unable  to  flex  the  ankle  and  extend  the 

first  phalanges  of  the  toes.     WTien  he  tries  to  walk,  he  cannot  lift  the  foot 

from  the  ground;  and  eventually  there  is  the  development  of  tahpes  equinus 


Anterior  surface. 


Posterior  surface. 


Fig.  432. — Distribution  of  the  cutaneous  nerves  of 
the  lower  extremity:  ti,  N.  ilio-inguinal.  (plex.  lumb.); 
It,  N.  lumbo-inguinal.  (to  the  genitocrural,  plex.  lum- 
bal.); se,  N.  spermat.  ext.  (to the  genitocrural);  cp, 
N.  cutan.  post.  (plex.  ischiad.);  cl,  N.  cutan.  lateral, 
(plex.  lumb.);  cr,  N.  cruralis  (plex.  lumbal.);  oW,  N. 
obturator,  (plex.  lumb.);  .la,  N.  saphen.  (plex.  lum- 
bal.); cpe,  N.  commun.  peron.  (N.  peron.  tibial.);  cli, 
N.  commun.  tibial  ;  per",  per",  N.  peronsei  ram.  su- 
perfic.  et  prof.;  cpm,  N.  cutan.  post.  med.  (plex. 
ischiad.);  cpp,  N.  cut.  plant,  propr.  (N.  tib.);  plm, 
pU,  N.  plantar,  medial,  et  lateral.  (N.  tib.)  (Henle). 


The  Treatment  of  Division  of  Nerves  773 

(Cowers).     The  anesthesia  is  manifest  on  the  outer  portion  of  the  anterior 
surface  of  the  leg,  and  also  on  the  dorsum  of  the  foot  (Fig.  432)- 

The  Internal  Popliteal  iVm-e.— Damage  to  this  nerve  paralyzes  the 
posterior  tibial  muscle,  the  flexor  longus  digitorum,  the  muscle  of  the  calf, 
the  popliteus  muscle,  and  the  muscles  of  the  plantar  surface  of  the  foot. 
The  toes  become  flexed  at  the  two  distal  jomts,  and  extended  at  the  prox- 
imal joints.  Walking  is  greatly  interfered  with.  There  is  loss  of  the  power 
of  rotatincr  the  flexed  leg  inward,  if  the  damage  is  above  the  branch  to  the  pop- 
liteus muscle;  and  extension  of  the  ankle-joint  is  lost.  As  the  consequence, 
tahpes  calcaneus  develops  (Gowers).  The  anesthesia  is  variable,  but  usually 
involves  the  sole  of  the  foot  and  the  outer  surface  and  lower  portion  of  the 

back  of  the  leg  (Fig.  432)-  ,  1         ,u 

The  Plantar  iVerce^.— Division  of  the  internal  plantar  nerve  paralyzes  the 
short-toe  flexor,  the  two  inner  lumbricales,  and  the  plantar  muscles  of  the 
great  toe,  except  the  adductor  (Gowers).  There  is  anesthesia  of  the  mner 
portion  of  the  sole  of  the  foot  and  of  the  plantar  surface  of  the  three  mner 
toes  and  of  half  of  the  fourth  toe  (Fig.  432)- 

Division  of  the  external  plantar  nerve  causes  paralysis  of  the  muscles  of 
the  Uttle  toe,  of  the  adductor  of  the  great  toe,  of  all  the  interossei,  of  the 
two  outer  lumbricales,  and  of  the  flexor  accessorius  (Gowers).  There  is 
anesthesia  of  the  skin  of  the  outer  half  of  the  sole  of  the  foot,  of  the  little  toe, 
and  of  half  of  the  fourth  toe  (Fig.  43  2)  • 

The  Facial  Nerve.— The  nerve  may  be  divided  during  the  mastoid  opera- 
tion or  may  be  lacerated  by  a  fracture  of  the  petrous  portion  of  the  temporal 
bone  and  a  peripheral  palsy  results.  The  fa<?e  is  asymmetrical  and  is  drawn 
to  the  sound  side.  Asymmetry  becomes  more  marked  on  attempting  to  smile 
or  to  show  the  teeth.  Whisding  and  frowning  are  impossible.  Sense  of 
taste  may  be  less  acute  or  lost  on  the  anterior  two-thirds  of  the  tongue.  There 
is  relaxation  of  the  palate  and  deviation  of  the  uvula.  Reactions  of  degenera- 
tion can  be  demonstrated  in  the  palsied  muscles.  In  some  cases  there  are 
sensory  disturbances  (h>Teresthesia  or  anesthesia)  and  in  some  there  are  vaso- 
motor perturbations  on  the  palsied  side.  On  the  paralyzed  side  the  muscles 
are  relaxed,  the  nasolabial  fold  is  to  a  great  extent  gone,  the  nostril  cannot 
be  dilated  The  brow  wrinkles  have  been  smoothed  out,  the  eyelids  cannot 
be  closed-  on  attempting  to  close  the  eye  the  globe  tilts  upward  and  outward, 
the  cornea  and  conjunctiva  inflame,  the  lower  lid  droops,  and  tears  run  down 

I'll P    PilPPk 

Treatment.— In  all  recent  cases  of  nerve-section,  try,  if  possible,  to  suture 
the  ends  of  the  di^-ided  nerve.  Primary  suture  means  suture  within  twenty- 
four  hours  of  the  accident.  In  123  reported  cases  of  primary  suture,  119  were 
cured  in  from  one  day  to  one  year  (WiUard).  The  return  of  sensation  may 
be  rapid  or  may  be  slow;  muscular  power  returns  more  slowly  than  sensa- 
tion If  the  patient  is  not  seen  until  long  after  the  accident,  incise  and  apply 
sutures  isecondarv  sutures);  if  the  nerve  cannot  be  found,  extend  the  incision, 
find  the  trunk  above  and  trace  it  down,  and  find  the  trunk  below  and  fol  ow 
it  up  In  130  reported  cases  of  secondary  suture  80  per  cent,  were  more  or  less 
improved  (Willard).  Even  after  primary  suture,  loss  of  function  is  bound  to 
occur  for  a  time.  After  secondary  suture,  sensation  may  return  m  a  tew 
days   but  it  may  not  return  until  after  a  much  longer  period;  in  any  case 


774  Diseases  and  Injuries  of  Nerves 

muscular  function  is  not  restored  for  months.  After  partial  section  of  a 
nerve  the  ends  should  be  sutured.  In  performing  secondary  suture  it  may 
be  necessary  to  effect  ''^lengthening''^  in  order  to  approximate  the  ends.  Trans- 
plantation of  a  portion  of  nerve  is  sometimes  practised  {implantation  or 
anastomosis).  Nerve- grafting  is  bridging  the  gap  by  means  of  a  portion  of 
nerve  from  one  of  the  lower  animals  or  from  a  recently  amputated  human 
limb.  Nerve- transplantation  may  fail  utterly;  it  may  be  followed  by  great 
improvement,  but  absolute  and  perfect  restoration  of  function  cannot  be 
obtained.  R.  Peterson  *  has  made  a  study  of  the  20  recorded  cases  of  nerve- 
grafting;  8  of  the  operations  were  primary  and  12  were  secondary.  The 
periods  after  the  injury  at  which  operation  was  performed  varied  from  forty- 
eight  hours  to  a  year  and  a  quarter;  4  of  the  8  primary  cases  improved;  8  of 
the  12  cases  of  secondary  operation  showed  improvement  in  motion  or  sen- 
sation. The  distance  between  the  nerves  did  not  seem  to  affect  the  results. 
No  case  recovered  completely,  but  in  one  case  sensation  returned  completely 
and  only  the  abductors  of  the  thumb  remained  weak.  In  most  of  the  cases 
that  were  benefited  sensation  returned  by  the  tenth  day  and  motion  within 
two  and  a  half  months.  In  one  of  the  successful  cases,  that  of  A.  W.  Mayo 
Robson,t  the  spinal  cord  of  a  rabbit  was  used.  A  facial  nerve  divided  in  the 
aqueduct  of  Fallopius  may  perhaps  be  sutured  at  the  site  of  the  injury.  This 
should  be  attempted  as  soon  as  the  palsy  is  observed,  as  was  suggested,  I 
believe,  by  Frederick  Sydenham  ("Brit.  Med.  Jour.,"  May  8,  1909).  If  the 
ends  of  the  divided  nerve  cannot  be  approximated,  suture  a  distance  may  be 
practised,  as  was  done  successfully  by  Sydenham  (Ibid.).  If  suture  at  the 
site  of  injury  is  impossible  the  end  of  the  peripheral  segment  of  the  divided 
nerve  may  be  anastomosed  to  the  h}'poglossal,  glossopharyngeal,  or  spinal 
accessory  ner\'e  (page  776). 

Pressure  upon  nerves  may  arise  from  callus,  scars,  a  dislocated  bone, 
a  tumor,  or  an  external  body. 

The  symptoms  may  be  anesthetic,  paralytic,  or  trophic. 

The  treatment  is  as  follows :  Remove  the  cause  (reduce  a  dislocated  bone, 
chisel  away  callus,  excise  a  scar,  etc.);  then  employ  massage,  douches,  exer- 
cise, and  electricity. 

Dislocation  of  the  Ulnar  Nerve  at  the  Elbow.— This  condition 
is  very  rare.  It  may  occur  as  a  com.plication  of  a  fracture  or  a  dislocation, 
or  as  an  uncompHcated  condition.  It  may  be  produced  by  violence  or  by 
muscular  effort,  which  ruptures  the  fascia,  the  function  of  which  is  to  retain 
the  nerve  back  of  the  inner  condyle  of  the  humerus.  In  some  'cases  the 
symptoms  are  slight  and  transitory,  the  nerve  functionating  well  in  its  new 
situation.  As  a  rule,  there  are  pain,  numbness,  or  anesthesia  of  the  ulnar 
trajectory,  some  stiffness  of  the  elbow,  and  stiffness  of  the  little  finger  and 
ring-finger.  The  nerve  can  be  felt  in  front  of  the  inner  condyle  of  the  humerus. 
In  some  cases  neuritis  follows,  with  trophic  changes. 

Treatment. — Expose  the  nerve  by  an  incision,  incise  the  fibrous  tissue 
back  of  the  inner  condyle,  and  press  the  nerve  into  the  bed  prepared  for  it  and 
hold  it  in  place  by  sutures  of  kangaroo-tendon  passing  through  the  triceps 

*  Amer.  Jour,  of  Med.  Sciences,  .\pril,  1899. 
t  Ibid. 


Neurorrhaphy,  or  Nerve-suture  775 

tendon.  Wharton  advises  suturing  also  "the  margin  of  the  fascial  expan- 
sion of  the  triceps  tendon  superficial  to  the  nerve."  * 

Contusion  of  Nerves. — The  symptoms  of  contusion  of  nerves  may 
be  identical  with  those  of  section.  Sensation  or  motion,  or  both,  may  be 
lost.  The  case  may  recover  in  a  short  time,  or  the  nerve  may  degenerate 
as  after  section. 

The  treatment  at  first  is  rest,  and  later  electricity,  massage,  frictions, 
and  douches. 

Punctured  Wounds  of  Nerves. — The  symptoms  of  punctured 
wounds  of  nerves  may  be  partly  irritative  (hyperesthesia,  acute  pain,  and 
muscular  spasm)  and  partly  paralytic  (anesthesia,  muscular  wasting,  and 
paralysis). 

The  treatment  after  the  puncture  has  healed  is  the  same  as  that  for  con- 
tusion. 

Operations  upon  Nerves. 

Neurorrhaphy,  or  Nerve=SUture. — When  a  nerve  is   completely  or 

partially  divided  by  accident,  it  should  be  sutured  at  the  first  possible  moment. 
The  instruments  required  are  an  Esmarch  apparatus,  a  scalpel,  blunt  hooks, 
dissecting  forceps,  hemostatic  forceps,  curved  round  intestinal  needles  or  sewing 
needles,  a  needle-holder,  and  fine  catgut,  silk,  or  kangaroo-tendon.  In  primary 
suture  render  the  part  bloodless  and  aseptic.  Enlarge  the  incision  if  necessary. 
If  the  ends  can  readily  be  approximated,  pass  two  or  three  sutures  through 
both  the  nerve  and  its  sheath  and  tie  them  (Figs.  433  and  434).  If  the  ends 
cannot  be  approximated,  stretch  each  end  and  then  suture.  The  sutures  do 
not  traverse  the  ners^e,  but  go  through  the  perineum  and  adjacent  connective 
tissue.  Remove  the  Esmarch  band,  arrest  bleeding,  suture  the  wound,  dress 
antiseptically,  and  put  the  part  in  a  relaxed  position  on  a  splint.  After  union 
of  the  wound  remove  the  splint  and  use  massage,  friction,  electricity,  and  the 
douche.  The  operation  in  some  instances  fails,  but  in  many  cases  succeeds. 
In  some  few  cases  sensation  returns  in  a  few  days,  but  in  most  cases  does  not 
return  for  many  weeks  or  months.  Sensation  is  restored  before  motor  power. 
After  successful  suturing  of  a  divided  median  nerv'e  sensations  of  skin  pain  and 
of  extreme  heat  and  cold  appeared  in  fifty-six  days  and  were  restored  in  two- 
hundred  and  seven  days.  Sensations  of  light  touch  and  shght  degrees  of  heat 
and  cold  appeared  in  two  hundred  and  sixty  days  and  were  not  completely 
restored  for  one  year  (Kenneth  A.  J.  Mackenzie,  in  "Annals  of  Surg.,"  July, 
1909) .  Secondary  suture  is  performed  upon  cases  long  after  division  of  a  nerve. 
If  operation  is  not  done  for  three  years  or  more  after  division  it  is  very  im- 
probable that  complete  regeneration  \\ill  ever  occur,  and  yet  it  is  always  worth 
trying,  for  muscular  control  has  been  regained  after  suturing  in  one  case 
twenty-nine  years  subsequent  to  nerv'e  division  (Alfred  S.  Taylor,  in  "Jour,  of 
Orthopedic  Surg.,"  Nov.,  1908).  The  part  is  rendered  aseptic  and  blood- 
less; an  incision  is  made;  the  bulbous  proximal  end  is  easily  found  and 
loosened  from  its  adhesions;  the  shrunken  distal  end  is  sought  for  and 
loosened  (it  may  be  necessary  to  expose  the  nerve  below  the  wound  and 

*  A  report  of  14  cases  of  dislocation  of  the  ulnar  nerve  at  the  elbow,  by  H.  R. 
Wharton,  Amer.  Jour,  of  Med.  Sciences,  Oct.,  1895. 


776 


Diseases  and  Injuries  of  Nerves 


trace  its  trunk  upward) ;  the  entire  bulb  oi  the  proximal  end  is  cut  off;  about 
one-quarter  of  an  inch  of  the  distal  end  is  removed.  All  scar-tissue  between 
the  ends  is  most  carefully  removed.  If  the  gap  between  the  ends  is  not 
wide,  each  end  is  gently  stretched,  and  the  ends  are  approximated  and 
sutured  together.  If  stretching  does  not  ])ermit  of  approximation,  adopt  the 
expedient  shown  in  Fig.  434,  d,  or  in  Fig.  435.  This  operation  is  neuroplasty 
by  the  flap  method.  Another  method  is  to  make  a  bridge  of  strands  of  catgut 
running  from  one  divided  end  to  the  other.  We  speak  of  this  plan  as  suture 
a  distance  (Fig.  434,  e).  The  catgut  bridge  supjiorts 
the  growing  reparadve  material,  (juelliot  suggested 
-  tuhulizatiou,  that  is,  erecting  barriers  along  the  path  of 
reparative  material  to  keep  surrounding  tissues  from 
entering  and  blocking  it.  Implantation  or  anastomosis 
Fig.  433. — Nerve-suture,  is  advisable  in  some  cases.  Letievant  attaches  the  cut 
end  of  the  ])eripheral  portion  of  the  divided  nerve  to  an 
adjacent  uncut  nerve,  which  has  been  partially  divided  to  receive  it.  Allis 
suggested  shortening  the  limb  by  resecting  a  piece  of  bone  and  then  suturing 
the  ends  of  the  nerves  together.  The  operation  has  been  carried  out  success- 
fully by  Keen,  Rose,  and  others. 

After  uniting  the  ends  of  the  nerve  it  is  highly  desirable  to  protect  them 
from  invasion  by  the  scar  in  the  jierineural  structures.  Numerous  plans  have 
been  employed  to  obtain  such  ])r()tection.  Vanlan  surrounded  the  ends  with 
decalcified  bone  and  Payr  with  a  tube  of  absorbable  magnesium.  Gelatin 
tubes  have  been  used,  silver-foil  has  been  tried,  and  Cargile  membrane  has 


Fig.  434. — Nerve-suture:  a.  Direct;  h,  perineurotir;   c,  paraneurotic;  (/,  e,  neuroplasty  (Senn). 


been  employed.  None  of  these  plans  is  satisfactory.  Murphy's  plan  gives 
the  best  results.  He  covers  the  Hne  of  nerve  suture  with  fascia,  muscle,  or  fat. 
In  regions  where  he  cannot  obtain  suitable  covering  tissue  he  wraps  about  the 
suture  line  with  a  material  composed  of  equal  parts  of  paraffin  and  oil  of  sesame. 
This  mixture  can  be  flattened  out  very  thin  ("Surg.,  Gynec,  and  Obstet.," 
April,  1907).  The  peripheral  portion  of  a  divided  nerve  may  be  inserted  into 
a  longitudinal  slit  of  a  sound  nerve.  The  anastomosis  may  be  end  to  side. 
The  operation  is  employed  after  exsection,  leaving  a  very  large  gap,  for 
facial  palsy,  for  infantile  palsy,  for  evulsion  of  the  brachial  plexus,  and  for 
brachial  birth  palsy. 


Sympathectomy  777 

Nerve=grafting  is  practised  Ijy  some.  A.  W.  Mayo  Robson  used  the 
spinal  cord  of  a  rabbit  to  till  a  gap  between  the  ends  of  the  divided  median 
nerve  of  a  man.  The  restoration  of  function  v^as  almost  complete.  Some 
surgeons  have  grafted  in  bits  of  nerve  obtained  from  a  recently  amputated 
limb.  It  makes  no  difference  whether  the  grafted  nerve  was  motor  or  sensory 
or  mixed.  The  results  of  grafting  are  seldom  good.  Chas.  A.  Powers 
("  Transactions  of  the  American  Surgical  Assoc,"  1904)  collected  22  cases  from 
literature,  20  from  Peterson's  paper,  i  case  of  Durante's,  and  i  of  his  own.  In 
this  series  there  were  3  good  results  and  3  "fair"  results.  The  bit  of  nerve 
grafted  does  not  participate  in  repair — it  is  a  mere  bridge,  and  acts  as  does  the 
suture  a  distance. 

Neurectasy,  Neurotomy,  and  Neurectomy.— Neurectasy,  or  nerve- 
stretching,  may  be  applied  to  motor,  sensory,  or  mixed  nerves.  A  nerve 
can  be  stretched  about  one-twentieth  of  its  length.  Neurectasy  has  been 
employed  for  neuralgia,  neuritis,  muscular  spasm,  hyperesthesia,  anesthesia, 
painful  ulcer,  perforating  ulcer,  the  pains  of  locomotor  ataxia,  and  many  other 
conditions.  The  operation,  which  was  once  the  fashion,  seems  to  benefit  some 
cases,  but  it  is  not  now  thought  so  highly  of  as  formerly.  The  incision  for  neur- 
ectasy is  identical  with  the  incision  for  neurectomy  or  neurotomy  of  the  same 
nerve.  Neurotomy,  or  section  of  a  nerve,  is  performed  only  upon  small  and 
purely  sensory  nerves.  It  is  performed  chiefly  for  peripheral  neuralgia  or  for 
some  other  painful  malady.  It  is  useless,  because  sensation,  as  a  rule,  soon 
returns.  Paget  saw  complete  return  of  sensation  in  four  weeks  after  division 
of  the  median  nerve.  Corning  endeavers  to 
prevent  this  regeneration  by  inserting  oil  between  ^,;:==3 

the  ends.     He  uses  oil  of  theobroma  containing         ^ .  ({  1        1 

enough  paraffin  to  make  the  melting-point  105°  F. 
The  oil  is  melted,  is  injected  around  the  nerve, 
and  cold  is  applied.  The  nerve  is  now  sec- 
tioned with  a  canaliculated  knife,  the  ends  are 
separated  widely,  more  oil  is  injected,  and  cold       Fig.  435 -suture  of  a  nerve  by 

,.     ,         rj^u       .-,  •      *u    4.    4.U-         -1  splitting  the  ends  (Beach). 

is  agam  applied.  The  theory  is  that  this  oil, 
which  is  solid  at  the  temperature   of    the    body, 

devitalizes  the  nerve  at  the  point  of  section  and  acts  as  a  barrier  to  the 
passage  of  regenerating  fibers.  This  method  has  been  applied  especially 
in  cervicobrachial  neuralgia.*  Neurectomy,  or  excision  of  a  portion  of 
a  nerve-trunk,  is  applicable  only  to  sensory  nerves  and  to  painful  affections. 
Sympathectomy. — Jonnesco's  Operation. — It  has  long  been  known 
that  division  of  the  sympathetic  nerve  in  the  neck  may  produce  important 
changes  in  the  eye  and  in  the  cerebral  circulation.  In  1893  Jaboulay  divided 
the  sympathetic  on  each  side,  for  the  purpose  of  treating  epilepsy.  The 
removal  of  the  ganglia  of  the  sympathetic  was  proposed  by  Baracz;  and  the 
operation  was  first  performed  by  Jonnesco,  in  1896,  for  epilepsy.  The 
operation  is  performed  by  some  surgeons  for  epilepsy,  for  exophthalmic 
goiter,  and  for  glaucoma  and  for  trifacial  neuralgia.  In  operating  for  glaucoma 
the  superior  cervical  ganglion  on  each  side  is  removed,  as  it  is  from  this  that 
the  sympathetic  fibers  that  pass  to  the  eye  are  derived.  If  the  operation  is 
done  at  all,  it  should  be  a  bilateral  one. 

*  Medical  Record,  Dec.  5,  1896. 


778  Diseases  and  Injuries  of  Nen'es 

The  operation  is  used  in  epilepsy  on  the  theory  that  there  is  an  anemic 
condition  of  the  brain  in  this  disease  which  is  corrected  by  producing  a 
h^'peremia,  and  that  the  hyperemia  improves  cerebral  nutrition.  The  opera- 
tion in  epilepsy  is  largely  theoretical,  although  Jonnesco  claims  12  per  cent, 
of  cures  in  a  large  number  of  operations.  In  exophthalmic  goiter  there 
seems  to  be  some  distinct  evidence  that  the  operation  may  be  beneficial, 
but  Curtis  shows  that  the  mortality  is  high.  Personally,  I  have  not  employed 
it  in  epilepsy,  and  at  the  present  time  I  should  not  be  inclined  to  do  so.  In 
exophthalmic  goiter,  if  any  operation  is  necessary,  I  should  perform  partial 
thyroidectomy;  but  in  progressive  glaucoma,  which  is  always  so  absolutely 
hopeless,  the  operation  is  a  justifiable  procedure  and  occasionally  seems  to 
have  a  distinct  influence  in  retarding  the  development  of  the  disease. 

The  incision  should  be  made  along  the  posterior  margin  of  the  sterno- 
cleidomastoid muscle.  I  have  become  convinced,  in  performing  two  opera- 
tions of  this  kind  and  through  studies  made  upon  the  dead  body,  that  the 
ganglion  may  be  more  easily  reached  from  behind  the  sternocleidomastoid 
than  from  in  front  of  it.  The  internal  jugular  vein  and  the  carotid  artery 
are  lifted  upward  and  forward;  and  the  superior  ganglion  will  usually  ad- 
here to  the  under  portion  of  the  carotid  sheath,  and  be  lifted  up  with  it. 
Theoretically,  it  is  not  necessary  to  open  the  carotid  sheath  in  this  operation, 
but,  practically,  this  had  better  be  done,  so  that  one  may,  without  any  possi- 
bility of  doubt,  distinguish  between  the  pneumogastric  and  the  sympathetic 
nerve.     The  moment  the  nerve  is  cut,  the  pupil  on  that  side  will  contract. 

Stretching  of  the  Sciatic  Nerve. — Some  surgeons  stretch  the  sciatic 
ner%^e  by  anesthetizing  the  patient  and  holding  the  leg  and  thigh  in  line, 
strong  flexion  being  made  upon  the  hip,  the  entire  lower  extremity  being 
used  as  a  lever  (Keen).  This  method,  which  has  caused  death,  inflicts  need- 
less damage,  and  stretching  after  an  incision  has  been  made  is  safer  and 
better.  The  instruments  required  are  a  scalpel,  hemostatic  forceps,  dissect- 
ing forceps,  a  dissector,  retractors,  and  a  scale  with  a  handle  and  a  hook. 
The  patient  lies  prone,  the  thigh  and  legs  being  extended.  An  incision  four 
inches  in  length  is  made  a  little  external  to  the  middle  of  the  thigh,  and  going 
at  once  tlirough  the  deep  fascia;  the  biceps  muscle  is  found  and  is  drawn  out- 
ward; the  nerv'e  is  discovered  between  the  retracted  biceps  on  the  outside  and 
the  semitendinosus  on  the  inside,  resting  upon  the  adductor  magnus  muscle. 
The  nen-e,  which  is  caught  up  by  the  finger,  is  first  pulled  down  from  the  spine 
and  then  up  from  the  periphery,  and  finally  the  hook  of  the  scale  is  inserted 
beneath  the  trunk  and  the  nen-e  is  stretched  to  the  extent  of  forty  pounds. 
Very  rarely  is  even  -a  single  ligature  needed.  The  wound  is  sutured  and 
dressed.  If  the  incision  is  made  at  a  higher  level  below  the  gluteofemoral 
crease,  the  sciatic  nerve  will  be  found  just  by  the  outer  border  of  the  biceps. 

Neurectomy  of  the  Infra=orbital  Nerve. — This  operation  was  first 
performed  by  Abernethy  in  1793.  The  instruments  required  in  this  opera- 
tion are  a  scalpel,  dissecting  forceps,  aneurysm  needle,  hemostatic  forceps, 
blunt  hooks,  a  dissector,  and  metal  retractors.  The  patient  lies  upon 
his  back,  the  head  being  a  little  raised  by  pillows.  The  surgeon  stands 
to  the  outside  of  and  faces  the  patient.  A  curved  incision  one  and  a  half 
inches  long  is  made  below  the  lower  border  of  the  orbit.  The  nerve  lies  in 
a  line  dropped  from  the  supra-orbital  notch  to  between  the  two  lower  bicuspid 


Injection  of  Osmic  Acid  779 

teeth.  The  nerve  fs  found  upon  the  levator  labii  superioris  muscle.  A 
piece  of  silk  is  passed  under  the  nerve  by  an  aneurysm  needle  and  firmly 
fastened.  The  upper  border  of  the  incision  is  drawn  upward;  the  perios- 
teum of  the  floor  of  the  orbit  is  elevated  and  held  by  a  retractor;  the  roof 
of  the  infra-orbital  canal  is  broken  through;  the  nerve  is  picked  up  far  back 
with  the  blunt  hook  and  is  divided  with  scissors,  and  the  entire  nerve  is 
drawn  out  by  making  traction  upon  the  silk.  The  bleeding  in  the  orbit  is 
checked  by  pressure.     The  wound  is  stitched  without  drainage. 

Neurectomy  of  the  Supra=orbital  Nerve.— Before  sterilizing  the 
parts  shave  off  the  eyebrow.  The  instruments  required  and  the  position  of 
the  patient  are  as  for  the  operation  upon  the  infra-orbital  nerve.  A  curved 
incision  one  inch  long  discloses  the  nerve  as  it  emerges  from  the  supra-orbital 
notch  or  foramen  at  the  junction  of  the  inner  and  middle  thirds  of  the  eye- 
brow.    The  nerve  is  pulled  forward  and  cut  off  above  and  below. 

Neurectomy  of  the  Inferior  Dental  Nerve. — The  instruments  are 
the  same  as  for  any  other  neurectomy,  and  in  addition  a  chisel,  a  mallet,  and 
a  rongeur  forceps.  Make  a  curved  incision  around  the  angle  of  the  jaw. 
Lift  the  supramaxillary  branch  of  the  facial  nerve  downward  (Kocher). 
Separate  the  masseter  muscle  with  a  periosteum-elevator  and  slight  touches 
with  the  knife.  Chisel  an  opening  in  the  center  of  the  ascending  ramus 
(Velpeau's  rule).  This  opening  exposes  the  beginning  of  the  dental  canal. 
If  necessary,  the  opening  may  be  enlarged  with  a  rongeur.  Pull  the  nerve 
out  with  a  hook  and  remove  a  piece  from  it. 

Extracranial  Operation  for  Neuralgia  of  the  Fifth  Nerve. — 
The  operation  for  removal  of  the  Gasserian  ganglion  is  diflicult,  bloody,  and 
dangerous.  Removal  of  portions  of  the  pain-haunted  nerve-trunks  some- 
times cures  the  condition  and  often  ameliorates  it  for  a  considerable  time. 
The  injection  of  osmic  acid  into  the  peripheral  nerves  may  actually  cure  or 
secure  prolonged  relief.  The  serious  operation  of  removing  the  ganglion  may 
be  performed  if  peripheral  operations  fail  or  in  violent  and  intractable  cases  of 
long  standing  in  which  pain  is  felt  in  more  than  one  branch.  Removal  of 
nerves  by  ordinary  neurectomy  often  gives  comfort  for  a  few  months,  but  rarely 
gives  prolonged  relief.  If  we  seek  striking  benefit  by  an  extracranial  operation, 
it  must  be  thoroughly  done. 

Injection  of  Osmic  Acid. — This  method  was  suggested  by  Bennett,  of 
London,  in  1897.  Osmic  acid  had  been  used  for  many  years  in  a  sort  of 
haphazard  way,  being  thrown  into  tissues  about  the  ner\'es  by  means  of  a 
hypodermatic  syringe.  Bennett  suggested  exposure  of  the  nerve  and  the  in- 
jection of  5  to  10  minims  of  a  i  per  cent,  solution.  Acid  when  so  used  actually 
destroys  nerve-fibers,  and  a  considerable  amount  of  fibrous  tissue  forms  which 
intercepts  regenerating  fibers.  It  is  probable  that  secondary  degenerative 
changes  occur  in  the  nerve-trunks,  and  it  is  possible  that  they  occur  in  the  gang- 
lion. jMurphy  warmly  advocates  the  method.  It  certainly  produces  immedi- 
ate relief  by  causing  immediate  anesthesia,  but  whether  such  relief  is  permanent 
it  is  as  yet  too  early  to  say.  I  have  used  it  in  several  cases  with  satisfaction. 
In  one  case  in  which  I  exposed  the  ganglion  I  injected  that  structure  and  the 
result  seems  to  be  the  same  as  if  I  had  removed  the  ganghon.  In  neuralgia 
of  the  fifth  nerve  the  painful  nerve  or  nerves  should  be  exposed,  and  from  5 
to  10  minims  of  a  2  per  cent,  solution  of  osmic  acid  injected  into  several 


78o 


Diseases  and  Injuries  of  Nerves 


different  parts  of  the  nerve  and  also  between  the  nerve-sheath  and  the  bony 
canal  (Murphy) .     The  osmic  acid  method  does  not  seem  to  grow  in  favor. 

Injections  of  Alcohol  Into  the  Second  and  Third  Divisions  (Schlos- 
ser\s  Method). — The  injections  are  made  into  peripheral  branches,  divisions 
of  the  ganglion,  and  even  into  the  ganglion.  Siccard  and  others  have  warmly 
praised  the  method;  80  per  cent,  alcohol  is  used.  It  acts  similarly  to,  but 
less  efficiently  than,  osmic  acid.  It  gives  relief  sometimes  after  one  injec- 
tion, sometimes  after  two  or  more.  The  method  is  not  to  be  used  if  pain  is 
felt  in  the  third  division.  The  permanence  of  the  rehef  is  uncertain.  Usually 
it  is  complete  for  six  months  and  then  recurrent  pain  requires  renewed  injecdon. 
Recurrences  are  milder  than  the  previous  condition.  It  seems  unsurgical 
and  dangerous  to  plunge  an  instrument  so  deeply  among  important  structures 
and  there  must  be  danger  of  wounding  them. 

Rose's  Method  of  Neurectomy.*— This  operation  is  a  modification  of 
the  Braun-Lossen  method,  and  is  employed  when  the  second  division  of  the 


Fig.  436. — a,  The  Braun-Lossen  incision  ;  c, 
Rose's  incision  for  reaching  the  sphenomaxillary 
fossa  (Rose). 


Fig.  437.— Lower    jaw  and     zygoma.      Drill- 
holes and  saw-cuts  are  shown  (Rose). 


fifth  nerve  is  the  seat  of  pain.  Besides  the  instruments  laid  out  for  any 
ordinary  operation,  the  surgeon  requires  chisels,  fine  saws,  blunt  hooks,  peri- 
osteum separators,  silver  wire  (No.  22),  and  drills.  The  infra-orbital  nerve 
is  exposed  by  an  incision,  a  ligature  is  tied  around  it,  the  roof  of  the  infra- 
orbital canal  is  opened  by  a  chisel,  and  the  nerve  is  traced  back  as  far  as 
possible.  The  wound  is  then  packed  temporarily  with  gauze.  The  next 
step  in  the  operation  is  to  open  a  way  into  the  sphenomaxillary  fossa  (Fig.  436). 
The  knife  is  inserted  slightly  below  the  external  angular  process  of  the  frontal 
bone,  is  carried  back  along  the  zygoma,  down  in  front  of  the  ear  to  just  above 
the  angle  of  the  jaw,  and  then  forward  for  two  inches.  This  flap,  which  is  com- 
posed of  skin  and  subcutaneous  fat  only,  is  dissected  forward,  and  Steno's  duct 
and  branches  of  the  facial  nerve  are  not  damaged.     The  flap  is  wrapped  in 

*  See  article  by  Wm.  Rose,  "Practitioner,"  March,  igoo. 


Removal  of  the  Gasserian  Ganglion 


781 


gauze  and  temporarily  stitched  to  the  side  of  the  nose.  The  zygoma  is  ex- 
posed by  a  transverse  incision.  At  the  root  of  the  zygoma  two  holes  are  drilled 
one-fourth  of  an  inch  apart,  and  two  more  holes  one-fourth  of  an  inch  apart  are 
drilled  through  the  zygomatic  process  of  the  malar  bone.  The  zygoma  is  then 
divided  by  a  saw  (Fig.  43  7) .  The  posterior  saw  line  runs  between  the  two  drill- 
holes at  the  root  of  the  zygoma.  The  anterior  cut  passes  between  the  two  an- 
terior drill-holes.  The  direction  of  the  first  cut  is  directly  downward.  The 
direction  of  the  second  cut  is  downward  and  forward  from  above.  The  arch  is 
freed  and  detached  downward  and  backward.  The  exposed  tendon  of  the  tem- 
poral muscle  is  retracted  backward.  The  removal  of  a  little  fat  exposes 
the  pter)'gomaxillary  fossa.  The  internal  maxillary  artery  is  exposed,  two 
ligatures  are  applied,  and  the  vessel  is  divided  between  them.  The  finger 
feels  for  the  sphenomaxillary  and  pter}'gomaxillar}^  fissures.  The  external 
pterygoid  muscle  is  separated  from  the  greater  wing  of  the  sphenoid  and  from 
the  root  of  the  external  pter}'goid  process.  On  the  edge  of  the  greater  wing 
of  the  sphenoid  a  long  prominence 
is  usually  detectable.  It  overhangs 
the  sphenomaxillary  fossa  and  should 
be  cut  away  by  the  use  of  a  chisel. 
The  superior  maxillary  nerve  is  lifted 
on  a  blunt  hook,  is  grasped  with  for- 
ceps, and  is  twisted  off  as  near  the 
ganghon  as  possible  (Fig.  438).  The 
distal  end  is  drawn  upon,  and  the  nerve, 
having  been  previously  loosened,  is 
drawn  back  through  the  infra-orbital 
canal.  The  zygomatic  arch  is  wired 
in  place,  the  temporal  fascia  is  sutured 
with  buried  sutures,  and  the  skin- 
wound  is  closed.  If  the  pain  involved 
not  only  the  second  division,  but  also 
the  third  division,  the  operation  pre- 
viously described  should  be  performed 
first,  and  the  third  division  should  be 
attacked  a  few  weeks  later.  The  third 
division  is  reached  by  removing  the 
coronoid  process.  The  inferior  dental 
and  lingual  nerves  are  found,  and  are 
traced  up  to  the  foramen  ovale,  and 
are  twisted  off  close  to  the  ganghon,  and  the  distal  portions  are  removed. 

Removal  of  the  Gasserian  Ganglion. — This  formidable  procedure 
was  first  suggested  by  J.  Ewing  Clears  in  1884  and  was  first  performed  by  Wm. 
Rose  in  1890.  This  operation  is  often  bloody  and  diflicult,  and  is  only 
undertaken  in  very'  severe  cases  of  tic  douloureux,  in  which,  the  first  division  is 
involved,  or  in  cases  upon  which  less  grave  procedures  have  failed.  Jaboulay 
and  CavailHn  ("Lyon.  Med.,"  May  17,  1908)  speak  of  it  as  a  grave  operation 
of  difficult  technic  which  should  be  left  as  a  final  resort.  Many  operators 
deny  that  there  is  a  large  mortality  after  gasserectomy  and  claim  that  it  is  only 
about  5  per  cent.     Some  operators  report  a  mortality  of  from  10  to  17  per 


Fig.  438. — a,  The  zygomatic  arch,  turned 
down  after  sawing  ;  6,  tendon  of  the  temporal 
muscle  retracted  ;  c,  superior  maxillary  nerve 
and  Meckel's  ganglion  ;  d,  infra-orbital  nerve 
emerging  from  canal ;  e,  internal  maxillary 
artery. 


782 


Diseases  and  Injuries  of  the  Head 


cent.  The  greater  the  experience  of  the  surgeon  in  this  operation,  the  smaller 
will  be  the  mortality.  Knowledge  of  the  region  and  parts,  dexterity  from  fre- 
quent repetition,  and  special  training  count  for  much.  The  operation  usually 
cures  the  pain  if  the  patient  recovers  from  the  actual  procedure.  It  is  claimed 
that  the  pain  may  recur  even  after  complete  removal  of  the  ganglion.  I  have 
never  seen  this  occur  and  am  disposed  to  think  that  recurring  pain  is  apt  to 
mean  that  there  was  a  partial  removal.  Carson  collected  100  cases,  Murphy 
and  Neff  42  cases.  The  mortahty  in  this  group  of  142  cases  was  15  per  cent. 
Most  of  the  cases  reported  by  ^lurphy  and  Neff  were  operated  upon  during 
or  after  1899,  and  in  this  group  the  mortahty  was  10  per  cent.  ("  Progressive 
Medicine,"  March,  1903).  In  Lexer's  series  of  201  cases,  referred  to  below, 
the  mortality  was  1 7  per  cent.  In  many  cases  a  perfect  cure  is  obtained.  In 
some  few  the  pain  returns  upon  the  side  operated  upon.  Occasionally  it 
arises  on  the  side  not  oper- 
ated upon.  In  some  cases 
ulceration  of  the  cornea 
follows  operation.  Such 
ulceration  may  be  trivial, 
may  result  in  opacity,  or 
may      destroy      the      eye. 


Fig.  439.— Hartley's  osteoplas- 
tic flap  in  removal  of  Gasserian 
ganglion  (Tiffany). 


Fig.  440. — Removal  of  Gasserian  ganglion  ;  a,  Middle 
meningeal  artery  :  ii,  ophthalmic  division  ;  in,  submaxillary 
division  ;   G,  ganglion  (Krause). 


Paralysis  of  the  abducens  occurs  in  some  cases.  The  hemorrhage  may  be 
so  profuse  as  to  require  packing  of  the  wound  and  susj^ension  of  the  opera- 
tion for  a  few  days.  The  bleeding  may  come  from  the  meningeal  artery, 
from  the  sinus,  or  from  the  veins  of  Santorini.  Lexer  ("Arch.  f.  khn. 
Chir.,"  Bd.  Ixv,  H.  4)  gives  a  table  of  201  cases.  Of  the  survivors,  93.4 
per  cent,  were  apparently  cured.  In  two-thirds  of  the  cases  the  trouble  was 
right-sided.  In  10  the  operation  was  temporarily  abandoned  because  of 
hemorrhage.  The  experience  of  surgeons  in  general  is  that  after  the  re- 
moval of  the  ganglion  there  is  apt  to  be  some  atrophy  of  the  tongue  and  the 
eye  usually  becomes  insensitive  and  watery.  The  masseter  muscle  vdll  be 
paralyzed. 

The  Hartley  Operation  for  Removal  of  the  Gasserian  Ganglion. — 


Removal  of  the  Gasserian  Ganglion  783 

This  operation  was  first  performed  by  Hartley  in  1891,  five  months  before 
Krause  j)erformed  it.  The  surgeon  is  provided  with  the  instruments  for 
osteoplastic  resection  of  the  skull.  Special  retractors,  various  hooks,  scalpels, 
a  dry  dissector,  dissecting  and  hemostatic  forceps,  and  an  electric  forehead- 
light  are  required.  Long  strips  of  gauze  must  be  ready  for  packing 
in  case  of  hemorrhage.  The  patient  is  placed  recumbent,  with  head 
turned  to  the  opposite  side.  The  application  of  a  provisional  ligature  or 
clamp  to  the  external  carotid  artery  is  advocated  by  some,  but  this  step 
will  not  control  the  venous  bleeding,  which  is  the  most  harassing  hemorrhage 
encountered.  Many  operators  form  a  large  osteoplastic  flap  in  front  of 
the  ear  (Fig.  439)  and  break  it  out.  I  do  not  believe  that  an  osteoplastic 
flap  is  necessary.  The  temporal  fascia  is  so  thick  and  tense  that  when  the 
wound  in  it  is  carefully  sutured  protection  is  perfect  and  safety  is  secured. 
Hemorrhage  is  arrested.  It  may  be  found  that  the  meningeal  artery  has  been 
ruptured.  If  this  accident  has  happened  and  the  vessel  hes  in  a  bony  canal, 
plug  with  Horsley's  wax.  If  the  vessel  is  bleeding  upon  the  dura,  ligate  by 
passing  suture-Hgatures  around  it.  If  it  is  torn  off  at  the  foramen  spinosum, 
pack  the  foramen  with  iodoform  gauze,  and  postpone  the  conclusion  of  the 
operation  for  forty-eight  hours.  It  may  be  necessary  at  any  stage  of  this 
operation  to  pack  the  wound  and  postj)one  completion  for  two  days.  Some 
surgeons  (Krause,  Bergmann)  Hgate  the  meningeal  artery  as  a  routine  proce- 
dure, but  this  operation  may  be  difficult  and  require  much  time.  If  the  un- 
ligated  vessel  is  divided,  the  hemorrhage  can  be  arrested  by  gauze  packing 
or  by  plugging  the  foramen  spinosum  with  a  bit  of  sterile  wood,  but  it  is  best 
to  hgate  the  vessel.  The  head  and  body  of  the  patient  should  now  be  elevated. 
This  allows  the  brain  to  drop  posteriorly  and  renders  forcible  retraction  un- 
necessary, and,  further,  it  lessens  venous  bleeding  (Lexer).  The  next  step 
is  to  lift  up  the  dura  and  with  it  the  brain  (Fig.  440) .  Find  the  inferior  max- 
illary nerve  and  clamp  it  with  hemostatic  forceps.  Find  the  superior  maxillary 
nerve  and  clamp  it.  Uncover  the  ganglion.  Loosen  the  nerves  from  their 
beds  with  a  dry  dissector  and  divide  each  one  at  its  foramen  of  exit.  Twist 
the  clamp  forceps  so  as  to  reel  up  the  nerves.  This  pulls  out  the  ganglion 
intact  with  the  motor  root  and  the  root  of  origin,  as  far  back  as  the  pons 
(Krause's  method) .  Arrest  bleeding;  close  the  flap;  sew  the  lids  of  the  affected 
side  together,  and  cover  the  eye  with  a  watch-crystal. 

Gushing  has  modified  the  Hartley  operation  so  as  to  permit  of  extra- 
dural manipulation  below  the  arch  made  by  the  middle  meningeal  artery 
and  thus  lessen  the  danger  of  laceration  of  the  artery  ("Jour.  Amer.  Med. 
Assoc,"  April  28,  1900).  The  anterior  arm  of  the  incision  of  the  soft  parts  is 
so  placed  that  it  does  not  cut  the  nerve  to  the  occipitofrontalis  muscle.  Thus 
drooping  of  the  Ud  and  oblation  of  brow  wrinkles  on  that  side  are  avoided. 
He  trephines  the  wall  of  the  temporal  fossa  very  low  down,  opens  into  the  skull 
below  the  arch  of  the  meningeal  vessels,  and  thus  avoids  the  meningeal  at  the 
foramen  spinosum  of  the  sphenoid  bone  and  the  sulcus  arteriosus  of  the  parietal 
bone. 

Horsley's  Intradural  Method. — An  opening  is  made  into  the  middle 
fossa  of  the  skull,  the  dura  is  opened,  and  the  ganghon  is  found  and  removed. 
This  operation  is  easier  than  the  extradural  method,  but  is  believed  to  be 
more  dangerous. 


784  Diseases  and  Injuries  of  the  Head 

The  Frazier=SpiIler  Operation  of  Intracranial  Neurotomy  of 
the  Sensory  Root  of  the  Trigeminus.— If  experience  shows  that  after 
division  of  the  sensory  root  the  nerve  does  not  regenerate,  and  it  seems  prob- 
able that  it  does  not,  the  operation  must  be  regarded  as  a  valuable  addition 
to  our  resources.  This  operation  is  by  many  surgeons  preferred  to  removal 
of  the  ganglion.  In  this  operation  the  zygoma  is  temporarily  resected. 
The  temporal  fossa  is  exposed,  the  bony  wall  is  trephined,  and  the  trephine 
opening  is  enlarged  by  the  use  of  a  rongeur.  The  dura  is  separated  and 
the  ganglion  and  its  sensory  root  exposed.  The  dural  envelope  of  the  gang- 
lion is  opened,  is  separated,  and  the  sensory  root  is  exposed.  The  sen- 
sory root  is  then  picked  up  on  a  blunt  hook  and  divided.  It  is  frequently 
possible,  Frazier  tells  us,  to  separate  the  sensory  root  from  the  motor  root. 
In  this  operation  we  avoid  the  venous  hemorrhage  from  the  foramen  ovale  and 
foramen  rotundum  which  is  apt  to  be  encountered  when  removing  the  ganglion. 

Abbe's  Operation  of  Intracranial  Neurectomy  of  the  Second  and 
Third  Divisions. — This  operation  is  preferred  by  Charles  A.  Ballance,  who 
opposes  exposure  of  the  ganglion  or  division  of  the  sensory  root  unless  the 
first  division  of  the  nerve  is  the  seat  of  pain.  He  advocates  this  in  spite  of 
knowing  full  well  that  the  pain  may  return  in  a  few  years.  He  advocates  it 
because  of  its  safety,  its  simplicity,  its  freedom  from  serious  hemorrhage,  its 
avoidance  of  opening  the  intradural  space  and  of  all  danger  of  corneal  anesthe- 
sia, and  also  because  if  pain  returns  the  operation  can  be  repeated.  The 
operation  is  performed  as  follows:  Ligate  the  external  carotid  artery  of  the 
diseased  side,  make  a  vertical  incision  over  the  middle  of  the  zygoma  down  to 
the  bone.  An  opening  into  the  skull  is  made  by  a  mallet  and  gouge,  and  this 
opening  is  enlarged  by  a  rongeur  until  it  is  one  and  one-half  inches  in  diameter. 
The  dura  is  lifted  from  the  middle  fossa  and  the  nerves  are  exposed.  Each 
nerve-trunk  is  clamped,  is  divided  near  its  foramen  of  exit,  and  is  separated 
from  the  ganglion  by  cutting  or  by  twisting  with  the  forceps.  A  strip  of  sterile 
rubber  tissue,  one  and  one-half  inches  in  length  and-  three-fourths  of  an  inch 
in  width,  is  laid  over  the  round  foramen  and  the  oval  foramen  and  is  pressed 
into  place  by  gauze.  In  a  few  moments  the  gauze  is  withdrawn  and  the 
ganglion  is  allowed  to  descend  upon  the  rubber  tissue.  The  wound  is  then 
closed.  (See  Robt.  Abbe,  in  "Annals  of  Surgery,"  Jan.,  1903.)  The  rubber 
tissue  is  used  to  block  the'  foramina  of  exit  and  prevent  future  emergence  of 
regenerating  nerves.  Alayo  Robson  blocks  the  foramen  with  a  thin  plate  of  lead 
or  silver,  a  knob  of  the  plate  entering  the  oval  foramen  to  prevent  displacement. 

Division  of  the  Auditory  Nerve  for  Tinnitus  Aurium. — Balance 
has  performed  this  operation  on  the  right  side  with  success  in  a  most  distressing 
case  of  painful  tinnitus. 

^  When  the  cerebellar  hemispheres  were  displaced  by  marine  sponges  the 
nerves  of  the  posterior  fossa  were  brought  into  view.  He  divided  the  eighth 
nerve,  but  made  no  attempt  to  preserve  the  nerve  of  Wrisberg.  Five  months 
after  operation  the  patient  was  well  except  for  deafness  and  de\aation  of  the 
tongue  to  the  left.  (See  Ballance,  in  "Lancet,"  1908,  vol.  ii.)  Frazier  has 
divided  the  auditory  nerve  fi^r  vertigo. 

Operation  for  Facial  Paralysis  of  Extracerebral  Origin  (Facio= 
accessory  Anastomosis  and  Faciohypoglossal  Anastomosis).— Op- 
eration for  this  condition  was  first  performed  in  1895.     (See  "Remarks  on  the 


Operation  for  Facial  Paralysis  of  Extracerebral  Origin         785 

Operative  Treatment  of  Facial  Palsy  of  Peripheral  Origin,"  by  Chas.  A. 
Ballance,  Hamilton  A.  Ballance,  and  Purves  Stewart,  "Brit.  Med.  Jour.," 
May  2,  1903;  and  also  the  "Surgical  Treatment  of  Facial  Paralysis  by 
Nerve  Anastomosis,"  by  Harvey  Gushing,  "Annals  of  Surgery,"  May,  1903.) 
In  1898  Furet  suggested  to  Faure  that  he  should  anastomose  the  peripheral 
end  of  a  divided  facial  nerve  to  that  portion  of  the  spinal  accessory  nerve 
which  goes  to  the  trapezius  muscle.  Faure  did  this,  but  the  operation  failed. 
Robert  Kennedy,  of  Glasgow,  did  the  first  successful  operation.  He  divided 
the  facial  for  the  relief  of  spasm  and  at  once  anastomosed  a  partially  divided 
spinal  accessory.  The  procedure  first  employed  by  Ballance  was,  after  noting 
by  galvanism  that  muscular  fiber  still  remained,  to  expose  the  facial  nerve  at 
its  point  of  exit  from  the  stylomastoid  foramen,  to  cut  the  nerve-trunk  across 
as  high  up  as  possible,  to  expose  the  spinal  accessory,  and  to  suture  the  distal 
end  of  the  facial  into  the  trunk  of  the  spinal  accessory.  The  spinal  accessory 
was  cut  half  through  to  make  a  bed  for  the  end  of  the  facial.  The  paper 
of  the  Ballances  and  Stewart  above  referred  to  recommends  end-to-side 
anastomosis  between  the  divided  facial  and  the  hypoglossal.  The  authors 
have  operated  five  times  for  facial  palsy.  Gushing,  Keen,  Hackenbruch, 
Korte,  Gurrie,  Beck,  Vidal,  Girard,  Lund,  Alt,  Frazier,  and  others  have  done 
similar  operations.  Marked  improvement  may  follow  operation  even  if  a 
palsy  has  lasted  for  a  considerable  time.  Improvement  followed  operation  in 
Gurrie's  case,  although  the  palsy  was  nearly  a  year  old.  The  period  when 
improvement  should  be  expected  is  uncertain.  Signs  of  improvement  may 
not  be  evident  for  six  months  or  longer.  In  Gushing's  cases  they  begun  in 
thirteen  days.  In  Kennedy's  case  in  seven  days.  In  most  cases  operation 
restores  facial  symmetry  when  at  rest  and  in  many  cases  vohtional  movements. 
The  patient  will  often  become  able  to  close  the  eye  and  raise  the  angle  of  the 
mouth.  Gurious  associated  movements  may  occur.  In  Gurrie's  case  when  the 
patient  lifted  his  shoulder  there  was  contraction  of  the  occipitofrontalis 
muscle  ("South  African  Med.  Record,"  1907). 

Facio-accessory  anastomosis  does  not  restore  emotional  movements,  but 
faciohypoglossal  anastomosis  may  restore  them.  Kiister  reports  a  case  which 
confirms  this. 

Operation  is  indicated  when  a  complete  facial  palsy  is  of  such  duration  that 
recovery  is  not  to  be  hoped  for  by  longer  delay.  The  Ballances  and  Stewart 
believe  that  when  a  palsy  has  lasted  six  months  without  sign  of  recovery, 
operation  is  indicated.  A  paralysis  due  to  traumatism  gives  a  much  better 
prognosis  after  operation  than  does  a  paralysis  due  to  a  septic  process  (Ghas.  A. 
Ballance,  Hamilton  Ballance,  and  Purves  Stewart,  in  "Brit.  Med.  Jour.," 
May  2,  1903).  Murphy  has  collected  33  cases  of  anastomosis  of  the  facial 
nerve  with  the  spinal  accessory,  hypoglossal,  or  glossopharyngeal,  and  Joseph 
Beck  has  added  5  cases  of  his  own  in  which  he  performed  faciohypoglossal 
anastomosis. 

The  hypoglossal  is  preferred  to  the  accessory.  Its  trunk  is  larger  and  its 
cortical  center  is  adjacent  to  the  facial  cortical  area.  After  such  an  operation 
associated  movements  are  not  observed  when  the  mouth  is  kept  closed  and, 
if  Gowers  is  correct,  the  fibers  of  the  facial,  which  supply  the  muscles  closing  the 
mouth,  may  take  origin  from  the  hypoglossal  nucleus  (John  B.  Murphy,  in 
"Surg.,  Gynec,  and  Obstet.,"  April,  1907).  Murphy  points  out  that  an 
50 


786  Diseases  and  Injuries  of  the  Head 

anastomosis  may  be  end  to  end,  implantation  of  the  facial  into  a  sUt  in  the  other 
nerve,  implantation  of  the  facial  into  a  partial  transverse  di\'ision  of  the  other 
nerve  or  end  to  side  (Ibid.). 

Operation  for  Brachial  Birth  Palsy.— (See  article  by  L.  P.  Clark, 
A.  S.  Taylor,  and  T.  P.  Prout,  in  "Am.  Jour.  ]Med.  Sciences,"  Oct.,  1905.) 
These  authors  report  8  cases  of  operation  with  some  notable  improvements  and 
with  2  deaths.  In  these  cases  they  found  great  thickening  of  the  fascia  and  in 
some  cases  fibrous  tissue  almost  completely  obscured  the  remains  of  lacerated 
trunks  or  roots.  They  advise  that  the  patient  be  placed  recumbent,  with  a  sand- 
pillow  beneath  the  shoulders  and  with  the  head  extended  and  bent  toward 
the  opposite  shoillder.  An  incision  is  made  at  the  posterior  border  of  the  sterno- 
cleidomastoid and  the  plexus  is  exposed  and  explored.  If  the  lesion  is  above 
the  clavicle,  it  is  at  once  attacked;  if  below  that  bone,  the  incision  is  carried 
down,  and  the  bone  is  sawed  in  two.  The  scar  tissue  with  the  lacerated  nerves 
is  removed  and  the  nerves  or  nerve-roots  are  sutured.  The  wound  is  closed, 
the  clavicle  being  ^\-ired  if  it  was  divided.  After  dressings  are  appHed  the  head  is 
bent  tov.-ard  the  shoulder  of  the  damaged  side  and  fixed  with  plaster-of-Paris. 

I  operated  on  a  case  of  Dr.  Charles  S.  Potts's  in  the  Phila.  Hospital. 
The  roots  were  not  torn,  but  were  found  imbedded  in  a  thin  layer  of  scar 
which  it  was  possible  to  remove.  The  result  was  good.  Nerve  anastomosis 
may  be  necessary  if  exsection  of  scar  leaves  an  unbridgable  gap  or  if  nerve 
roots  were  divided  with  foramina. 


XXIIl.  DISEASES  AND  INJURIES  OF  THE  HEAD. 

Diseases  of  the  He.\d. 

In  approaching  a  case  of  brain  disorder,  first  endeavor  to  locate  the  seat 
of  the  trouble;  next,  ascertain  the  nature  of  the  lesion;  and,  finally,  deter- 
mine the  best  plan  of  treatment,  operative  or  otherwise.  In  all  operations 
upon  the  brain  the  surgeon  must  be  able  to  determine  accurately  the  situations 

of  certain  fissures  and  convolutions,  the 
finding  of  the  situations  of  these  convolu- 
tions and  fissures  comprising  the  science 
of  craniocerebral  topography. 

The  regional  terms  used  in  craniocere- 
bral topography  are  derived  from  Broca 
(Fig.  442).  The  middle  meningeal  artery 
is  found  at  the  pterion,  one  and  one- 
quarter  inches  posterior  to  the  external 
angular  process,  on  a  level  with  the  roof 
of  the  orbit  (Fig.  441).  The  fissures  and 
convolutions  of  the  brain  are  shown  in 
„.       ''      ^  .       ,    ^  ■   Figs.  44 3-44 s)-    T')^&  iissure  of  Bichat  is 

Fig.  441— The   meningeal  arterj'  exposed         o'^    ^^>J    ^^o'  i      -j     j 

by  trephining  (after  Esmarch).         marked  by  a  line  on  each  side  drawn  from 

the  inion  to  the  external  auditory  process. 
A  fine  from  the  glabella  to  the  inion  overUes  the  median  fissiu-e  and  the  superior 
longitudinal  sinus.    The  fissure  of  Rolando  is  very  important,  as  marking  the  pes- 


Diseases  of  the  Head 


787 


terior  limit  of  the  motor  region  of  the  brain.  It  begins  near  the  median  h"ne,  half 
an  inch  posterior  to  the  middle  of  the  distance  between  the  inion  and  glabella 
(Thane).     This  fissure  runs  downward  and  forward  at  an  angle  of  67.5° 


Fig.  442. — Skull,  showing  the  points  named  by  Broca:  As,  Asterion  (junction  of  the  occipital, 
parietal,  and  temporal  bones);  basion,  middle  of  anterior  wall  of  foramen  magnum;  £,  bregma  (junc- 
tion of  the  sagittal  and  coronal  sutures);  G.  ophryon  (on  a  level  with  the  superior  border  of  the  eye- 
brows, and  corresponding  nearly  to  the  glabella,  the  smooth  swelling  between  the  eyebrows);  ^, 
gonion  (angle  of  the  lower  jaw);  /,  inion  (external  occipital  protuberance);  L,  lambda  (junction  of 
sagittal  and  lambdoidal  sutures);  TV,  nasion  (junction  of  the  nasal  and  frontal);  Ob,  obelion  (the 
sagittal  between  the  parietal  foramina);  P,  pterion  (point  of  junction  of  great  wing  of  sphenoid  and 
the  frontal,  parietal,  and  squamous  bones.  This  may  be  H-shaped  or  K-shaped  or  "retourng,"  in 
which  the  frontal  and  temporal  just  touch);  .S",  stephanion  (or,  better,  the  superior  stephanion,  inter- 
section of  ridge  for  temporal  fascia  and  coronal  suture);  S',  inferior  stephanion  (intersection  of  ridge 
for  temporal  muscle  and  coronal  suture). 

for  a  distance  of  three  and  three-eighth  inches.  Chiene  finds  the  fissure 
of  Rolando  by  the  following  method :  He  takes  a  square  piece  of  paper  and 
folds  it  into  a  triangle  Fig.  446,  i) ;  the  angle  b  a  c  of  this  triangle  is  45°; 
the  edge  d  a  is  folded  back  on  the 
dotted  hne  A  e;  the  angle  d  A  E 
equals  half  of  45°,  or  22.5°,  and  the 
angle  c  A  e  equals  the  same  (Fig. 
446,  2) ;  unfold  the  paper  in  the  Hne 
c  a;  in  the  figure  thus  formed  B  A  c 
=  45°  and  E  A  c  =  22.5°;  E  a  B 
=  67.5°,  which  is  the  angle  desired. 
Place  the  point  A  in  the  mid-line  of 
the  head,  over  the  point  of  origin  of 
the  Rolandic  fissure;  the  side  A  B  is 
laid  along  the  middle  line  of  the 
head,  and  the  line  a  e  corresponds 
to  the  fissure  of  Rolando.* 
Horsley  determines  the  situa- 
tion of  the  Rolandic  fissure  by  the 
use  of  his  metal  cyrtometer  (Fig. 
447).  He  places  the  point  marked 
zero  over  the  inioglabellar  Hne  and 
midway  between  the  inion  and  the 
glabella.     To  find  the  fissure  of  Sylvius  (Fig.  444,  S,  S\  S") ,  draw  a  line  from 


443. — View  of  the  brain  from  above  (Ecker). 


*  "American  Text-Book  of  Surgery." 


788 


Diseases  and  Injuries  of  the  Head 


the  external  angular  process  to  the  occipital  protuberance.     The  fissure  of 

Sylvius  begins  on  this  line  one 

and  one-eighth  inches  behind 

the  external  angular  process; 

the  main  branch  of  the  fissure 

runs  toward  the  parietal  emi- 

...f     nence;   the  ascending  branch 

of  the  fissure  corresponds  to 

the   squamososphenoidal   su- 

-  -•*    ture,  and  continues  upward  in 

-°'     the  same   line   half  an  inch 

" "'     above  the  suture.     The  pre- 

central  sulcus    (Fig.   444,    f) 

limits  anteriorly  the  ascending 

frontal  convolution;    it  runs 

parallel  with  and  just  behind 

the    coronal    suture,    and    a 

finger's   breadth   in   front   of 

the  fissure  of  Rolando.     The 

intraparietal  fissure  (Figs.  443, 

444,  ip)  hmits  the  ascending  parietal  convolution  posteriorly.     It  begins  oppo- 


Fig.  444.— Outer  surface  of    the    left    hemisphere  of  the 
brain  (Ecker). 


Fig.  445. dinner  surface  of  the  right  hemisphere  of  the  brain  (Ecker). 


Fig.  446. — Chiene's    method  of  fixing    position    of    Rolandic    fissure    ("American    Text-book    of 

Surgery"). 


site  the  juncdon  of  the  lower  and  middle  thirds  of  the  fissure  of  Rolando,  passes 


Diseases  of  the  Head 


789 


upward  in  a  line  parallel  with  the  longitudinal  fissure  and  midway  between  the 
Rolandic  fissure  and  the  parietal  eminence,  passes  by  the  parieto-occipital  fissure, 
and  downward  and  backward  into  the  occipital  lobe.     The  motor  areas,  which  on 


t».  .  .^1  ■  ■  .61  ■  ,  .si  .  .  .-.I  ■  ■  .31  .  ,  ?|  .  ,  ..|  .  ,  PI     .    ]..  .  .  |»  .  .  [a  ,  .  h  .  .  |6.  . .  |«  .  .  I,. .  M 


Fig.  447-— Horsley's  cyrtometer. 


the  outer  surface  are  adjacent  to  the  fissure  of  Rolando,  are  shown  in  Figs.  443 
and  444-*  The  superior  longitudinal  sinus  is  overlaid  by  a  line  from  the  inion  to 
the  glabella.  The  lateral  sinus  is  indicated  by  a  fine  running  from  the  occipital 
protuberance  horizontally  outward  to  a  point 
one  inch  posteriorly  to  the  external  auditory 
meatus,  and  from  this  point  by  a  second  Une 
dropped  to  the  mastoid  process.  The  supra- 
meatal  triangle  of  Macewen  is  bounded  by 
the  posterior  root  of  the  zygoma,  the  posterior 
bony  wall  of  the  auditory  meatus,  and  a  Hne 
joining  the  two.  The  mastoid  antrum  is 
opened  through  Maceweri's  triangle  to  avoid 
injury  to  the  lateral  sinus.  Barker's  point, 
the  proper  spot  to  apply  the  trephine  in  ab- 
scess of  the  temporo-sphenoidal  lobe,  is  one 
and  one-fourth  inches  above  and  one  and  one- 
fourth  inches  behind  the  middle  of  the  external 
auditory  meatus.  Fig.  448  shows  clearly  the 
main  points  of  craniocerebral  topography, 
obtained  by  methods  approved  by  many  scien- 
tists. 

Kronlein's  method  of  localizing  certain 
points  is  the  most  generally  serviceable.  (See 
Fig.  449.)  A  hne,  known  as  the  base  line, 
z  M,  is  carried  horizontally  backward  from  the 
lower  border  of  the  orbit  through  the  upper 
border  of  the  external  auditory  meatus.  An- 
other horizontal  Hne,  k  k',  is  drawn  parallel 
with  this,  on  a  level  with  the  supra-orbital 
ridge.     A  hne  z  k  is  erected  from  the  middle 

of  the  zygoma  to  the  supra-orbital  Hne.     A  vertical  line  is  drawn  from  the 
articulation  of  the  lower  jaw,  a,  and  is  prolonged  to  r.     A  vertical  line  is 

*  Recent  studies  indicate  that  the  motor  region  is  entirely  in  front  of  the  Rolandic 
fissure. 


Fig.  44S.— Head,  skull,  and  cere- 
bral fissures;  B  Corresponds  to  Broca's 
convolution;  EAP,  external  angular 
process;  FR,  fissure  of  Rolando;  IF, 
inferior  frontal  sulcus;  IPF,  intrapa- 
rietal  sulcus;  MMA,  middle  menin- 
geal artery  ;  OPr,  occipital  protuber- 
ance; PE,  parietal  eminence  ;  POF, 
parieto-occipital  fissure ;  SF,  Sylvian 
fissure;  A,  its  ascending  limb;  TS, 
tip  of  temporo-sphenoidal  lobe.  The 
pterion  (to  the  left  of  B)  is  the  region 
where  three  sutures  meet,  viz.,  those 
bounding  the  great  wing  of  the 
sphenoid  where  it  joins  the  frontal, 
parietal,  and  temporal  bones  (adapted 
from  Marshall  by  Hare). 


790 


Diseases  and  Injuries  of  the  Head 


drawn  from  the  posterior  border  of  the  mastoid  base  (m  k')  and  is  taken  to  p, 
the  middle  Hne  of  the  skull.  A  line  is  drawn  from  k  to  p,  and  between  the 
points  R  and  p'  it  overlies  the  fissure  of  Rolando.  The  angle  of  p  k  k'  is 
bisected  by  the  hne  k  s,  which  corresponds  to  the  fissure  of  Sylvius  from  its 
point  of  bifurcation  to  its  posterior  termination,  k  marks  the  bifurcation  of 
the  fissure  of  Sylvius.  To  reach  the  anterior  branch  of  the  middle  meningeal 
artery  trephine  at  k;  to  reach  the  posterior  branch,  trephine  at  k'. 


Supra-orbital  line  {upper  korizontal) 


Auriculo-orbital line  {lower  horizontal)    ^       ^  -/W 

Fig- 449'"Kr6nlein's  method  of  locating  the  fissures  of  Rolando  {RP')  and  Sylvius  {KS)\ 
Kronlein's  point  of  trephining  for  hemorrhage  from  the  middle  meningeal  (KK')\  and  von  Berg- 
mann's  region  for  trephining  for  abscess  of  the  temporo-sphenoidal  lobes  {AaK'M)  ("American 
Text-book  of  Surgery"). 

Head  Injuries  During  Labor.— Caput  Succedaneum.— This  condi- 
tion is  edema  of  the  scalp  due  to  prolonged  pressure.  The  edema  is  circular 
and  circumscribed  and  occupies  the  part  not  subjected  to  continued  pressure 
during  the  uterine  contractions  of  labor.  The  ring  of  tissues  which  are  im- 
pressed around  project  hke  a  cup  into  the  birth  canal.  The  veins  become 
congested  and  edema  results.  The  parts  subjected  to  pressure  may  appear 
normal  or  may  exhibit  ecchymoses  or  even  excoriations.     The  pressure  is 


Diseases  of  the  Scalp  791 

usually  made  by  the  os,  and  its  situation  varies  with  the  presentation,  but 
because  the  most  frequent  presentation  is  left  occipito-anterior,  the  common 
position  of  the  caput  is  over  the  superior  and  posterior  portion  of  the  right 
parietal  bone.  In  a  face  presentation  great  disfigurement  may  occur.  It  is 
seldom  that  a  double  caput  is  encountered.  It  always  means  that  the  pre- 
sentation has  shifted.  The  worst  cases  of  caput  follow  prolonged  labor.  The 
edematous  swelling  contains  bloody  serum,  pits  on  pressure,  does  not  fluc- 
tuate, is  not  limited  to  the  outline  of  one  bone,  and  the  skin  above  it  is  usually 
discolored  by  ecchymoses.  No  treatment  is  necessary,  as  the  condition 
will  disappear  in  from  a  few  hours  to  three  days. 

Cephalhematomata. — By  this  term  we  mean  extravasations  of  blood 
beneath  the  untorn  pericranium.  It  is  supposed  by  many  to  be  always  due 
to  pressure  and  venous  congestion,  as  is  a  caput  succedaneum.  As  Gushing 
points  out,  the  condition  cannot  result  only  from  the  venous  stasis  of  prolonged 
pressure.  If  it  did  it  would  always  exhibit  above  it  a  caput  succedaneum 
"and  this  is  far  from  our  actual  experience"  (Harvey  Gushing,  in  "Keen's 
Surgery,"  vol.  iii) .  It  is  certainly  due  in  some  cases  to  bending  or  breaking  of 
a  cranial  bone.  The  condition  is  said  to  occur  in  i  labor  out  of  200.  In  most 
cases  there  is  but  one  cephalhematoma,  but  there  may  be  two,  three,  or 
even  four.  The  commonest  situation  is  over  the  right  parietal  bone  (the 
common  seat  of  caput  succedaneum)  and  caput  succedaneum  may  be  asso- 
ciated with  a  cephalhematoma.  The  blood  begins  to  flow  beneath  the  peri  - 
cranium  during  labor  and  the  swelling  increases  during  the  first  few  days  after 
birth;  in  fact,  it  is  frequently  not  noticed  for  a  day  or  two.  The  sweUing  is 
tense  and  smooth  with  a  convex  outHne.  It  may  cover  but  a  small  portion 
of  a  bone  or  an  entire  bone,  but  never  extends  beyond  the  bounding  sutures. 
This  hmitation  is  due  to  the  fact  that  the  pericranium  is  adherent  to  the 
sutures.  In  the  course  of  a  couple  of  weeks  the  tumor  may  become  sur- 
rounded by  a  hard  ring  due  to  the  formation  of  new  bone,  and  a  shell  of 
bone  may  eventually  surround  and  cover  over  the  clot,  an  area  of  permanent 
bony  thickening  remaining.  In  other  cases  no  bone  forms,  but  the  clot 
gradually  disappears.  An  extradural  and  even  a  subdural  cephalhematoma 
may  be  associated  with  a  subpericranial  cephalhematoma. 

Gephalhematomata  unassociated  with  cerebral  symptoms  usually  disappear 
without  operation.  If  there  is  no  sign  of  subsidence  after  two  weeks,  follow 
Gushing's  rule,  evacuate  by  a  puncture-Hke  incision  and  apply  pressure.  If 
suppuration  occurs,  incision  is  necessary.  Suppuration  may  occur  if  the  scalp 
was  excoriated. 

Diseases  of  the  Scalp. — The  scalp  is  composed  of  skin,  subcutaneous 
fat,  and  the  occipitofrontalis  muscle  and  aponeurosis.  The  scalp  is  hable 
to  inflammation  from  various  causes,  and  also  to  other  diseases — namely, 
tumors,  cysts,  warts,  moles  (local  cutaneous  hypertrophies),  cirsoid  aneurysm 
(page  432),  nevi,  and  lupus.  Abscesses  0}  the  scalp  are  common.  If  an 
abscess  fornis  beneath  the  pericranium,  the  pus  diffuses  over  the  area  of 
one  bone,  being  limited  by  the  attachment  of  the  pericranium  in  the  sutures. 
If  an  abscess  forms  in  the  tissue  between  the  occipitofrontalis  and  the  peri- 
cranium, it  is  widely  diffused.  Treves  calls  this  subaponeurotic  connective 
tissue  "the  dangerous  area."  Abscess  of  the  subcutaneous  tissue  is  apt  to 
be  hmited  because  of  the  great  amount  of  fibrous  tissue.  Abscess  is  treated 
by  instant  incision  at  the  most  dependent  part,  and  drainage. 


792  Diseases  and  Injuries  of  the  Head 

Diseases  and  Malformations  of  the  Bones  of  the  Skull.— Thr 

bones  of  the  skull  are  liable  to  caries,  necrosis,  osteitis,  periostitis,  atrophy, 
hypertrophy,  tumors,  etc.  (see  Diseases  of  Bones). 

Cranial  Pneumatocele.— This  rare  condition  is  a  result  of  perforation 
of  a  bone  which  permits  air  to  collect  beneath  the  periosteum.  It  may 
occur  in  the  mastoid  or  occipital  region  or  over  the  frontal  region.  These 
protrusions  vary  greatly  in  size;  and  as  their  shape  depends  upon  the  periosteal 
attachment  to  sutures  in  the  neighborhood,  they  vary  in  shape.  The  over- 
lying tissues  are  natural  in  appearance.  The  protrusion  is  tense,  but  may 
lessen  or  disappear  on  pressure.  McArthur  points  out  ("Jour.  Am.  Med. 
Assoc,"  May  6,  1905)  that  if  diminished  by  pressure,  the  patient  may  hear 
a  sound  like  rushing  air  or  water  in  the  ear  if  the  protrusion  is  occipital  or 
mastoid;  and  in  the  nose,  if  it  is  frontal.  An  elevated  ridge  of  bone  sur- 
rounds a  pneumatocele.  The  protrusion  is  tympanitic  on  percussion.  The 
condition  is  due  to  perforation  of  the  bony  wall  of  an  air  sinus  by  disease 
or  injury  or  rupture.  McArthur  points  out  that  in  half  of  the  reported  cases 
the  rupture  was  not  preceded  by  any  history  of  inflammation  or  injury. 
The  condition  is  not  dangerous. 

Treatment. — Incision,  finding  the  opening,  enlarging  it,  removing  osteo- 
phytes; bringing  the  walls  of  the  cavity  together  and  applying  pressure. 

Microcephalus. — By  microcephalus  is  meant  unnatural  smallness  of 
the  head  due  to  imperfect  development.  Marked  microcephalus  is  not  a 
common  condition,  but  it  is  an  occasional  cause  or  associate  of  idiocy.  A 
child  may  be  born  with  a  skull  completely  ossified  even  at  the  fontanelles, 
or  the  ossification  may  become  complete  soon  after  birth,  but  in  many  cases 
of  microcephalus  ossification  takes  place  late  or  not  at  all.  In  microcephalus 
the  face  is  usually  fairly  well  developed;  the  jaws  are  prominent;  the  fore- 
head is  flat;  the  cranium  and  brain  are  small;  the  convolutions  of  the  brain 
are  simpler  than  is  natural;  there  is  apt  to  be  marked  asymmetry  of  the 
two  sides  of  the  brain;  internal  hydrocephalus  may  exist;  areas  of  sclerosis 
and  atrophy  are  common;  porencephaly  is  not  unusual.  Some  patients  have 
perfect  motor  power;  others  are  slow  and  incoordinate.  Epilepsy,  chorea, 
and  athetosis  frequently  complicate  the  case.  Idiots  of  this  type  often  pre- 
sent deformities  such  as  cleft  palate,  strabismus,  distorted  ears,  hypertrophied 
tongue,  deformed  genitals  or  extremities,  ill-shaped  and  irregularly  developed 
teeth.  They  exhibit  irregular  muscular  movements,  are  frequently  paralyzed 
in  childhood  (infantile  paraplegia  or  hemiplegia),  and  suffer  from  subsequent 
contractures.  They  are  active,  destructive,  excitable,  and  are  hable  to  be 
violent  and  almost  demoniacal.  As  Clouston  says,  they  look  impish  and 
unearthly. 

Treatment. — SkiUed  training  in  a  school  for  the  feeble-minded  or  in  an  in- 
stitution for  idiots  is  necessary  in  treating  microcephalic  idiocy.  Idiots  have 
but  little  power  of  attention,  and  sensory  impressions  give  rise  to  but  few 
concepts,  and  these  are  feeble  and  fleeting.  In  order  to  educate  the  idiot 
it  is  highly  desirable  that  speech  be  acquired,  and  "the  more  strongly  the 
attention  can  l^e  aroused,  the  more  perfect  does  speech  become"  (Kirchhoff). 
The  principle  of  the  education  of  idiots  is  to  stimulate,  coordinate,  and 
guide  sight,  hearing,  and  feeling. 

Lannelongue,  of  Paris,  has  suggested  an  operation  in  cases  of  idiocy 


Hydrencephalocele  793 

with  premature  ossification  (see  Linear  Craniotomy,  page  849) .  In  this  pro- 
cedure the  author  has  no  confidence.  Idiocy  is  a  general  disorder  and  not 
a  local  brain  disease.  Soft  parts  mould  bone,  and  bone  does  not  control 
soft  parts.  There  is  no  evidence  that  the  brain  is  being  compressed;  in 
fact,  the  simplicity  of  the  convolutions  suggests  the  contrary.  In  many 
typical  cases  of  microcephalic  idiocy  there  is  no  synostosis  even  years  after 
birth.  The  operation  has  been  much  abused.  It  is  sometimes  fatal,  and, 
although  a  fatality  may  gratify  the  family,  a  surgeon  is  not  a  legal  executioner. 
The  remarkable  improvement  which  has  been  reported  in  some  cases  is 
wrongly  supposed  to  be  due  to  the  operation.  As  a  matter  of  fact,  the  new  sur- 
roundings, the  strange  faces,  the  firm  discipline,  the  effect  of  the  anesthetic,  and 
the  shock  of  the  operation  attract  the  feeble  attention  and  rouse  the  sluggish 
senses.  Many  cases  are  brought  for  operation  because  they  are  for  the  time 
being  unusually  intractable  and  excitable,  and  the  return  to  the  usual  level  of 
conduct  after  operation  is  regarded  as  a  permanent  gain,  when  it  is  often  but 
a  temporary  alleviation.  We  believe  that  scientific  training  is  the  proper 
treatment,  and  that  the  efficiency  of  training  is  not  increased  by  the  previous 
performance  of  craniotomy,  and  we  follow  the  precept  of  Agnew,  that  a 
surgeon  might  as  well  cut  a  piece  out  of  a  turtle's  back  to  make  a  turtle 
grow  as  to  cut  a  piece  out  of  the  skull  to  make  the  brain  grow. 

Diseases  and  Malformations  Involving  the  Brain.— Cephal- 
oceles. — A  cephalocele  is  a  congenital  protrusion  of  intracerebral  contents 
through  a  defect  in  the  skull.  These  protrusions  are  covered  with  skin. 
The  defect  through  which  the  protrusion  occurs  is  always  in  the  median  line, 
although  in  some  cases  (as  at  inner  angle  of  the  orbit)  the  visible  protrusion 
may  be  at  the  side.  Nearly  all  such  protrusions  are  either  frontal  or  occipital, 
although  now  and  then  one  presents  in  the  pharynx,  having  emerged  from  the 
skull  between  the  body  of  the  sphenoid  and  the  ethmoid. 

Frontal  cephaloceles  are  divided  into: 

1.  Nasofrontal — those  which  are  in  the  region  of  the  glabella. 

2.  Naso-orbital — those  at  the  inner  angle  of  the  orbit. 

3.  Nasoethmoidal — those  below  a  nasal  bone. 

Each  one  of  the  above  forms  passes  through  the  horizontal  plate  of  the 
ethmoid. 

Occipital  cephaloceles  are  divided  into: 

1.  Superior — those  above  the  external  occipital  protuberance.  In 
these  the  bony  gap  may  join  the  posterior  fontanel. 

2.  Inferior — those  below  the  external  occipital  protuberance.  In  these 
the  bony  gap  may  join  the  foramen  magnum. 

The  above  regional  classification  is  that  advocated  in  von  Bergmann's 
"System  of  Practical  Surgery"  (translated  and  edited  by  Wm.  T.  Bull  and 
Walton  Martin). 

The  commonest  form  is  hydrencephalocele,  and  all  other  forms  result 
from  retrograde  changes  in  this. 

Hydrencephalocele. — This  is  by  far  the  commonest  and  is  also  the 
most  dangerous  form  encountered.  The  protrusion  consists  of  arachnoid,  a 
layer  of  brain  tissue,  and  a  cavity  containing  ventricular  cerebrospinal  fluid 
and  connected  with  the  lateral  ventricle.  It  is  in  reality  a  protrusion  of  the 
lateral  ventricle.     It  is  covered  with  skin — natural  skin,  unless  the  protrusion 


794  Diseases  and  Injuries  of  the  Head 

is  very  large,  in  which  case  the  skin  is  more  or  less  atrophied.  Beneath  the 
skin  is  fascia  and  beneath  this,  arachnoid.  The  pericranium  and  dura 
do  not  cover  it,  but  each  has  a  gap  in  it  and  these  two  tissues  join  each  other 
around  the  bone  margins. 

Encephalocele. — Results  from  retrograde  changes  in  a  hydrencephalo- 
cele.  The  protrusion  of  the  ventricle  has  become  reduced  and  the  hernia 
consists  of  a  portion  of  brain  covered  by  arachnoid.  Encephalocele  is  only 
seen  in  the  nasofrontal  region.  If  there  is  any  fluid  in  this  protrusion,  it  is 
not  in  its  interior,  but  on  its  surface,  and  results  from  a  cyst  of  the  arachnoid. 

Meningocele. — We  formerly  understood  by  a  meningocele  a  protrusion 
of  the  membranes  alone;  we  now  regard  it  as  a  condition  resulting  from 
retrograde  changes  in  a  hydrencephalocele.  The  brain  tissue  of  the  latter 
disappears;  beneath  the  arachnoid  is  a  layer  of  cells  identical  with  those 
which  line  the  ventricles;  the  connection  with  the  ventricle  is  entirely  or  almost 
completely  cut  oS;  a  cyst  forms  in  the  subarachnoid  tissue,  and  thickened 
pia  surrounds  the  cyst.  (See  "  System  of  Practical  Surgery, "  by  E.  von  Berg- 
mann,  vol.  i,  translated  and  edited  by  Wm.  T.  Bull  and  Walton  Martin.) 
The  above  condition  is  called  by  von  Bergmann  encephalocysto-meningocele. 

Diagnosis. — The  congenital  origin  and  situation  make  certain  that  the  con- 
dition is  cephalocele.  The  bony  gap  can  usually  be  felt;  whether  it  can  or  can- 
not, an  A;-ray  picture  should  be  taken.  Such  a  picture  may  indicate  that  the 
mass  contains  brain  matter.  The  protrusions  vary  greatly  in  size  and  shape. 
Some  are  rounded,  some  are  flattened,  some  are  stalked.  The  skin  covering 
them  may  be  natural,  atrophied,  filled  with  vessels,  scarred,  or  ulcerated.  Some- 
times the  cephalocele  is  very  tense;  sometimes  it  is  loose.  In  naturally  hairy 
regions  the  skin  over  the  summit  of  the  protrusion  is  bald,  but  that  around  the 
base  is  hairy.  If  there  is  connection  between  the  interior  of  the  protrusion  and 
the  ventricle,  the  mass  can  be  diminished  in  size  by  compression.  If  it  shrinks 
rapidly  from  compression,  the  opening  into  the  ventricle  is  large.  In  such 
cases  compression  of  the  mass  quickly  causes  signs  of  cerebral  pressure.  Lum- 
bar puncture  may  cause  the  protrusion  to  diminish  in  size;  crying  may  cause 
it  to  increase  in  size.  Large  cephaloceles  fluctuate  and  perhaps  pulsate. 
Meningocele  feels  and  looks  like  a  cyst  (is  translucent  and  fluctuates);  it 
does  not  usually  pulsate,  it  has  a  small  base,  it  becomes  tense  on  forcible 
expiration,  and  some  cases  can  be  very  slowly  diminished  by  compression. 

Encephalocele  is  small,  opaque,  does  not  fluctuate,  has  a  broad  base, 
does  pulsate,  becomes  tense  on  forced  expiration,  and  attempts  at  reduction 
fail  and  cause  pressure  symptoms. 

Hydrencephalocele  is  larger  than  a  meningocele,  is  translucent,  fluctuates, 
rarely  pulsates,  is  pedunculated,  is  rendered  a  little  tense  on  forced  expiration, 
and  can  be  lessened  in  size  by  compression  but  cannot  be  reduced. 

Treatment. — In  von  Bergmann's  "System  of  Practical  Surger\'"  we  find 
the  wise  caution  to  attempt  no  operation  for  an  occipital  protrusion  beneath 
the  protuberance,  when  the  cleft  enters  the  foramen  magnum  and  is  associated 
with  cleft  of  the  cervical  vertebrae — for  a  condition  in  which  the  soft  parts 
are  defective  and  the  brain  is  exposed  {cranioschisis) — on  a  case  complicated 
with  hydrocephalus  or  on  a  case  complicated  by  some  other  condition  which 
is  of  necessity  fatal.  We  no  longer  refuse  to  operate  because  the  mass 
contains  some  brain  matter  or  because  it  communicates  with  the  ventricle, 


Chronic  Internal  Hydrocephalus  795 

although  if  it  does  so,  the  [)rognosis  is  much  worse.  For  a  large  hydren- 
cephalocele  nothing  can  be  done  and  early  death  is  inevitable.  In  rare 
instances  an  encephalocele  is  converted  into  a  meningocele,  and  the  bony 
aperture  closes,  thus  bringing  about  a  cure.  Among  the  expedients  for  treat- 
ing meningocele  are  electrolysis,  injection  of  Morton's  fluid  (gr.  x  of  iodin, 
gr.  XXX  of  iodid  of  potassium,  5  j  of  glycerin),  pressure,  and  excision.  In  cases 
of  cephalocele,  when  portions  of  the  nerve-centers  are  not  contained  in  the 
sac,  A.  W.  Mayo  Robson  advises  the  performance  of  a  plastic  operation.  He 
ligates  the  neck  of  the  sac,  excises  the  sac,  sutures  the  skin-flaps  separately, 
and  leaves  the  stump  outside  the  line  of  superficial  sutures.  It  is  usually 
possible  to  tell  by  palpation  if  nerve-centers  are  in  the  sac,  but  if  in  doubt, 
make  an  exploratory  incision,  and  sweep  the  finger  around  inside  of  the  sac* 
Meningoceles  should  be  operated  upon  by  Robson's  plan. 

Spurious  Meningocele. — It  occasionally  happens,  after  a  fracture  of  a 
child's  skull,  that  cerebrospinal  fluid  gathers  beneath  the  pericranium  and 
bulges  the  pericranium  and  scalp.  This  condition  is  called  spurious  men- 
ingocele. When  a  spurious  meningocele  forms,  the  bone  must  have  been 
broken  and  the  dura  and  arachnoid  ruptured.  This  protrusion  fluctuates, 
pulsates,  and  is  influenced  by  respiration.  In  some  cases  there  is  commu- 
nication with  the  ventricles  of  the  brain.  The  parietal  and  frontal  regions 
are  the  most  usual  seats  of  the  trouble.  The  opening  in  the  skull  may 
close;  it  may  remain  stationary;  it  may  actually  enlarge  by  bone-absorption. 
In  some  cases  the  spurious  meningocele  undergoes  spontaneous  cure;  in  some 
cases  rupture  occurs;  in  other  cases  death  takes  place  as  a  result  of  the 
cerebral  injury.  (See  Joseph  Sailer  on  "Spurious  Meningocele,"  "  University 
Med.  Magazine,"  Sept.,  1900.) 

Treatment. — Close  the  opening  by  a  plastic  operation. 

Hydrocephalus. — In  external  hydrocephalus  the  fluid  is  on  the  surface  of 
the  brain;  in  internal  hydrocephalus  the  fluid  is  in  the  ventricles.  Hydro,- 
cephalus  may  be  acute  or  chronic,  congenital  or  acquired. 

Acute  hydrocephalus  is  usually  internal,  but  may  be  external.  It  results 
from  meningitis — usually  tuberculous  meningitis  of  the  base.  The  symp- 
toms are  headache,  elevated  temperature,  delirium,  stupor,  convulsions, 
paralysis,  and  choked  disc. 

Treatment  of  acute  hydrocephalus  by  medical  means  is  of  no  avail.  Tap- 
ping of  the  ventricles  may  be  tried. 

Chronic  internal  hydrocephalus  is  usually  congenital,  but  may  arise 
after  birth  in  children  under  seven.  In  congenital  hydrocephalus  the  con- 
dition may  be  due  to  circulatory  disturbances  in  the  brain  of  the  embryo 
resulting  from  uterine  disease  or  injury  during  pregnancy.  Syphilis  and 
alcoholism  in  parents  seem  sometimes  to  be  responsible.  Chronic  acquired 
hydrocephalus  results  from  inflammation,  especially  tuberculous  inflam- 
mation. A  tumor  pressing  on  the  veins  of  Galen  may  cause  it.  In  chronic 
acquired  internal  hydrocephalus  there  is  overproduction  or  underabsorp- 
tion  of  cerebrospinal  fluid  and  perhaps  both  conditions  may  exist. 
The  usually  causative  condition  is  an  inflammation  of  the  interior  of  the 
ventricles,  particularly  of  the  choroid  plexuses,  and  as  a  consequence  venous 
return  is  obstructed  and  oversecretion  occurs.  One  or  both  foramina  of 
*"Amer.  Jour.  Med.  Sciences,"  Sept.,  1895. 


796  Diseases  and  Injuries  of  the  Head 

Monro  may  be  closed,  and  if  only  one  is  closed,  unilateral  hydrocephalus  may 
arise  (Alfred  S.  Taylor,  in  "Am.  Jour,  of  Med.  Sciences,"  August,  1904). 
The  aqueduct  of  Sylvius,  the  foramen  of  Magendie,  and  the  central  canal  of 
the  cord  may  be  occluded.  The  cranium  enlarges  enormously  and  the  bones 
of  the  skull  are  widely  separated.  The  brain  is  distended  and  thinned  and 
the  sulci  are  obliterated.  The  broad  forehead  overhangs  the  eyes;  the 
fontanelles  are  elevated.  The  child  is  mentally  weak  or  is  an  idiot,  and 
very  often  does  not  learn  to  walk  or  to  talk.  Convulsions,  palsies,  and  con- 
tractures are  common,  and  blindness  is  frequent.  Such  children  usually 
die  young. 

The  treatment  of  chronic  hydrocephalus  is  rarely  of  much  avail.  Pressure 
by  strapping  with  adhesive  plaster  has  been  tried.  Tappings  through  a  fon- 
tanelle  may  be  performed  by  means  of  a  trocar  (only  §  ij  or  o  iij  of  fluid  being 
withdrawn  at  a  time).  If  much  fluid  is  allowed  to  flow  out,  the  head  must  be 
strapped  with  adhesive  plaster  aftenvard.  If  the  skull  ossifies,  the  lateral  ven- 
tricles may  be  tapped  after  trephining.  It  has  been  proposed  to  drain  by  tap- 
ping the  theca  of  the  spinal  cord  (Quincke).  This  last  operation  is  called 
lumbar  puncture  (pp.  878,  879).  It  will,  of  course,  fail  if  the  foramina  in  the 
floor  of  the  fovu^th  ventricle  or  the  aqueduct  of  Sylvius  are  blocked.  Even  if 
they  are  open,  it  is  of  little  service.  The  operation  which  promises  most  was 
devised  by  Sutherland  and  Cheyne,  and  is  known  as  intracranial  drainage 
("Brit.  Med.  Jour.,"  Oct.  15,  1898).  Their  theory  is  that  in  hydrocephalus 
fluid  distends  the  ventricles  because  the  channels  of  communication  between 
the  ventricles  and  the  subarachnoid  spaces  are  closed.  The  subarachnoid 
spaces  communicate  directly  with  veins,  hence  fluid  cannot  collect  under  pres- 
sure in  these  spaces.  Intracerebral  drainage  establishes  a  communication 
between  the  subarachnoid  space  and  one  ventricle.  It  is  not  necessary  to 
operate  on  both  sides  in  bilateral  hydrocephalus,  because  the  lateral 
ventricles  communicate.  A  small  opening  is  made  in  the  skull.  The  dura 
is  incised.  A  number  of  strands  of  catgut,  which  are  tied  together,  are  pushed 
through  the  brain  so  that  one  end  of  the  catgut  mass  lies  in  a  ventricle  and  the 
other  end  beneath  the  dura.  The  dura  and  scalp  are  then  sutured.  Brewer 
makes  an  osteoplastic  occipital  flap,  makes  a  dural  flap,  lifts  the  cerebral 
lobe,  and  pushes  a  drain  of  rubber  tissue  into  a  lateral  ventricle. 

The  elder  Senn  passed  a  rubber  tube  into  the  ventricle  and  put  the  outer 
end  of  the  tube  beneath  the  skin  of  the  scalp. 

Alfred  S.  Taylor  ("Am.  Jour.  Med.  Sciences,"  August,  1904)  makes 
an  osteoplastic  flap  with  its  base  over  the  right  mastoid,  cuts  a  dural  flap, 
passes  a  slender  aspirating  needle  through  the  second  temporo-sphenoidal  con- 
volution into  the  lateral  ventricle,  draws  ofl'  a  little  fluid,  and  measures  the 
thickness  of  the  brain.  He  then  takes  6  strands  of  No.  2  forty-day  catgut,  each 
strand  half  an  inch  longer  than  the  thickness  of  the  brain.  The  strands 
are  tied  together  with  a  spiral  of  catgut,  i\  inches  of  the  loop  being  left  free. 
Three  layers  of  Cargile  membrane  are  wrapped  about  the  shaft,  but  the  tip 
remains  free.  It  is  carried  into  the  ventricle  along  the  needle  track  by  thumb 
forceps,  and  the  loops  are  slipped  here  and  there,  but  chiefly  downward,  under 
the  dura.  Cargile  membrane  is  placed  between  the  loops  and  dura  and  the 
dura  and  skin  are  sutured.  Taylor  operated  on  6  cases  and  2  recovered, 
with  relief  of  all  signs  of  pressure. 


Concussion,  Contusion,  and  Laceration  of  the  Brain  797 

Cushing,  after  determining  by  luml)ar  puncture  that  the  ventricles  can  be 
emptied,  obtains  retroperitoneal  drainage  by  a  combined  laparotomy  and 
laminectomy. 

« 

Injuries  of  the  Head. 

Caput  Succedaneum. — (See  page  790.) 

Scalp=WOunds. — Scalp- wounds  bleed  profusely  because  the  scalp  is 
very  vascular,  because  many  of  the  blood-vessels  are  in  fibrous  tissue  and 
cannot  contract  and  retract,  and  because  even  blunt  force  splits  the  scalp 
almost  like  an  incision.  Scalp-wounds  are  treated  as  are  other  wounds. 
Even  a  large  piece  of  scalp  with  only  a  narrow  pedicle  may  not  slough ;  hence 
try  to  save  any  piece  that  has  an  attachment.  Always  shave  a  wide  area 
and  disinfect  the  shaven  area  and  the  wound.  Arrest  hemorrhage,  and 
exercise  great  care  in  cleansing  the  wound  and  the  parts  about  it.  Stitch 
the  wound  with  silkworm-gut.  Very  few  sutures  are  needed  if  the  wound  is 
longitudinal,  but  many  are  required  if  it  is  transverse.  The  permanent  arrest 
of  hemorrhage  is  rarely  effected  by  ligatures,  but  rather  by  sutures  judiciously 
placed.  If  drainage  is  required,  use  a  few  strands  of  silkworm-gut;  but  drain- 
age is  rarely  used  unless  we  know  the  wound  is  grossly  infected.  Wet  antisep- 
tic dressings  are  used  for  the  first  few  days  and  moderate  pressure  is  applied  by 
wet  gauze  bandages.     Avulsion  of  the  scalp  is  discussed  on  page  275. 

Contusions  of  the  Head. — Scalp-swelling  from  hemorrhage  is  usually 
considerable.  The  patient  may  be  stunned  or  dazed.  The  swelling  of 
hematoma  must  not  be  mistaken  for  fracture  with  depression.  In  hematoma 
there  is  a  central  depression;  hard  pressure  on  the  center  finds  bone  on  a 
level  with  the  general  contour  of  the  bone,  and  the  margin  of  a  hematoma 
is  circular,  is  not  quite  hard,  and  is  elevated  above  the  general  contour.  In 
depressed  fracture  the  edge  is  on  a  level  with  or  below  the  level  of  the  general 
bony  contour,  and  the  margin  is  sharp  and  irregular.  The  treatment  is 
by  bandage-pressure.     If  suppuration  arises,  at  once  incise. 

Concussion,  Contusion,  and  Laceration  of  ttie  Brain. — For  many 
years  it  was  customary  to  regard  concussion  as  a  condition  produced  by  molec- 
ular vibrations  in  the  nervous  substance  of  the  brain.  Buret's  classical  obser- 
vations profoundly  modified  surgical  thought,  and  led  to  the  opinion  that  in 
concussion  of  the  brain  there  is  injury  to  the  brain  itself,  a  rupture  of  cere- 
bral vessels  brought  about  by  the  advance  and  recession  of  a  wave  of  cere- 
brospinal fluid.  This  wave,  it  is  thought,  first  flows  in  the  direction  of  the 
force.  Keen  says  that  there  may  be  slight  brain  injuries  which  can  properly  be 
called  "concussions,"  but  it  is  better  to  consider  concussion  as  synonymous 
with  laceration  of  the  brain.  Kocher  considers  concussion  as  identical  with 
contusion  oj  the  brain.  It  seems,  however,  highly  improbable  that  slight 
cases  of  concussion  are  accompanied  by  vascular  rupture  or  organic  mis- 
chief; the  symptoms  are  too  transitory,  and  reaction  too  rapid  and  com- 
plete to  permit  of  any  such  view.  Experiments  on  animals  show  we  can 
develop  concussion  without  laceration  or  contusion.  Autopsies  have  been 
carefully  made  in  some  cases  of  death  from  concussion,  and  no  organic  lesion 
has  been  discovered.  It  is  quite  true  that  the  same  force  which  causes  the  con- 
cussion may  cause  contusion  or  multiple  lacerations,  and  a  severe  force  is  apt  to 
do  so.     But  we  are  not  then  justified  in  assuming  that  concussion  is  contu- 


79^  Diseases  and  Injuries  of  the  Head 

sion  or  laceration :  we  should  rather  conclude  that  the  individual  had  both 
concussion  and  a  demonstrable  injur}'.  Both  conditions  arise  from  violence, 
but  the  two  conditions  are  not  identical.  I  believe  with  von  Bergmann  that 
there  is  such  a  condition  as  concussion,  which  may  be  pure  concussion  or 
may  be  associated  with  organic  damage,  and  even  if  a  man  dies  and  is  found 
to  have  an  organic  injur}^  the  concussion  may  have  caused,  or,  at  least,  have 
hastened,  the  fatal  result.  I  believe  with  von  Bergmann  that  it  is  not  repeated 
waves  of  force  from  the  blow  but  the  concussion  of  the  blow  itself  that  does 
the  harm.  The  brain  is  momentarily  displaced  by  the  blow.  The  blow  acts 
on  the  entire  brain ;  the  centers  are  first  stimulated  and  then  depressed,  and  in 
fatal  cases  are  not  only  depressed  but  are  paralyzed.  The  cause  of  concussion 
is  violent  force  either  direct  (as  a  blow  upon  the  head)  or  indirect  (as  a  fall 
upon  the  buttocks).  This  force  shakes,  oscillates,  jars,  or  displaces  the  brain, 
giving  rise  to  stimulation  and  then  to  exhaustion  of  the  nerve-centers,  and 
perhaps  to  rupture  of  vascular  twigs,  large  vessels,  or  even  the  membranes. 
In  the  less  severe  cases  concussion  only  exists;  in  the  more  severe  cases  there 
is  also  contusion  or  laceration  or  compression  soon  arises. 

As  von  Bergmann  points  out,  the  entire  cortex  in  concussion  is  momentarily 
stimulated  and  then  depressed.  The  momentary'  stihiulation  exists  when  a 
man  "sees  stars"  as  a  result  of  a  blow.  The  depression  or  exhaustion  is 
manifested  by  heaviness,  dvilness,  stupor,  perhaps  by  unconsciousness.  The 
stimulation  of  the  medullary  centers,  von  Bergmann  points  out,  lasts  longer,  as 
a  rule,  than  the  stimulation  of  the  cortex,  and  is  manifested  particularly  by  a 
slow  pulse.  If  the  pulse  grows  rapid  and  weaker,  the  pnemnogastric  center 
is  becoming  exhausted  and  the  patient  is  in  danger  of  death.  In  sHght  cases 
of  concussion  only  the  cortex  may  be  involved,  the  medullar}-  center  escap- 
ing. In  rapidly  fatal  cases  of  concussion  the  medullar}-  centers  are  quickly 
paralyzed. 

Symptoms. — In  very  trivial  cases  the  patient  is  sUghtly  and  momentarily 
dazed  and  the  pulse  is  temporarily  slow  and  weak,  but  he  is  otherwise  un- 
affected. In  a  rather  shght  case  of  brain  concussion  the  patient  may  or  may  not 
fall;  his  face  is  pale;  he  feels  weak,  giddy,  nauseated,  and  confused;  but  he 
soon  reacts,  and  often  vomits.  The  pulse  is  w-eak  and  is  slow  for  a  time  and 
then  becomes  normal.  In  a  severe  case  he  hes  in  a  state  of  complete  muscular 
relaxation.  The  extremities  are  cold;  the  skin  is  pale  and  cold;  the  pulse  is 
small,  soft,  slow,  and  weak,  because  of  stimulation  of  the  pneumogastric  cen- 
ter; the  respiration  varies,  being  sometimes  deep,  sometimes  superficial, 
sometimes  rapid,  and  sometimes  irregular.  He  seems  unconscious,  but  can 
usually  be  roused  to  monosyllabic  response  by  shouting,  pinching,  or  holding 
a  bright  light  near  his  face.  Occasionally,  however,  there  is  complete  uncon- 
sciousness. The  urine  and  feces  are  often  passed  involuntarily.  The  pupils 
may  be  unaltered,  may  be  dilated  or  contracted,  may  be  equal  or  unequal,  but 
in  any  case  they  will  react  to  light.  Paralysis  rarely  exists,  but  if  there  is 
paralysis,  it  is  temporan,-.  The  temperature  at  first  is  subnormal.  In  a  very 
severe  concussion  in  which  there  is  great  danger  of  death  the  pulse  is  very 
rapid,  small,  weak,  and  probably  irregular  because  of  exhaustion  of  the  medul- 
lary center,  and  the  patient  is  absolutely  unconscious  because  of  depression  of 
the  cortex.  In  a  severe  cortical  laceration  there  will  be  tw-itchings  or  even 
general  convulsions,  or  the  patient  will  lie  curled  up  with  limbs  flexed  and 


Treatment  of  Concussion  of  the  Brain  799 

evclids  shut,  and  will  resist  all  attempts  to  open  his  eyes  or  mouth  or  to  move 
his  Hmbs  (A.  Pearce  Gould).  Erichsen  called  this  condition  "cerebral  irri- 
tability." If  a  patient  with  very  severe  concussion  and  very  rapid  pulse  is 
going  to  get  better,  the  pulse  will  become  slower.  If  a  patient  with  severe  con- 
cussion and  a  slow  pulse  is  improving,  the  pulse  will  become  normally  rapid 
and  stronger;  if  he  is  getting  worse,  it  will  become  abnormally  rapid  and  weaker. 
How  long  may  concussion  last?  As  von  Bergmann  well  says:  Concussion  is 
transient  in  its  manifestations.  It  is  a  matter  of  a  few  minutes  or  at  most  a 
few  hours,  and  any  prolongation  of  severe  symptoms  beyond  this  time,  especi- 
ally if  they  are  intensifying  as  time  goes  on,  indicates  an  associated  injury. 
When  the  patient  reacts  from  concussion,  he  will  most  probably  vomit.  Within 
twenty-four  hours  he  usually  improves,  but  is  feverish  and  complains  of  head- 
ache and  lassitude,  sometimes  becomes  delirious,  and  in  rare  cases  develops 
mania.  After  concussion  recovery  may  be  complete,  but,  on  the  contrary, 
a  person's  whole  nature  may  change:  he  may  develop  hysteria,  insanity,  or 
epilepsy,  and  in  many  cases  there  is  complaint  for  a  long  time  of  headache, 
insomnia,  low  spirits,  and  lassitude.  Concussion  may  pervert  or  wipe  out  all 
memory  of  the  causative  accident  and  also,  strange  to  say,  of  a  varying  period 
preceding  the  accident.  The  loss  of  memory  of  the  accident  is  permanent; 
the  amnesia  for  a  period  preceding  the  accident  may  be  permanent,  but  may 
only  be  temporary.  Statements  made  regarding  an  accident  by  those  who 
have  had  concussion  must  be  received  with  many  grains  of  salt.  If  the  patient 
in  concussion  recedes  from,  instead  of  advancing  toward,  recovery,  coma  will 
set  in  or  inflammation  will  develop.  The  prognosis  is  always  uncertain.  Any 
concussion  producing  more  than  very  temporary  unconsciousness  is  almost 
surely  a  serious  injury,  because  considerable  laceration  has  probably  oc- 
curred. 

Treatment. — In  treating  brain  concussion  bring  about  reaction  by  the 
administration  of  aromatic  spirits  of  ammonia  (no  alcohol,  as  this  agent 
excites  the  brain),  by  pouring  a  few  drops  of  ammonia  on  a  handkerchief  and 
holding  it  near  the  nose,  by  surrounding  the  patient  (who  lies  in  bed  with  a 
pillow)  with  hot  bottles,  by  hot  irrigation  of  the  head,  by  the  apphcation  of 
mustard  over  the  heart,  and  by  the  administration  of  enemata  of  hot  coffee  or 
hot  saline  fluid.  Do  not  pour  fluid  into  the  patient's  mouth  until  he  becomes 
able  to  swallow  easily.  If  he  cannot  easily  swallow,  rely  on  hot  enemata  and 
hypodermatic  injections  of  strychnin.  Place  the  patient  in  bed  in  a  quiet  room 
and  watch  him.  If  reaction  is  inordinate,  apply  cold  to  the  head,  give  arterial 
sedatives  and  diuretics,  and  purge.  For  some  days  or  for  some  weeks,  accord- 
ing to  the  case,  insist  on  an  easy  life.  For  many  weeks  after  a  grave  concus- 
sion a  patient  must  be  kept  away  from  business  and  be  watched,  because  of 
the  possibility  of  an  abscess  of  the  brain  arising,  and  because  of  the  liability 
of  such  patients  to  develop  hysteria,  neurasthenia,  or  insanity.  Give  a  plain 
diet  containing  a  minimum  of  meat,  administer  an  occasional  purgative,  and 
secure  sleep.  Sleep  can  often  be  obtained  bysome  simple  expedient,  such  as  the 
administration  of  warm  milk,  placing  a  hot-water  bag  to  the  abdomen  or  feet, 
or  applying  a  mustard  plaster  for  a  short  time  to  the  back  of  the  neck.  In 
cases  where  obstinate  wakefulness  exists,  it  becomes  necessary  to  give  bromid, 
chloral,  sulphonal,  trional,  or  some  other  hypnotic.     Morphin  is  avoided  be- 


8oo  Diseases  and  Injuries  of  the  Head 

cause  it  is  thought  to  increase  venous  congestion  of  the  brain,  but  the  elder 
Gross  often  used  it,  especially  in  cerebral  irritation.  If  signs  of  compression 
arise,  it  is  best  to  trephine,  as  the  compressing  agent  may  be  a  clot  (see 
page  804).  If  inflammation  arises,  some  surgeons  will  not  trephine;  but  it 
is  wise  and  proper,  especially  if  the  damage  seems  to  be  localized,  to  incise 
the  scalp  and  inspect  the  bone.  If  a  fracture  is  discovered  and  the  symp- 
toms are  serious,  perform  an  exploratory  trephining,  open  the  dura,  and 
secure  drainage  for  inflammatory  products. 

In  any  severe  concussion  of  the  brain  with  contusion  of  the  scalp  the  sur- 
geon should  at  once  incise  the  scalp  and  inspect  the  bone. 

Compression  of  the  Brain. — The  combination  of  symptoms  indica- 
tive of  cerebral  compression  may  be  present  in  a  number  of  different  condi- 
tions. We  find  these  S}'mptoms  in  abscess  of  the  brain,  tumor  of  the  brain, 
intracranial  hemorrhage,  foreign  bodies,  inflammatory  exudate,  and  fracture 
of  the  skull  with  marked  depression.  The  s\TTiptoms  of  compression  are 
expressive  of  impairment  of  the  functions  of  the  entire  brain  by  insufficient 
and  imperfect  circulation  of  blood,  this  impairment  of  circulation  being  the 
result  of  a  lessening  in  capacity  of  the  cavity  containing  the  brain,  its  mem- 
branes, the  blood-vessels,  and  the  cerebrospinal  fluid  (von  Bergmann). 
If  a  brain  tumor,  or  abscess,  or  blood-clot,  or  portion  of  depressed  bone 
occupies  space  previously  given  to  brain  matter,  vessels,  etc.,  there  is  less 
room  within  the  skull  to  contain  the  special  structures;  they  are  squeezed 
and  the  circulation  is  greatly  impeded.  This  condition  is  compression. 
The  circulation  is  slowed,  and  because  of  slow  circulation  the  actixity  of  the 
centers  is  finally  inhibited.  It  is  stated  by  Gushing  that  the  rise  which  occurs  in 
the  blood  pressure  is  conservative  and  is  expressive  of  nature's  effort  to  main- 
tain the  circulation  in  the  compressed  medullary  centers.  The  cortex  is 
temporarily  stimulated  and  then  depressed,  because  of  impairment  of  nutri- 
tion. The  medullary  centers  are  first  stimulated.  The  respiratory  center 
is  stimulated  by  retention  of  CO,  in  the  blood,  then  the  vasomotor  center  is 
stimulated,  then  the  vagus,  and  finally,  perhaps,  the  convulsive  center  (von 
Bergmann's  "System  of  Practical  Surgery").  The  stimulation  of  the  cere- 
bral centers  is  followed  after  a  time  by  weakening  or  actual  paralysis.  The 
centers  are  said  to  suffer  in  regular  order,  viz.,  the  cortex,  the  corona  radiata, 
the  gray  matter  of  the  cord,  and,  finally,  the  medulla  (Huguenin).  As  von 
Bergmann  points  out,  by  the  time  the  convulsive  center  becomes  stimulated, 
the  cortex  is  usually  exhausted  and  the  patient  is  unconscious.  In  compres- 
sion the  sensitive  cortex  first  feels  the  effect  and  feels  it  most  gravely,  and  the 
cortical  impairment  may  last  long  after  other  trouble  has  passed.  In  some 
cases  the  cortex  alone  seems  to  be  distinctly  involved.  When  the  vagus  center 
is  stimulated,  the  pulse  becomes  slow;  later,  as  the  center  becomes  exhausted, 
it  becomes  rapid  and  weak,  and  this  change  has  the  same  unfavorable  sig- 
nificance as  in  concussion.  If  death  occurs  it  results  from  paralysis  of  res- 
piration and  not  of  circulation. 

Symptoms. — The  symptoms,  known  as  pressure  symptoms,  are  divided 
into  those  occurring  during  the  period  of  stimulation  and  those  occurring 
during  the  period  of  increasing  exhaustion.  The  symptoms  of  the  first  stage 
are  headache,  vomiting,  flushing  of  the  face,  contraction  of  the  pupils,  choked 


Symptoms  of  Compression  of  the  Brain  8oi 

disc,  mental  excitement,  elevation  of  blood-pressure,  restlessness,  and  slowing 
of  the  pulse.  The  pulse  becomes  slow,  regular,  and  strong.  The  symptoms 
of  the  second  stage  are  heaviness,  dulness,  drowsiness,  passing  into  stupor, 
and  finally  into  coma.  The  respirations  are  stertorous  and  after  a  time  be- 
come Cheyne-Stokes.  The  pulse  is  weak,  intermittent,  compressible,  and  in- 
creasingly rapid.  There  are  involuntary  evacuations  of  feces  and  urine,  and 
finally  paralysis  of  respiration  which  causes  death,  the  heart  beating  for  a 
time  after  respiration  has  ceased  (von  Bergmann's  "System  of  Practical 
Surgery"). 

The  headache  usually  present  in  the  first  stage  of  compression  is  in- 
tense, persistent,  sometimes  general  and  sometimes  more  or  less  localized, 
and  often  aggravated  by  percussion  of  the  cranium.  It  persists  even  in 
delirium,  and  the  patient  ceases  to  appreciate  it  only  when  unconscious- 
ness begins.  The  vomiting  is  usually  without  nausea  and  is  due  to  stimu= 
lation  of  the  medullary  center.  At  first  vomiting  may  arise  from  taking  food, 
but  it  soon  continues  independent  of  food.  The  tongue  is  probably  clean. 
Cerebral  vomiting  is  usually  associated  with  severe  headache.  Restlessness 
is  a  pressure  symptom  in  the  stage  of  stimulation,  and  the  patient  rolls  his 
head,  tosses  his  body,  and  groans  with  pain.  The  heart  does  not  begin  to 
slow  until  the  patient  begins  to  be  dull  and  drowsy,  or  until  stupor  arises,  when 
the  pulse  slows  and  the  tension  rises.  Finally  it  becomes  very  slow — perhaps 
less  then  40  in  a  minute.  If  the  condition  grows  worse,  the  pulse  after  a  time 
suddenly  becomes  rapid  and  of  low  tension  instead  of  slow  and  of  high  ten- 
sion, a  most  unfavorable  sign,  indicating  exhaustion  and  approaching  par- 
alysis of  the  vagus.  In  the  stage  of  stimulation  the  patient  is  excited,  unstable, 
deUrious,  and  the  condition  of  dehrium  gradually  gives  way  to  drowsiness, 
stupor,  and  coma.  In  some  cases  of  compression  there  is  distinct  protrusion 
of  the  eyeballs.  Before  the  patient  is  unconscious  the  pupils  are  contracted. 
When  the  patient  is  comatose,  they  are  usually  dilated,  but  may  be  con- 
tracted and  respond  slowly  to  light  or  not  at  all.  If  the  conjunctival  reflex 
is  gone,  they  will  not  respond  at  all  (Gowers) .  In  a  lesion  making  unilateral 
compression  toward  the  base,  the  pupil  on  the  side  of  the  compressing  cause 
is  apt  to  be  much  dilated  and  even  immobile.  Choked  disc  begins  in  the 
stage  of  stimulation  and  continues  to  the  end.  That  choked  disc  is  due 
to  intracranial  pressure  seems  demonstrated  by  numerous  operation  reports, 
especially  by  Gushing,  of  Johns  Hopkins  Hospital,  in  which  rehef  of  pressure 
abates  choked  disc  (see  page  828) .  The  existence  of  choked  disc  is  determined 
by  the  use  of  the  ophthalmoscope.  The  respirations  become  stertorous  or 
snoring  as  coma  develops  because  of  the  \-ibrations  of  the  relaxed  palate  in 
the  air-current,  and  the  cheeks  flap  during  expiration.  As  the  activity  of  the 
respiratory  center  fails  from  increasing  anemia,  the  respirations  become 
shallow  and  infrequent,  or,  perhaps,  of  the  Che\Tie-Stokes  t}-pe.  Gowers 
defines  Cheyne-Stokes  breathing  as  ''alternating  periods  of  decreasing  and 
increasing  depth  of  breathing,  separated  by  a  pause"  (Lectures  on  Diseases 
of  the  Brain).  The  unconsciousness  of  compression  may  be  sudden  or  gradual, 
may  be  partial  or  complete.  Apoplexy  and  many  traumatisms  cause  imme- 
diate unconsciousness.  A  meningeal  hemorrhage  causes  a  gradually  increas- 
ing unconsciousness.     A  brain  tumor  may  cause  hea\-iness,  dulness,  stupor,  or, 


802 


Diseases  and  Injuries  of  the  Head 


perhaps,  after  a  long  time,  even  coma.     If  compression  comes  on  gradually, 
the  brain  more  or  less  accommodates  itself,  and  unconsciousness,  if  it  occurs 
at  all,  is  considerably  deferred.     A  sudden  increase  of  pressure  may  pro- 
duce immediate  unconsciousness.     Stupor  is  partial  unconsciousness,  a  con- 
dition in  which  a  person  lies  as  though  asleep,  though  he  rouses  partially 
and  temporarily  when  positively  spoken  to.     In  profound  coma  the  limb 
reflexes  are  diminished  or  lost,  the  muscles  are  flaccid,  and  s\vallo\Anng  is 
impossible.     In  coma  there  is  incontinence  of  feces  and  either  incontinence 
or  retention  of  urine.     There  may  be  the  incontinence  of  retention.     The 
temperature  of  a  patient  suffering  from  compression  varies.     In  traumatic 
cases  it  may  be  at  first  subnormal  and  later  normal  or  elevated.     In  inflamma- 
tory conditions  it  is  elevated,  except  in  abscess  of  the  brain,  in  which  it  is  sub- 
normal in  half  the  cases.     After  an  apoplexy  it  is  for  a  time  subnormal, 
but  as  shock  passes  away  it  becomes  somewhat  elevated.     Any  sudden  com- 
pression  causes  shock   and   temporarily  subnormal  temperature.     Lesions 
of  the  pons  and  medulla  cause  elevation — perhaps  remarkable  elevation  of 
temperature.     In  great  or  sudden  brain  compression  complete  coma  alwavs 
exists   without   voluntary    movement.       In    cerebral    compression   paralysis 
may  exist,  which  may  be  very  hmited  (monoplegia),  may  be  of  one  side 
(hemiplegia),  or  may  be  general.     In  hemorrhage  into  the  interior  of  the 
brain  the  unconsciousness  is  immediate  or  nearly  so.     In  bleeding  from  the 
middle  meningeal  artery  a  period  of  consciousness  intervenes  between  the 
injury  and  the  coma,  in  which  period  blood  collects  and  the  coma  comes 
on  gradually.     In  compression  from  depressed  fracture  or  from  a  foreign 
body  the  symptoms  usually  come  on  at  once,  but  they 
may  be  deferred  for  some  hours.     Compression  from 
inflammation  or  pus  begins  gradually  after  a  consider- 
able time  has  elapsed.     The  symptoms  described  as 
pressure  symptoms  are  those  of  pure  compression. 
When  traumatism  causes  the  condition,  the  compres- 
sion symptoms  are  mingled  with  those  of  concussion, 
or  perhaps  of  contusion  or  hemorrhage.     The  brain 
adjacent  to  any  lesion  causing  compression  suffers 
more  than  the  brain  distant  from  it.     The  blood-sup- 
ply of  the  entire  brain  is  affected,  but  the  adjacent 
brain  has  its  capillaries  particularly  and  directly  com- 
pressed.    Hence  the  paralysis  sometimes  produced  by 
certain  lesions.     The  course  of  compression  depends 
on  the  nature  and  persistence  of  the  cause.     Great 
temporary  pressure  may  produce  no  permanent  harm. 
Moderately  severe  pressure  may  be  recovered  from 
even  after  weeks  of  stupor.     Great  pressure,  suflScient 
to  induce  coma,  if  not  relieved  quickly,  will  cause 
death.     Persistent  cerebral  symptoms  after  a  head 
injury,  when  no  obvious  lesion  can  be  made  out,  are 
probably  due  to  edema  of  the  brain. 
Determination  of  the  Cause  of  Coma  in  a  Patient. — A  diagnosis 
must  be  made  between  coma  due  to  brain  injury  and  the  comatose  condition 


Fig.  450.— Fracture  of 
skull  with  depressed  frag- 
ments. Compression  of 
brain  by  bone  (Scudder). 


Determination  of  the  Cause  of  Coma  in  a  Patient 


80: 


of  apoplexy,  uremia,  epilepsy,  hysteria,  diabetes,  opium-poisoning,  and  alco- 
holic intoxication.  In  hospital  practice  cases  of  unconsciousness  without  a 
known  history  are  frequent.  In  attempting  to  diagnosticate,  examine  carefully 
for  any  evidence  of  traumatism,  and  inquire  as  to  how  and  where  the  patient 
was  found,  if  any  fit  occurred,  and  if  a  bottle  or  a  pill-box  was  found  near  by 
or  in  the  pockets.  The  surgeon  should  himself  examine  the  pockets.  Smell 
the  breath  to  notice  alcohol  or  opium,  but  always  remember  that  a  victim  of 
Bright's  disease  is  liable  to  apoplexy,  that  a  man  may  be  stricken  \\ath  apo- 
plexy while  he  is  drunk,  and  may  fracture  his  skull  by  faUing  when  under  the 
influence  of  opium  or  of  alcohol.  The  odor  of  acetone  (violets)  on  the  breath 
or  in  the  urine  indicates  the  existence  of  diabetes.  Draw  the  urine  with  the 
catheter  if  any  water  is  in  the  bladder.  Examine  the  urine  for  albumin, 
acetone,  and  sugar,  and  take  the  specific  gravit}\  In  doubtful  cases  of  coma 
have  an  ophthalmologist  use  the  ophthalmoscope.  He  might  find  optic 
atrophy  indicative  of  Bright's  disease  or  choked  disc  indicating  compression. 
The  cerebrospinal  fluid  obtained  by  lumbar  puncture  will  contain  blood  if 

hemorrhage  has  taken  place  beneath 
the  cerebral  dura  or  in  a  ventricle  of 
the  brain.  This  test  is  valuable  in 
fracture  of  the  base  of  the  skull,  for 
in  this  condition  cerebrospinal  fluid 
is  usually  bloody.     In  post-epileptic 


JiuSurt  on  laryerfDolet 
flaek  bristtf  in  /jimm. 
,"—       cf  arfery. 


^  arCoy 


Fig.  451— Frontal  section  of  skull.  Mid- 
dle meningeal  hemorrhage.  The  dura  bulges 
inward  toward  the  skull  cavity  (diagram) 
(Scudder). 


Fig-  452.— A  case  of  rupture  of  middle  men- 
ingeal artery.  Preparation  of  dura.  In  the 
Warren  Museum.  The  specimen  is  viewed 
from  the  outer  side  (Scudder). 


coma  the  temperature  is  never  below  normal,  there  are  no  unilateral  symptoms, 
the  condition  resembles  sleep,  and  the  patient  can  be  aroused.  Hysterical  coma 
occurs  in  boys  and  women;  there  are  no  objective  symptoms,  and  the  patient, 
though  swallowing  what  is  put  into  his  mouth,  cannot  be  roused.  In  uremia, 
besides  the  condition  of  the  urine  (and  always  remember  that  a  person  with 
albuminuria  is  apt  to  develop  apoplexy),  there  is  a  persistent  subnormal 
temperature,  and  convulsions  are  prone  to  occur.  There  is  perhaps  edema 
of  the  legs,  and  paralysis  and  stertor  are  absent.  In  apoplexy  hemiplegia 
exists,  and  the  initial  temperature  is  for  a  short  time  subnormal.  A  single 
convulsion  may  have  ushered  in  the  case.  Alcoholic  unconsciousness  is  often 
diagnosticated  when  apoplexy  really  exists.  A  man  will  smell  of  alcohol  who 
has  had  one  drink,  but  one  drink  will  not  produce  coma;  hence  the  smell  of 


8o4  Diseases  and  Injuries  of  the  Head 

alcohol  is  not  conclusive.  In  any  case  of  doubt  some  hours  of  watching  will 
clear  up  the  diagnosis.  Regard  a  doubtful  case  as  serious  undl  the  truth  is 
clear.  In  opium-poisoning  the  pupils  are  contracted  to  a  pin-point,  the  res- 
pirations are  usually  slow,  shallow,  and  quiet,  and  may  be  stertorous,  but  there 
is  no  paralysis.  Always  remember  that  hemorrhage  into  the  pons  will  pro- 
duce pin-point  pupils,  but  it  also  causes  paralysis  (crossed  paralysis  if  in  the 
lower  half  of  the  pons)  and  high  temperature  with  sweating.  In  opium- 
poisoning  the  temperature  is  subnormal.  In  diabetic  coma  the  pupils  wall 
react  to  a  very  bright  hght,  the  temperature  is  subnormal,  and  the  breath  and 
the  urine  smell  of  acetone. 

Treatment  of  Brain  Compression. — The  treatment  of  brain-compres- 
sion depends  on  the  cause.  Hemorrhage  (extradural  or  subdural)  requires 
trephining  and  arrest  of  bleeding;  coma  from  depressed  fracture  demands 
trephining  and  elevation;  foreign  bodies  must  be  removed;  abscesses  must 
be  evacuated;  some  tumors  are  to  be  removed.  In  many  tumor  cases  the 
growth  is  not  removed,  but  a  decompression  operation  is  performed  (page  850) . 
In  cerebral  compression,  if  death  is  threatened  by  respiratory  failure, 
make  artificial  respiration  and  at  once  trephine  over  the  supposed  region 
of  compression.  Horsley  has  shown  that  irrigation  of  the  head  with  hot 
water  is  of  great  value  in  bringing  about  reaction  from  shock  in  cases  of 
brain  injur}-. 

Intracranial  hemorrhage  may  be  either  spontaneous  or  traumatic.  In 
the  vast  majority  of  instances  spontaneous  hemorrhage  comes  from  the  len- 
ticulostriate  artery  (Charcot's  artery. of  cerebral  hemorrhage),  and  produces 
apoplexy,  a  disease  belonging  to  the  physician,  except  in  some  ingravescent 
cases,  for  which  ligation  of  the  common  carotid  on  the  same  side  as  the  rupture 
may  be  indicated.  In  adults  traumatism  is  almost  always  the  cause  of  a  men- 
ingeal hemorrhage.  The  blood  may  flow  from  a  sinus,  from  the  middle 
meningeal  artery  or  one  of  its  branches,  or  from  vessels  of  the  pia.  Trauma- 
tism during  delivery  is  an  occasional  cause  of  hemorrhage  from  the  middle 
meningeal  artery  (Richardiere)  and  a  not  unusual  cause  of  hemorrhage  from 
cortical  veins.  Violent  paroxysms  of  coughing  in  whooping-cough  occasionally 
produce  extradural  hemorrhage  or  subdural  hemorrhage.  Geo.  S.  Brown 
reports  such  a  case.  He  diagnosticated  the  condition  and  operated  success- 
fully ("New  York  Med.  Jour.,"  April  25,  1903). 

Traumatic  Meningeal  Hemorrhage.— Hemorrhage  may  take  place — 
(i)  between  the  bone  and  the  dura  {extradural);  (2)  between  the  dura  and  the 
brain  (subdural);    and  (3)  in  the  brain  substance  (cerebral). 

I.  Extradural  hemorrhage  arises  usually  from  the  middle  meningeal 
artery  or  from  one  of  its  branches.  A  spicule  of  bone  may  penetrate  a 
venous  sinus  and  produce  extradural  hemorrhage,  or  a  sinus  may  rupture. 
Rupture  of  the  meningeal  artery  or  one  of  its  branches  is  usually,  but  not 
always,  accompanied  by  fracture  (Fig.  453) ;  in  fact,  in  some  cases  not  even  a 
bruise  can  be  found  (Fig.  452).  The  ruptured  vessel  may  be  upon  the  oppo- 
site side  to  that  on  which  the  force  was  appHed,  hence  the  evidence  of  scalp 
injury  is  not  a  certain  sign  of  the  side  of  the  skull  involved.  The  accident  may 
or  may  not  cause  temporary  unconsciousness;  but  even  if  it  does,  from  this 
unconsciousness  the  patient  almost  always  reacts,  and  there  is  a  distinct  period 


Subdural  Hemorrhage 


805 


Fig.  453. — Fracture  of 
skull  with  middle  menin- 
geal hemorrhage.  Com- 
pression of  brain  by  blood 
(Scudder). 


of  consciousness  between  the  accident  and  the  lasting  coma,  the  coma  being 
due  to  pressure  from  a  continually  increasing  mass  of  extravasated  blood  (Fig. 
451).  If  the  main  trunk  or  a  large  branch  is  rup- 
tured, the  period  of  consciousness  is  short;  if  a  small 
branch  is  ruptured,  the  period  of  consciousness  is 
prolonged  for  hours  or  perhaps  for  days.  As  the  clot 
forms  and  enlarges  the  patient  becomes  heavy,  dull, 
stupid,  and  sleepy;  he  sleeps  so  soundly  he  can 
scarcely  be  aroused,  and  snores  loudly,  and  finally 
passes  into  stupor  and  then  into  coma.  The  other 
signs  of  this  condition  are  paralysis  of  the  side  oppo- 
site the  blood-clot  (not  necessarily  of  the  side  oppo- 
site the  point  of  application  of  the  force,  for  the  artery 
may  rupture  from  contre-coup  on  the  uninjured  side); 
this  paralysis  is  apt  at  first  to  be  localized,  but  it  grad- 
ually and  progressively  widens  its  domain.  If  the 
clot  extends  toward  the  base,  the  pupil  on  the  same 
side  as  the  clot  ceases  to  react  to  light,  becomes  immo- 
bile, and  dilates  widely,  and,  if  the  clot  be  on  the  left 
side,  aphasia  may  be  noted.  As  the  clot  enlarges  ad- 
jacent centers  become  involved.  The  face  becomes 
paralyzed,  then  the  arm,  and  finally  the  leg.  Not 
unusually  epileptiform  attacks  occur,  starting  in  dis- 
charges from  the  centers  which  are  irritated  by  the 
advancing  clot  before  their  function  is  abolished  by 

pressure.  The  pulse  becomes  full,  strong,  usually  slow,  but  occasionally 
frequent;  the  breathing  becomes  stertorous;  the  temperature  rises,  that  of  the 
paralyzed  side  exceeding  that  of  the  sound  side.  In  a  compound  fracture  the 
pressure  of  escaping  blood  may  force  brain  matter  out  of  the  wound.  In 
extradural  hemorrhage  from  a  sinus  the  symptoms  cannot  be  differentiated 
from  those  produced  by  arterial  rupture. 

Treatment. — In  treating  extradural  hemorrhage  localize  the  clot,  not  by 
the  seat  of  the  wound  or  contusion,  but  entirely  by  the  symptoms.  In  a 
doubtful  case  endeavor  to  bring  about  reaction;  but  if  the  state  of  shock  deepens 
or  does  not  improve  and  if  pressure-symptoms  increase,  operate  at  once. 
To  reach  the  middle  meningeal  artery  or  its  anterior  branch  trephine  one 
and  one-fourth  inches  back  of  the  external  angular  process,  at  the  level  of  the 
upper  border  of  the  orbit  (Figs.  441  and  449).  If  this  incision  does  not 
expose  the  clot,  trephine  again  at  the  level  of  the  upper  border  of  the  orbit 
and  just  below  the  parietal  eminence  (Fig.  449).  The  first  incision  gives 
access  to  the  main  trunk  and  to  the  anterior  branch;  the  second  incision 
exposes  the  posterior  branch.  If  signs  indicate  that  the  clot  is  traveling  to 
the  base,  the  trephine  should  be  used  half  an  inch  lower  than  the  point  first 
directed.  Arrest  bleeding  by  a  suture  ligature  or  by  packing  (page  453), 
and  always  open  the  dura  and  inspect  the  brain.  By  this  procedure  a  sub- 
dural hemorrhage  may  be  discovered  which,  without  it,  would  have  been 
missed.     Drainage  must  be  employed. 

2.  Subdural  hemorrhage  is  usually  due  to  depressed  fracture  and  rupture 
of  the  middle  cerebral  artery  or  of  a  number  of  small  vessels.  The  symptoms 
are  identical  with  those  of  extradural  bleeding,  but  are  usually  very  rapid  in 


8o6 


Diseases  and  Injuries  of  the  Head 


onset  and  are  accompanied  by  a  more  disdnct  drop  in  temperature  and 
graver  depression.  The  cerebrospinal  fluid  obtained  by  lumbar  puncture 
is  bloody. 

The  treatment  is  trephining  at  the  first  point  named  in  the  previous  article, 
enlarging  the  opening  upward  and  backward  with  a  rongeur,  opening  the 
dura,  turning  out  the  clot,  ligating  the  bleeding  point  or  packing,  elevating  any 
depression  of  bone,  draining,  and  stitching  the  dura  with  catgut.  Hemor- 
rhage from  internal  pachymeningitis  requires  the  same  treatment. 

3.  Cerebral  Hemorrhage. — The  symptoms  of  cerebral  hemorrhage  are 
identical  with  those  of  apoplexy.  The  treatment  is  the  same  as  that  for  apo- 
plexy, except  in  ingravescent  cases,  when  the  common  carotid  on  the  same 
side  as  the  clot  may  be  ligated. 

Rupture  of  a  sinus  may  arise  without  a  bone  injury,  but  is  usually  due 
to  a  compound  fracture.  A  sinus  may  be  wounded  during  a  brain  operation. 
The  treatment,  if  the  rupture  happens  from  fracture,  is  trephining.  En- 
large the  bone  opening  by  the  rongeur,  pack  with  one  large  piece  of  iodoform 


Fig.  454. — Section   of  outer  and   inner  tables, 
with  two  parallel  lines  (after  Ag^ew). 


Fig.  455.— Greater  yielding  of  the  inner 
table  than  of  the  outer  after  the  application  of 
violence  (after  Agnew). 


gauze,  or  catch  the  rent  with  hemostatic  forceps,  leaving  them  in  place  for 
three  or  four  days,  or  apply  a  lateral  hgature  or  a  suture  Hgature.  Elevate 
depressed  bone.  If  during  an  operation  a  sinus  should  be  wounded,  use  a 
lateral  ligature,  a  suture  ligature,  or  control  hemorrhage  by  packing. 

Intracranial  Hemorrhage  in  the  Newborn. — Certainly  most  of  the 
cases  of  birth  palsy  seen  in  children  are  the  result  of  subdural  and  subarach- 
noid hemorrhage  at  birth  and  damage  of  the  cortical  motor  area.  In  such 
conditions  there  is  spastic  paralysis  of  the  hemiplegic  type,  or  if  both  hemi- 
spheres suffered  there  is  plastic  diplegia  and  usually  amentia  (Gushing,  in 
"Am.  Jour.  Med.  Sciences,"  Oct.,  1905).  It  has  not  been  the  custom  to 
operate  for  hemorrhage  in  the  newborn;  most  of  the  cases  do  not  die,  but  re- 
main for  life  weakened  and  paralyzed,  or  epileptic  or  idiotic. 

The  hemorrhage,  in  cases  of  birth  palsy,  is,  as  Gushing  points  out,  usually 
venous  and  due  to  "rupture  of  some  of  the  delicate  and  poorly  supported 
venous  radicles  of  the  cerebral  cortex"  ("Am.  Jour.  Med.  Sciences,"  Oct., 
1905).  It  may  result  from  traumatism  due  to  bone  overlapping  or  forceps  pres- 
sure during  parturition,  or  may  arise  during  asphyxia  after  birth.  Gushing  dis- 
covered in  examining  stillborn  infants  and  infants  that  died  soon  after  birth 
that  many  of  them  died  with  cortical  hemorrhage.  In  some  the  extravasa- 
tions were  very  large — in  fact,  completely  overlying  a  cerebral  hemisphere. 
In  some  they  were  much  smaller.     In  one  the  clot  was  in  the  cerebellar  fossa. 

The  vessels  usually  torn  are  on  one  side  and  are  the  unsupported  venous 
radicles  which  enter  the  longitudinal  sinus,  hence  the  leg  center  of  one  side 


Fractures  of  the  Skull  807 

is  the  cortical  area  most  apt  to  be  gravely  damaged.     If  the  vessels  of  both 
sides  are  torn,  a  bilateral  cortical  lesion  results. 

Symptoms  oj  Hemorrhage.— In  Cushing's  masterly  paper  ("Am.  Jour. 
Med.  Sciences,"  Oct.,  1905)  the  symptoms  of  recent  hemorrhage  are  set 
forth.  There  is  the  history  of  a  long  and  difficult  labor,  forceps  perhaps 
having  been  used,  or  a  history  of  postpartum  asphyxiation.  The  fonta- 
nelle  bulges  and  perhaps  does  not  pulsate.  The  fluid  obtained  by  lumbar 
puncture  contains  blood-corpuscles.  There  is  usually  twitching  and,  as  a 
rule,  convulsions  occur.  They  may  occur  soon  after  birth  or  not  for  several 
days.  When  they  occur  soon,  they  may  be  general;  when  they  occur  later, 
they  may  be  unilateral.  Paralysis  is  rare  in  the  early  days  after  birth. 
There  may  be  alterations  in  the  circulation  and  respiration.  Pupillary  alter- 
ation and  ocular  palsy  seldom  occur.  If  the  child  is  not  operated  upon  it 
may  die  or  it  may  apparently  recover.  If  it  apparently  recovers  after  a 
considerable  hemorrhage,  several  months  may  pass  before  ominous  symp- 
toms are  recognized.  The  late  manifestations  of  the  disease  may  be  "spas- 
tic palsies,  or  bhndness,  or  deafness,  or  feeble-mindedness,  or,  in  severe  cases, 
even  complete  amentia"  (Gushing).     Epilepsy  may  be  a  result. 

Treatment. — Osteoplastic  craniotomy  in  the  parietal  region,  on  one  side 
or  both,  according  to  the  unilateral  or  bilateral  nature  of  the  hemorrhage; 
opening  of  the  dura;  washing  out  and  turning  out  the  clot;  suturing  the  dura 
and  closing  the  scalp  without  drainage.  Gushing  reports  4  cases,  in  one  of 
which  operation  was  done  on  both  sides.  He  says  chloroform  should  be 
given  and  that  the  parietal  bone  can  be  cut  with  blunt,  curved  scissors. 

Fractures  of  the  skull  may  be  simple,  compound,  depressed,  non- 
depressed,  or  punctured.  A  fracture  of  the  skull  may  be  produced  by  a  bending 
force,  by  a  bursting  force,  or  by  an  explosive  force  (see  Gunshot-wounds) . 

A  bending  force  is  usually  apphed  by  the  forcible  impact  of  a  body  of 
small  area.  It  produces  a  fracture  and  seldom  causes  distant  injuries.  The 
fracture  may  be  of  the  inner  table  only,  or  of  both  tables.  If  both  tables  are 
fractured  the  broken  bone  is  displaced  and  remains  so. 

In  fracture  by  bursting,  lines  of  fracture  run  to  distant  points  from  the  seat 
of  appHcation  of  the  force.  Such  an  injury  is  inflicted  by  the  impact  of  a  flat 
surface  of  considerable  area.  In  some  cases  we  have  a  force  which  first  is  bend- 
ing in  character,  but  causes  bursting  to  also  occur,  because  there  is  no  rebound. 

Falls  of  large  heavy  objects  or  falls  on  the  head,  blows  from  large  flat  ob- 
jects on  the  head,  crushes  in  railroad  accidents,  etc.,  may  burst  the  skull.  In 
bursting  fracture  there  is  often  widespread  injury. 

Fractures  are  divided  into  fractures  of  the  vault,  usually  due  to  direct 
force,  and  fractures  of  the  base,  due  to  extension  of  fractures  of  the  vault, 
to  indirect  violence  (a  fall  upon  the  feet,  the  buttocks,  or  the  vault),  to  forc- 
ing of  the  condyles  of  the  lower  jaw  against  or  through  the  base,  or  to  foreign 
bodies  breaking  through  the  orbit,  vault  of  the  pharynx,  the  ear,  or  the  roof 
of  the  nostrils.  Fracture  by  contre-coup,  which  occurs  on  the  side  opposite 
the  point  of  application  of  the  violence,  is  very  rare.  Fractures  of  the  skull 
are  uncommon  in  early  youth,  but  they  are  much  more  frequent  in  the  aged. 
Usually  the  entire  thickness  of  the  bone  is  fractured,  but  either  the  outer 
or  the  inner  table  (Fig.  456)  may  be  broken  alone.  In  complete  fractures 
the  inner  table  is  broken  more  extensively  than  is  the  outer  table,  because  the 


Diseases  and  Injuries  of  the  Head 


inner  table  is  the  more  brittle,  because  the  force  diffuses,  and  also,  as  Agnew 
taught,  because  the  inner  table  is  part  of  a  smaller  curve  than  is  the  outer 
table,  and  violence  forces  bone-elements  together  at  the  outer  table,  but  tears 
them  asunder  at  the  inner  table  (Figs.   454,  455. 

Fractures  of  the  Vault. — A  fracture  of  the  vault  of  the  skull  may  be 
simple  and  undepressed,  or  it  may  be  depressed  (Figs.  450  and  456),  com- 
pound, or  comminuted.     A  mere  crack  may  exist  in  a  bone,  and  if  a  rent 

exists  in  the  soft  parts,  a 
bit  of  dirt  or  a  hair  may 
be  caught  in  the  crack. 
Fractures  of  the  vault 
arise  from  direct  force. 
A  fissure  may  escape  recog- 
nition, although  in  some 
cases  percussion  gives  a 
' '  cracked-pot "  sound. 
Any  considerable  depres- 
sion can  be  detected.  In 
a  simple  fracture  occasion- 
ally the  cerebrospinal  iluid 
collects  under  the  scalp 
and  forms  a  tumor  which 
pulsates  and  becomes  tense 
on  forcible  expiration 
(spurious  meningocele, 
page  795).  Compound 
fracture  can  be  readily  recognized,  but  do  not  mistake  a  suture,  a  Wormian 
bone,  or  a  tear  in  the  pericranium  for  a  fracture.  A  iissured  fracture  is 
marked  by  a  dark  line  of  blood  which  sponging  will  not  remove.  Fracture 
of  the  inner  table  alone  can  only  be  suspected.  The  prognosis  of  fracture 
of  the  vault  depends  upon  the  extent  of  brain  injury  rather  than  upon  the 
extent  of  bone  injury.  Simple  fractures  unite  by  bone;  compound  fractures 
with  loss  of  bone  unite  only  by  fibrous  tissue.  The  dangers  may  be  immediate 
(hemorrhage,  brain  injury,  and  septic  inflammation)  or  be  distant  (epilepsy, 
insanity,  and  persistent  headache). 

Treatment. — The  mortality  of  fracture  of  the  skull  was  formerly  much 
greater  than  at  present.  Before  the  days  of  antisepsis  it  was  51  per  cent. 
(Harte).  Trephining  is  performed  much  oftener  than  was  once  the  custom, 
and  is  vastly  safer.  Out  of  26  trephined  cases,  3  died  (Harte).  In  any 
case  of  fracture  of  the  skull  endeavor  to  bring  about  reaction  before  operating, 
unless  the  signs  of  pressure  continually  increase  or  the  evidences  of  shock 
remain  unimproved  or  become  graver.  A  simple  fracture  without  depression 
and  without  brain  symptoms  is  treated  expectantly  (by  rest,  quiet,  low  diet, 
purgation,  moderate  elevation  of  and  cold  to  the  head,  and  arterial  sedatives). 
A  simple  fracture  with  moderate  depression  and  without  cerebral  symptoms 
is  treated  expectantly,  and  so  also  is  a  simple  fracture  in  which  symptoms 
existed  but  are  abating.  Simple  fracture  with  marked  depression  requires 
immediate  trephining,  even  when  brain  symptoms  are  absent.  Some  sur- 
geons make  an  exception  in  young  children,  and  wait  a  while  before  trephining, 
in  the  expectation  that  the  expansile  brain  will  lift  the  depressed  but  elastic 


Fig.  456.— Fracture  of  the  vault  with  extensive  depression  of 
the  inner  table  ("American  Text-book  of  Surgery  "). 


Fractures  of  the  Base 


809 


bone  up  to  the  level.  Trephining  in  cases  where  no  symptoms  exist,  ahhough 
there  is  marked  depression,  often  prevents  disastrous  consequences  arising 
in  the  future,   and  is  known    as  "preventive   trepliining"   (Agnew,   Keen, 


Fig.  457.— Extensive  fracture  of  the  base  of  the  skull  ("American  Text-book  of  Surgery  "). 

Horsley,  Macewen,  von  Bergniann,  and  others).  In  all  compound  fractures 
shave  and  asepticize  the  entire  scalp,  enlarge  the  incision,  and  explore  the 
bone.  If  a  fissure  exists,  it  must  be  asepticized,  and  if  a  hair  or  other  foreign 
body  is  found  in  it,  in  order  to  effect  removal  and  secure  asepsis  the  outer 
table  of  the  skull  must  be  cut  away  with  a  chisel,  the  fissure  being  thus  con- 
verted into  a  broad  groove.  In  a  compound  fracture  with  much  depression 
trephine,  elevate,  and  irrigate.  In  any  fracture  trephine  if  distinct  symptoms 
exist.  In  punctured  wounds  of  the  brain  {punctured  fractures)  always  trephine, 
open  the  dura,  and  disinfect  (Keen).  In  any  case  of  fracture  of  the  vault 
where  trephining  has  been  performed  it  is  wise  to  open  the  dura  and  ex- 
amine the  brain. 

Fractures  of  the  Base. — A  fracture  of  the  base  of  the  skull  may  exist  in 
only  one  of  the  three  fosss,  in  two  of  them,  or  it  may  involve  all.  Fig.  457 
shows  an  extensive  fracture  of  the  base  of  the  skull.  The  middle  fossa 
is  oftenest  involved.  Fracture  of  the  posterior  fossa  is  the  most  fatal.  These 
fractures  may  be  due  to  direct  volence,  to  indirect  force,  and  to  extension 
of  a  fracture  of  the  vault.  Extension  from  the  vault  is  always  by  the  shortest 
route.  Fracture  by  direct  violence  may  arise  from  the  penetration  of  the 
nasal  roof,  the  orbital  roof,  or  the  pharyngeal  roof  by  a  foreign  body.  The 
posterior  fossa  may  suffer  from  a  fracture  by  direct  violence  applied  to  the 
neck.  Fractures  by  indirect  force  may  arise  from  blows  upon  the  frontal 
bone  (the  orbital  portion  of  the  frontal  or  the  cribriform  process  of  the  ethmoid 
breaking),  from  falls  upon  the  chin  (the  condyle  of  the  jaw  breaking  the 


8io         '  Diseases  and  Injuries  of  the  Head 

middle  fossa),  or  from  falls  upon  the  buttocks,  the  knees,  or  the  feet  (fracture 
occurring  in  the  posterior  fossa).  The  base  is  very  rarely  broken  by  contre- 
coup  (Treves). 

Symptoms. — Fractures  of  the  base  of  the  skull  are  apt  to  be  compound.  A 
solution  of  continuity  in  the  pharynx,  roof  of  the  nares,  orbit,  or  ear  permits 
access  of  air  to  the  seat  of  fracture  and  allows  blood  and  cerebrospinal  fluid  to 
flow  externally.  In  frackire  of  the  anterior  fossa  the  fracture  may  be  com- 
pound, because  of  laceration  of  the  mucous  membrane  of  the  nares  or  of  the 
conjunctiva.  Blood  may  run  from  the  nose,  its  source  being  the  vessels  of 
the  mucous  membrane  or  the  dura,  the  fracture  being  compound.  Epistaxis 
does  not  prove  the  fracture  to  be  compound,  but  only  suggests  it;  but  if  the 
epistaxis  is  prolonged,  the  probability  is  greatly  increased;  and  if  the  flow  of 
blood  is  succeeded  by  a  flow  of  cerebrospinal  fluid,  the  diagnosis  of  compound 
fracture  is  positive.  Cerebrospinal  fluid  appears  only  when  the  mucous  mem- 
brane, the  dura,  and  the  arachnoid  are  each  lacerated  (Treves).  In  fractures 
of  the  anterior  fossa  blood  is  apt  to  flow  into  the  orbit,  producing  subcon- 
junctival ecchymosis,  and  some  blood  is  often  swallowed  and  vomited.  In 
fractures  of  the  middle  fossa  blood  may  flow  from  the  ear  through  a  tear  in  the 
tympanum,  its  source  being  the  vessels  of  the  tympanum,  the  meningeal 
vessels,  or  a  sinus.  Blood  may  flow  through  the  Eustachian  tube  and  come 
from  the  nose,  may  be  spit  up,  or  may  be  swallowed  and  vomited.  In  some 
cases  a  quantity  of  cerebrospinal  fluid  flows  from  the  ear,  the  discharge  being 
increased  by  expiratory  effort  and  a  position  which  favors  gravity.  The 
cerebrospinal  fluid  must  not  be  confused  with  either  blood-serum  or  liquor 
Cotunnii.  The  cerebrospinal  fluid  is  always  present  in  large  amount;  the 
liquor  Cotunnii  can  be  present  only  in  minute  amount.  Blood-serum  is 
highly  albuminous;  cerebrospinal  fluid  is  a  serous  fluid  of  very  low  specific 
gravity,  never  shows  more  than  a  trace  of  albumin,  and  contains  considerable 
chlorid  of  sodium  and  in  some  instances  sugar,  which,  when  present,  reacts  to 
Trommer's  and  to  Moore's  tests,  but  does  not  refract  polarized  light  nor 
ferment  with  yeast  (Keetley,  from  Collins).  Treves  states*  that  cerebrospinal 
fluid  cannot  flow  from  the  ear  in  fractures  of  the  middle  fossa — (i)  unless  the 
line  of  fracture  crosses  the  internal  meatus;  (2)  unless  the  prolongation  of  the 
membranes  into  the  meatus  is  torn;  (3)  unless  a  communication  exists  between 
the  internal  ear  and  tympanum;  and  (4)  unless  the  drum-membrane  is  torn. 
Miles,  of  Edinburgh,!  claims  that  bleeding  from  the  ear  followed  by  a  flow 
of  cerebrospinal  fluid  is  not  pathognomonic  of  fracture  of  the  middle  fossa 
of  the  base.  He  maintains  that  when  the  drum  is  ruptured,  we  may  have 
these  signs;  when  bone  is  not  broken,  the  chief  source  of  the  blood  being 
the  vessels  of  the  pia  and  temporo-sphenoidal  lobe,  the  blood  and  cerebrospinal 
fluid  flowing  inside  the  sheath  of  the  auditory  nerve,  passing  into  the  vestibule, 
through  the  lamina  cribrosa,  and  from  the  vestibule  into  the  middle  ear, 
finding  exits  from  this  space  by  way  of  the  Eustachian  tube  and  also  through 
the  rent  in  the  drum-membrane.  Profuse  serous  discharge  may  flow  from 
the  ear  after  an  injury  without  fracture  when  the  drum  is  ruptured,  the  fluid 
coming  from  the  cells  of  the  mastoid.  It  must  be  understood  that  fracture 
of  the  base  may  exist  when  there  is  no  flow  of  blood  or  of  serous  fluid.  A 
fracture  of  the  middle  fossa  is  usually  compound,  made  so,  even  when  the 

*  "Applied  Anatomy." 

t  Edinburgh  Med.  Jour.,  Nov.,  1895. 


Fractures  of  the  Base  8ii 

drum  is  not  ruptured,  by  the  Eustachian  tube,  and  there  is  often  paralysis 
of  the  seventh  or  eighth  nerve  or  of  both  of  them.  In  fracture  of  the  posterior 
fossa  there  is  usually  respiratory  derangement  and  blood  accumulates  beneath 
the  deep  fascia  and  produces  discoloration  in  the  line  of  the  posterior  auricular 
artery  {Battlers  sign),  the  discoloration  first  appearing  near  the  tip  of  the 
mastoid.  The  discoloration  appears  in  the  line  of  nerves  and  vessels  which 
emerge  from  the  deep  fascia,  the  vessels  passing  through  openings  and  the 
extravasated  blood  emerging  from  the  same  openings.  Fractures  of  the 
posterior  fossa  are  apt  to  be  compound  through  the  pharynx,  and  in  such 
cases  the  patient  spits  or  vomits  blood.  Fractures  of  the  posterior  fossa  are 
more  fatal  than  fractures  in  either  of  the  other  fossae  because  of  the  adjacency 
of  vital  centers.  Fractures  of  the  base  are  apt  to  be  associated  with  paralysis 
of  cranial  nerves.  Optic  neuritis  often  arises  after  the  first  week.  In  fractures 
of  the  base  the  temperature  is  subnormal  during  the  shock,  rises  to  ioo°  to 
ioi°,  falls  again  to  about  normal,  and  remains  normal  or  subnormal  unless 
there  be  inflammation  or  sepsis.  Lumbar  puncture  may  obtain  bloody  fluid. 
Such  a  finding  means  subarachnoid  bleeding  and  indicates  fracture.  Harte 
("Annals  of  Surgery,"  Oct.,  1901)  has  collected  46  positive  cases  of  fracture 
of  the  base  of  the  skull  from  the  records  of  the  Pennsylvania  Hospital;  35.5 
per  cent,  recovered. 

Treatment. — In  fracture  of  the  base  I  now  always  do  a  subtemporal  de- 
compression usually  on  both  sides  as  Cushing  advocates.  This  is,  first  of  all, 
exploratory  and  may  disclose  a  bleeding  meningeal  artery.  After  the  dura  is 
opened  it  enables  us  to  evacuate  fluid  causing  pressure  and  in  which  bacteria 
could  multiply,  and  to  prevent  recurrence  of  pressure  after  the  wound  has  been 
closed.  If  there  is  bleeding  under  the  dura  the  brain  should  be  lifted  to  let 
the  blood  out,  and  a  drain  of  rubber  tissue  should  be  inserted.  If  there  is  only 
brain  edema  no  drain  is  required. 

In  addition  to  performing  decompression  I  always  give  urotropin,  as 
advised  by  surgeons  in  Johns  Hopkins.  (S.  J.  Crowe,  in  "The  Johns 
Hopkins  Hospital  Bulletin,"  April,  1909).  This  drug  renders  the  cerebro- 
spinal fluid  bactericidal.  Other  methods  of  treatment  are  secondary  to 
the  above.  My  experience  is  that  this  plan  saves  many  cases  which 
would  otherwise  perish.  Until  lately  the  methods  were  as  follows.  In 
treadng  a  compound  fracture  of  the  base  of  the  skull  collect  any  serous 
discharge  and  analyze  it,  and  disinfect  any  cavity  involved.  In  fractures 
of  the  middle  fossa  with  ruptured  drum  clean  the  ear  mechanically, 
wash  it  out  with  a  stream  of  warm  corrosive  sublimate  solution  of  a  strength 
of  I  :  2000  (turn  the  head  toward  the  affected  side  while  washing,  so  that  the 
mercurial  solution  will  not  run  down  the  Eustachian  tube),  wash  with  normal 
salt  solution,  insufflate  iodoform,  insert  a  piece  of  iodoform  gauze,  and  apply 
an  antiseptic  dressing.  Several  times  daily  the  ear  is  to  be  irrigated,  and 
insufflated  with  iodoform.  The  nasopharynx  must  be  frequently  irrigated 
with  normal  salt  solution  or  boric-acid  solution,  and  insufflated  with  iodoform. 
The  conjunctival  sac  is  frequently  irrigated  with  boric-acid  solution.  If 
after  a  head  injury  blood  accumulates  back  of  the  drum,  this  membrane 
should  be  incised  to  permit  of  drainage  and  disinfection.  In  fractures  of 
both,  the  middle  and  anterior  fossae  and  in  fractures  of  the  posterior  fossa 
■communicating  with  the  pharynx  the  nasopharynx  must  always  be  cleaned. 
The  exact  method  depends  on  the  choice  of  the  surgeon.     We  may  wash  out 


8l2 


Diseases  and  Injuries  of  the  Head 


these  cavities  frequently  with  hot  water,  next  with  peroxid  of  hydrogen,  and 
finally  with  boric-acid  solution,  or  can  simply  use  normal  salt  solution.  After 
washing,  insufflate  the 
nasopharynx  with  iodo- 
form. Repeat  the  cleans- 
ing at  regular  intervals 
and  also  cleanse  the  con- 
junctival sac  frequently. 
In  some  cases  drainage 
has  been  obtained  from 
the  anterior  fossa  by 
breaking  through  the 
cribriform  plate  and  in- 
troducing a  tube  by  way 
of  the  nostril  (AUis), 
and  from  the  middle 
fossa  by  trephining 
above  and  behind  the 
external  auditory  mea- 
tus. In  a  compound 
fracture  of  the  orbit 
disinfect  and  drain.  It 
may  be  necessary  to  tre- 
phine the  roof  of  the 
orbit  to  secure  drain- 
age. In  fracture  of  the 
posterior   fossa   examine 


Fig.  458. — Extensively  comminuted  gunshot-fracture  of  the  skull 
(after  von  Bergmann). 


to   see   if 


the  fracture  is  compound,  into  the 
pharynx,  and  if  it  is,  cleanse  with 
great  care  the  nasopharynx  and 
mouth,  as  previously  directed.  In  a 
very  extensive  fracture  of  the  base, 
besides  use  of  the  methods  set  forth 
above,  the  entire  head  should  be 
shaved  and  a  plaster-of-Paris  cap  be 
applied.  A  patient  with  fracture  of 
the  base  must  be  put  into  a  quiet  and 
darkened  room  and  be  kept  upon  a 
low  diet,  sleep  being  secured,  and 
the  bowels  and  bladder  being  at- 
tended to.  If  we  are  uncertain  as  to 
whether  a  fracture  exists  or  not,  keep 
the  patient  quiet  and  in  a  darkened 
room  and  on  a  low  diet.  Attend 
to  the  bladder,  keep  the  bowels 
loose,  examine  the  nasopharynx  with 
mirrors  and  the  ear-drum  through 
a  speculum,  and  make  a  lumbar 
puncture. 

Wounds  of  the  brain  are  pro- 
duced by  violence  and  by  foreign  bodies  (knives,  bullets,  etc.).     Except  when 


Fig.  459.— Gunshot-fracture  of  internal  table 
the  skull  (after  von  Bergmann). 


of 


Wounds  in  War  813 

due  to  penetration  of  a  fontanelle  in  a  child  or  of  a  parietal  foramen  in  adults, 
wounds  of  the  brain  are  accompanied  by  fracture  of  the  skull.  These  wounds 
are  very  dangerous;  foreign  bodies  (bone,  hair,  clothing,  etc.)  are  often  lodged 
in  the  brain,  hemorrhage  is  usually  severe,  and  sepsis  is  almost  inevitable 
without  proper  treatment.  Such  cases  are  very  fatal,  though  some  astonishing 
recoveries  are  on  record.  Figs.  458  and  459  show  gunshot-fractures  of  the 
skull. 

The  symptoms  of  brain-w<nmds  may  be  slight  and  long-deferred  or  may 
be  immediate  and  overwhelming;  they  depend  upon  the  site  and  extent  of  the 
injury.  Locahzing  symptoms  may  exist,  and  encephalitis  with  coma  is  apt 
to  arise.     Abscess  not  unusually  follows. 

In  treating  wounds  of  the  brain  always  shave  the  entire  scalp  and  examine 
the  weapon,  if  possible,  to  see  if  a  piece  were  broken  off.  Asepticize,  enlarge 
the  wound,  trephine,  arrest  bleeding,  elevate  any  depression,  remove  foreign 
bodies,  irrigate  the  wound,  drain  with  gauze,  suture  the  dura,  and  dress. 

Wounds  in  War. — When  the  bullet  of  a  mihtary  rifle,  fired  at  very  close 
range,  crosses  the  brain  it  may  blow  the  skull  into  fragments,  but  often  it  does 
not,  and  produces  fracture  of  the  skull  and  wound  of  the  brain.  The  "ex- 
plosive effect"  is  far  less  marked  on  the  head  of  a  living  man  than  on  the  head 
of  a  corpse  and  may  even  be  absent  when  the  range  was  only  100  yards. 
At  moderate  range,  at  the  point  of  initial  contact  of  the  bullet  with  the  skull 
a  fracture  is  produced,  the  opening  is  slightly  larger  than  the  bullet,  and  short 
fissures  commonly  radiate  from  it.  Fragments  from  the  internal  table  are 
usually  displaced  and  driven  into  the  brain.  The  wound  of  exit  is  more  ir- 
regular and  is  apt  to  exhibit  more  and  longer  fissures  than  the  wound  of  en- 
trance. When  a  bullet  strikes  a  glancing  blow  it  may  fracture  the  outer  table 
alone;  it  may  produce  a  "gutter-fracture"  (two  scalp  openings,  and  "a  gutter 
ploughed"  through  both  tables  of  a  portion  of  the  skull,  as  O'Reilly  expresses 
it),  very  seldom  a  fracture  of  the  inner  table  only,  penetration  of  the  skull,  and 
lodgment  of  the  bullet,  and  perforation  of  the  skull,  the  bullet  passing  through 
the  head  and  emerging.  Nearly  half  the  cases  are  instances  of  perforating 
wound. 

In  all  of  these  injuries  there  is  great  shock,  but  concussion  symptoms  may 
be  absent.  The  patient  may  die  at  once  or  almost  at  once,  but  if  he  is  alive  a 
few  hours  after  the  injury  he  has  still  to  face  the  danger  of  infection  and  result- 
ing inflammation.  The  danger  depends  on  the  brain  injury  and  the  amount 
of  infection  and  not  on  the  extent  of  the  bone  damage.  The  symptoms  vary 
according  to  the  part  of  the  brain  injured  and  the  extent  of  the  damage. 

In  practically  all  cases  bone  fragments  are  driven  into  the  brain,  and  as 
the  scalp  is  a  dirty  region,  the  wound  is  more  or  less  infected. 

The  mortality  from  these  injuries  is  very  large.  In  the  American  C\\\\ 
War  it  was  61.2  per  cent.  In  the  Franco-Prussian  War  it  was  51.3  percent. 
In  the  Boer  War,  among  the  British  it  was  only  33.1  per  cent.,  a  very  notable 
improvement.  (See  Alilitary  Surgery,  by  Surgeon  General  Robert  X.  O'Reilly, 
U.  S.  A.,  in  "Keen's  Surgery,"  vol.  iv.)  In  the  Russo-Japanese  War  the 
mortality  seems  to  have  been  something  over  37  per  cent. 

In  estimating  mortality  those  killed  outright  and  those  dying  before  reach- 
ing the  hospital  are  not  counted.  Much  brain  matter  may  ooze  out  from  such 
a  wound.  Cerebral  hernia  is  common  after  these  injuries,  especially  if  much 
bone  was  destroyed  by  the  injury  or  removed  by  the  surgeon. 


8i4  Diseases  and  Injuries  of  the  Head 

Treatment  of  Wounds  in  War. — At  the  first  aid  station  antiseptic  dress- 
ings are  apf^hed.  On  reaching  the  field  hospital  the  wound  is  explored,  if 
time,  situaUon,  and  military  necessides  permit.  Every  wound  of  this  scjrt  is  re- 
garded as  being  complicated  by  infection  and  by  depression  or  wide  dispersion 
of  bone  fragments.  The  patient  is  reacted  from  shock  and  a  flap  of  scalp  is 
turned  down  to  permit  of  exploration.  Depressed  fragments  of  bone  are 
elevated  or  removed  and  loose  pieces  are  removed.  Treatment  is  the  same 
as  for  wounds  from  revolver  bullets  (see  belowj. 

W  ounds  from  Revolver  Bullets.— The  bullet  may  strike  the  skull 
and  glance  (if  fired  at  an  angle;  with  or  without  the  p»roduction  of  a  fracture. 
A  small  bullet  (Xo.  22)  may  strike  perpendicularly  and  fail  to  enter,  some- 
times causing  a  fracture  and  sometimes  not  doing  so.  Even  a  Xo.  22  may  enter 
the  skull,  and  I  recently  removed  a  bullet  of  this  size  which  had  entered  and 
crossed  the  skull  and  lodged  beneath  the  cortex  on  the  opposite  side  of  the 
brain.  A  bullet  may  cause  a  "gutter-fracture" — may  enter  the  cranium  and 
lodge — or  may  cause  a  complete  perforation.  A  revtjlver  bullet  is  much  more 
apt  to  lodge  than  a  military  bullet. 

The  wound  of  entrance  is  small;  the  wound  of  exit  i.-,  larger.  At  the  wound 
of  entrance  the  inner  table  is  more  extensively  fractured  than  the  outer  table; 
at  the  wound  of  exit  the  outer  table  is  more  widely  broken  than  the  inner  table. 
In  these  ca.se5  there  is  always  great  shock  and  concussi(m,  and  concussion- 
symptoms  exist  even  when  the  bullet  has  entered  the  brain.  In  moderate 
concussion  the  action  of  the  heart  is  retarded;  in  severe  concussion  it  is  ac- 
celerated (page  797).  A  bullet  may  be  lodged  within  the  cranium  when 
merely  a  fracture  without  a  bullet-hole  can  be  detected.  In  these  ca.ses  the 
bullet  produced  a  fracture  and  entered  the  cranium,  and  then  the  depressed 
bone  flew  back  into  place  (v.  Bergmann).  In  such  cases,  if  complete  perfora- 
tion occurs,  the  one  existing  opening  is  the  opening  of  exit.  A  bullet  may 
lodge  in  the  bone,  between  the  dura  and  the  bone,  between  the  dura  and  brain, 
in  the  brain,  between  the  dura  and  bone  of  the  opposite  side,  or  in  the  bone  of 
the  opposite  side,  in  the  nasal  fossa,  maxillary  antrum,  or  orbit.  Always  examine 
the  side  of  the  head  opposite  to  the  wound  of  entrance  to  determine  if  there  is  any 
bulging  or  fracture.  A  bullet  may  pass  across  the  brain  and  be  deflected  from 
the  inner  surface  of  the  skull.  Ruth  does  not  believe  the  bullet  can  rebound 
from  the  opposite  wall.*  If  certain  regions  are  injured  localizing  symptoms  may 
arise.  Much  brain  matter  may  ooze  out  from  the  wound.  Sometimes  this 
causes  great  impairment  of  function,  sometimes  little  or  none.  The  secondary 
symptoms  of  gunshot-wounds  of  the  head  are  varied  and  uncertain,  and 
may  not  be  observed  at  all  before  death.  Fowler  wisely  points  out  that  a 
patient  with  a  gunshot-wound  of  the  head  may  have  also  received  other  in- 
juries, and  the  other  injuries  may  be  in  part,  at  least,  responsible  for  cerebral 
symptoms. 

Treatment  of  Wounds  from  Revolver  Bullets. — Endeavor  to  bring 
about  reaction  (see  Concu-.-ionj.  In  severe  cases  apply  heat  to  the  head  and 
make  artificial  respiration.  It  will  sometimes  be  necessarj'  to  operate  while 
artificial  respiration  is  being  made.  In  treating  gunshot-wounds  of  the  head 
shave  and  asepticize  the  whole  scalp,  disinfect  the  entire  track  of  the  ball,  and 
arrest  hemorrhage  at  the  wounds  of  entrance  and  exit,  using  the  rongeur  to 
expose  the  bleeding  points  if  the  bullet  be  large,  emplo\ing  the  trephine  if  it  be 
♦See  the  instructive  article  by  Fowler,  in  .\nnals  of  Surgery,  Nov.,  1895, 


Prolapse  of  the  Brain  and  Hernia  of  the  Brain  815 

small.  If  the  bullet  has  emerged  and  has  been  picked  up,  examine  it  to  see  if 
it  is  entire.  The  bullet,  if  retained,  is  to  be  sought  for.  The  jc-rays  are  in- 
valuable in  locating  the  missile.  Place  the  head  in  such  a  position  that  the 
track  of  the  ball  will  be  vertical,  then  introduce  Fluhrer's  aluminum  probe  or 
Senn's  probe,  and  let  it  find  its  way  by  gravity.  The  probe  may  find  the  ball 
near  the  wound  of  entrance,  in  which  case  extract  the  ball  with  forceps;  or  the 
probe  may  find  the  ball  near  the  opposite  side  of  the  head,  in  which  case  make  a 
counter-opening  through  the  bone  at  a  point  the  probe  would  touch  if  it  were 
pushed  entirely  across.  Take  a  new  and  clean  rubber  catheter  (No.  g,  French) , 
insert  a  stylet,  and  carry  the  catheter  through  the  wound  (Keen).  Knowing 
the  depth  of  the  ball,  search  for  it  around  the  catheter-tube  as  an  axis,  and 
when  found,  extract  it.  After  extraction  drain  the  wound  by  means  of  a  tube. 
When  a  counter-opening  exists,  drain  through  and  through.  If  the  ball 
cannot  be  detected,  drain  by  a  tube  carried  to  the  depths  of  the  wound.  After 
dressing  always  place  the  head  in  a  position  favorable  to  drainage.  Fluhrer 
tells  us  that  when  a  counter-opening  fails  to  disclose  the  bullet,  use  the  new 
opening  as  a  doorway  through  which  to  search  for  the  ball.  He  believes  the 
bullet  is  not  unusually  deflected.  The  angle  of  deflection  is  somewhat  greater 
than  the  angle  of  incidence,  and  the  bullet  is  apt  to  fall  a  little  toward  the  base. 
Splinters  of  bone  are  often  driven  into  the  brain  by  a  bullet,  and  these  should 
be  removed  whether  the  ball  is  found  or  not.  Several  varieties  of  probes  have 
been  commended.     Fluhrer  uses  a  large-sized  aluminum  probe.     Senn  uses 


sss^l 


Fig.  460.— Senn's  bullet-probe. 


an  instrument  shaped  like  the  Nelaton  probe,  but  of  the  same  diameter  as  the 
bullet  (Fig.  460).  (Of  course,  the  porcelain  probe  will  not  show  a  black 
mark  from  contact  with  a  hard -jacketed  bullet.)  Fowler  uses  a  graduated 
pressure  probe;  so  long  as  the  pressure  is  within  the  limits  of  the  spring,  as 
shown  by  the  scale,  the  probe  is  in  the  bullet-track.  Girdner's  telephonic 
probe  is  a  valuable  aid  to  diagnosis.  Bullets  are  now  located  by  the  Rontgen 
rays.  There  can  be  no  doubt  that  many  gunshot-wounds  have  been  recovered 
from  without  operation,  and  it  is  beyond  question  that  many  deaths  follow 
operation  (about  2)Z\  per  cent.,  according  to  Hahn).  Von  Bergmann  is  so 
impressed  with  these  facts  that  he  does  not  operate  when  cerebral  symptoms 
are  absent. 

Prolapse  of  the  Brain  and  Hernia  of  the  Brain. — In  a  compound  frac- 
ture, especially  a  gunshot-fracture,  with  torn  dura  and  pia,  brain-matter  may 
emerge  from  the  wound.  In  fracture  of  the  base  brain-matter  may  enter  the 
orbit,  the  nose,  or  the  ear.  A  flow  of  brain-matter  may  continue  from  a 
wound  for  many  hours.  A  week  or  more  after  an  injury  a  portion  of  the 
brain  may  protrude  or  prolapse.  To  this  condition  the  term  prolapse  should 
be  applied.  In  many  instances  the  protrusion  is  covered  with  pia,  but  if  the 
pia  were  torn  or  cut,  it  will  not  be  a  covering.  This  protrusion  emerges  from 
the  opening  in  the  skull,  mounts  up,  growing  larger  and  larger,  until  it  may 


8i6 


Diseases  and  Injuries  of  the  Head 


Fig.  461. — Hernia  cerebri  under  scalp  after  operation 
for  brain  tumor  (W.  W.  Keen). 


become  the  size  of  a  fist.     It  usually  pulsates.     When  bare  it  is  soft,  lobu- 
lated,  of  a  dirty  white  color,  pulsating,  painless  to  the  touch,  often  bleeding, 

and  sometimes  discharging  cere- 
brospinal fluid.  Death  may  soon 
follow  such  protrusion,  but  the  pro- 
truding mass  may  become  necrotic 
and  be  sloughed  off,  a  granulating 
surface  remaining,  which  heals. 
Hernia  cerebri  (Fig.  461)  some- 
times follows  operations  upon  the 
brain  or  injuries  of 'the  skull  and 
dura,  when  large  pieces  of  bone 
have  been  removed  or  when  the 
dura  has  been  widely  cut  or  torn 
and  has  not  been  carefully  sutured. 
The  condition  is  due  to  increased 
cerebral  pressure.  Hernia  of  the 
brain  is  protrusion  through  the 
dura  but  not  through  the  scalp, 
the  scalp  wound  being  healed 
above  the  protrusion.  In  a  de- 
compression operation  we  deliber- 
ately create  a  hernia  of  the  brain. 
Prolapse  of  the  brain  is  treated 
by  antiseptic  dressings  and  perhaps  by  craniotomy  to  relieve  pressure. 
Skin-grafting  benefits  some  cases.  Pressure  is  dangerous.  Excision  by 
the  knife  or  cautery  seldom  does  any  good.  Hernia  in  some  cases  can 
be  treated  by  repeated  lumbar  punctures,  in  some  others  by  craniotomy 
of  the  opposite  side  of 
the  skull. 

Fungus  Cerebri 
(Fig.  462).- — When  the 
brain  is  exposed,  a  gran- 
uloma may  grow  from 
the  neuroglia  and  fungate 
through  the  skull.  This 
condition  is  fungus  cere- 
bri and  is  not  composed 
of  brain-matter.  It  is 
due  to  infection  of  the 
brain,  and  is  most  fre- 
quent when  a  bit  of  bone 
or  some  other  foreign 
body  is  retained.  A  fun- 
gus is  soft  to  the  touch,  is 
livid  in  hue,  bleeds  easily, 
frequently  contains  multiple  foci  of  suppuration,  and  pulsates.  It  often  attains 
the  size  of  a  small  orange.  It  is  treated  by  removing  the  granulations  and  any 
foreign  body,  and  applying,  with  moderate  pressure,  aseptic  dressing  soaked  in 
alcohol.     After  healing,  a  depression  marks  the  site  of  the  fungus. 


Fig.  462. — Fungus  cerebri  (W.  W.  Keen). 


Acute  Leptomeningitis  gi^ 

Traumatic  inflammation  of  the  brain  and  its  membranes  is 

divided  into  encephalitis  or  cerebritis,  inflammation  of  the  cerebrum;  cere- 
belliiis,  inflammation  of  the  cerebeUum;  meningitis,  inflammation  of  the 
meninges;  arachnitis,  inflammation  of  the  arachnoid;  pachymeningitis, 
inflammation  of  the  dura;  and  leptomeningitis,  inflammation  of  the  arachnoid 
and  pia. 

Pachymeningitis  Externa.— Inflammation  of  the  external  layer  of  the 
dura  is  called  pachymeningitis  externa.  It  may  arise  from  tumor,  caries, 
necrosis,  middle-ear  disease,  sunstroke,  or  traumatism.  Syphilis  is  a  not 
unusual  cause.  The  other  membranes  may  become  involved.  Suppuration 
may  arise,  having  extended  by  contiguity  from  neighboring  parts.  The 
symptoms  of  pachymeningitis  externa  are  uncertain.  They  resemble  often 
those  of  leptomeningitis  (page  8i8).  Pressure-symptoms  may  arise.  Head- 
ache is  always  present.  Paralysis  may  or  may  not  exist.  If  pus  forms,  the 
ordinary  constitutional  symptoms  of  suppuration  are  evident  (high  temper- 
ature and  sweats),  not  the  symptoms  of  abscess  in  the  brain.  In  a  severe  case 
the  other  membranes  become  involved. 

The  treatment  consists  in  removing  the  cause  (carious  bone,  pus,  middle- 
ear  disease).  In  pachymeningitis  from  traumatism  it  is  sometimes  advisable 
to  trephine  in  order  to  drain  inflammatory  products;  in  a  case  with  localizing 
symptoms  always  trephine;  in  an  ordinary  case,  without  pus  and  with  no 
evidences  of  traumatism,  use  wet  cups  back  of  the  mastoid  processes,  apply  an 
ice-bag  to  the  head,  and  purge  by  means  of  calomel.  Administer  iodid  of 
potassium  in  most  cases.  If  sunstroke  is  the  cause,  treat  according  to  ordi- 
nary medical  rules. 

Pachymeningitis  Interna. — This  term  means  inflammation  of  the 
inner  layer  of  the  dura.  Inflammation  may  extend  from  the  pia,  or  from  the 
outer  layer  of  the  dura.  The  disease  is  most  often  met  with  in  infants  and 
in  the  chronic  insane,  but  may  occur  in  those  not  insane  in  late  middle  age  or 
beginning  old  age.  The  form  known  as  hematoma  6f  the  dura  mater,  or 
pachymeningitis  interna  hfcmorrhagica,  may  arise  during  infectious  disease 
(typhoid  fever  and  rheumatism),  in  persons  of  the  hemorrhagic  diathesis,  in 
diseases  causing  atrophy  of  the  brain,  in  chronic  diseases  of  the  heart  and 
kidneys,  and  in  syphilitics.  Among  the  exciting  causes  are  traumatism,  in- 
flammation in  adjacent  parts,  and,  especially,  the  abuse  of  alcohol.  In  this 
disease  blood  is  extra vasated  on  the  inner  surface  of  the  dura.  Many  ob- 
servers do  not  class  hemorrhagic  pachymeningitis  as  inflammation,  but  regard 
the  hemorrhage  as  primary. 

The  symptoms  of  internal  pachymeningitis  are  very  chronic,  come  on 
gradually,  are  not  characteristic,  and  may  be  absent.  They  consist  usually  of 
mental  irritability  or  excitement,  followed  perhaps  by  hebetude  and  persistent 
headache;  and  apoplectiform  attacks,  with  contraction  of  the  pupil,  slow 
pulse,  and  vomiting;  there  may  also  be  muscular  rigidity  and  spasm  of  the  ex- 
tremities. Choked  disc  is  not  infrequent;  localizing  symptoms  may  be  made 
out,  and  coma  is  apt  to  arise.     Cranial  nerves  are  seldom  affected. 

The  treatment  is  operation.  This  is  unpromising,  but  Munro  saved 
I  case  out  of  5  ("Chicago  Med.  Recorder,"  Dec,  1902). 

Acute  leptomeningitis  is  a  purulent  inflammation  of  the  soft  mem- 
branes of  the  brain.     The  pathological  changes  can  be  noted  in  the  pia  and  in 

52 


8i8  Diseases  and  Injuries  of  the  Head 

the  brain-substance.  The  brain  is  edematous,  the  pia  purulent,  the  convolu- 
tions are  flattened,  the  ventricles  are  distended  with  fluid,  and  hemorrhages 
occur  into  the  brain-substance.  Pus  may  be  localized  upon  the  pia,  but  it  is 
usually  difl'used  over  one  hemisphere  or  over  both.  Various  organisms  may 
be  found,  especially  streptococci,  staphylococci,  and  diplococci.  In  some 
cases  we  find  the  bacillus  pyocyaneus  or  the  bacillus  pyoc}'aneus  foetidus, 
which  is  identical  with  the  colon  bacillus  and  with  the  bacillus  meningitis 
purulenta  (Park).  Saprophytic  organisms  are  occasionally  present.  This 
disease  may  be  acute  or  chronic,  and  a  severe  case  is  spoken  of  as  encephalitis. 
Secondary  leptomeningitis  is  apt  to  affect  the  convexity;  primary  lepto?nen- 
ingitis  is  apt  to  aft"ect  the  base. 

The  causes  of  leptomeningitis  are  epidemic  cerebrospinal  fever,  tuber- 
culosis, acute  general  disease  (pneumonia,  typhoid,  erj-sipelas,  and  rheu- 
matism), bone-diseases,  traumatisms,  middle-ear  disease,  syphilis,  and  sun- 
stroke. The  tissues  of  the  pia  and  the  cerebrospinal  fluid  contain  diplococci 
identical  with  pneumococci.  Infection  may  take  place  by  various  avenues. 
It  may  pass  from  the  nose  by  way  of  the  Eustachian  tube  to  the  ear,  or  from 
the  nose  to  the  frontal  sinus  or  ethmoid  sinuses  (Hirt),  and  from  these  situations 
to  the  brain.  It  may  pass  from  the  middle  ear  or  mastoid  to  the  membranes 
of  the  brain.  In  fractures  at  the  base  the  organisms  enter  by  way  of  the  phar>Tix 
and  the  Eustachian  tube,  or  the  ear.  The  symptoms  of  acute  leptomenin- 
gitis are  violent  headache  persisting  during  delirium,  flushing  of  the  face, 
rigidity  of  the  neck,  cerebral  vomiting,  a  slow  pulse,  elevated  temperature, 
photophobia,  contraction  of  the  pupils,  intolerance  of  sound,  hyperesthesia 
of  the  skin  and  muscles,  and  delirium  passing  into  stupor  and  coma.  A 
chill  or  a  succession  of  chills  may  occur.  Choked  disc,  strabismus,  and 
nystagmus  are  not  unusual.  Convulsions  or  paralyses  may  occiu-.  Death 
is  the  rule  within  one  week.  The  treatment  usually  consists  of  the  administra- 
tion of  urotropin  (this  drug  rapidly  enters  the  cerebrospinal  fluid,  see  page  8ii); 
purgation  wnth  calomel;  cold  to  the  head;  warm  baths  with  cold  affusions  to  the 
head;  iodid  of  potassium,  bromid  of  potassium,  or  morphin  for  vomiting  and 
headache.  Lumbar  puncture  is  usually  performed,  but  for  diagnostic  rather 
than  therapeutic  reasons.  A  patient  in  this  condition  should  be  trephined  in 
order  to  reheve  pressure  and  to  give  exit  to  inflammator}'  products.  It  gives 
some  hope  of  recovery,  and  the  usually  adopted  medical  treatment  is  practically 
useless.  After  trephining,  the  administration  of  urotropin  should  be  continued. 
Should  the  patient  recover,  he  must  be  guarded  for  a  long  time  from  physical 
exertion,  mental  excitement,  worry,  irritation,  constipation,  and  insomnia. 

Chronic  Leptomeningitis  (or  Chronic  Emephalitis). — The  causes  of 
chronic  leptomeningitis  are  the  same  as  those  of  the  acute  form.  If  trauma- 
tism is  the  cause,  the  inflammation  arises  at  a  later  period  than  it  would  in 
acute  encephalitis.  The  symptoms  of  concussion  foflow  a  head-injury. 
Days,  or  even  weeks,  after  the  accident,  a  series  of  symptoms  occur — namely: 
localized  pain  at  the  seat  of  injury,  often  accentuated  by  tapping;  listlessness ; 
irritability;  apathy  regarding  business  aft'airs  and  home  obhgations,  or  pro- 
found depression  and  hypochondria  with  inability  to  attend  to  business. 
Choked  disc  may  exist.  In  any  case  acute  encephalitis  may  arise,  with  or 
without  a  chiU.  The  treatment  of  this  disease  is  symptomatic  unless  local 
symptoms  exist.  Always  operate  if  localizing  symptoms  are  found.  Intense 
local  pain  justifies  trephining. 


Abscess  of  the  Brain  819 

Tuberculous  Meningitis  (Acute  Hydrocephalus ;  Water  on  the 
Brain). — This  inflammatory  condition  is  due  to  the  bacilH  of  tuberculosis. 
In  a  child  affected  with  tuberculous  meningitis  there  is  often  a  record  of  a 
fall,  the  injury  acting  as  an  exciting  cause  by  establishing  an  area  of  least 
resistance.  Prodromal  symptoms  are  common  (restlessness,  irritability, 
anorexia,  change  of  character).  The  disease  begins  with  a  convulsion  or 
with  headache,  fever,  and  vomiting,  the  child  cries  out  from  pain  (the  hydren- 
cephalic  cry),  and  the  bowels  are  constipated.  The  pulse  is  rapid  in  the 
beginning,  but  later  becomes  slow  and  irregular.  The  pupils  are  contracted, 
there  is  muscular  twitching,  and  the  sleep  is  impaired.  The  temperature 
is  about  103°.  In  the  second  period  of  the  disease  the  vomiting  ceases, 
constipation  becomes  more  marked,  the  belly  retracts,  headache  is  not  so 
violent,  and  the  patient  hes  in  a  soporose  condition  interspersed  with  episodes 
of  delirium.  In  this  stage  the  pupils  dilate  and  are  often  unequal,  the  head 
is  retracted,  convulsions  occur  or  limited  rigidity  is  noted,  the  respirations 
are  sighing,  and  if  a  finger-nail  is  drawn  along  the  skin,  a  red  line  develops 
(the  tdche  cerehrale,  due  to  vasomotor  paresis).  Squint  and  consequent 
double  vision  are  usual.  In  the  last  stage  coma  becomes  absolute  and  general 
convulsions  or  hmited  spasms  are  apt  to  occur.  Optic  neuritis  exists,  and 
the  child  passes  to  death  along  a  road  identical  with  that  of  typhoid  collapse. 
In  some  cases  the  examination  of  cerebrospinal  fluid  withdrawn  by  lumbar 
puncture  throws  light  upon  the  diagnosis.  In  children  the  base  of  the  brain 
is  usually  involved,  and  the  disease  is  apt  to  last  from  two  to  four  weeks;  in 
adults  the  convexity  is  usually  involved,  and  death  is  apt  .to  occur  in  a  few 
days. 

The  treatment  is  like  that  for  traumatic  meningitis.  Operation  seldom 
offers  any  chance  of  improvement,  and  never  does  unless  the  process  is  limited 
in  area  and  confined  to  the  convexity.  Lumbar  puncture  is  usually  per- 
formed but  for  diagnostic  rather  than  for  therapeutic  reasons. 

Abscess  of  the  brain  is  a  localized  collection  of  pus.  The  organisms 
found  are  noted  upon  page  818  (Acute  Leptomeningitis).  The  causes  are 
suppurative  otitis  media  (in  half  of  all  the  cases),  fracture  of  the  skull,  osteo- 
myehtis  of  the  cranial  bones,  abscess  of  the  lung,  gangrene  of  the  lung,  empy- 
ema, and  concussion  or  wound  of  the  brain,  and  general  diseases.  As  Ballance 
points  out,  abscess  of  the  brain  complicating  head  injury  is  not  really  an  abscess 
of  the  brain  unless  the  wounding  material  entered  into  the  brain  substance. 
In  most  cases  the  abscess  is  "a  local  meningeal  suppuration  with  participa- 
tion of  the  adjacent  brain  cortex,  a  meningocortical  abscess  rather  than  a 
brain  abscess  proper"  ("Some  Points  in  the  Surgery  of  the  Brain,"  by  Chas. 
A.  Ballance).  General  infections  may  cause  abscess  (pyemia,  tuberculosis, 
and  specific  fevers) .  A  tuberculous  mass  may  caseate  (tuberculous  abscess) . 
The  abscess  may  be  betw^een  the  dura  and  skull  (extradural),  adhesions  form- 
ing and  preventing  a  general  leptomeningitis,  between  the  dura  and  brain 
(subdural),  or  in  the  brain-substance  (cerebral  or  cerebellar).  Leptomenin- 
gitis may  arise  because  no  adhesions  are  created,  because  septic  clots  form  in 
veins  or  sinuses,  or  because  infected  blood  regurgitates  into  the  sinuses  (Park) . 
A  traumatic  abscess  is  generally  beneath  the  area  to  which  the  traumatism  was 
appUed,  but  it  may  be  on  the  opposite  side.  Source  of  infection  may  be  the 
nose,  the  orbit,  or  the  middle  ear  (page  820).  Roswell  Park  says  infection 
may  pass  along  blood-vessels,  lymph-vessels,  nerve-sheaths,  or  the  prolonga- 


820  Diseases  and  Injuries  of  the  Head 

tions  of  the  membranes  which  extend  outside  of  the  skull.  An  acute  inflam- 
mation of  the  middle  ear  rarely  causes  abscess,  because  an  acute  inflamma- 
tion in  sound  tissue  causes  the  formation  of  granulation  tissue,  which  acts  as 
a  barrier  to  infection.  Chronic  inflammadon  of  the  middle  ear  is  the  most  fre- 
quent cause  of  abscess.  Park  tells  us  that  if  the  roof  of  the  tympanum  is 
involved,  it  may  perforate  and  abscess  of  the  middle  fossa  may  form;  if  the 
tympanum  is  perforated  toward  the  mastoid  antrum,  the  abscess  arises  in  the 
temporosphenoidal  lobe;  if  the  perforation  is  toward  the  sigmoid  groove,  the 
abscess  forms  in  the  cerebellum.* 

Chronic  bone  disease  is  seldom  followed  by  spreading  meningitis,  often  by 
abscess.  When  infection  reaches  the  brain  by  direct  extension  from  a  sup- 
purating bone  it  must  pass  through  the  membranes,  but  it  is  usually  Umited 
by  adhesions.  The  cortex  is  very  vascular,  and  strongly  resists  infection  and 
is  seldom  extensively  destroyed,  but  the  white  matter  is  far  less  resistant  and 
abscess  tends  to  form  in  it  (Ballance,  Ibid.).  In  some  cases  of  abscess  of  the 
temporal  lobe  following  ear  disease  the  cortex  seems  normal,  in  others  the 
membranes  and  cortex  are  fused  over  a  narrow  area  which  constitutes  the 
stalk  of  an  abscess  in  the  white  substance  of  the  lobe.  This  is  the  "mush- 
room abscess  "  of  Ballance.  An  abscess  may  increase  rapidly  in  size  and  finally 
break  into  a  ventricle  or  through  the  cortex.  It  may  become  encapsuled  and 
latent.  A  slow-growing  abscess  may  push  aside  nerve-fibers  as  does  an  en- 
capsulated tumor,  but  a  rapidly  growing  abscess  destroys  them. 

In  the  cerebrum  multiple  abscesses,  except  in  cases  of  general  infection,  are 
seldom  seen.  In  .the  cerebellum  they  are  not  uncommon.  One  or  several 
abscesses  may  arise  from  a  primary  one.  If  they  are  adjacent  to  the  primary 
one  they  are  called  satellite  abscesses  and  tend  to  break  into  the  older  purulent 
area. 

Ballance,  in  considering  the  onset  of  abscess,  adopts  the  views  as  to  the  five 
types  set  forth  by  Brissaud  and  Souques.  These  types  are  as  follows  ("Some 
Points  on  the  Surgery  of  the  Brain,"  by  Chas.  H.  Ballance) : 

(i)  A  subacute  evolution.  In  this  there  is  a  febrile  onset,  hke  the  onset  of  a 
specific  fever,  with  headache,  vomiting,  and  elevated  temperature.  After  a  few 
days  there  comes  a  remission,  the  period  of  delusive  calm.  In  this  period 
symptoms  are  absent  or  trivial.  Though  there  may  be  progressive  emaciadon, 
there  is  no  elevation  of  temperature  in  this  period. 

Suddenly  convulsions  occur  which  are  followed  by  coma,  or  coma  arises 
without  antecedent  convulsions.  The  padent  may  die  in  coma  or  the  coma 
may  pass  away,  "  the  symptoms  indicating  a  local  brain  lesion"  (Ballance., 
Ibid.).     In  this  stage  elevated  temperature  may  appear  again. 

(2)  Evoludon  with  violent  general  infection,  the  symptoms  of  abscess 
being  merged  and  usually  lost  in  the  symptoms  of  general  infection. 

(3)  Evolution  with  complete  latency.  The  patient  presents  no  symptoms 
until  a  few  hours  before  death  or  he  may  die  suddenly  without  a  symptom 
having  been  observed.  In  this  connection  Ballance  speaks  of  the  difference 
between  "symptoms  not  noticed  and  symptoms  not  present"  (Ibid.). 

(4)  Only  when  symptoms  were  not  present  does  he  use  the  term  "com- 
plete latency"  to  indicate  the  condition.  Ransohofif  has  reported  the  case  of 
a  boy  in  whom  an  abscess  in  the  frontal  lobe  was  latent  for  three  years  and  an- 
other case  in  a  man  due  to  gunshot  injury,  which  was  latent  for  four  and  a  half 

*  Park,  in  Chicago  Med.  Record,  Feb.,  1S95. 


Treatment  of  Abscess  of  the  Brain  821 

years  and  in  which  nearly  ten  years  elapsed  between  the  injury  and  death 
("Annals  of  Surgery,"  July,  1909). 

(5)  Onset  not  to  be  disdnguished  from  a  brain  tumor. 

(6)  Onset  with  headache  and  fever,  or  with  mental  excitement.  Then 
the  ])atient  appears  to  get  completely  well  and  remains  so  for  weeks,  for  months, 
or  for  a  year,  or  more.  This  condition  may  occur  in  abscess  secondary  to  in- 
fluenza (Ibid.). 

Symptoms  of  Abscess  of  the  Cerebral  Substance  or  of  the  Cerebel- 
lum.— The  symptoms  due  to  pus-formation  are  as  follows:  There  is  an 
initial  rise  of  temperature,  but  (except  in  extradural  abscess)  the  tempera- 
ture may  quickly  become  normal  or  even  subnormal.  Subnormal  temperature 
is  not  nearly  so  com.mon  as  is  usually  supposed.  It  has  been  present  in 
about  one-half  of  the  cases  I  have  seen.  Toward  the  end  of  the  case  the 
temperature  may  rise  and  the  fever  becomes  linked  with  delirium.  Surface 
elevation  of  temperature  over  the  seat  of  the  abscess  is  occasionally  observed. 
A  chill  may  occur,  but  seldom  does.  Anorexia  and  vomiting  are  present. 
Urinary  chlorids  are  diminished  and  the  phosphates  are  increased  (Somer\'ille). 
Certain  symptoms  are  due  to  pressure:  Headache  begins  (which  at  first  is 
general,  then  local,  and  grows  worse  later  in  the  case,  and  exists  even  in  delir- 
ium; this  fact  distinguishes  it  from  the  headache  of  fever,  which  ceases  in 
delirium);  pulse  is  very  slow;  respiration  tends  to  the  Cheyne-Stokes  type; 
drowsiness  lapses  into  stupor  and  stupor  passes  into  coma;  paralysis  of  the 
sphincters  takes  place;  convulsions  are  common;  sensation  is  rarely  impaired; 
and  paralysis  of  the  basal  nerves  may  occur  (third  and  sixth  especially).  The 
pupil  on  the  same  side  as  the  abscess  is  sometimes  dilated  and  fixed.  Choked 
disc  is  not  invariably  found.  It  may  be  more  marked  on  the  same  side  as  the 
abscess.  LocaUzing  symptoms,  spasmodic  and  paralytic,  depend  upon  the 
center  which  is  irritated  or  destroyed.  In  cerebellar  abscess  there  are  vertigo, 
vomiting,  occipital  headache,  rigidity  of  the  post-cervical  muscles,  and  inco- 
ordination, but  choked  disk  may  be  present  or  absent. 

Meningitis  arises  soon  after  an  accident;  an  abscess,  more  than  a  week,  and 
often  many  weeks,  after  an  accident.  Meningitis  presents  high  temperature 
and  the  general  symptoms  before  outlined.  Mastoid  disease  may  occasion 
cerebral  symptoms  without  abscess,  or  it  may  cause  abscess.  In  sinus- 
thrombosis  there  is  septic  temperature,  the  veins  of  the  face  and  neck  are 
enlarged,  and  a  clot  can  usually  be  felt  in  the  jugular.  A  tumor  grows  slowly, 
usually  presents  almost  from  the  start  localizing  symptoms,  and  double  choked 
disc  is  frequently  present.     In  tumor  the  temperature  is  apt  to  be  normal. 

Treatment. — If  abscess  is  due  to  ear  disease  with  implication  of  the 
mastoid  cells,  at  once  open  and  clean  out  the  mastoid  (Fig.  476),  and 
after  this  proceed  to  trephine  the  skull  in  order  to  reach  the  abscess.  In  any 
case,  if  symptoms  of  abscess  exist,  trephine  the  skull  at  once.  If  localizing 
symptoms  are  present,  open  over  the  suspected  region.  If  localizing  symptoms 
are  not  present  and  the  cause  is  ear  disease,  trephine  at  Barker's  point  (Fig. 
476).  If  no  pus  is  found  between  the  bone  and  dura,  open  the  membrane. 
When  the  dura  is  opened,  if  the  abscess  is  subdural,  pus  will  be  evacuated; 
if  the  abscess  is  in  the  brain-substance,  the  brain  will  bulge  very  much  and  will 
not  be  seen  to  pulsate.  A  grooved  director  is  plunged  into  the  brain,  in  the 
direction  of  the  abscess,  for  two  or  two  and  a  half  inches  (Keen).  If  pus  is  not 
found,  withdraw  the  director  and  introduce  it  at  another  point.     WTien  pus 


822  Diseases  and  Injuries  of  the  Head 

is  discovered,  incise  the  brain  \\itli  a  knife,  enlarge  the  opening  by  inserting  a 
closed  pair  of  forceps  and  withdrawing  the  instrument  with  the  blades  open. 
Scrape  away  the  granulation  tissue  lining  the  abscess-cavity,  irrigate  with 
hot  salt  solution,  and  introduce  a  rubber  drainage-tube  and  suture  it  to  the 
scalp;  stitch  the  dura,  but  leave  an  ample  opening  for  the  tube;  bring  the  tube 
out  through  a  button-hole  in  the  scalp,  and  after  the  first  two  days  pull  the 
tube  out  a  little  every  day  and  cut  off  a  piece.  If  the  first  trephhiing  does  not 
find  pus,  trephine  again  at  another  point.  In  cerebellar  abscess  make  a  flap 
with  the  base  up,  and  trephine  or  gouge  away  the  bone  just  below  the  line  of 
the  lateral  sinus.     Puncture  the  brain  as  for  cerebral  abscess. 

Brain  Disease  from  Suppurative  Ear  Disease.— Chronic  disease 
of  the  middle  ear  is  apt  to  destroy  the  bone  between  the  tympanum  and 
the  middle  fossa  of  the  skull,  and  thus  produce  meningitis,  thrombosis  of 
the  petrosal  or  lateral  sinuses,  abscess  of  the  temporo-sphenoidal  lobe  or  of 
the  cerebellum,  or  extradural  abscess.  Chronic  otitis  media  also  induces 
inflammation  or  suppuration  of  the  mastoid  cells  (empyema  of  the  mastoid). 
Pus  in  the  mastoid  may  discliarge  itself  into  the  middle  ear,  and  from  this 
point  into  the  external  auditor}'  canal,  through  a  perforation  in  the  drum- 
membrane  (especially  in  acute  cases).  In  some  cases  the  pus  becomes  blocked 
up  within  the  mastoid  process.  Pus  in  the  mastoid  may  after  a  time  break 
into  the  cavity  of  the  cranium  or  into  the  lateral  sinus,  or  may  find  its  way 
externally  and  open  into  the  sheaths  of  muscles  arising  from  the  mastoid. 
It  not  unusually  opens  into  the  sheath  of  the  digastric  muscle  (Bezold's 
abscess).  These  facts  teach  the  surgeon  that  chronic  ear  disease  should 
never  be  neglected,  but  should,  if  possible,  receive  the  closest  attention  of 
the  specialist.  If  no  perforation  exists  in  the  drum,  the  surgeon  must  make 
one.  In  ordinary  cases  cleanliness  and  antisepsis  are  sufficient,  the  ear 
being  svringed  ever}'  day  with  a  warm  2  per  cent,  solution  of  common  salt. 
If  only  a  small  drum-perforation  exists,  10  drops  of  pure  alcohol  or  of  cor- 
rosive subhmate  solution  (i  :  5000)  are  dropped  into  the  ear  daily;  but  if 
a  large  drum-perforation  exists,  boric  acid  and  iodoform  (7  to  i)  are  insuffiated. 
Never  inject  alum.  A  strong  silver  solution  is  not  safe;  if  it  is  used,  wash 
the  ear  out  aftenvard  with  warm  salt  water.  If  granulations  or  polypi  exist, 
they  must  be  removed.  Some  cases  require  the  removal  of  the  drum-mem- 
brane and  the  ossicles  of  the  ear.  'Manx  cases  of  mastoid  necrosis  are  due 
to  tuberculosis.  If  headache,  vomiting,  and  mastoid  tenderness  exist,  open 
the  mastoid  (see  page  848),  in  order  to  prevent  abscess  of  the  brain.  In 
acute  otitis  media  it  is  ver}'  rarely  necessar}'  to  open  the  mastoid.  The  middle 
ear  is  on  a  lower  level  than  the  antrum  of  the  mastoid,  and  in  most  acute 
cases  both  the  middle  ear  and  mastoid  cells  drain  safely  through  a  drum-per- 
foration. Because  a  man  has  chronic  otitis  media  it  is  by  no  means  always 
necessary  to  trephine  the  mastoid.  In  many  cases  removal  of  the  ossicles  and 
drum- membrane  effects  a  cure.  In  chronic  otitis  media,  even  if  the  mastoid  is 
trephined,  the  ossicles  and  membrane  ought  to  be  removed. 

Cerebral  abscess  from  ear  disease  is  almost  always  in  the  temporo- 
sphenoidal  lobe,  but  may  arise  in  the  cerebellum.  The  symptoms  are  a 
transient  rise  of  temperature,  followed  in  many  cases  by  a  normal  or  subnormal 
temperature;  vomiting;  mastoid,  frontal,  and  temporal  pain.  The  mind  is 
dull,  and  stupor  arises  which  passes  into  coma;  the  bowels  are  constipated; 
choked  disc  may  be  present;  and  convulsions  or  spasms  or  paralyses  may  exist. 


Infective  Sinus-thrombosis  823 

Trephine  and  clean  out  the  mastoid,  and  asepticize  (see  Operations  upon  the 
Skull  and  Brain).  Also  trephine  at  Barker's  point,  one  and  one-fourth  inches 
behind,  and  the  same  distance  above,  the  middle  of  the  external  auditory  meatus, 
open  the  dura,  and  seek  for  pus.     If  pus  is  not  found,  open  the  cerebellum. 

Extradural  Abscess. — The  eye-symptoms  and  pain  are  the  same  in 
this  as  in  cerebral  or  subdural  abscess,  but  the  temperature  is  different, 
rising  to  103°  or  104°  F.  There  is  often  considerable  tenderness  above  and 
behind  the  mastoid.  In  extradural  abscess  following  disease  of  the  middle 
ear  trephine  and  clean  out  the  mastoid;  follow  up  a  bone-sinus  to  the  al)scess, 
rongeur  away  the  bone,  being  careful  to  avoid  injuring  the  lateral  sinus;  curet, 
irrigate,  and  drain. 

Infective  Sinus=thrombosis. — Any  sinus  may  be  attacked.  The 
disease  may  result  from  scarlet  fever,  smallpox,  diphtheria,  influenza,  typhoid, 
or  any  acute  suppuration.  In  erysipelas  of  the  scalp,  septic  clots  may  form 
in  the  veins  which  pass  through  the  bone  and  reach  the  longitudinal  sinus. 
Infective  thrombosis  of  the  superior  longitudinal  sinus  is  thus  produced. 

In  carbuncle  of  the  lip  and  orbital  suppuration  the  cavernous  sinus  may 
become  involved. 

In  caries  of  the  basilar  portion  of  the  occipital  bone  the  circular  sinus 
or  the  cavernous  sinus  may  suffer.  In  caries  of  the  petrous  portion  of  the 
temporal  bone,  and  in  suppuration  of  the  middle  ear  and  mastoid  process, 
infective  thrombosis  of  the  lateral  sinus  may  occur. 

In  any  case  the  symptoms  are  those  of  pyemia.  The  lateral  sinus  is 
the  one  most  frequently  attacked.  In  infective  thrombosis  of  the  lateral 
sinus  there  is  usually  a  history  of  an  old  discharge  from  the  ear. 

Infective  thrombosis  of  the  lateral  sinus  may  result  from  a  specific  fever, 
but  is  usually  due  to  chronic  suppuration  of  the  middle  ear  associated  in 
most  cases  with  carious  bone  and  pus  in  the  mastoid  process.  Thrombosis 
of  the  lateral  sinus  occasionally  follows  an  operation  upon  a  suppurating 
mastoid,  or  develops  in  an  individual  who  suffers  from  middle-ear  disease 
who  has  been  struck  upon  the  head,  who  has  had  the  ear  syringed  with  force, 
or  who  has  had  injected  a  corrosive  or  very  irritant  fluid.  Tuberculous 
bone  disease  is  an  occasional  cause. 

Symptoms. — In  most  cases  there  is  a  history  of  chronic  ear  disease. 
In  children  the  symptoms  are  more  acute  than  in  aduUs.  In  any  case  the 
symptoms  may  rapidly  become  violent.  In  some  cases  there  are  preliminary 
symptoms  of  extradural  abscess,  pus  being  lodged  in  the  groove  of  the  sinus. 
It  has  been  pointed  out  that  pus  in  the  jugular  foramen  may  make  pressure 
upon  the  pneumogastric,  spinal  accessory,  and  glossopharyngeal  nerves, 
producing  aphonia,  hoarseness,  dyspnea,  dysphagia,  and  slow  pulse  (Geo. 
F.  Cott  *).  Marked  headache  ushers  in  sinus-thrombosis.  The  pain  is  apt 
to  be  localized  about  the  ear  and  mastoid  process,  but  may  become  general. 
There  is  usually  tenderness  of  the  mastoid.  There  is  high  fever  from  the 
start,  but  when  the  clot  begins  to  soften  and  break  down,  hard  rigors  develop 
and  the  temperature  fluctuates  violently.  The  temperature  varies  each  day 
between  subnormal  and  106°  to  107°.  A  chill  may  occur  once  or  even  twice  a 
day,  and  it  lasts  from  ten  to  twenty  minutes.  The  pulse  is  soft  and  usually 
rapid.  The  patient  is  nauseated,  labors  under  vertigo,  is  very  restless, 
*  Am.  Med.,  April  19,   1902. 


824  Diseases  and  Injuries  of  the  Head 

is  sometimes  delirious,  may  become  dull  and  stupid,  and  the  muscles  of  the 
neck  are  stifif.  Tenderness  and  marked  edema  are  detected  over  the  mastoid, 
and  the  veins  of  the  neck  and  mastoid  region  may  be  enlarged.  When  the 
clot  extends  into  the  jugular  vein  there  is  pain  on  moving  the  head  and  on 
swallowing,  the  cervical  glands  are  swollen,  and  a  clot  may  be  felt  in  the  neck. 
Choked  disc  exists  in  about  half  of  all  cases.  There  is  often  a  profuse  discharge 
of  pus  from  the  ear,  but  in  some  cases  the  discharge  is  found  to  have  abated 
or  ceased.  Exophthalmos  and  swelling  of  the  eyelids  point  to  involvement 
of  the  cavernous  sinus  in  the  process.  In  early  cases  there  is  thrombosis  of 
the  lateral  sinus  alone,  or  of  the  lateral  sinus  and  jugular  vein.  The  internal 
jugular  vein  may  be  felt  as  a  cord  in  the  neck.  In  advanced  cases  other 
sinuses  become  involved  (superior  petrosal,  inferior  petrosal,  both  cavernous, 
the  lateral  sinus  of  the  opposite  side,  the  ophthalmic  veins,  and  the  torcular 
Herophili).  A  patient  with  sinus-thrombosis  is  in  great  danger  of  developing 
pulmonary  metastasis  and  septic  meningitis  (Jansen).  Septic  meningitis 
is  accompanied  by  abscess  about  the  sinus.  Infective  sinus-thrombosis  is  a 
very  fatal  disease  and  usually  runs  its  course  in  from  seven  to  ten  days,  but 
occasionally  lasts  for  weeks.  It  is  a  form  of  pyemia,  and  death  arises  from 
the  causes  which  have  been  referred  to  in  discussing  that  disease. 

Infective  thrombosis  of  the  cavernous  sinus  occurs  when  an  infected  clot 
comes  from  another  sinus,  from  disease  of  the  nasal  sinuses,  from  orbital 
infection,  or  from  a  pyogenic  process  of  the  face  or  lids.  It  causes  pain  and 
the  general  symptoms  of  pyemia  and  also  edema  of  the  lids,  chemosis,  and  an 
extreme  degree  of  exophthalmos.  Choked  disk  may  exist.  Vision  may  be 
normal  or  impaired.  The  condition  almost  invariably  spreads  to  the  other 
eye  along  the  circular  sinus. 

Infective  thrombosis  of  the  petrosal'  sinus  produces  pyemic  symptoms  but 
no  characteristic  signs. 

The  prognosis  largely  depends  upon  early  recognition.  The  surgeon 
should,  whenever  it  is  possible,  open  a  mastoid  before  sinus-thrombosis  arises, 
and  should  evacuate  an  abscess  about  the  sinus  before  a  clot  forms  in  the 
venous  channel,  or  at  least  before  that  clot  becomes  septic  (Jansen). 

Treatment. — In  1880  Zaufal  proposed  the  operation  now  practised, 
and  Horsley  first  did  it  in  1886.  (See  article  by  Geo.  F.  Cott,  in  "American 
Medicine,"  April  19,  1902.)  Infective  thrombosis  of  the  lateral  sinus  is 
treated  as  follows:  Open  and  clean  out  the  mastoid,  and  expose  the  sinus  by 
the  use  of  the  chisel  or  rongeur  (Fig.  476).  Follow  M.  Ballance's  advice  and 
expose  the  sinus  from  the  bulb  to  the  torcular.  The  jugular  vein  should 
now  be  exposed  at  the  level  of  the  cricoid  cartilage  and  ligated  below  any 
clot  which  may  exist.  This  is  done  to  prevent  propagation  of  an  infected 
clot  and  diffusion  of  sepsis.  Even  if  a  clot  does  not  exist  in  the  jugular,  the 
vein  should  be  tied  in  two  places  and  divided,  because  the  sinus  may  contain 
infected  clot  or  putrid  material  even  when  the  vein  as  yet  does  not.  Accord- 
ing to  Ballance,  the  portion  of  the  vein  above  the  point  at  which  it  was  divided 
should  be  extirpated.  Some  surgeons  after  ligating  the  jugular  do  not  excise 
it,  but  if  it  contains  or  comes  to  contain  a  septic  clot,  incise  the  vein  up  to 
the  base  of  the  skull  and  pack  the  wound.  After  attacking  the  vein  open  the 
sinus,  and  if  a  clot  is  found  to  exist,  cut  away  the  wall  of  the  sinus.  Introduce 
a  small  spoon  into  the  lumen  and  carry  it  toward  the  torcular  Herophili,  and 


Intracranial  Tumors  825 

scrape  away  the  clot  until  blood  flows.  Arrest  hemorrhage  by  plugging  a 
piece  of  iodoform  gauze  into  the  wound  and  toward  the  torcular.  Jansen 
opposes  removing  the  entire  clot  toward  the  jugular,  and  does  not  tie  the  jugu- 
lar, believing  that  to  do  so  increases  the  danger  of  thrombosis  of  the  inferior 
petrosal  and  cavernous  sinuses.  He  simply  removes  the  soft  clot,  but  does 
not  disturb  the  solid  clot  toward  the  heart.  Most  surgeons  differ  from  him. 
Surgeons  are  of  the  opinion  that  it  is  futile  to  do  any  operation  if  pulmonary 
metastasis  has  taken  place.  In  a  recent  case  of  the  author's  in  the  Jefferson 
Medical  College  Hospital  the  patient  recovered  after  operation  in  spite  of 
the  fact  that  endocarditis  had  developed. 

Until  recently  it  was  thought  that  the  lateral  sinus  was  the  only  sinus 
which  should  be  attacked  surgically,  but  in  one  case  Knapp,  of  New  York, 
requested  Hartley  to  remove  from  the  cavernous  sinus  a  clot  which  was 
causing  blindness  and  was  due  to  sarcoma.  The  operation  was  success- 
fully executed  by  Hartley,  the  incision  being  the  same  as  is  employed  to 
reach  a  Gasser^an  ganglion  in  the  Hartley  operation.  This  patient  lived 
several  months.  Dwight  operated  upon  another  case  by  incision  of  the  sinus 
(£.  W.  Dwight  and  H.  H.  Germain,  "Boston  Med.  and  Surg.  Jour.,"  May 
I,  1902).  Some  surgeons  advise  removal  of  the  eyeball  and  curetment  of 
the  sinus. 

Intracranial  Tumors. — An  encephalic  tumor  may  originate  within 
the  skull.  It  may  have  arisen  from  an  external  growth  invading  the  cranial 
cavity,  or  may  be  metastatic.  A  tumor  that  arises  within  the  cranium  may 
take  origin  from  the  periosteum,  from  one  of  the  membranes  of  the  brain, 
from  the  vessels,  from  the  neuroglia,  or  from  the  brain-substance. 

No  region  of  the  body  is  so  liable  to  tumors  as  the  brain.  During  the 
course  of  a  number  of  years  the  autopsies  of  the  Munich  Pathological  Insti- 
tute are  stated  by  Bollinger  to  have  shown  one  tumor  of  the  brain  in  every 
85  autopsies.  Hale  White's  experience  is  that  such  tumors  are  even  more 
common  than  this,  and  he  estimates  them  at  one  in  every  59  autopsies. 

In  endeavoring  to  determine  the  causes  of  intracranial  tumors  we  must 
accredit  heredity  with  considerable  influence  in  tuberculoma,  and  possibly 
with  some  force  in  sarcoma  and  carcinoma.  Tumors  of  the  brain  are  decidedly 
more  common  in  males  than  in  females,  probably  because  of  the  greater 
male  liability  to  injury,  syphilis,  and  alcoholism. 

The  majority  of  cases  of  tumor  of  the  brain  occur  between  the  ages  of 
twenty-five  and  fifty.  Children  are  particularly  prone  to  suffer  from  glioma 
and  from  tuberculous  growths.  In  aged  persons  a  tumor  of  the  brain  very 
rarely  develops.  In  100  cases  of  brain-tumor  collected  by  Hale  White 
only  2  were  aged  seventy  or  over.  In  100  cases  collected  by  Mills  and  Lloyd 
only  I  was  over  seventy. 

Injury  may  be  responsible  for  the  development  of  sarcoma,  of  fibroma, 
and  possibly  of  other  forms;  in  fact,  a  syphiloma  may  arise  in  a  syphilitic 
person  at  the  seat  of  an  injury. 

We  use  the  term  intracranial  or  encephalic  tumor  not  only  to  include 
true  neoplasms,  but  also  to  designate  growths  of  parasitic,  syphilitic,  or 
tuberculous  origin.  It  is  of  importance  to  attempt  to  make  a  diagnosis  as 
to  the  form  of  tumor  that  is  present,  and  this  may  be  possible  on  account 
of  the  fact  that  in  many  cases  the  form  affects  the  symptoms.     A  useful  class- 


826  Diseases  and  Injuries  of  the  Head 

ification  of  these  growths  has  been  made  by  Knapp,  and  is  as  follows:  (i) 
The  infective  granulomata,  including  tuberculous  growths,  gummata,  and 
actinomycotic  areas;  (2)  connective-tissue  growths;  (3)  epithelial  growths; 
(4)  aneurysms.  The  most  common  of  all  these  tumors  is  undoubtedly  that 
due  to  tubercle.  In  fact,  Gowers  estimates  that  if  we  exclude  syphiloma, 
tubercle  is  responsible  for  one-half  of  the  cases,  and  glioma  and  sarcoma 
together  for  one-third. 

Tuberculous  Tumors  {Tuberculous  Gummata;  Tuberculomata). — Tuber- 
culous tumors  are  the  most  common  form  met  with.  They  are  at  least 
four  times  as  common  in  children  as  in  adults.  They  may  be  single,  espe- 
cially in  adults,  but  are  often  multiple,  especially  in  children;  and  multiple 
growths  may  be  very  wide-spread.  According  to  Allan  Starr,  these  growths 
are  most  common  in  the  cerebral  axis  (especially  in  the  basal  ganglia), 
next  in  the  cerebellum,  next  in  the  cerebral  cortex,  and  are  least  common 
in  the  centrum  ovale.  A  tuberculous  tumor  usually  arises  in  the  pia  mater, 
particularly  in  an  arterial  distribution,  but  may  begin  in  a  ventricle,  or  even 
in  the  brain-substance.  Some  of  these  growths  are  distinctly  subcortical. 
The  tubercle  bacilli  responsible  for  the  condition  are  carried  by  the  blood. 
A  large  tuberculous  tumor  is  due  to  the  coalescence  of  many  foci.  It  under- 
goes caseation  in  the  center,  and  is  surrounded  by  a  zone  of  softened  or 
sclerotic  brain-substance.  Tuberculous  meningitis  is  present  in  two-thirds 
or  three-fourths  of  the  cases  of  tuljerculoma. 

Gummatous  Tumors  (Syphilomata). — We  find  a  single  gumma,  but, 
far  more  often,  syphihtic  growths  are  multiple.  Such  a  growth  may  be 
round,  or  may  be  irregular  in  outline;  in  fact,  the  outline  is  frequently  blurred 
and  indistinct.  Some  of  these  growths  are  soft,  and  some,  which  contain  a 
quantity  of  connective  tissue,  are  hard.  A  syphiloma  usually  arises  from  the 
membranes,  and,  hence,  is  generally  on  the  surface  of  the  brain;  and  the 
membranes  in  the  region  of  the  growth  usually  show  distinct  inflammation. 

Actinomycosis. — This  is  a  very  rare  condition,  in  which  the  mass  may 
remain  solid  like  a  tumor,  but  is  far  more  apt  to  break  down  into  an  actino- 
mycotic abscess. 

Sarcomata. — Injury  seems  to  play  a  considerable  part  in  the  production 
of  intracranial  sarcoma.  Any  variety  of  sarcoma  may  arise.  As  a  rule,  at 
least  in  the  beginning,  the  growth  is  single;  but  it  may  be  multiple,  or  may 
become  so.  The  majority  of  sarcomata  arise  from  the  membranes  or  from 
the  periosteum,  but  some  cases  take  origin  from  beneath  the  cortex.  Early 
in  their  progress  these  growths  may  be  encapsulated,  but  some  of  them,  from 
the  very  start,  are  infiltrating;  and  even  those  that  were  at  first  encapsulated 
later  infiltrate.  Endothelioma  is  sometimes  met  with.  What  is  called  an- 
gioma 0}  the  brain  is,  in  reality,  angiosarcoma.  A  psammoma  is  usually 
sarcomatous. 

Gliomata. — A  glioma  is  a  growth  so  ill  defined  and  so  shghtly  differen- 
tiated in  appearance  from  the  brain-substance  that  it  may  easily  be  over- 
looked in  an  exploratory  operation.  It  arises  much  more  frequently  from 
the  white  than  from  the  gray  matter,  and  develops  from  the  neuroglia  of 
the  cerebrum,  of  the  cerebellum,  of  the  pons,  or  of  the  medulla  oblongata. 
A  glioma  may  be  soft  or  may  be  hard;  and  soft  gliomata  are  probably,  in 
reality,  sarcomata.     Hemorrhage  is  very  apt  to  occur  in  these  growths. 


Symptoms  of  Intracranial  Tumors  827 

Fibromata. — Intracranial  fibroma  is  a  rare  growth.  It  is  of  firm  con- 
sistence, is  encapsulated,  and  may  grow  to  a  large  size.  Such  growths  can 
be  readily  enucleated.  Injury  seems  occasionally  to  be  responsible  for  their 
formation. 

Ostcomata. — Osteophytic  growths  not  uncommonly  take  origin  from  the 
inner  surface  of  the  skull,  but  the  osteomata  arising  in  the  dura  or  in  the 
brain-substance  are  rare.     Such  growths,  however,  occasionally  occur. 

Cholcsteatomata. — These  tumors  are  fibrous  growths  covered  with  endo- 
thelium and  containing  layers  of  cholesterin.  They  are  particularly  apt  to 
arise  in  the  pia  mater,  but  may  begin  in  either  of  the  other  membranes  or 
in  the  brain-substance.     A  cholesteatoma  is  commonly  called  a  pearl  tumor. 

Eiichondrotnata  and  true  neuromata  are  rare,  and  lipomata  are  exceedingly 
uncommon. 

Adenomata. — An  adenoma  occasionally  springs  from  the  conarium,  or 
the  pituitary  body. 

Carcinomata. — Primary  intracerebral  carcinoma  is  rare,  but  does  occur. 
Secondary  carcinoma  is  more  common,  and  may  follow  cancer  of  any  part 
of  the  body,  although  it  is  most  apt  to  follow  cancerous  growths  about  the 
face  and  neck.  A  primary  growth  may  begin  in  the  meninges  or  in  the 
lining  of  the  ventricle.  Intracerebral  carcinomata  may  be  single  or  multiple. 
They  are  soft  and  non-encapsulated  growths. 

Cysts. — Mills  says  that  cysts  arise  about  an  old  hemorrhage,  are  small 
retention-cysts  of  a  vascular  plexus,  or  are  porencephalic.  Dermoid  cysts 
are  extremely  rare. 

Sjrmptoms. — They  are  divided  into  two  sets:  (i)  General,  due  to  increase 
of  pressure,  and  (2)  local,  localizing,  or  special,  arising  because  of  the  part  of 
the  brain  involved. 

In  some  cases  general  symptoms  are  absent,  in  some  special  symptoms 
are  absent,  in  others  even  tumors  of  large  size  produce  no  recognizable 
symptoms,  either  general  or  special.  A  large  infiltrating  growth,  a  glioma,  for 
instance,  may  produce  no  symptoms  at  all  if  situated  in  a  silent  region,  and 
if  it  destroys  brain  substance  as  it  grows,  so  that  intracerebral  pressure  is  not 
increased. 

General  Symptoms. — The  chief  general  symptoms  are  headache,  vomiting, 
and  choked  disk.  All  of  these  may  be  present,  any  one  of  them  may  be  absent, 
any  two  of  them  may  be  absent,  and  in  some  cases  all  of  them  are  absent. 
Other  general  symptoms  that  may  or  may  not  be  present  are  vertigo,  general 
convulsions,   insomnia,   mental   failure,   and   somnolence  or  partial  stupor. 

Headache. — This  is  the  symptom  most  commonly  present.  It  occurs 
sooner  or  later  in  a  very  great  majority  of  cases. 

At  first  it  may  be  noted  only  at  certain  times  of  the  day  and  it  is  usually 
complained  of  most  on  rising  in  the  morning.  The  headache  of  brain  tumor 
when  once  established  is  intense  in  most  cases,  and  as  a  general  thing  it  is 
practically  continuous,  with  episodes  of  increased  violence.  In  rare  cases  it  is 
paroxysmal.  In  some  cases  it  is  trivial,  in  some  few  cases  it  never  arises  at 
all.  The  headache  of  brain  tumor  usually  interferes  with  sleep.-  It  may  be 
general,  one  sided,  frontal,  or  occipital.  The  situation  of  the  pain  is  without 
localizing  value  unless  there  is  tenderness  on  percussion  or  pressure  over  the 
seat  of  pain,  which  is  sometimies  noted  in  growths  of  the  meninges  or  cortex. 


828  Diseases  and  Injuries  of  the  Head 

Headache  is  less  common  in  children.  In  very  young  children  the  ex- 
planation of  this  is  found  in  the  open  fontanelles  and  the  expansile  cranium. 
In  older  children  in  the  fact  that  gliomata  are  common  in  children  and  gliomata 
may  not  cause  intracerebral  pressure. 

The  dura  is  sensitive,  as  Cushing  says  to  "pull  or  pressure,  not  to  an  inci- 
sion."    The  headache  of  brain  tumor  is  due  to  stretching  of  the  dura. 

Vomiting. — Vomidng  is  present  at  times  in  many  of  the  cases.  It  may 
happen  occasionally  or  it  may  never  occur. 

It  is  usually  cerebral,  that  is,  vomiting  with  a  clean  tongue  without  nausea, 
and  without  any  reladon  to  the  taking  of  food.  In  some  cases  it  is  projectile, 
quandties  of  vomitus  being  suddenly  projected  from  the  mouth.  It  may. 
however,  be  associated  with  nausea,  and  in  some  cases  there  is  nausea  without 
vomidng.  It  is  apt  to  be  most  severe  on  getting  up,  especially  on  rising  in 
the  morning.     It  is  apt  to  be  most  severe  when  headache  is  most  intense. 

The  worst  attacks  of  vomiting  occur  in  cases  of  cerebellar  tumor. 

The  cause  of  vomidng  is  uncertain.  Some  beheve  it  to  be  due  to  stimula- 
tion of  the  vagus  center,  others,  to  reflex  sdmulation  of  a  vomiting  center  in  the 
medulla.     If  associated  with  verdgo  it  may  arise  from  the  auditory  centers. 

Choked  Disk  {Optic  Neuritis,  Papillitis,  Descending  Neuritis,  Papillo- 
edema). — This  is  a  most  important  symptom.  When  present  it  is,  as  Cushing 
says,  one  of  the  "most  reliable"  signs  of  tumor.  It  is  present  in  80  per  cent, 
of  all  cases.  It  may  be  noted  in  a  few  weeks  after  a  tumor  begins  to  grow, 
in  a  few  months,  or  longer.     It  may  come  on  rapidly  or  gradually. 

It  is  particularly  common  and  severe  in  growths  beneath  the  tentorium.  It 
is  decidedly  less  common  in  tumors  of  the  motor  cortex.  It  is  nearly  always 
bilateral,  but  it  is  common  to  find  it  more  marked  in  one  eye  than  in  the  other. 
That  it  is  worse  on  one  side  suggests,  but  only  suggests,  that  the  tumor  may  be 
on  the  side  on  which  the  choked  disk  is  worst.  Monocular  choked  disk  is 
very  rare.  When  it  exists  it  indicates  that  the  growth,  in  all  Hkehhood,  is 
situated  near  the  back  of  the  orbit  on  the  same  side  as  the  choking  of  the  disk. 
Gowers  recently  recorded  a  case  of  unilateral  choked  disk  due  to  a  tumor 
compressing  the  left  optic  nerve  ("Lancet,"  July  10,  1909). 

Choked  disk  may  exist  for  some  dme  and  attain  a  high  grade  without 
nodceably  impairing  vision,  but  ultimately  it  leads  to  retinal  hemorrhage, 
white  atrophy,  and  blindness.  When  atrophy  begins  vision  wanes.  The 
presence  of  choked  disk  does  not  prove  the  existence  of  tumor.  The  cerebral 
edema  of  Bright's  disease  may  cause  a  condition  known  as  albuminuric  retinitis, 
which  practically  is  not  to  be  distinguished  from  the  choked  disk  caused  by 
tumor.  Cushing  believes  that  the  processes  are  identical  in  tumor  and  Bright's 
disease.  Choked  disk  may  occur  in  meningitis,  brain  abscess,  cerebral  syphilis, 
sinus  thrombosis,  myelitis,  infectious  diseases  (typhoid,  influenza,  diphtheria, 
and  other  conditions),  toxemias  from  lead,  arsenic,  and  alcohol,  anemia,  dia- 
betes, or  as  an  hereditary  or  family  disease. 

The  cause  of  choked  disk  has  been  much  disputed.  Some  believe  that  the 
condition  is  a  neuritis  due  to  a  toxic  condition  of  the  cerebrospinal  fluid. 
Others  believe  that  it  is  not  inflammatory,  but  is  a  papillo-edema  due  purely  to 
mechanical  pressure,  and  is  an  edema  or  dropsy.  The  latter  theory  is  largely 
held  by  surgeons  because  they  have  become  convinced  by  experience  that  rehef 
of  intracranial  pressure  relieves  or  cures  choked  disk.  De  Schweinitz  and 
Hollaway  ("Therapeutic  Gazette,"  July  15,  1909)  make  the  following  state- 


Diagnosis  of  Intracranial  Tumors  829 

ment  in  regard  to  mechanical  pressure  causing  choked  disk:  "That  this  is 
the  only  etiological  factor  may  with  propriety  be  disputed;  indeed,  it  seems  cer- 
tain that  a  combination  of  factors  must  be  active  in  the  production  of  this 
condition,  but  increased  intracranial  pressure  is  the  one  of  which  we  have 
most  certain  knowledge." 

Gushing,  of  Baltimore,  who  has  done  such  notable  work  on  this  subject, 
believes  that  "almost  all,  if  not  all  cases  of  choked  disk  are  primarily  of 
mechanical  origin  and  do  not  justify  the  term  neuritis"  ("Keen's  Surgery," 
vol.  iii).  The  presence  of  choked  disk  is  disclosed  by  the  ophthalmoscope. 
'  Convulsions. — Generalized  convulsions  may  occur  and  children  are  espec- 
ially liable  to  them.  Many  cases  of  supposed  general  convulsions  have  an 
unobserved  local  beginning  which  is  a  focal  symptom. 

Vertigo. — Mills  says  it  is  noted  in  one-third  of  all  cases  and  is  due  to  dural, 
ocular,  or  labyrinthine  irritation. 

Insomnia  is  often  due  to  headache  and  is  apt  to  be  associated  with  rest- 
lessness, lack  of  emotional  control,  and  irritability.  It  is  most  pronounced  in 
cases  of  syphiloma  and  some  forms  of  mahgnant  disease,  and  is  worse  in  adults 
than  in  children. 

In  rare  cases  there  is  somnolence  or  partial  stupor  rather  than  insomnia. 
In  such  cases  slow  speech  is  often  noted. 

Mental  Failure. — There  is  often  great  lack  of  emotional  control,  charac- 
terized by  irritability  and  outbreaks  of  anger.  Failure  of  memory  is  common 
and  change  of  character  is  the  rule.  There  may  be  great  slowness  of  thought 
and  of  mental  response  to  stimuli,  with  defective  power  of  orientation.  Pro- 
gressive mental  deterioration  may  occur.  There  may  be  mental  depression, 
apathy,  or  mental  excitement.  Tumors  in  certain  regions  may  cause  de- 
lusions, illusions,  or  hallucinations. 

Hysteria  and  neurasthenia  sometimes  arise. 

Pulse  and  Respiration. — Whereas  the  pulse  is  often  slow,  it  is  very  variable, 
and  I  agree  with  Gushing  that  "pressure  symptoms  which  characterize  acute 
lesions  (namely,  rise  in  blood-pressure;  slow,  vagus  pulse,  and  Gheyne-Stokes 
respiration)  are  conspicuous  by  their  absence"  ("Keen's  Surgery,"  vol.  iii). 

Special  Focal  or  Localizing  Symptoms. — These  symptoms,  when  present, 
indicate  the  situation  of  the  growth.  If  the  tumor  is  in  a  silent  region  there  will 
be  no  focal  symptoms.  General  symptoms  may  exist  without  focal  symptoms 
and  focal  symptoms  may  exist  without  general  symptoms. 

Among  localizing  symptoms  we  should  mention  various  forms  of  aphasia, 
hemianopsia,  paralysis,  Jacksonian  epilepsy,  sensory  disturbances  (to  touch, 
pain,  or  temperature),  sensory  aura,  disturbances  of  taste  and  smell,  impair- 
ment of  muscular  sense,  alteration  or  impairment  of  reflexes,  nystagmus,  and 
incoordination. 

Diagnosis. — In  abscess  the  symptoms  develop  much  more  acutely  than  in 
tumor.  It  is  true  that  some  cases  of  abscess  last  for  months,  but  in  them  inter- 
vals of  complete  remission  of  symptoms  occur,  which  is  not  the  case  in  tumor. 
An  abscess  follows  middle-ear  disease  or  some  other  pyogenic  process  or  per- 
haps a  head  injury.  There  may  be  fever  and  leukocytosis.  Ghoked  disk  is 
far  less  common  than  in  tumor. 

Chronic  meningitis  from  syphilis  exhibits  periods  of  increase  and  periods 
of  subsidence  of  the  symptoms,  and  usually  palsy  of  one  or  more  cranial  nerves. 
The  symptoms  may  pass  away  under  the  use  of  mercury  and  iodid  of  potassium. 


830  Diseases  and  Injuries  of  the  Head 

Examination  of  the  fluid  obtained  by  lumbar  puncture  may  make  the  diagnosis 
evident. 

In  Brighfs  disease  symptoms  strongly  suggesrive  of  tumor  may  arise 
(headache,  vomiting,  and  choked  disk)  \vith,  perhaps,  but  Httle  change  in  the 
urine.  The  difficulty  in  diagnosis  becomes  evident  when  we  recall  that  in 
cases  of  brain  tumor  the  urine  may  contain  casts  and  albumin. 

Epefidymitis  \Aith  ventricular  dropsy  may  cause  symptoms  resembling 
tumor  \vith  hydrocephalus. 

The  .v-rays  may  aid  us  in  diagnosis  and  many  brain  tumors  can  be  skia- 
graphed.  Lumbar  puncture  may  aid  in  the  diagnosis,  but  it  must  be  used  with 
the  greatest  care,  because  in  tumor  the  withdrawal  of  any  considerable  quantitv 
of  fluid  may  be  followed  by  sudden  death. 

Cause,  Duration,  and  Termination. — A  brain  tumor,  unless  caused  by 
syphihs,  is  a  certainly  fatal  legion  if  nut  removed  by  operation. 

Some  brain  tumors  grow  for  years  before  they  produce  symptoms.  Some 
grow  with  great  rapidity.  When  pressure  symptoms  appear  the  patient's  life 
will  terminate  in  a  few  months  unless  an  operation  is  performed.  It  is  usually 
stated  that  the  average  duration  of  life  is  three  years. 

Sudden  death  may  occur  at  any  time. 

Horsley  states  that  in  a  very  few  cases  brain  tumors  have  disappeared 
after  mere  operative  exposure,  the  tumor  not  having  been  removed.  Gushing 
has  had  the  same  experience,  and  regards  such  an  amazing  disappearance  as 
due  to  the  cystic  degeneration  of  a  ghoma. 

The  situation  of  a  tumor  is  determined  not  only  from  locahzing  symp- 
toms but  also  from  their  mode  of  onset  and  manner  of  combination.  In  some 
cases  the  symptoms  are  not  characteristic,  in  others  they  are  definite.  The 
more  marked  the  signs  of  compression,  the  less  the  value  of  locahzing  symp- 
toms. The  nature  of  the  tumor,  its  depth,  and  whether  it  is  single,  and  if 
other  tumors  exist  is,  if  possible,  determined.  Localizing  symptoms  may 
be  due  to  irritation  or  destruction  of  functionating  power.  Irritation  causes 
spasm,  and  destruction  induces  paralysis.  Convulsions  which  are  local 
or  which  begin  locally  are  known  as  Jacksonian  epilepsy.  A  local  convulsion 
points  to  an  irritative  lesion  of,  or  immediately  adjacent  to,  the  center  which 
presides  over  the  muscular  movements  of  the  part  convulsed.  Local  paral- 
ysis points  to  a  destructive  lesion  of  the  center  which  presides  over  the  move- 
ments of  the  paralyzed  part.  In  some  cases  a  center  is  damaged  and  the 
muscular  movements  it  controls  are  paralyzed,  but  the  adjacent  brain-areas 
are  irritated  and  the  muscles  they  represent  are  attacked  with  spasms.  In 
some  cases  an  apparently  paralyzed  part  becomes  convulsed,  the  center  not 
being  completely  destroyed  and  sudden  hv-peremia  serving  to  awaken  spasm. 
Always  note  the  order  of  invasion  of  different  regions  and  observ'e  if  spasm 
is  followed  by  muscular  weakness  or  anesthesia. 

I.  Lesions  in  the  Cortical  Motor  Area. — A  slow-growing  tumor  which 
irritates  the  cortex  will  cause  tonic  or  clonic  convulsions  on  the  opposite  side 
of  the  body.  These  convulsions  have  a  local  beginning  (Jacksonian  epilepsy) . 
After  a  time  paralysis  may  develop  (monoplegias  and  perhaps,  ultimatelv,  hemi- 
plegia). An  irritative  lesion  of  the  lower  third  of  this  area  causes  spasm  of  the 
opposite  side  of  the  face,  angle  of  mouth,  or  tongue;  and  this  condition  is  often 
associated  with  tingling.  The  spasm  may  remain  limited  or  may  extend  widely, 
and  may  even  become  general.     An  irritative  lesion  of  the  middle  third  of  the 


Tumors  of  the  Tcmporosphenoidal  Lobe  831 

cortical  area  causes  spasm,  which  is  limited  to  or  begins  in  the  lingers,  thumb, 
wrist,  or  shoulder.  An  irritative  lesion  of  the  upper  third  of  the  cortical  motor 
area  causes  spasm,  which  is  limited  to  or  begins  in  the  toes,  ankle,  leg,  or  hip. 
If  such  lesions  e.xist,  an  aura  is  occasionally  felt  in  the  affected  region  before  the 
spasm  begins,  and  there  is  often  numbness  after  the  spasm.  Destructive  lesions 
of  the  motor  area  cause  local  paralysis,  which  may  be  preceded  by  local  spasm 
of  the  same  parts,  and  is  often  associated  with  local  spasm  of  other  parts.  If 
paralysis  comes  on  unpreceded  by  convulsions  the  lesion  is  subcortical  rather 
than  cortical,  that  is,  it  is  in  the  white  matter  between  the  motor  area  and  the 
internal  capsule. 

2.  Tumors  of  the  anterosuperior  portion  of  the  prefontal  region 
give  no  definite  localizing  symptoms,  but  produce  general  symptoms.  Mental 
disorders  may  arise  in  tumors  of  any  area  of  the  brain,  but  in  tumors  of  the 
prefrontal  region  they  are  most  apt  to  occur.  The  intelligence  is  nearly 
always  impaired,  and  there  is  apt  to  be  mental  apathy,  loss  of  memory, 
irascibility,  and  pronounced  change  of  character.  As  the  tumor  grows  it 
may  subsequently  involve  the  motor  region,  which  in  all  probability  lies 
entirely  in  front  of  the  fissure  of  Rolando. 

In  tumors  of  the  prefrontal  region  there  may  be  focal  convulsions  or  local 
palsy  on  the  opposite  side,  due  either  to  a  spread  of  irritation  from  a  super- 
ficial tumor  to  the  motor  cortex  or  to  involvement  by  a  deep  tumor  of  the 
commissural  fibers  which  join  the  frontal  lobe  and  the  motor  cortex. 

3.  Tumors  of  the  Antero-inferior  Portion  of  the  Frontal  Lobe. — 
In  a  right-handed  man  tumor  of  the  second  left  frontal  convolution  causes 
agraphia,  and  of  the  third  left  frontal  convolution,  motor  aphasia.  In  a  left- 
handed  person  these  localizations  are  on  the  right  side  of  the  brain. 

4.  Tumors  of  the  parietal  lobe  may  occupy  a  silent  region  of  this  lobe. 
The  centers  for  general  sensibility  and  for  the  muscular  sense  are  back  of  the 
fissure  of  Rolando  in  the  parietal  lobes.  Hence  a  tumor  in  this  region  may 
cause  disturbance  of  muscular  sense  and  general  sensibility  in  the  limbs  with- 
out spasm  or  palsy  (Durante).  There  may  be  word-bhndness  when  the  left 
angular  gyrus  is  affected. 

The  extension  forward  of  a  parietal  tumor  will  involve  the  motor  zone  and 
produce  spasm  or  palsy.  Extension  backward  will  involve  the  occipital  lobe 
and  produce  hemianopsia. 

5.  Ttmiors  of  the  occipital  lobe  are  apt  to  produce  lateral  homonymous 
hemianopsia  (bUndness  of  the  nasal  half  of  one  retina  and  the  temporal  half 
of  the  other  retina.  If  the  right  side  of  the  brain  contains  the  lesion  the 
right  side  of  each  retina  is  bhnd,  and  vice  versa).  Lesions  of  the  cuneus  and 
of  the  calcarine  fissure  are  especially  apt  to  produce  hemianopsia.  A  lesion 
of  the  occipital  cortex  may  produce  it.  Tumors  of  both  occipital  lobes  cause 
blindness.  In  tumor  of  an  occipital  lobe  color  vision  only  may  be  afifected 
(Gushing).  Tumor  of  the  optic  radiation  may  produce  hemianopsia  (that  is, 
growths  of  the  chiasm,  optic  nerve,  a  pulvinar  may,  but  it  is  not  certain  that 
a  growth  of  the  quadrigeminal  bodies  or  of  the  external  geniculate  body  can). 

6.  Tumors  of  the  temporosphenoidal  lobe  frequently  produce  no 
symptoms.  In  the  temporal  lobes  the  cortical  centers  for  hearing  are  placed, 
and  each  center  is  connected  with  both  auditory  nerves,  but  the  crossed  auditory 
bundle  is  larger  and  more  active  than  the  direct  (Francesco  Durante,  "Brit. 


832  Diseases  and  Injuries  of  the  Head 

Med.  Jour.,"  Dec.  13,  1902).  Tumors  in  the  left  lobe  are  particularly  apt 
to  cause  deafness  and  may  cause  word-deafness.  Tumors  at  the  apex  of  the 
lobe  may  cause  perversion  or  impairment  of  taste  and  smell. 

7.  Tumors  of  any  size  in  or  about  the  corpus  striatum  cause  hemi- 
plegia by  pressure  upon  the  internal  capsule.  Pressure  upon  the  optic  thala- 
mus produces  homonymous  hemianopsia  and  hemianesthesia.  Growths  near 
the  basal  ganglia  produce  intense  optic  neuritis  and  early  pressure  because  of 
distention  of  the  ventricles.  Tumors  of  the  corpora  quadrigemina  are  apt 
to  involve  the  crura,  and  later  the  third  nerve.  Ocular  symptoms  are  always 
present  (loss  of  pupillary  reflex  and  nystagmus) .  If  the  third  nerve  is  involved 
there  are  paralysis  of  the  motor  ocuh  area  on  the  side  of  the  lesion  (external 
strabismus,  dilated  pupil,  and  drop-Hd)  and  hemiplegia  of  the  opposite  side  of 
the  body  from  pressure  upon  the  crus.  This  condition  is  a  form  of  crossed 
paralysis. 

8.  Tumors  of  the  Pons. — Pontine  lesions  produce  symptoms  by  pressure 
upon  the  particular  nerves  which  come  from  this  region,  with  or  without 
the  evidences  of  pressure  upon  the  motor  path.  Forms  of  crossed  paralysis 
may  exist.  Lesions  in  the  lower  half  of  the  pons  may  effect  the  fifth,  sixth, 
and  seventh  nerves  on  the  side  of  the  lesion  and  the  limbs  on  the  opposite 
side.  The  auditory  nerve  may  be  involved  in  the  lesion.  In  crossed  paral- 
ysis the  face  on  the  side  of  the  limb  paralyzed  is  usually  not  affected,  but  in 
extensive  tumors  it  may  be  paralyzed.  Conjugate  deviation  of  the  eyes  may 
occur  away  from  the  facial  paralysis.  In  tumors  of  the  upper  part  of  the  pons 
the  pupils  may  be  first  contracted  from  irritation  of  the  third  nerve  nuclei, 
and  later  dilated  from  destruction  of  these  nuclei.  Anesthesia  as  a  result 
of  pontine  tumors  is  not  nearly  so  common  as  is  motor  paralysis,  and  convul- 
sions are  rare. 

9.  Tumors  of  the  Medulla. — An  extensive  lesion  inevitably  causes 
death.  Cranial  nerves  only  may  be  involved,  but  crossed  paralysis  may  take 
place.  Vomidng  is  common,  retraction  of  the  head  is  not  unusual;  respira- 
tory and  circulatory  disturbances  and  dysphagia  are  frequently  noted;  some- 
times there  is  numbness  and  occasionally  there  are  convulsions;  usually 
there  is  incoordination,  because  of  pressure  upon  the  cerebellum. 

10.  Tiunors  of  the  Cerebellima. — In  general  it  may  be  said  that  tumors 
of  the  cerebellum  cause  headache,  vomiting,  vertigo,  choked  disk,  and  early 
blindness.  Tumors  of  the  middle  peduncle  cause  sudden  uncontrolable 
movements  of  the  trunk,  either  toward  the  side  of  the  tumor  or  away  from 
it.  Vertigo  and  nystagmus  are  common.  Symptoms  are  frequently  com- 
plicated by  evidences  of  pontine  disease  proper. 

Tumors  of  the  middle  lobe  of  the  cerebellum  cause  a  sense  of  lost  equi- 
librium and  obvious  unsteadiness  in  attempting  to  walk  or  even  to  stand. 
The  patient  has  a  tendency  to  fall;  there  are  giddiness  and  vomiting. 

Tumors  of  the  cerebellar  hemisphere  produce  no  localizing  symptoms. 
The  usual  unsteadiness  of  gait  is  due  to  pressure  upon  the  middle  lobe  (Noth- 
nagel) . 

11.  Tumors  of  the  Hypophysis  Cerebri.— The  pituitary  body  may  be 
subjected  to  pressure  from,  or  become  involved  in,  tumors  of  the  region  about  it 
or  tumors  or  cysts  may  spring  from  it  directly.  Tumors  of  or  tumors  making 
pressure  upon  the  hypophysis  may  in  some  cases  cause  acromegaly,  and  m 


Treatment  of  Intracranial  Tumors 


others  impotence,  genital  infantalism,  a  tendency  to  fat  deposit,  and  stunted 
stature.  There  is  intense  headache,  amblyopia  due  to  primary  atrophy  (no 
preceding  choked  disk),  appearing  often  as  a  bitem[K)ral  hemianopsia  (Cash- 
ing, "Jour.  American  Med.  Assoc."  July  24,  1909). 

Any  brain  tumor  which  causes  internal  hydrocephalus  may  thus  cause  {pres- 
sure on  the  hypophysis  and  lead  to  the  devel()[)ment  of  hypo[)hyseal  symptoms 
(Gushing)  .* 

Treatment. — If  any  doubt  exists  as  to  the  nature  of  a  brain  tumor, 
give  the  j)atient  a  course  of  iodid  of  potassium,  and  as  doubt  is  the  rule,  we 
almost  invariably  administer  it.  Give  the  drug  at  first  in  small  amounts,  but 
rapidly  increase  it  until  heroic  doses  are  taken  (100  or  more  grains  a  day). 
Mercury  should  also  be  given  hypodermatically  or  by  inunction.  If  iodid  of 
potassium  and  mercury  really  relieve  the  symptoms,  and  if  the  improvement 
is  not  merely  temporary,  operation 
is  unnecessary,  although  it  may  be 
demanded  later  in  order  to  remove 
an  irritant  scar.  If  antisyphilitic 
treatment  fails,  the  question  of  op- 
eration must  be  considered.  The 
test  of  success  is  improvement  in 
the  choked  disk.  If  this  improves, 
the  treatment  is  succeeding,  if  it 
does  not,  the  treatment  is  a  failure. 
It  should  not  be  persisted  in  over 
six  weeks  if  there  is  no  improve- 
ment in  the  eye  grounds.  To  de- 
lay operation  further  may  mean 
blindness.  We  must  always  bear 
in  mind  that  in  certain  cases  of 
glioma  the  symptoms  temporarily 
improve  under  antisyphihtic  treat- 
ment. The  term  operable  case  does 
not  of  necessity  mean  a  tumor  which 
can  be  entirely  removed  by  opera- 
tion. Some  tumors  which  can  be 
only  partially  removed  should  be 
operated  upon.  An  operable  case  is  one  in  which  an  attempt  may  be 
made  to  remove  the  tumor  and  in  which  the  tumor  can  be  entirely  re- 
moved or  in  which  a  part  can  be  removed,  the  removal  of  this  part 
promising  relief.  We  are  justified  in  being  radical  because  without  opera- 
tion a  brain  tumor  is  a  certainly  fatal  malady.  In  many  cases  of  un- 
doubted tumor  excision  for  cure  is  not  attempted  because  of  the  absence  of 
localizing  symptoms  or  because  of  the  inaccessible  situation  of  the  growth.  In 
all  cases  operation  is,  first  of  all,  exploratory.  Tumors  of  the  dura  which  have 
not  infiltrated  the  brain,  many  cortical  and  some  subcortical  growths,  are  oper- 
able.    Cerebral  cysts  if  accessible  should  be  opened  and  drained  in  hope  that 

*  For  full  consideration  of  localizing  symptoms  see  particularly  the  writings  of 
Gowers,  Mills,  Allan  Starr,  Dana,  Dercum,  Osier,  and  Gushing,  which  have  been  freely 
used  in  the  above  section. 

53 


Fig.  463. — Case  of  cerebellar  tumor.     Bulging  of 
flap  after  osteoplastic  exploratory  operation. 


834  Diseases  and  Injuries  of  the  Head 

benefit  will  result.  Some  subtentorial  tumors  can  be  removed.  In  certain 
cases  it  is  justifiable  to  attempt  the  removal  of  a  glioma  if  the  growth  is  in  an 
accessible  region.  Byrom  Bramwell  maintains  that  tumors  at  the  base,  tumors 
of  the  pons  and  medulla,  of  the  corpus  callosum,  of  the  basal  ganglia,  and  of 
the  deeper  parts  of  the  centrum  ovale  are  irremovable.  Most  tumors  at  the 
base  are  inoperable,  but  some  few  are  operable.  Surgeons  now  regard  some 
tumors  of  the  cerebello-pontine  angle  as  operable,  but  agree  with  Bramwell's 
views  as  to  growths  in  the  other  situations  he  mentions.  Frazier  has  con- 
cluded that  "  if  the  tumor  is  found  to  be  very  vascular  and  of  the  infiltrating 
type,  it  is  very  questionable  .  .  .  as  to  whether  any  attempt  whatsoever 
should  be  made  to  extirpate"  ("Univer.  of  Penn.  Med.  Bulletin,"  April-May, 
1906),  and  with  this  opinion  I  certainly  agree.  In  tumors  which  are  very 
extensive  complete  removal  is  usually  out  of  the  question.  There  is  no  use 
in  removing  secondary  malignant  tumors.  It  often  happens  that  the  brain 
itself  (as  in  syphilis)  is  so  extensively  diseased,  or  that  other  organs  (as  in 
tuberculosis)  are  so  involved,  as  to  render  attempts  at  removal  of  the  tumor 
futile  or  actual  removal  useless.  Mills  thinks  that  50  per  cent,  of  cerebellar 
tumors  can  be  attacked  surgically  ("New  York  and  Phila.  Med.  Jour.,"  Feb. 
11-18,  1905).  He  classifies  operable  tumors  of  the  cerebellum  as  follows: 
I.  Tumors  situated  entirely  or  chiefly  in  the  lateral  lobe.  2.  Tumors  upon  or 
even  invading  a  part  of  the  vermis  or  middle  lobe.  3.  Tumors  of  the  cerebello- 
oblongatopontile  angle.  Among  inoperable  tumors  are  most  gliomata  and 
infiltrating  sarcomata,  metastatic  tumors,  and  multiple  tumors.  Bramwell 
tells  us*  that  he  has  studied  eighty-two  cases  of  intracranial  tumor,  and  he 
considers  that  in  only  five  of  them  could  the  tumor  have  been  entirely  removed. 
In  157  reported  cases  the  tumor  was  either  not  found  or  not  removed;  in  104 
reported  cases  the  tumor  was  found,  and  in  some  of  them  it  was  removed 
(Ransohoff,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  11,  1902).  The  conclusion  is 
that  though  some  tumors  of  the  brain  may  be  successfully  removed,  extir- 
pation is  feasible  in  only  a  small  minority  of  cases  and  is  to  be  decided  on  only 
after  careful  study  of  all  the  indications  and  contraindications  offered  by 
the  case.  When  an  operation  is  decided  upon,  some  surgeons  apply  an  appa- 
ratus to  the  arm  and  the  blood-pressure  is  taken  just  before  the  operation  and 
at  frequent  intervals  during  it.  Thus  by  noting  a  great  fall  in  blood-pressure 
they  get  early  warning  of  dangerous  shock,  learn  when  to  hasten,  and  if  the 
operation  should  be  temporarily  abandoned  and  be  completed  at  another 
time  rtwo-stage  operation) .  We  may  be  driven  to  abandon  operation  after 
cutting  the  bone  and  dural  flaps,  and  if  we  are  forced  to  stop,  we  restore  the 
bone  and  dura  to  position,  and  complete  the  operation  after  a  day  or  two.  I 
agree  with  Frazier  that  the  lessening  of  hemorrhage  by  temporarily  clamping 
the  carotids  in  the  neck  is  not  free  from  danger,  and  it  is  not  proper  to  do  more 
than  apply  Crile's  clamp  to  the  vessel  on  the  side  operated  upon.  In  a  brain- 
tumor  when  the  dura  is  first  opened  there  is  usually  at  once  marked  bulging 
of  the  brain,  which  is  called  ''initial  bulging^';  after  working  for  a  time  on  a 
brain,  even  when  there  is  no  tumor,  bulging  occurs  from  traumatic  edema, 
vs^hich  is  called  "consecutive  bulging.^'  That  consecutive  bulging  may  occur 
is  a  sound  reason  for  operating  rapidly  (Frazier).  The  mortality  from  tumor 
operations  is  large,  death  being  due  to  shock  and  hemorrhage.  Haas  col- 
*  Edinburgh  Med.  Jour.,  June,  1894. 


Treatment  of  Intracranial  Tumors  835 

lected  122  cases  in  which  the  tumor  was  removed;  the  mortality  was  60  per 
cent.     Oi)erations  completed  at  one  seance  give  a  larger  mortality  than  two- 
stage  operations.     During  the  operation  an  erect  posture  causes  the  bram 
to  recede  and  permits  of  extensive  exploration  under  the  dura  (Ransohoff- 
Cushing).      The  same  thing  is  accom]jlished  by  lumbar  i)uncture  (Gush- 
ing)     The  fibromata  consdtute  the  best  cases  for  operation.     In  operating 
on  a  cerebral  tumor  make  a  large  osteoplasdc  flap.     If  on  opening  the  dura  the 
tumor  is  not  visible,  and  if  the  localizing  symptoms  were  reasonably  positive, 
the  surgeon  is  jusdfied  in  making  an  exploratory  incision  through  the  cortex 
to  see  5  there  is  a  subcortical  growth.     Operations  for  cerebellar  tumors  are 
peculiarly  difficult  because  of  the  large  blood  sinuses,  because  of  the  limited 
space  obtained  to  work  through,  because  of  the  great  bulging  after  the  dura 
has  been  opened,  because  of  the  impossibility  of  reaching  the  anterior,  mesial, 
or  upper  surfaces  through  the  incision,  because  of  the  liability  to  injure  the 
pons  and  medulla,  and  because  of  the  difficulty  of  retracting  the  parts  (Frazier, 
"New  York  and  Phila.  Med.  Jour.,"  Feb.    11-18,   1905).     In  approaching 
tumors  which  are  not  within  a  cerebellar  hemisphere  by  a  one-sided  exposure 
of  the  cerebellum,  it  is  usually  best  to  remove  a  considerable  portion  of  the 
hemisphere  in  order  to  obtain  free  access  to  the  growth.     I  prefer  Cushing's 
"cross  bow"  incision  and  bilateral  exposure.     This  enables  the  surgeon  to 
dislocate  the  sound  lobe  outward  and  so  obtain  room  to  work  upon  the  lobe 
containing  the  tumor.     The  diagnosis  of  cerebellar  tumor  is  usually  doubtful, 
hence  practically  all  operations  are  at  first  exploratory  and  are  then  made 
palliative  or  radical  as  the  case  demands.     Operation  must  be  early,  because 
cerebellar  growths  quickly  cause  blindness.     Sir  Victor  Horsley,  McArthur, 
Hochenegg,  Von  Eiselsberg,  and  Gushing  have  operated  for  tumor  of  the  hypo- 
physis     Removal  of  a  healthy  pituitary  body  from  dogs  is  sure  to  be  fatal,  as 
the  gland  is  necessary  to  the  life  of  the  dog.     Removal  of  a  healthy  pituitary 
in  man  would  in  all  probability  prove  fatal.     Diseased  pituitaries  have  been 
successfully  removed.       Perhaps  in  these  cases  the  function  of  the  gland  was 
more  or  less  compensated  before  operation  was  done.     If  the  tumor  is  asso- 
ciated with  acromegaly,  removal  of  the  tumor  may  greatly  benefit  the  acro- 
megaly.    One  route  of  approach  to  the  hypophysis  is  from  the  side,  just  as 
we  reach  the  Gasserian  ganglion.     Another  route  is  across  the  frontal  smus 
then  dividing  the  septum  of  the  nose,  removing  the  turbinated  bones,  and 
breaking  through  the  sphenoid.    Though  thorough  extirpation  is  feasible  in  but 
few  cases  of  brain  tumor,  operation  should  often  be  performed  for  palhative 
purposes.      Grainger  Stewart,  Annandale,  Horsley,  Macewen,  Gushing,  and 
Keen  have  advocated  palliative  trephining  in  certain  cases.     Simple  trephining 
is  of  little  value.     In  order  to  really  relieve  pressure  the  dura  must  be  opened 
and  left  unsutured,  so  that  hernia  cerebri  may  follow.    Gushing  has  had  some 
cases  of  extraordinary  improvement  in  cases  of  cerebral  tumor  after  trephinmg 
in  the  right  temporal  region  and  removing  a  piece  of  the  dura.     The  operation 
is  called  by  Gushing  a  decompression  operation.     The  brain  bulges  through  the 
dural  opening,  but  the  dense  temporal  fascia  stitched  together  over  it  prevents 
fungation.     It  is  the  temporosphenoidal  lobe  that  bulges,  and  the  right  side  is 
selected  because  word-deafness  might  ensue  if  the  operation  were  done  on  the 
left  side.     I  have  seen  several  of  Gushing's  cases.    One  of  them,  a  colored  man, 
had  been  almost  blind  for  some  time  and  was  unconscious  and  had  rapidly 


836  Diseases  and  Injuries  of  the  Head 

failing  respiration  wlien  the  operation  was  performed.  He  was  so  much 
benefited  that  he  returned  to  work  and  has  useful  vision  and  no  pain.  I 
have  had  several  very  gratifying  results  in  my  own  pracdce.  In  cases  of 
cerebral  tumor  subtemporal  decompression,  and  in  cases  of  cerebellar  tumor 
suboccipital  decompression,  may  be  performed. 

Decompression  may  reheve  choked  disk  and  thus  retard  or  prevent  optic 
atrophy  and  blindness.  Gushing  demonstrates  that  intracerebral  pressure  is 
the  chief  element  in  choked  disk. 

This  procedure  is  of  value  in  diminishing  excessive  intracranial  pressure, 
and  thus  reheving  headache  and  choked  disk,  and  decreasing  the  tendency 
to  sudden  death  from  inhibition  of  the  heart  or  from  respiratory  failure. 
The  usual  method  of  decompression  will  not  reheve  the  headache  caused  by 
tumor  of  the  hypophysis.  This  headache  is  due  to  distention  of  the  dural 
box  in  which  the  gland  is  placed,  and  can  be  reheved  only  by  incision  of  the 
dural  box  (Harvey  Gushing,  "Jour.  American  Med.  Assoc,"  July  24,  1909). 

We  conclude  that  in  most  cases  of  brain  tumor  operation  should  be  per- 
formed for  exploration;  in  some  cases  extirpadon  may  be  performed;  in  most 
cases  extirpation  is  impossible,  and  the  surgeon  must  be  content  with  the  palH- 
ative  influence  of  Gushing's  decompression  operation.  A  tumor  of  the  brain  if 
not  cured  by  antisyphilitic  treatment  is  of  necessity  fatal  if  unoperated  upon, 
and  exploratory  operation  is  not  very  dangerous. 

.  In  a  case  of  brain-tumor  if  operation  is  refused,  if  extirpation  is  impossible, 
or  if  decompression  fails,  it  may  be  necessary  to  use  the  bromids  for  convul- 
sions and  morphin  for  headache.  The  headache  is  often  benefited  by  pur- 
gatives, courses  of  potassium  iodid,  the  ice-bag  to  the  head,  and  the  application 
of  a  hot  iron  to  the  nape  of  the  neck. 

Operative  Treatment  of  Epilepsy. — The  shock  of  an  accident  or 
a  cerebral  concussion  may  estabhsh  epilepsy,  especially  in  those  predisposed 
by  heredity  or  other  causes.  Traumatic  epilepsy,  Le  Dentu  tells  us,'^  may 
be  due  to:  (i)  Bone-fragments  from  skull- fracture;  (2)  outgrowths  of  bone 
due  to  tumor;  (3)  cicatrices  of  meninges  resulting  from  laceration  of  mem- 
branes by  bone-fragments;  (4)  chronic  meningitis  which  ends  in  sclerosis 
of  membranes;  (5)  cysts  resulting  from  intracranial  hemorrhage  at  the  point 
of  fracture;  (6)  arteriovenous  aneurysm.  We  would  add:  (7)  tumors  of 
the  brain;  (8)  sclerosis  of  the  cortex.  W^e  refer  here,  in  speaking  of  traumatic 
epilepsy,  purely  to  the  condition  when  it  follows  a  head-injury,  and  this 
is  the  common  meaning  of  the  term.  Remember  that  epilepsy,  as  shown 
by  Sachs,  may  follow  a  long-forgotten  injury.  Before  undertaking  a  brain 
operation  for  epilepsy  it  is  a  sound  rule  to  remove  all  sources  of  definite  periph- 
eral irritation.  I  have  seen  apparent  cure  follow  the  removal  of  a  tender 
cicatrix  and  follow  circumcision  of  a  patient  laboring  under  phimosis.  Briggs 
reported  a  case  of  epilepsy  in  which  there  was  a  distinct  depression  of  a  por- 
tion of  the  skull.  There  was  also  necrosis  of  the  tibia,  and  after  the  cure  of 
the  necrosis  the  convulsions  ceased.  The  removal  of  supposed  peripheral 
irritation,  however,  is  beneficial  only  occasionally.  Are  operations  upon  the 
skull  and  brain  curative?  Surgeons  are  much  less  enthusiastic  than  they 
were  a  few  years  ago.  I  believe  operation  can  cure  less  than  5  per  cent,  of 
cases,  but  it  is  important  to  remember  that  in  some  cases  in  which  operation 
*La  Presse  medicale,  June  9,  1894. 


Idiopathic  Epilepsy  with  Local  Onset  of  Attacks  837 

seems  to  have  failed  medical  treatment  becomes  much  more  efficient  than 
it  was  before  the  operation.  The  high  rate  of  cure  (70  per  cent.)  once  claimed 
for  operations  was  due  to  failing  to  follow  the  patient  sufficiently  long.  A 
patient  should  not  be  reported  as  cured  until  at  least  three  years,  and  better, 
five  years,  have  passed  without  any  evidence  of  the  disease.  Another  source 
of  error  was  a  failure  to  understand  that  any  traumatism  may  improve  epi- 
lepsy for  a  time.  "  The  administering  of  an  anesthetic,  the  shock  of  an  injury, 
the  traumatism  of  an  operation,  just  like  a  febrile  seizure,  may  interrupt  an 
epileptic  habit  and  cause  a  patient  to  go  for  weeks  or  months  without  an 
attack"  (the  author,  in  "Medicine,"  Feb.,  1904). 

Operation  must  never  be  indiscriminately  applied.  In  some  cases  it  gives 
hope  of  relief,  in  others  it  is  obvious  that  it  would  be  utterly  futile.  In  order 
to  determine  if  a  case  is  or  is  not  suitable  for  operation  it  must  be  studied 
with  great  care.  The  history  must  be  carefully  obtained,  particularly  as  to 
hereditary  predisposition,  the  first  convulsion,  and  its  supposed  cause.  The 
question  of  injury,  recent  or  old,  should  be  thoroughly  investigated,  and  it  is 
a  sound  rule  to  have  the  head  shaved  and  then  examine  for  a  scar  and  for  a 
depression.  Convulsive  seizures  must  be  studied  by  an  expert,  hence  the 
patient  should  be  in  a  hospital,  constantly  watched  by  a  trained  nurse,  until 
one  or  two  fits  have  occurred.  The  nurse  watches  the  convulsion  and  de- 
scribes it  in  writing,  noting  particularly  if  it  had  a  local  beginning.  The 
general  health  must  be  investigated. 

I  am  accustomed,  for  surgical  purposes,  to  make  the  following  classification 
of  epilepsy.  It  is  a  modification  of  Sir  Victor  Horsley's  classification  (the 
author,  in  "Medicine,"  Feb.,  1904): 

1 .  Reflex  epilepsy,  the  surgical  treatment  of  which  I  shall  not  discuss  in  detail. 

2.  The  common  non-traumatic,  idiopathic,  or  essential  epilepsy,  in 
which  the  attacks  are  general  and  are  without  a  local  onset. 

3.  Idiopathic  epilepsy  with  a  local  onset  of  attacks  (focal  or  Jacksonian 
epilepsy) . 

4.  Traumatic  epilepsy.  This  may  be  subdivided  into  two  forms: 
{a)  attacks  without  a  local  onset;  and  {b)  attacks  with  a  local  onset  (focal 
or  Jacksonian  epilepsy). 

5.  Jacksonian  epilepsy  due  to  gross  brain  disease  (tumor,  aneurysm,  etc.). 

6.  Epilepsy  following  infantile  cerebral  palsy. 

7.  The  posthemiplegic  epilepsy  of  adults. 

1.  Reflex  Epilepsy. — Remove  the  supposed  cause  of  irritation.  When 
epilepsy  follows  traumatism  and  a  scar  is  found  on  the  scalp,  excise  the  scar. 
This  is  an  imperative  duty  if  the  scar  is  tender  or  the  seat  of  an  aura. 

2.  Essential  or  Idiopathic  Epilepsy. — Operation  upon  the  brain  is  use- 
less. If  persistent  headache  exists,  it  is  then  proper  to  trephine  and  open  the 
dura  for  exploration.  Such  an  operation  is  done  to  relieve  headache.  Some 
claim  remarkable  results  from  bilateral  excision  of  the  cervical  ganglia  of  the 
sympathetic  (page  777).  The  operation  is  a  theoretical  one  and  of  doubtful 
utility.  It  was  founded  upon  a  misconception  as  to  the  cause  of  epilepsy, 
and  favorable  reports  are  no  more  favorable  than  have  been  set  forth  regarding 
various  other  now  abandoned  procedures. 

3.  Idiopathic  Epilepsy  with  Local  Onset  of  Attacks  {Focal  or  Jacksonian 
Epilepsy). — Many  of  these  cases  begin  in  young  children  who  have  had  infan- 


838  Diseases  and  Injuries  of  the  Head 

tile  palsy,  the  traces  of  the  palsy  hanng  disappeared.  In  such  cases  the  con- 
vulsions may  begin  on  one  side,  and  in  fact  may  be  nearly  limited  to  one  side. 
If,  from  the  ver}'  beginning,  the  attacks  began  in  one  group  of  muscles  or  in 
one  extremity,  whether  or  not  they  spread  to  the  rest  of  the  body,  and  if  the 
case  is  seen  within  two  years  of  the  first  attack,  the  surgeon  is  justified  in 
exposing  the  brain  and  excising  the  irritated  portion  of  cortex.  This  operation, 
it  is  true,  cures  very  few  cases,  but  it  benefits  many  for  a  considerable  time 
and  seems  to  make  them  more  amenable  to  medical  treatment.  In  the  vast 
majority  of  cases  fits  recur,  but  rarely  as  severely  as  before.  After  fits  have 
been  going  on  for  two  years  operation  offers  no  prospect  of  cure,  as  the  associa- 
tion fibers  have  surely  degenerated.  But,  even  in  very  old  cases,  if  the  attacks 
are  frequently  repeated  and  thus  threaten  life,  the  excited  center  should  be 
removed  to  save  life. 

In  cortical  excision  more  of  the  cortex  than  the  excited  center  is  of  ne- 
cessity removed,  because,  in  order  to  get  the  entire  center,  we  must  go  wide 
of  it.  Paralysis  of  the  parts  controlled  by  the  extirpated  cortical  area  follows. 
The  paralysis  is  seldom  permanent  except  to  the  finer  movements.  The 
operation  gives  the  best  prognosis  in  young  persons,  and  when  done  early 
in  the  case.  The  return  of  fits  after  apparent  cure  is  thought  to  be  due,  at 
least  in  some  cases,  to  the  formation  of  adhesions  between  the  brain  and  its 
membranes.  Various  unsatisfactor}-  attempts  have  been  made  to  prevent 
adhesion  by  the  insertion  of  silver  foil,  gold  foil,  rubber  tissue,  egg-shell 
membrane,  and  Cargile  membrane.  In  operating  for  cortical  epilepsy  a 
laige  osteoplastic  flap  is  required.  In  the  previous  remarks  we  dealt  with 
partial  epilepsy  and  with  generalized  epilepsy  in  which,  from  the  first,  the 
attacks  had  a  local  beginning.  If  cases  of  apparent  idiopathic  epilepsy 
develop  Jacksonian  attacks  (attacks  with  a  local  beginning),  it  is  useless 
to  excise  the  cortex.  The  entire  cortex  is  diseased,  though  one  region  is 
particularly  unstable. 

4.  Traumatic  Epilepsy. — Always  remember  that  a  traumatism  to  a 
person  who  becomes  epileptic  may  have  been  only  a  coincidence;  the  con- 
dition may  be  essential  epilepsy  and  the  traumatism  may  have  had  nothing 
to  do  with  it.  Epilepsy  ensuing  upon  traumatism  may  not  begin  until  months 
or  even  several  years  after  the  injur)'.  In  the  earliest  attacks  consciousness 
may  or  may  not  be  lost.  The  causative  injur}'  may  have  been  slight  or  severe. 
"An  injury  may  cause  a  hemorrhage  or  a  depressed  fracture;  may  be  followed 
by  a  scar  upon  the  membranes;  may  occasionally  lead  to  the  development 
of  an  innocent  or  malignant  tumor  or  a  cyst,  or  may  merely  induce  some 
trivial  change  in  the  subtle  chemistry  of  the  nen-e-cells"  (the  author,  in 
"Medicine,"  Feb.,  1904).  Injun,-  may  produce  general  epilepsy  or  Jack- 
sonian epilepsy.  If  an  identified  traumatism  exists,  the  surgeon  should 
operate  even  after  years.  When  the  traumatism  has  not  left  definite  evidence, 
the  surgeon  is  justified  in  making  an  exploration  any  time  up  to  the  termina- 
tion of  the  third  year  after  the  accident.  The  earlier  the  operation,  the 
better  the  prognosis.  The  best  prognosis  of  any  form  of  epilepsy  is  given 
by  Jacksonian  epilepsy  of  traumatic  origin. 

"In  focal  epilepsy  with  evidences  of  skull  injury  or  depression,  trephining 
is  imperative  and  somewhat  promising.  The  dura  should  invariably  be 
opened,  even  if  it  seems  in  good  condition.     A  dural  scar  should  be  extirpated. 


Post-hemiplegic  Epilepsy  of  Adults  839 

The  brain  should  be  examined  by  sight  and  by  touch,  and  should  l>e  explored 
with  the  little  finger  and  with  the  dural  separator  to  well  beyond  the  limits 
of  the  opening  in  the  dura.  If  a  tumor  is  found,  it  should  be  removed;  if 
a  scar  upon  the  brain  exists,  it  should  be  extirpated;  if  a  cyst  is  discovered, 
it  should  be  drained;  and  if  there  is  any  obviously  damaged  area  in  the  brain 
tissue,  it  should  be  unhesitatingly  cleared  away.  If  nothing  obvious  is  found  on 
exploration,  and  if  the  attacks  have  been  distinctly  focal  in  origin,  it  is  justifi- 
able to  extirpate  the  motor  center  from  which  the  discharge  seems  to  originate. 

"When  Jacksonian  epilepsy  has  followed  an  injury  in  the  motor  region, 
the  chances  of  effecting  a  cure  are  much  better  than  they  are  when  the  epilepsy 
has  followed  an  injury  in  the  sensory  region.  When  it  has  followed  an  injury 
in  the  frontal  region,  operation  affords  very  little  hope  of  cure. 

"When  the  condition  is  not  focal  but  essential  epilepsy,  the  surgeon  will 
remove  a  scalp  scar;  and  if  there  is  any  evidence  of  bone  injury,  he  will  tre- 
phine the  bone,  open  the  dura,  and  explore  the  brain.  It  is  needless  to  say, 
however,  that  in  such  a  case  he  will  not  extirpate  any  of  the  cortex. 

"In  cases  of  focal  epilepsy  I  use  the  osteoplastic  method  of  operating. 
In  cases  of  generalized  epilepsy  I  use  the  simple  trephine  and  leave  the  button 
of  bone  out,  as  a  means  of  effecting  a  prolonged  modification  in  the  intra- 
cerebral pressure"  (the  author,  in  "  Medicine,"  Feb.,  1904). 

Bramwell  maintains  that  when  traumatism  is  followed  by  epilepsy  and 
the  epileptic  discharge  starts  from  a  cortical  center  which  is  not  beneath 
the  scar,  the  surgeon  should  trephine  first  at  the  seat  of  injury,  and  if  this 
fails,  he  should  trephine  over  the  excited  center. 

5.  Jacksonian  Epilepsy  due  to  Gross  Brain  Disease.— The  treatment 
of  this  condition  is  the  treatment  of  the  brain  disease. 

6.  Epilepsy  following  Infantile  Cerebral  Palsy .^In  this  group  of 
cases  the  palsy  is  manifest.  It  is  justifiable  to  operate  upon  a  child  but  not 
later  in  life.     The  prospect  of  benefit  is  poor  even  in  a  child. 

7.  The  Post-hemiplegic  Epilepsy  of  Adults.— Operation  is  useless. 
Our  conclusions  are  that  these  operations  sometimes  seem  to  cure  epilepsy, 

but  so,  occasionally,  does  any  operation.  White  records*  ninety  trephinings 
in  which,  though  no  cause  was  found  for  the  epilepsy,  great  relief  followed, 
and  two  cases  were  apparently  cured;  he  mentions  benefit  or  apparent  cure 
following  tracheotomy,  ligation  of  the  carotid  artery,  incision  of  the  scalp,  etc. 
The  same  effect  may  be  obtained  by  a  great  shock,  high  fever,  the  adminis- 
tration of  an  anesthetic,  or  an  accident.  The  fact  seems  to  be  that  any  opera- 
tion, by  means  of  nervous  shock,  may  interrupt  the  epileptic  habit;  but  in 
ordinary  operations  the  fits  tend  after  a  time  to  recur  and  soon  reach  their 
old  standard  of  frequency.  In  the  special  brain-operations  with  removal  of 
obvious  lesions  or  extirpation  of  discharging  centers  the  fits  usually  recur, 
but  they  will  rarely  reach  the  old  standard  of  frequency,  and  will  be  more 
amenable  to  medical  treatment. 

In  non-traumatic  chronic  epilepsy  without  localizing  symptoms  trephining 
is  not  justifiable  unless  persistent  headache  calls  for  it  as  a  means  of  relief 
from  intracranial  pressure.  Annandale  has  recently  advised  us  to  consider 
experimental  operation  in  such  cases   when  the  drug-treatment    has    failed 

*"The  Supposed  Curative  Effects  of  Operations  per  se,"  Annals  of  Surgery,  Aug. 
and  Sept.,  1891 


840  Diseases  and  Injuries  of  the  Head 

and  when  the  patient's  condition  seems  hopeless.  He  says  there  is  no  chance 
of  improvement  without  operation,  and  operation  may  possibly  disclose  a 
removable  lesion*  After  trephining  for  epilepsy  five  years  should  elapse 
without  a  convulsion  before  cure  is  reasonably  assured;  and  if  convulsions 
arise,  they  must  at  once  be  met  by  medical  treatment.  A  man  having  once 
had  a  convulsion  may  at  any  time  have  others;  hence  he  should  always  be 
watched.  It  is  not  unusual  for  a  few  convulsions  to  occur  soon  after  an 
operation  for  epilepsy,  and  then  to  cease  for  a  considerable  time.  These 
early  fits  result  from  habit  Qiahit  fits).  Among  the  operative  procedures 
suggested  for  the  treatment  of  epilepsy  may  be  mentioned  circumcision, 
clitoridectomy,  ocular  tenotomy,  ligation  of  the  vertebral  arteries,  removal  of 
the  cervical  ganglia  of  the  sympathetic  (page  777)  (Alexander,  Jonnesco, 
Jaboulay),  and  the  actual  cautery  to  the  head  (Fere). 

Operative  Treatment  of  Insanity  (see  the  author  in  "Journal  of  Ner- 
vous and  Mental  Diseases,"  June,  1904). 

1.  Epileptic  Insanity. — The  conditions  which  call  for  operation  on  a 
non-insane  epileptic  (page  837)  call  for  it  on  an  insane  epileptic.  It  is  some- 
times justifiable  to  operate  if  there  has  been  a  head  injury,  and  operation  may 
lessen  the  number  and  diminish  the  violence  of  the  attacks.  If  focal  seizures 
exist,  we  may  proceed  as  for  focal  seizures  in  the  sane.  In  status  epilepticus 
we  may  operate  to  relieve  pressure.  It  will  be  observed  that  operation  is  for 
the  convulsions  and  not  for  the  insanity. 

2.  Paresis. — I  do  not  advocate  operation  in  paresis.  If  we  believe  in 
traumatic  paresis,  we  may  be  inclined  to  advise  operation.  Personally  I  do 
not  believe  that  genuine  paresis  is  ever  cured;  the  lesions  of  the  disease  are 
widely  disseminated;  the  pons,  medulla,  and  even  the  cord  may  be  diseased 
and  the  lesions  cannot  be  removed. 

3.  Non-traumatic  Insanity  and  Paranoia. — Operation  cannot  cure  the 
insanity  and  is  not  to  be  advised. 

4.  Hypochondriacal  Delusions. — Operation  is  useless.  Some  practice 
it  with  the  idea  of  getting  rid  of  a  delusion  by  removing  a  part  to  which  the 
attention  is  directed.  Such  attempts  always  fail,  because  it  is  the  insanity 
which  causes  the  delusion,  not  the  delusion  which  causes  the  insanity. 

5.  Operations  for  Traumatic  Insanity.— A  pyschosis  constructed  on  the 
basis  of  a  traumatic  neurosis  never  calls  for  operation.  The  only  cases  in 
which  operation  is  ever  justifiable  are  those  in  which  traumatism  is  the  direct 
cause.  Insanity  may  begin  at  once  or  soon  after  an  injury,  but  is  often  unrecog- 
nized for  weeks  or  even  months.  Nearly  all  of  these  cases  are  predisposed 
to  insanity  and  the  injury  has  been  only  an  exciting  cause.  Traumatism 
is  the  direct  cause  in  about  2  per  cent,  of  cases  of  insanity. 

"An  antecedent  injury  may  have  directly  induced  the  alienation;  it  may 
have  had  no  bearing  at  all  upon  the  latter;  or  it  may  have  produced  an  insanity 
by  fear  and  shock,  and  not  by  creating  a  direct  brain  lesion.  Again,  the 
head  injury,  by  increasing  the  individual's  susceptibility  to  alcohol  and  to 
the  effects  of  the  sun,  may,  if  this  person  drinks  alcohol  or  exposes  himself 
to  the  rays  of  the  sun,  be  indirectly  responsible  for  lunacy. 

"In  insanity  following  an  injury  to  the  head  there  may  be  various  sup- 
posed causative  lesions:  A  fracture  of  the  skull,  with  or  without  depression; 

*  Edinburgh  Med.  Jour.,  April,  1894. 


Abdominal,  Gynecological,  and  Gcnito-urinary  Operations      841 

the  development  of  an  exostosis;  sclerosis  or  softening  of  the  cortex;  edema 
of  the  membranes  or  of  the  brain  itself;  cerebral  hyperemia  or  congestion; 
thickening  of  the  membranes;  adhesion  of  the  membranes  to  the  skull,  to 
each  other,  or  to  the  brain;  new-growth;  inflammation  of  the  membranes; 
or  minute,  slowly  developing,  wide-spread  nutritive  changes.  The  injury 
may  be  assumed  to  be  the  cause  of  the  insanity  if  the  insane  condition  becomes 
manifest  almost  at  once  or  soon  after  the  accident;  but  if  the  symptoms  do 
not  appear  until  long  after  the  accident,  the  traumatism  may  be  considered 
to  be  the  directly  exciting  cause  in  some  cases,  and  not  in  others.  It  may  be 
blamed  if,  between  the  time  of  the  accident  and  the  appearance  of  the  insanity, 
there  has  been  a  marked  change  in  the  patient's  disposition,  temperament, 
or  character;  if  he  has  developed  headache,  insomnia,  irritability,  passionate 
outbreaks  of  temper,  moodiness,  or  lapses  of  memory;  if  he  has  plunged  into 
immorality  or  excesses  in  alcohol;  if  he  has  displayed  a  tendency  to  neglect 
business  or  family  obligations;  and  if  he  has  shown  increased  susceptibility 
to  alcohol  and  to  the  sun.  Sometimes  epilepsy  may  develop  during  this 
period.  (Richardson,  'American  Journal  of  Insanity,'  July,  1903.  The 
author's  'Address  on  Surgery,'  delivered  before  the  meeting  of  the  Medical 
Society  of  the  State  of  Pennsylvania,  May  18,  1897.)  I^  there  were  none  of 
these  intermediate  changes  in  the  normal  mode  of  thinking  and  way  of  acting, 
one  cannot  count  the  traumatism  as  causative.  Many  persons  that  have 
received  severe  head  injuries  have  shown  these  changes,  but  have  never  gone 
insane.  I  have  been  studying  this  point  for  a  number  of  years,  and  have 
decided  that  quite  a  few  patients  that  have  been  trephined  for  fracture  or 
for  meningeal  hemorrhage  have  subsequently  shown  pronounced  and  per- 
manent changes  in  character  and  disposition.  Of  the  number  that  show' 
such  changes,  many  never  go  insane,  but  some  do.  Such  an  insanity  is 
distinctly  traumatic  in  origin."  (The  author  in  the  "Journal  of  Nervous  and 
Mental  Diseases,"  June,  1904.)  The  prognosis  is  very  unfavorable;  some 
recover  after  operation,  many  do  not.  Some  recover  without  operation. 
Sometimes  operation  cures  by  removing  a  lesion;  sometimes  by  shock,  etc. 
Some  cures  following  operation  did  not  result  from  the  operation. 

On  what  cases  should  we  operate? 

We  should  operate  on  cases  "in  which  insanity  has  soon  followed  a  head 
injury;  if  the  site  of  the  trauma  is  indicated  by  a  scar,  a  depression  of  bone, 
local  tenderness,  fixed  headache,  or  some  localizing  symptom, — motor  or 
sensory, — operation  should  positively  be  undertaken.  In  a  case  in  which 
the  insanity  has  developed  later,  in  which  the  intermediate  period  between 
the  injury  and  the  development  of  the  insanity  has  shown  the  change  from 
the  normal  mode  of  thinking  and  way  of  acting  previously  alluded  to,  and 
in  which  the  site  of  trauma  is  indicated  by  any  of  the  evidences  mentioned 
above — operation  should  positively  be  performed.  One  should  not  operate 
upon  a  case  simply  because  there  is  a  dubious  record  of  an  antecedent  fall 
or  blow,  which  merely  suggests  the  possibility  of  a  traumatic  origin  for  the 
insanity.  In  any  case  in  which  there  are  positive  signs  of  increased  pres- 
sure it  may  be  considered  proper  to  trephine  as  a  palliative  measure." 
(The  author  in  the  "Journal  of  Nervous  and  Mental  Diseases,"  June,  1904.) 

Abdominal,  Gynecological,  and  Genito-urinary  Operations. — If  an  in- 
sane person  has  a  disease  which  is  dangerous  to  life  or  which  is  productive  of 


842  Diseases  and  Injuries  of  the  Head 

pain,  discomfort,  or  ill  health,  he  or  she  is  entitled  to  be  cured,  if  possible, 
by  a  surgical  operation.  The  removal  of  pain  and  other  depressing  influ- 
ences may  result  in  great  improvement  in  the  general  health  and  in  notable 
mental  improvement.  The  operation  may  thus  indirectly  exercise  a  bene- 
ficial influence  on  the  insanity,  but  the  influence  is  not  direct  and  it  is  never 
justifiable  to  do  such  an  operation  as  oophorectomy  upon  an  insane  woman 
unless  the  condition  of  the  ovaries  would  call  for  it  in  one  not  insane. 

Operations  on  the  Skull  and  Brain. — As  a  prehminary  it  is  well  to 
note  that  urotro]nn  given  by  the  mouth  quickly  appears  in  the  cerebrospinal 
fluid,  and  that  the  fluid  contains  the  maximum  amount  in  from  one-half  hour 
to  an  hour  after  ingestion.  The  presence  of  this  drug  decidedly  inhibits  the 
growth  of  bacteria  in  the  fluid.  We  beheve  it  wise  to  give  this  drug  in  all 
cases  in  which  meningitis  is  threatened  or  exists  (S.  J.  Crowe,  in  "Johns 
Hopkins  Hospital  Bulletin,"  April,  1909). 

Trephining  (for  a  Fracture  of  the  Skull) . — Shave  the  scalp,  scrub  it  with 
ethereal  soap  and  sterile  water,  wash  it  with  sterile  water  and  then  with  alcohol  or 
ether,  scrub  with  a  brush  wet  with  corrosive  subHmate  solution  (i:  1000),  and 
wrap  the  scalp  in  wet  corrosive  sublimate  gauze  (i :  2000).  The  instruments  re- 
quired are  a  scalpel,  a  dissector,  hemostatic,  dissecting,  and  mouse-toothed  for- 
ceps, trephines  of  several  sizes  (Fig.  464) ,  a  periosteum  elevator,  Hey's  saw, 
rongeur  forceps,  a  bone-elevator,  scissors,  straight  and  curved  on  the  flat,  a 
dural  separator,  a  tenaculum,  small  curved  brain  needles  and  large  curved 
needles  for  the  scalp;  a  needle-holder;  catgut,  fine  silk,  silkworm-gut,  and  Hors- 
ley's  wax.  Provide  a  sand-pillow.  The  patient  should  be  anesthetized  unless  he 
is  unconscious,  and  should  be  placed  upon  the  back  with  the  shoulders  a  little 
raised.  A  sand-pillow  is  placed  under  the  neck,  and  his  head  is  turned  away 
from  the  side  to  be  operated  upon.  The  position  of  the  surgeon  is  such  that 
the  patient's  head  is  a  little  to  his  left.  A  large  semilunar  incision  is  made 
with  the  base  down,  which  incision  goes  through  the  periosteum,  and  the  flap 
is  lifted.  The  bleeding  vessels  of  the  flap  are  caught  with  forceps.  The 
fracture  is  sought  for  and  found.  The  pin  of  the  trephine  is  projected  beyond 
the  crown  and  is  set  upon  sound  bone,  the  crown  overhanging  the  fine  or 
edge  of  the  fracture.  The  surgeon  tries  to  avoid  the  region  of  a  sinus  or 
large  artery.  A  gutter  is  cut  in  the  bone,  the  pin  of  the  instrument  is  with- 
drawn, and  the  trephining  is  completed.  In  going  through  the  diploe  bleeding 
is  copious.     The  inner  table  feels  very  dense.     Stop  from  time  to  time,  clean 

out  the  gutter  in  the  bone  with 
the  dissector,  and  try  the  bone 
with  an  elevator  to  see  if  it  is 
loose.  When  the  fragment  is 
loose  enough,  pry  it  out.  If  the 
Fig.  464.-Gaifs  conical  trephine.  surgcon  dcsires  to  replace  the 

button,  hand  it  to  an  assistant, 
who  places  it  at  once  in  a  bowl  of  warm  normal  salt  solution,  kept  warm  by  stand- 
ing in  a  basin  of  water  at  105°  F.,  or  who  puts  it  in  warm  carbolized  towels. 
The  edges  of  the  opening  should  be  rounded  with  a  rongeur,  and  the  bone,  if 
depressed,  must  be  elevated.  Sometimes  it  may  be  necessary  to  remove 
splinters  and  fragments  of  bone.  After  removing  the  fragments  the  edges 
of  the  opening  should  be  smoothed  by  the  use  of  the  rongeur  forceps.     The 


Osteoplastic  Resection  of  the  Skull 


843 


dura  should  be  examined  to  see  if  injury  exists,  and  hemorrhage  must  be 
stopped.  Bleeding  from  the  dura  is  arrested  by  passing  a  ligature  of  silk  or 
catgut  threaded  in  a  small  curved  needle  under  the  vessel  on  each  side  of  the 
wound,  and  tying  the  ligatures  {suture  ligatures).  Bleeding  from  the  pia  is 
arrested  by  direct  ligation,  Ijy  suture  ligature,  or  by  gauze  packing.  Bleed- 
ing from  the  diploe  is  arrested  by  the  use  of  Horsley's  wax.  The  wound  is 
cleansed,  the  edges  of  the  dura  are  sutured  with  catgut  or  fine  silk;  in  some 
cases  the  button  of  bone  is  reintroduced,  in  other  cases  some  chips  are  cut 
from  the  bone  and  scattered  upon  the  dura,  but  in  most  cases  no  attempt  is 
made  to  fill  up  the  gap  in  the  bone.  The  scalp  is  sutured  with  silkworm-gut, 
and  horse-hair  or  gauze  drainage  is  employed  for  a  day  or  two.  Sterihzed 
gauze  dressings  are  put  on,  a  rubber-dam  is  laid  over  them,  and  a  gauze 
bandage  wet  with  bichlorid  of  mercury  is  appHed. 

Instead  of  the  trephine  some  surgeons  use  the  chisel  or  gouge  and  hammer 
to  remove  a  portion  of  the  bone.  Other  operators,  believing  that  this  proce- 
dure may  cause  concussion,  employ  the  surgical  engine. 

Osteoplastic  Resection  of  the  Skull. — Wolff  suggested  this  operation, 
and  in  i88g  Wagner  performed  it.     It  is  employed  for 'the  removal  of  tumors 


Figs.  465-467. — Hudson's  burrs. 


and  the  Gasserian  ganglion,  for  focal  epilepsy,  and  for  exploration.  It  is  the 
operation  of  choice  when  a  large  opening  is  needed,  as  when  the  operation  is, 
first  of  all,  for  diagnosis.  A  horseshoe-shaped  incision  is  made  through  the  scalp 
and  periosteum;  a  groove  corresponding  to  this  incision  is  cut  in  the  bone 
by  special  gouges  or  chisels.  Some  surgeons  prefer  a  saw  attached  to  a  sur- 
gical engine;  some  make  trephine  openings  and  then  cut  from  wdthin  outward 
by  the  GigH  wire  saw  (Obahnski).  Gushing,  of  Baltimore,  does  what  is 
called  the  combined  method.  I  prefer  this  to  any  other  plan.  It  is  rapid 
and  free  from  all  danger  of  wounding  the  dura.  I  make  two  or  several  open- 
ings with  Hudson's  burr.  This  excellent  instrument  divides  bone  with  great 
rapidity,  but  does  not  divide  the  dura.  In  fact,  one  cannot  divide  the  dura 
with  it,  for  the  burr  binds  as  soon  as  it  is  through  the  bone.      Figs.  465-467 


844 


Diseases  and  Injuries  of  the  Head 


shows  Hudson's  burrs.  The  sides  of  this  bone  tlap  are  rapidly  cut  down 
by  Hudson's  impjrovement  of  the  DeVilbiss  forceps  (Fig.  468).  The  upper 
margin  is  cut  on  a  bevel  with  the  Gigli  saw.  Because  of  this  bevel  when 
the  flap  is  restored  to  place  the  upper  edge  of  the  flap  rests  on  a  shelf  of  bone  and 
does  not  press  on  the  brain.  By  whatever  method  performed,  three  sides  of  the 
bone-flap  are  cut  through,  but  the  bone  is  left  attached  to  the  scalp.  It  is  a 
good  plan  to  save  the  scalp  from  detachment  by  temporarily  naihng  it  in  place. 
The  bone  is  then  broken  outward,  the  fracture  taking  place  at  the  base  of  the 
bone-flap,  the  dura  is  opened  a  little  distance  from  the  edge  (sufficient  space 
being  retained  for  sutures),  and  the  exploradon  is  made  and  the  operation  is 
performed.  When  we  are  ready  to  suture  the  dura,  we  note  if  the  brain  bulges 
greatly.  If  it  does,  manipulation  will  surely  injure  it,  and  we  should  cause 
the  brain  to  recede  before  suturing  by  placing  the  patient  nearly  erect  or  by 


Fig.  468. — Hudson's  modified  DeVilbiss  forceps. 

performing  lumbar  puncture.  After  suturing  the  dura  the  bone  which  is  still 
adherent  to  the  pericranium  is  restored  to  its  proper  place,  and  the  scalp  is 
sutured. 

Besides  restoring  a  flap  of  bone  into  position,  or  replacing  .a  button  of 
bone,  or  strewing  the  dura  with  bone-fragments,  other  methods  of  closing  the 
opening  have  been  practised — for  instance,  heteroplasty  with  a  decalcified 
bone-plate  and  heteroplasty  with  a  celluloid  plate  or  other  foreign  material.* 

Osteoplastic  Resection  of  the  Skull  by  the  Use  of  Stellwagen  Trephine. — 
The  concussion  inflicted  by  the  mallet  I  believe  adds  to  shock,  may  increase 
or  cause  hemorrhage,  may  extend  a  line  of  fracture  or  produce  fracture, 
and  may  diffuse  a  purulent  collection.  For  these  reasons  I  prefer  a  differ- 
ent plan.  The  surgical  engine  gives  satisfaction  to  some,  but  it  is  difficult 
to  render  it  sterile,  and  it  runs  at  such  a  high  rate  of  speed  that  regulation  is 
troublesome  and  the  instrument  is  dangerous  except  in  the  most  careful  hands. 
The  trephine  shown  in  the  cut  (Fig.  471)  has  proved  satisfactor}'.  It  has 
since  been  modified  by  substituting  screws  for  spikes  in  the  pivot  plate. 
Dr.  Park  suggested  putting  a  handle  to  the  spiked  plate  to  keep  it  from 
slipping.  The  area  of  bone  to  be  removed  is  carefully  determined,  as  sug- 
gested by  !Mills  (see  Figs.  469  and  470),  the  plate  is  screwed  into  the  skull, 
*  See  Bretano,  in  Deutsche  med.  Woch.,  May  i",  1894. 


Technique  of  Brain-operations 


845 


the  scalp  is  cut  with  the  knife-blade,  the  base  of  the  flap  being  made  narrow; 
the  saw  is  substituted  for  the  knife  in  the  instrument.  The  bone  is  cut  by 
short,  quick  cuts,  making  no  attempt  to  swing  the  saw  through  the  entire 
length  of  the  incision  at  each  turn  of  the  wrist.  When  the  inner  plate  is  nearly 
cut  through,  the  division  is  completed  by  a  small  osteotome.  The  operation 
can  be  completed  on  an  ordinarily  thick  skull  in  from  eight  to  eighteen  minutes. 
(See  article  by  author  in  "Annals  of  Surgery,"  July,  1903.)  I  still  use  this 
method,  but  not  so  frequently  as  formerly,  preferring  Cushing's  combined 
plan  to  any  other. 

Trephining  the  Frontal  Sinus. — This  operation  may  be  employed  for 
inflammation  of  the  lining  membrane  of  the  sinus  or  for  empyema.  Make 
a  vertical  incision  in  the  middle  of  the  forehead,  starting  one  and  one-half 
inches  above  the  nasion  and  terminating  at  the  root  of  the  nose.  The  button 
of  bone  is  removed  and  the  opening  is  enlarged  if  necessar}-.     The  mucous 


Fig.  469. — Cranial  areas  for  osteoplastic  operations 
with  the  Stellwagen  trephine,  these  areas  corresponding 
to  the  regions  of  the  left  hemicerebrum,  with  definite 
syndromes  (Mills). 


Fig.  470. — The  motor  region 
outlined  on  the  skull  previous  to 
osteoplastic  operation  with  the 
Stellwagen  trephine:  x.  Point 
for  the  insertion  of  the  pin  of 
the  Stellwagen  trephine;  y-z, 
base  Une  (Mills). 


membrane  is  incised,  the  opening  into  the  nose  is  found  and  is  dilated,  and 
a  drainage-tube  is  passed  into  the  nose  from  the  sinus,  the  upper  end  being 
left  in  the  sinus.  In  some  severe  cases  Jacobson  advises  us  to  curet  the 
sinus,  to  disinfect  it  by  the  use  of  silver  nitrate  or  chlorid  of  zinc,  and  to 
insufflate  an  "aseptic  powder."  In  some  cases  resect  the  mucous  membrane. 
I  prefer  an  osteoplastic  resection  to  trephining  the  frontal  sinus. 

Trephining  the  Mastoid  (operation  for  mastoid  suppuration,  page  848). 

Technique  of  Brain-operations  (after  Horsley  and  Keen). — Instru- 
ments as  for  fractured  skull.  In  focal  epilepsy  a  faradic  battery  is  required. 
Always  shave  the  scalp,  and  always  antisepticize  it.  In  localizations,  mark 
out  the  fissure  upon  the  scalp  with  an  anilin  pencil,  with  iodin,  or  with  silver 
nitrate.  Have  the  patient  semirecumbent.  Mark  three  points  upon  the 
bone  with  the  center-pin  of  the  trephine  before  incising  the  scalp  (both  ends 


846 


Diseases  and  Injuries  of  the  Head 


of  the  Rolandic  fissure  and  the  point  at  which  the  trephine  is  to  be  applied). 
Make  a  semilunar  flap  three  inches  in  diameter,  with  the  base  below.  Con- 
trol bleeding  in  the  flap  by  forceps  pressure.  If  the  operation  is  by  trephining, 
the  one  and  a  half  inch  trephine  should  be  employed,  but  if  a  smaller  trephine 
is  used,  the  opening  must  be  enlarged  with  a  rongeur.  Before  enlarging  the 
opening,  separate  the  dura  from  the  bone  by  a  dural  separator.  In  most  cases 
an  osteoplastic  flap  is  preferable  to  trephining.  It  is  always  employed  in 
explorations  for  tumor.  As  a  rule,  open  the  dura  and  examine  the  brain. 
The  dura  is  hfted  by  mouse-toothed  forceps  and  is  opened  with  scissors 


Fig.  471. — Stellwagen's  trephine. 

Fig.  472. — Combined  osteoplastic  opiera- 
'  tion.      First  step.      Incision  througli  super- 

ficial tissues  and  bone. 

along  a  line  a  quarter  of  an  inch  from  the  bone-edge,  a  broad  pedicle  of  dura 
being  left  uncut.  Hemorrhage  is  arrested  by  pressure  and  hot  water  or  by 
passing  a  thread  of  silk  or  catgut  around  any  bleeding  vessel  by  means  of  a 
curved  needle.  In  some  cases  packing  must  be  retained  or  forceps  must  be 
kept  on.  In  packing,  endeavor  to  use  but  one  piece  of  gauze,  so  as  to  avoid 
leaving  in  a  forgotten  piece.  Upon  opening  the  dura  cerebrospinal  fluid  flows 
out,  the  stream  being  increased  with  each  expiration.  Absence  of  pulsation 
of  the  brain  points  to  abscess  or  tumor,  and  a  livid  color  indicates  subcortical 
growth.  An  old  laceration  is  brownish.  If  the  brain  bulges  through  the 
opening,  it  means  increased  pressure  (tumor,  abscess,  effusion  into  the  ven- 
tricles, etc.).  After  opening  the  dura  employ  no  antiseptics,  especially  when 
the  surgeon  intends  using  electricity  to  locate  a  center.  Irrigate  only  with 
warm  salt  solution.  In  operating  for  tumor  the  dura  is  opened  and  in  some 
cases  the  brain  is  incised.  The  tumor  is  turned  out  by  the  finger,  or,  if  this 
is  impossible,  by  the  dry  dissector,  the  scissors,  the  dull  knife,  or  the  sharp 
spoon.  If  the  entire  tumor  cannot  be  removed,  it  is  sometimes  proper  to  take 
away  as  much  as  possible.  The  removal  of  a  portion  often  retards  the  growth 
of  the  remainder,  and  the  trephining,  by  lessening  cerebral  pressure,  relieves 
the  symptoms  and  prolongs  life.  After  removing  a  tumor  arrest  distinct 
points  of  bleeding  with  the  ligature  alone  or  the  ligature  passed  around  the 
vessel  by  means  of  a  needle.     Pack  the  tumor  cavity  with  gauze  and  bring  the 


Technique  of  Brain-operations 


847 


end  of  the  strand  out  of  the  wound.  Stitch  the  dura  with  silk  and  suture  the 
scalj)  with  silkworm-gut.  In  electrifying  the  brain  faradism  is  employed  of  a 
strength  about  sufficient  to  move  the  fibers  of  the  exposed  temporal  muscle. 
The  best  electrode  is  that  of  Gushing  (Fig.  475).  It  is  a  "glass  unipolar 
electrode  carrying  a  fine  platinum  wire  core,  coiled  into  a  spiral  at  the  end" 
(Gushing,  in  ''Keen's  Surgery,"  vol.  iii).  The  other  pole  is  attached  to  an 
extremity  "preferably  on  the  hom.olateral  side."     During  the  electric  test  the 


Fig.  473. — Combined  oslcoplaaiic  opera- 
tion. Second  step.  Bone  flap  turned 
down. 


Fig.  474. — Combined  osteoplastic  opera- 
tion. Third  step.  Showing  exposure  of 
brain  by  removal  of  dural  flap. 


patient  must  not  be  deeply  anesthetized.  A  careful  observer  watches  the 
muscular  movements.  If,  for  instance,  the  surgeon  wishes  to  remove  the 
thumb  center,  he  moves  the  electrode  from  point  to  point  until  he  obtains 
thumb  movements.  The  region  is  sliced  away  bit  by  bit  until  the  center 
which  is  responsible  for  the  conclusive  movements  is  removed.  It  will  be 
found  impossible  to  remove  only  the  thumb  center.     Adjacent  centers  are  sure 


Fig.  475. — Showing  terminal  and  connection  of  Cushing's  electrode  (f  natural  size).     Instru- 
ment should  be  16  inches  or  more  in  length. 

to  be  more  or  less  damaged,  and  a  certain  amount  of  paralysis  follows  the 
operation.  If  we  wish  to  tap  the  ventricles,  Keen  directs  the  trephine  opening 
to  be  one  and  one-fourth  inches  behind  the  external  auditory  meatus  and 
the  same  distance  above  the  base-line  of  Reid  (Fig.  476,  a) .  A  grooved  director 
or  metal  tube  is  passed  into  the  brain  in  the  direction  of  a  point  "two  and  one- 
half  to  three  inches  above  the  opposite  meatus."  The  normal  ventricle  will 
be  entered  at  a  depth  of  two  to  two  and  one-fourth  inches,  but  the  dilated 
ventricle  will  be  entered  sooner.     The  moment  of  entry  is  marked  by  lessened 


848 


Diseases  and  Injuries  of  the  Head 


resistance  and  a  flow  of  cerebrospinal  fluid.  Drainage  can  be  maintained 
by  introducing  a  rubber  tube.  This  operation  has  been  employed  in  hydro- 
cephalus. Kocher  punctures  the  ventricle  2^  cm.  from  the  midline  and  3  cm. 
in  front  of  the  fissure  of  Rolandi.  After  an  aseptic  cerebral  operation,  as  a  rule, 
do  not  drain  unless  hemorrhage  has  been  considerable.  In  many  cases  after 
trephining  replace  the  bone,  but  not  when  the  bone  is  diseased,  is  infected, 
is  very  compact,  or  if  it  is  desired  to  alter  pressure.  The  dura  is  sutured  by  a 
continuous  suture  of  silk  or  catgut;  the  scalp  is  sutured  by  interrupted  silk- 
worm-gut sutures. 

Operation  for  Mastoid  Suppuration. — The  instruments  required  in 
this  operation  are  a  scalpel,  a  gouge,  a  chisel,  a  mallet,  curets,  a  probe,  a 
dissector,  dissecting  and  hemostatic  forceps,  and  needles.  Provide  a  sand- 
bag to  place  under  the  neck.  An  incision  is  made  one-quarter  of  an  inch 
posterior  to  the  auricle  and  down  to  the  bone,  and  in  the  direction  of  the 


Fig.  476.— Opening  the  mastoid  antrum  and  the  lateral  sinus  ;  exposure  of  the  temporo-sphenoidal 
lobe  and  puncture  of  the  descending  horn  of  the  lateral  ventricle  :  a,  Temporo-sphenoidal  lobe  (de- 
scending cornu  of  lateral  ventricle  is  i  cm.  deeper) ;  d,  inner  surface  of  periosteum;  c,  mastoid 
antrum  ;  d,  lateral  sinus  (Kocher). 


long  axis  of  the  mastoid.  The  bone  is  bared  and  examined,  especially  at 
a  point  in  the  line  of  the  incision,  which  is  on  a  level  with  the  roof  of  the  meatus 
(Fig.  476,  c).  The  bone  will  usually  be  found  softened.  Gouge  it  away 
and  thus  open  the  mastoid  antrum.  The  bone-opening  is  within  the  limits 
of  Macewen^s  suprameatal  triangle,  a  space  bounded  by  the  posterior  root 


Linear  Craniotomy  849 

of  the  zygoma,  the  posterior  bony  wall  of  the  meatus,  and  an  imaginary 
line  joining  the  two.  If  the  mastoid  is  opened  in  this  triangle,  the  antrum 
is  entered  directly  and  there  is  no  chance  of  wounding  the  lateral  sinus.  If, 
in  the  adult,  pus  is  not  found  on  opening  the  mastoid  antrum,  gouge  down- 
ward and  backward,  but  with  great  care,  so  as  to  avoid  the  lateral  sinus. 
If  there  be  any  possibility  of  the  existence  of  pus  in  the  groove  of  the  sinus, 
the  sinus  should  be  unhesitatingly  exposed.  After  evacuating  the  pus  from 
the  mastoid  gouge  away  bony  septa,  enlarge  the  opening  between  the  mastoid 
and  the  middle  ear  with  the  gouge  and  remove  the  posterior  bony  wall  of  the 
meatus  (avoid  the  facial  nerve  on  the  floor  of  the  meatus),  turn  the  head 
toward  the  side  operated  upon,  and  irrigate  the  mastoid  with  salt  solution, 
dust  with  iodoform,  pack  with  iodoform  gauze  for  a  few  days,  and  then  intro- 
duce a  silver  drainage-tube.  Treat  the  causative  ear  disease.  Sheild  and 
Macewen  operate  on  inveterate  cases  of  mastoid  disease  as  follows:  A  thick 
flap  is  raised  behind  the  auricle,  the  flap  including  the  orifice  of  any  sinus 
and  being  "left  attached  by  its  stalk."  The  auricle  is  "detached  forward 
and  the  soft  parts  over  the  mastoid  are  turned  backward  by  horizontal  incision." 
The  "lining  membrane  of  the  canal  is  separated  from  the  bone."  The  mas- 
toid is  opened  and  dead  bone  and  caseous  matter  are  removed,  overhanging 
edges  are  chiseled  down,  and  the  posterior  bony  wall  of  the  external  auditory 
meatus  is  gouged  away.  The  skin-flap  is  pushed  into  the  cavity  and  is  held 
in  place  with  pads  of  gauze.  The  margins  of  the  flap  may  be  sutured,  but 
this  is  not  necessary.  Macewen  calls  this  procedure  "papering"  the  cavity 
with  skin.* 

If  mastoid  suppuration  has  established  abscess  in  the  temporo-sphenoidal 
lobe,  trephine,  one  and  a  quarter  inches  behind  and  one  and  a  quarter  inches 
above  the  middle  of  the  external  meatus  (Barker's  point),  and  search  for 
pus  as  directed  on  page  821.  If  abscess  of  the  cerebellum  exists,  trephine 
below  the  line  of  the  lateral  sinus.  "The  position  of  the  lateral  sinus  is 
indicated  by  a  line  running  horizontally  outward  from  the  occipital  protu- 
berance to  within  about  an  inch  of  the  external  auditory  meatus,  and  thence 
downward  to  the  mastoid  process"  (Owen's  "Manual  of  Anatomy").  If 
infective  sinus-thrombosis  exists,  break  into  the  lateral  sinus  (Fig.  476,  d) 
from  the  mastoid  opening  and  proceed  as  directed  on  page  824. 

Linear  Craniotomy. — Instruments  as  for  any  brain  operation,  plus, 
however,  several  kinds  of  rongeur  forceps.  Make  a  large  flap.  Trephine 
the  skull  a  finger's  breadth  from  the  sagittal  suture,  and  the  same  distance 
back  of  the  coronal  suture.  Rongeur  the  bone  away  in  a  line  parallel  with 
the  sagittal  suture  and  a  safe  distance  from  the  longitudinal  sinus,  up  to  a 
point  in  front  of  the  lambdoidal  suture.  Remove  the  pericranium  which 
covered  the  bone  excised.  Insert  the  dural  separator,  or  pass  it  along  the 
margins.  In  some  cases  an  additional  portion  of  the  bone  is  removed  over  the 
fissure  of  Rolando.  Various  suggestions  have  been  made  as  to  the  direction 
and  situation  of  bone-sections.  Bleeding  is  arrested  and  the  flap  is  closed 
without  drainage. 

Removal  of  Gasserian  Ganglion. — (See  page  781). 

Operation  for  Infective  Sinus-thrombosis. — (See  page  824). 

*  Lancet,  Feb.  8,  1896. 
54 


850 


Diseases  and  Injuries  of  the  Head 


The  Decompression  Operation  (Decompressive  Trephining). — This 
operation  is  employed  particularly  in  cases  of  inoperable  brain  tumor.  It 
differs  from  palliative  trephining  in  the  fact  that  the  dura  is  incised  and  an 
opening  left  to  permit  of  bulging  of  the  brain.  The  bulging  reheves  press- 
ure. By  Cushing's  method  we  get  a  hernia  of  the  brain,  but  not  a  fungus 
cerebri.  I  have  followed  Cushing's  recommendation  in  tumors,  and  have 
used  it  in  fractures  of  the  base  of  the  skull,  and  I  believe  it  saves  vision  and 
life  (in  the  latter  condition  it  is  done  on  both  sides). 

Gushing  and  Bordley  have  performed  it  in  cases  of  uremia  and  improve- 
ment has  followed  ("Am.  Jour,  of  Med.  Sciences,"  Oct.,  1908).  They  suggest 
that  the  operation  be  used  in  certain  cases  of  renal  disease  when  medical 


Fig-  477- 


-Sketch  of  the  intermusculotemporai  iield  of  operation,  showing  exposure  with  sub- 
temporal bone  defect  partly  made  (Gushing  in  "  Keen's  Surgery"). 


treatment  and  lumbar  puncture  have  failed  to  abate  uremic  symptoms,  or 
when  blindness  is  impending. 

The  effect  of  the  operation  in  cases  of  brain  tumor  is  sometimes  extra- 
ordinary. Its  most  prominent  benefit  is  in  abolishing  choked  disk.  It  must 
not  be  done  directly  over  a  tumor,  because  the  bulging  tumor  might  become 
the  seat  of  hemorrhage. 

It  is,  of  course,  useless  in  relie\ing  blindness,  for  blindness  means  atrophy, 
but  it  is  often  very  valuable  in  preventing  blindness.  When  choked  disk  exists 
operation  should  be  done  early  even  if  there  is  good  vision.  If  in  advanced 
cases  any  sight  remains,  it  should  be  performed.  Xow  and  then  there  is  an  un- 
favorable result,  for  instance,  the  development  of  retinal  hemorrhages  or  the  loss 
of  \'ision,  which  was  good  pre\ious  to  operation.    (See  DeSchweinitz  and  Hoi- 


The  Decompression  Operation 


851 


loway  on  "  Operative  Treatment  of  Papillo-edema  Dependent  upon  Increased 
Intracranial  Tension/'  "Therapeutic  Gazette,"  July  15,  1909.)  The  perma- 
nence of  the  relief  to  the  choked  disk  is  variable.  It  is  not  always  permanent. 
Cushing's  subtemporal  decompression  is  done  upon  the  right  side,  as  a  rule, 
but  in  some  cases  on  the  left  side.  An  objection  to  doing  it  on  the  left  side  is 
that  the  bulging  of  the  left  temporal  lobe  may  cause  word-deafness.  A  curved 
incision  is  made  through  the  skin  and  subcutaneous  tissue,  the  flap  is  turned 
down,  the  temporal  fascia  is  incised  in  the  direction  of  the  muscle-fibers  be- 


Fig.  478. — The  suboccipital  exposure  showing  opening  partly   made  and  Gushing 
bow  "  incision  (Gushing  in  "  Keen's  Surgery-"'). 


"  cross- 


neath  it,  the  temporal  muscle  is  split  and  not  cut,  the  periosteum  is  separated 
from  the  bone,  the  soft  parts  are  retracted,  the  bone  is  opened  as  the  surgeon 
prefers,  and  the  opening  is  enlarged  with  a  rongeur.  The  dura  is  opened  and 
radiating  incisions  are  made  through  it  toward  the  edges  of  the  bone  gap. 
The  wound  is  closed  by  four  layers  of  fine  silk  sutures. 

Fig.  478  exhibits  the  e.xposure  for  suboccipital  depression  as  done  for 
subtentorial  tumors.  The  same  exposure  is  obtained  in  order  to  remove  a 
cerebellar  tumor. 


852  Surgery  of  the  Spine 


XXIV.  SURGERY  OF  THE  SPINE. 

Congenital  Deformities. — Myelocele  or  Rachiscliisis. — This  condi- 
tion is  due  to  deficiency  in  the  formation  of  the  vertebral  arches,  the  cord 
being  rudimentary,  the  medullary  plates  having  failed  to  coalesce,  the  central 
canal  not  having  formed,  and  the  endothelium  which  should  line  it  being 
exposed.  If  the  entire  cord  is  involved,  the  condition  is  called  aniyelia  or 
total  rachischisis.  If  a  part  of  the  cord  is  involved,  the  condition  is  called 
partial  rachischisis.  In  partial  rachischisis  a  portion  of  skin  is  absent  in  the 
midline.  At  this  area  is  a  circular,  dark-red  focus  surrounded  by  a  very  thin 
and  glistening  membrane  which  becomes  continuous  with  the  skin.  A 
dimple  at  the  upper  part  and  a  dimple  at  the  lower  part  of  the  dark  area 
indicates  the  situation  of  the  central  canal  above  and  below.  Victims  of 
rachischisis  are  usually  stillborn  or  at  most  live  but  a  few  days. 

Spina  Bifida. — This  is  a  deformity  similar  to  the  one  just  discussed, 
but  in  it  the  cord  is  much  more  developed.  The  first  accurate  description 
of  it  was  given  by  Tulpius  in  1685.  It  is  a  congenital  sac  of  fluid  due  to 
vertebral  deficiency,  permitting  protrusion  of  the  contents  of  the  spinal 
canal  in  the  median  line.  In  this  condition  the  cutaneous  epiblast  is  adherent 
to  the  spinal  exiblast,  because  structures  from  the  mesoblast  have  failed  to 
grow  between.  The  laminae  or  spines  of  one  vertebra  or  of  several  verte- 
brae or  of  many  vertebrae  may  be  deficient,  most  frequently  in  the  lumbo- 
sacral region.  In  very  rare  cases  there  is  division  of  the  vertebral  l)odies 
and  the  projection  is  foward  and  to  the  side.  A  case  in  which  there  are  ununited 
laminae  but  no  protrusion  is  called  spina  bifida  occulta.  Sometimes  there 
are  two  protrusions  in  one  person.  In  spina  bifida  the  dura  does  not  cover  the 
sac  because  it  is  cleft  as  well  as  the  laminae.  There  are  three  distinct  varieties 
of  spina  bifida:  i.  Meningocele.  In  this  condition  the  dura  is  cleft  (Hilde- 
brand),  there  is  a  protrusion  of  the  arachnoid,  fluid  gathers  in  the  arachnoid 
meshes  and  "distends  this  so  as  to  form  one  continuous  cavity  which  is  tra- 
versed by  nerve-roots"  (Henle,  in  "A  System  of  Practical  Surgery"  by  von 
Bergmann,  Bruns,  and  von  Mikulicz.  Translated  and  edited  by  Wm.  T. 
Bull  and  Carlton  P.  Flint).  The  cord  is  not  in  the  sac.  2.  Meningo- 
myelocele (the  commonest  form)  is  a  protrusion  of  arachnoid,  the  sac 
containing  cerebrospinal  fluid,  nerves,  and  cord-substance.  The  cord 
may  spread  upon  the  sac-wall  or  it  may  pass  through  the  sac  and  reenter 
the  canal.  A  cutaneous  dimple  or  furrow  indicates  that  the  cord  is  attached 
and  hence  is  within  the  sac.  3.  Syringomyelocele  is  great  distention  of  the 
central  canal,  the  sac-wall  being  formed  of  the  thinned  cord  and  the  spinal 
membranes.  A  spina  bifida  varies  in  size  from  that  of  a  walnut  to  that  of 
an  infant's  head;  it  grows  rapidly  during  the  early  weeks  of  life;  it  is  usually 
sessile,  but  may  present,  where  it  joins  the  body,  a  definite  constriction,  or 
even  a  pedicle;  the  base  of  the  sac  is  covered  with  healthy  skin,  and  the  fundus 
is  covered  only  by  thin  epidermis  or  by  the  spinal  membranes  themselves. 
Pressure  upon  the  tumor  may  diminish  its  size  and  increase  the  tension 
of  the  anterior  fontanelle,  and  possibly  cause  convulsions  or  stupor.  The 
cyst  is  translucent,  and  the  margins  of  the  bony  aperture  are  distinct. 
Crying,  coughing,  or  pressure  upon  the  anterior  fontanelle  makes  the  tumor 


Anosacral  Cysts  853 

more  tense.  Spina  bifida  is  apt  to  be  associated  with  club-foot,  with  hydro- 
cephalus, and  with  rectal  or  vesical  paralysis.  Spina  bifida  usually  causes 
death  (go  per  cent,  of  cases  die  during  the  first  year  of  life).  A  few  men- 
ingoceles and  a  very  few  meningomyeloceles  undergo  spontaneous  cure  by 
growth  of  the  vertebral  arches  constricting  the  neck  of  the  sac.  The  sac 
may  remain  distended  with  fluid  or  may  shrink.  Syringomyelocele  is  invari- 
ably fatal.  The  cause  of  death  may  be  rupture  of  the  sac  or  marasmus. 
The  .T-rays  show  the  bony  gap.  Spina  bifida  occulta  is  a  cleft  in  the 
vertebral  column  without  any  protrusion  of  the  cord  or  the  membranes. 
In  this  condition  there  is  usually  a  profuse  growth  of  hair  in  the  skin 
over  the  bony  gap  and  the  hairy  condition  may  be  much  more  wide-spread. 
In  some  cases  the  hair  is  present  at  birth;  in  others  it  appears  at  puberty. 
Trophic  changes  and  deformities  may  exist  in  the  lower  extremities. 

Treatment. — Very  small  protrusions  which  grow  slowly  and  are  covered 
with  sound  skin  may  be  treated  by  the  use  of  a  compress  and  bandage,  by  an 
elastic  bandage,  or  by  applications  of  contractile  collodion.  It  was  formerly 
regarded  as  proper  to  tap  and  drain  the  sac.  Injection  was  used  by  many. 
The  skin  being  cleansed,  the  child  was  placed  on  its  side  and  a  little  chloroform 
was  given.  A  fine  trocar  was  plunged  obliquely  in  at  the  side  of  the  sac 
through  sound  skin,  little  or  no  fluid  being  drawn  off,  and  5j  of  Morton's 
fluid  injected  (iodin,  gr.  x;  iodid  of  potassium,  gr.  xxx;  glycerin,  §j).  The 
trocar  was  withdrawn  and  the  puncture  was  sealed  with  a  bit  of  gauze  and 
iodoform  collodion.  The  child  was  put  to  bed.  If  injection  proved  successful, 
the  sac  was  found  to  shrink;  if  the  injection  failed,  it  was  the  custom  to  repeat 
it  at  intervals  of  from  seven  to  ten  days  (Jacobson,  White).  Surgeons  now 
prefer  excision  of  the  sac.  Whenever  possible  the  incision  should  be  through 
healthy  skin.  If  the  sac  contains  nerves  they  should  be  placed  within  the  canal. 
Bayer  treats  it  as  he  would  a  hernia.  Robson  in  some  cases  excises  the  entire  sac. 
Operations  upon  children  much  under  the  age  of  five  have  an  enormous  mortal- 
ity. Operations  are  comparatively  safe  when  the  child  reaches  the  age  of  five. 
We  should  not  operate  if  there  is  hydrocephalus  or  extensive  paralysis,  if  the 
mass  is  very  large  and  growing  rapidly,  or  if  there  are  other  marked  deformities. 
A  ruptured  sac  should  be  operated  on  at  once,  otherwise  death  is  practically 
certain.  Operations  for  spina  bifida  have  been  done  successfully  immediately 
after  birth  (Lovett,  in  "iVm.  Jour.  Orthop.  Surg.,"  Oct.,  1907). 

Sacrococcygeal  Tumors. — Dermoids  external  to  the  sacrum  are 
occasionally  seen  in  this  region.  Dermoids  also  arise  between  the  rectum  and 
sacrum.  In  the  lower  sacral  or  coccygeal  region  the  cutaneous  structures 
sometimes  fail  of  complete  coalescence  and  a  post-anal  dimple  or  sinus  is  the 
result.  Such  a  sinus  is  lined  with  skin  and  its  wall  contains  numerous 
glands  and  often  hairs.  It  may  inflame  or  suppurate.  If  it  blocks  up  at  the 
outlet,  a  form  of  dermoid  develops.  Teratomata,  lipomata,  and  hydatid  cysts 
may  develop  in  the  sacrococcygeal  region. 

Treatment. — Dermoids  require  extirpation.  If  a  post-anal  dimple  causes 
no  trouble,  it  is  let  alone;  otherwise  it  is  dissected  out.  It  may  or  may  not  be 
possible  to  remove  teratomata.     Lipomata  and  hydatids  are  extirpated. 

Anosacral  Cysts. — These  cysts  develop  between  the  sacrum  and  rec- 
tum and  originate  from  remnants  of  the  post-anal  gut  and  neurenteric  canal. 
Such  cysts  may  be  multilocular  or  unilocular.  They  can  be  detected  by  a 
finger  in  the  rectum. 


854  Surgery  of  the  Spine 

Treatment. — Some  of  these  growths  are  removed  after  osteoplastic  re- 
section of  a  portion  of  the  sacrum;  others  are  removed  by  incising  the  rectal 
w^all. 

Tumors  of  the  Spinal  Cord.— Tumors  may  arise  from  the  cellular 
tissue,  fatty  tissue,  the  nerve  roots,  the  membranes  of  the  cord,  or  from  the 
vertebra  {exlramedullary  turners).  They  may  arise  with  the  cord  (cord  tumors 
proper  or  intramedullary  tumors) . 

Extramedullary  Tumors. — Syphilomata,  hydatid  cysts,  tuberculomata, 
and  inflammatory  masses  or  adhesions  may  compress  the  cord  and  produce 
symptoms  indistinguishable  from  genuine  tumor.  Among  extramedullar^ 
tumors  are  secondary  carcinoma,  sarcoma  (primary  or  secondary),  fibroma, 
myxoma,  lipoma,  chondroma,  and  neuroma.  Dermoid  sacral  cysts  may  exist. 
Lipoma,  fibroma,  and  certain  cysts  may  be  congenital. 

Injury  of  the  back  sometimes  seems  to  bear  a  causal  relation  to  extra- 
medullary  tumors. 

The  symptoms  are  due  to  pressure  upon  nerve-roots  and  the  cord. 

Symptoms. — The  most  prominent  symptoms  are  pain  in  the  back  and 
evidences  of  nerve-root  irritation. 

The  early  or  irritative  symptoms  are  pain  and  stiffness  of  the  back,  usually 
very  severe  and  interfering  with  sleep,  shooting  pains  in  the  area  of  the  im- 
plicated nerve-roots,  and  sensory  abnormahties  in  the  same  area.  There  may 
be  hyperesthesia  of  a  limited  area.  The  area  of  distribution  from  one  or  two 
roots  is  involved  in  pain,  sensory  disturbance,  and  slight  motor  impairment. 
In  some  cases  the  nerve-roots  of  one  side  only  exhibit  irritation  and  the  symp- 
toms are  strictly  unilateral.  In  other  cases  the  symptoms  are  bilateral,  but 
are  most  marked  on  one  side.  In  some  cases  the  symptoms  are  symmetrically 
bilateral  and  indicate  pressure  upon  the  cord  rather  than  upon  nerve-roots. 
Muscular  spasms  may  occur.  There  may  be  lateral  curvature  of  the  back,  the 
concavity  of  the  curve  being  on  the  side  of  the  tumor.  Sooner  or  later  para- 
lytic symptoms  come  on  (motor  and  sensory  paralysis) .  They  may  be  due  to 
pressure  upon  and  destruction  of  nerve-roots  or  to  compression  of  the  cord. 
When  anesthesia  exists  there  may  be  a  zone  of  hyperesthesia  above  its  upper 
limit.  As  motor  palsy  develops  from  root  compression  the  pain  usually 
abates.     The  muscles  undergo  atrophy. 

A  tumor  may,  by  cord  pressure,  produce  the  symptoms  of  compression- 
myelitis,  locomotor  ataxia,  or  myelitis.  Contractures  or  paraplegia  may  arise 
from  tumor.  The  location  of  the  growth  can  be  inferred  by  a  study  of  the  terri- 
tory of  paralysis  and  the  zone  of  sensory  disturbance.  The  tumor  is  always 
situated  somewhat  above  the  upper  hmit  of  anesthesia.  In  many  cases  the  diag- 
nosis is  impossible.  Gradually  increasing  painful  paraplegia,  with  pain  in  the 
back  and  with  hyperesthesia  or  anesthesia  after  a  time  appearing  and  ascend- 
ing from  the  feet  toward  the  trunk,  points  to  tumor  as  a  cause.  The  paralysis 
is  usually  spastic,  but  may  be  flaccid,  or  it  may  be  spastic  at  first  and  become 
flaccid.  In  spastic  paraplegia  the  reflexes  are  increased.  In  flaccid  paraplegia 
they  are  decreased.  In  spastic  paraplegia  there  are  ankle  clonus,  the  Babinski 
sign  (extension  of  the  great  toe  or  all  the  toes  when  the  sole  of  the  foot  is  irri- 
tated), Gordon's  paradoxical  reflex  (extension  of  the  great  toe  or  all  the  toes 
when  pressure  is  made  upon  the  deep  calf  muscles),  and  Oppenheim's  reflex 
(extension  of  the  great  toe  or  all  the  toes  when  the  handle  of  the  percussion 


Treatment  of  Tumors  of  the  Cord  855 

hammer  is  drawn  along  the  inner  edge  of  the  tibia  so  as  to  make  pressure 
from  above  downward).  Trophic  lesions  are  apt  to  arise  in  the  trajectory  of 
nerve  involvement.  The  sphincters  are  usually  involved.  Growths  outside 
the  membranes  produce  particularly  pain  and  spasm;  growths  within  the  mem- 
branes produce  especially  motor  paralysis  and  anesthesia.  Symptoms  that 
are  unilateral  were  at  first  unilateral,  or  v/hich  are  most  marked  on  one  side, 
are  very  significant. 

Intramedullary  Tumors. — These  tumors  develop  in  the  substance  of  the 
cord.  These  are  far  less  common  than  extramedullary  growths.  The.se 
growths  are,  as  a  rule,  primary  and  solitary  and  do  not  produce  symptoms  of 
pressure  until  they  attain  the  size  of  a  hazel-nut.  The  most  common  tumors 
are  glioma,  sarcoma,  and  tuberculoma.  Syphiloma  occasionally  arises. 
Alost  tumors  in  cord  substance  are  small,  but  the  glioma  may  involve  practically 
the  entire  cord.  A  tumor  is  often  for  a  time  limited  to  one  side  of  the  cord, 
but  later  it  presses  upon  and  finally  involves  the  opposite  side.  When  the 
cord  is  pressed  upon,  degeneration  occurs.  In  some  cases  a  wrench  or  bruise 
of  the  back  is  supposed  to  be  causal.     Glioma  may  be  congenital. 

Symptoms. — They  are  at  first,  in  most  cases,  very  uncertain.  In  some 
cases,  however,  paralysis  develops  early. 

There  is  often  pain  in  the  back,  but  it  is  not  nearly  so  severe  as  in  extra- 
medullary  tumor.  The  most  prominent  symptom  is  a  slow-developing  motor 
palsy.  In  some  cases  the  palsy  is  at  first  unilateral,  but  later  becomes  bilateral. 
Irritative  root  symptoms  are  absent  (spasm  and  darting  pain) .  Anesthesia  or 
hyperesthesia  develop.  The  sphincters  are  involved  and  trophic  disturbances 
arise.  There  may  be  spastic  paraplegia  or  flaccid  paraplegia.  If  the  tumor 
is  in  or  presses  upon  the  anterior  corner  there  will  be  limited  muscular  atrophy. 
Tuberculoma  produces  the  symptoms  of  transverse  myehtis. 

In  ghoma  there  are  paresis  and  muscular  atrophy.  Although  sensibiHty 
to  pain,  heat,  and  cold  are  lost,  sensibility  to  touch  is  preserved  (sensory  dis- 
sociation) . 

Treatment  of  Ttmiors  of  the  Cord. — If  syphilis  is  suspected,  give  the 
patient  a  course  of  heroic  doses  of  iodid  of  potassium,  and  administer  mercury 
hypodermatically  or  by  inunction.  In  a  focal  lesion  not  due  to  dissemination 
of  a  known  malignant  growth,  perform  the  operation  of  laminectomy  to  permit 
of  exploration  and  possibly  of  removal.  The  lamina?  of  at  least  three  vertebrae 
should  be  removed  and  the  tumor  is  looked  for  distinctly  above  the  upper  level 
of  the  zone  of  anesthesia.  It  is  not  necessary  for  the  patient  to  wear  a  spinal 
support  after  the  performance  of  laminectomy.  McCosh  truly  says  that  opera- 
tion for  spinal-cord  tumor  is  decidedly  more  hopeful  than  for  brain  tumor, 
because  locahzation  is  much  more  accurate  and  removal  can  be  effected  with 
less  permanent  damage.  Lloyd  collected  51  operations:  10  per  cent,  died  and 
31  per  cent,  were  actually  cured  or  improved.  Joseph  Collins  ("Med.  Rec- 
ord," Dec.  6,  1902)  collected  70  cases  of  spinal  tumor,  30  of  which  were 
operated  upon.  In  12  the  operation  was  a  success,  that  is,  the  pain  disap- 
peared and  motor  power  returned;  in  8  the  operation  was  partly  successful, 
that  is,  the  pain  disappeared  and  the  motor  power  improved;  in  10  the 
operation  failed  and  death  occurred  within  a  few  weeks.  If  the  tumor  is 
found  to  be  irremovable,  McCosh  suggests  division  of  several  nerve- roots  to 
relieve  the  pain. 


856  Surgery  of  the  Spine 

Acute  osteomyelitis  of  the  vertebrae  is  a  rare  disease;  it  may  be 
associated  with  osteomyehtis  of  other  bones,  may  be  secondary  to  some 
distant  suppurative  focus,  but  may  occur  alone.  Infections  of  the  viscera 
not  unusually  accompany  it.  In  many  cases  there  is  a  history  of  trauma. 
Any  part  of  a  vertebra  may  suffer  from  it.  This  condition  may  follow  cold, 
overexertion,  or  traumatism,  and  is  more  common  in  the  first  two  decades 
of  life  than  in  elderly  people.  The  process  may  be  superficial,  or  it  may 
involve  the  bone  deeply  and  widely.  Suppuration  always  occurs;  sequestra 
generally  form;  and  phlebitis  is  a  dangerous  complication.  Any  region  of 
the  spine  may  be  attacked,  but  the  lumbar  region  is  particularly  liable  to 
invasion,  next  the  dorsal,  next  the  cervical.  The  sacral  region  is  least  often 
affected.  The  situation  of  the  abscess  varies  with  the  situation  of  the  dis- 
ease. If  the  vertebral  bodies  are  diseased,  the  pus  passes  forward  (retro- 
pharyngeal, mediastinal,  psoas,  or  pelvic  abscess).  If  the  vertebral  arches 
suffer,  the  pus  passes  backward  (lumbar  or  dorsal  abscess).  The  membranes 
of  the  cord,  the  cord  itself,  the  nerves,  and  the  vertebral  articulations  are  fre- 
quently involved  in  the  process.  Staphylococci,  streptococci,  or  other  pyogenic 
bacteria  may  be  cultivated  from  the  pus. 

Symptoms. — The  general  symptoms  are  those  of  osteomyelitis.  The 
local  symptoms  depend  on  the  seat  of  disease.  If  the  posterior  portion  of  the 
column  is  diseased,  there  is  a  hard  swelling,  which,  in  the  neck,  is  in  the  middle 
hne;  in  the  dorsal  and  lumbar  regions,  in  the  middle  or  to  the  side;  and  in  the 
sacral  region,  invariably  to  one  side. 

Rigidity  of  the  spine  always  exists.  If  the  vertebral  bodies  are  affected, 
rigidity  is  noted,  the  spine  is  tender,  and  special  symptoms  appear,  their 
nature  dependent  on  the  region  affected  (retropharyngeal  abscess,  etc.). 
Occasionally  symptoms  of  meningomyelitis  are  noted.  The  constitutional 
symptoms  of  sepsis  are  marked.  The  condition  is  sudden  in  onset,  and 
purulent  collections  diffuse  widely  and  rapidly.  These  points  enable  the 
surgeon  to  make  a  diagnosis  between  osteomyelitis  and  Pott's  disease.  In 
osteomyelitis  angular  deformity  very  rarely  arises,  because  the  patient  is 
obliged  to  be  recumbent  and  because  hyperostosis  is  taking  place.  The 
mortality,  according  to  Hahn,  is  60  per  cent.  Death  may  be  due  to  pachy- 
meningitis, pneumonia,  empyema,  retropharyngeal  abscess,  invasion  of  the 
cord,  or  amyloid  disease  (H.  S.  Warren,  "Boston  Med.  and  Surg.  Jour.," 
May  7,  1903). 

Treatment. — The  patient  is  kept  recumbent.  His  constitutional  treat- 
ment is  such  as  will  combat  sepsis  (food,  stimulants,  etc.).  A  puriform  area 
must  be  incised  and  disinfected.  If  bone  denuded  of  periosteum  is  found,  it  is 
touched  wnth  a  solution  of  chlorid  of  zinc  or  with  the  actual  cautery.  If  a 
sequestrum  exists,  it  is  removed.  A  drainage-tube  is  inserted  and  dressings 
are  applied  (Miiller,  Makins,  Abbot,  and  Chipault). 

Typhoid  Spine. — It  was  pointed  out  by  Gibney  in  1889  that  typhoid  fever 
may  leave  as  a  legacy  a  painful,  stiff,  and  weak  back.  Seventy-four  cases  of 
this  condition  have  been  reported  (F.  W.  White,  in  "Jour.  Am.  Med.  Assoc," 
Feb.  13,  1908).  The  muscles  of  the  back  are  found  to  be  rigid  and  there  is 
tenderness  of  one  or  more  vertebrae.  The  pain  may  only  be  appreciated  on 
motion,  but  in  some  cases  there  is  aching  even  when  the  patient  is  at  rest. 
The  pain  may  be  locaHzed,  may  run  into  one  or  both  thighs,  or  may  be  felt 


Cervical  Rib 


857 


in  the  abdomen.  The  symptoms  arise  at  an  uncertain  period  after  the  fever, 
develop  rapidly,  and  are  occasionally  associated  with  transient  episodes  of 
fever.  Kyphosis  or  lateral  curvature  may  develop.  (See  L.  W.  Ely,  "Medical 
Record,"  Dec.  20,  1902).  Usually  the  patient  is  hysteric.  The  condition 
is  due  to  osteitis  and  periosteitis,  or  chronic  osteomyelitis.  The  prognosis  is 
excellent. 

Treatment. — The  use  of  a  plaster  or  leather  jacket;  countcrirritation  by 
the  hot  iron;  later,  massage  and  electricity. 

Cervical  Rib. — This  condition  was  first  described  by  Hunauld  in  1743. 
The  anterior  limb  of  the  transverse  process  of  the  seventh  cervical  vertebra, 
which  has  an  independent  center  of  ossification,  may  develop  into  a  separate 
bone  of  large  size,  known  as  a  cervical  rib.     Such  a  rib  mav  form  on  one 


Fig.  479. — Cervical  ribs. 


side  or  on  both.  It  may  scarcely  reach  beyond  the  transverse  process,  it  may 
project  well  beyond  the  transverse  process  and  have  a  free  end,  or  it  may  con- 
stitute a  complete  rib  w^hich  fuses  anteriorly  with  the  sternum,  the  cartilage  of 
the  first  rib,  or  with  a  cervical  rib  of  the  opposite  side. 

Most  instances  described  were  found  in  the  dead  body,  although  Tillmanns 
collected  26  cases  among  the  living  (Carl  Beck,  in  "Jour.  Am.  Med.  Assoc," 
June  17,  1905).  Of  late  .r-ray  findings  indicate  that  the  condition  is  much 
more  common  than  was  formerly  supposed.  I  have  seen  4  cases.  It  may 
never  produce  any  uneasiness,  and  hence  may  escape  detection  and  seldom 
does  produce  trouble  in  youth.  It  may  lead  to  damage  of  the  subclavian 
artery  (Keen's  case  developed  aneurysm),  or  gangrene  of  the  hand  may  result 
from  bending  or  blocking  of  the  vessel,  or  neuritis  of  the  brachial  plexus  may  arise 
from  pressure.     When  sufficiently  large  to  produce  venous  or  vascular  trouble, 


858 


Surgery  of  the  Spine 


a  cervical  rib  can  be  felt  and  the  pulsating  artery  over  it  is  very  distinct  and 
higher  than  natural  in  the  neck.  The  A'-rays  confirm  the  diagnosis.  The 
treatment,  when  the  rib  is  causing  trouble,  is  excision  of  the  rib  with  its  peri- 
osteum (page  720).  (See  Kammerer,  in  "Annals  of  Surg.,"  Nov.,  1901, 
on  "The  Diagnostic  Difficulties.") 

CONDENSED    DIFFERENTIAL    DIAGNOSIS    TABLE  OF   SPINAL  DISEASES  AND   CONDI- 
TIONS WITH  WHICH  THEY   MAY   BE  CONFOUNDED. 


Hyper- 

Arthritis 

Torticol- 

Hip 
Disease. 

Scoliosis. 

Rachitic 
Spine. 

Potts' 
Disease. 

esthetic 
Spine. 

Defor- 
mans. 

lis,  Con- 
genital. 

Age. 
Onset. 

8  to  16. 

4  to  6. 

4  to  6. 

16  to  20. 

After  30. 

Any  age. 

4  to  6. 

Insidious . 

Insidious. 

Insidious. 

Sudden. 

Insidious. 

From  birth. 

Insidious. 

Pain. 

In  back. 

None. 

Referred  to 
anterior 
abdomen. 

Severe      in 
spine. 

In  spine. 

None. 

In  knee. 

History. 
Posture. 

None. 

Rachitic. 

TB. 

Trauma. 

None. 

From  birth. 

TB. 

Free. 

Excessively 

Guarded 

Guarded. 

Guarded 

Typic. 

Guarded 

free. 

spine. 

spine. 

hip. 

Muscular 

None. 

Free. 

In  spine. 

In  spine. 

In  spine. 

In   one  di- 

In   hip    in 

rigidity. 

rection 
only. 

all    direc- 
tions. 

Temperature. 
Local    tender- 

None. 

None. 

I  degree. 

Varies. 

None. 

None. 

I  degree. 

None. 

None. 

In  spine. 

Painful   all 

All   over 

None. 

In  hip. 

ness. 

over. 

spine. 

Night  cries. 
Tendency      to 

.\bsent. 

Absent. 

Present. 

Absent. 

Absent. 

None. 

Present. 

None. 

None. 

Probable. 

None. 

None. 

None. 

Probable. 

abscess. 

X-ray. 

Character- 

Normal. 

Focus  in 

Normal. 

La».e 

Distortion 

Spine    nor- 

istic    de- 

spine. 

bridges 

of  cervical 

mal. 

formity. 

of  bone. 

spine. 

Hot-water  test. 

No  tender- 

None. 

Localized 

Sensitive 

No  necrosed 

No  tender- 

No tender- 

ness. 

in  spine. 

all  over 
spine. 

sensitive- 
ness. 

ness. 

ness       in 
spine. 

General  symp- 

Constant. 

Constant. 

Intermit- 

Constant. 

Constant. 

Constant. 

Intermit- 

toms. 

tent. 

tent. 

Spinal  Curvatures. — There  are  four  chief  forms  of  spinal  curvature: 
(i)  Lateral  curvature  (the  scoliosis  of  the  older  surgeons) ;  (2)  posterior  cur- 
vature (the  excurvation,  gibbosity,  or  kyphosis  of  the  older  surgeons);  (3) 
anterior  curvature  (the  lordosis  of  the  older  surgeons) ;  and  (4)  angular  cur- 
vature (from  spinal  caries).  The  normal  spine  has  four 
curves:  the  cervical  curve,  the  convexity  of  which  is  for- 
ward; the  dorsal  curve,  the  convexity  of  which  is  back- 
ward; the  lumbar  curve,  which  is  convex  anteriorly;  and 
the  pelvic  curve,  which  is  concave  anteriorly.  The 
dorsal  and  the  pelvic  curves,  which  are  primary,  are 
due  to  the  formation  of  the  cavities  of  the  chest  and 
pelvis,  and  depend  upon  the  shape  of  the  bones  (Treves). 
The  cervical  and  lumbar  curves,  which  are  compensa- 
tory, depend  upon  the  shape  of  the  intervertebral  discs, 
and  only  appear  after  birth  when  the  erect  position  is 
assumed. 

Scoliosis. — Scoliosis  is  a  non-pathologic  distortion  of 
the  spine  characterized  by  rotation  and  lateral  bending, 
hence  the  name,  rotary  lateral  curvature  (Plate  8).     It  is 
functional  or  organic. 

Functional  scoliosis  is  caused  by  any  prolonged  alteration  in  the  relation- 
ship normally  existing  between  the  axis  of  the  shoulders  and  the  axis  of  the  hips. 


Fig.  480.— Lateral 
dorsal  cur\'ature  to  the 
right,  and  compensa- 
tory lumbar  cur\-e  to  the 
left. 


SPINAL    CURVATURE. 


Plate  8. 


Rotary  lateral  curvature  of  the  spine. 


Scoliosis  859 

The  etiologic  factors  depend  upon  the  maintenance  of  faulty  postures  in  occu- 
pations, especially  during  i^eriod  of  growth.  School-life  is  especially  influential 
in  producing  the  condition  because  school  furniture  is  adapted  to  the  average 
requirements  of  a  given  class,  and  therefore  a  very  small  proportion  of  pupils 
are  able  to  find  desks  and  benches  that  are  suitable.  Properly  furnished 
modern  schools  are  supplied  with  desks  and  seats  that  are  adjustable  to  each 
occupant.  Gould  ("The  Ocular  Factors  in  the  Etiolog)-  of  Spinal  Curvature," 
H  Augustus  Wilson,  "New  York  Medical  Journal,"  July  12, 1906)  has  directed 
attention  to  the  errors  of  refraction  that  produce  head  tilting  and  thereby  induce 
scoliosis.  In  adults,  scoliosis  is  observable  in  blacksmiths,  fencing  masters,  and 
waiters,  where  excessive  use  of  the  right  arm  produces  an  assymmetric  posture 
of  the  body. 

When  functional  scoliosis  is  not  corrected  or  occurs  in  rachitic  or  indolent 
children,  it  results  in  organic  or  permanent  changes  in  the  contour  of  the  bones 
composing  the  spinal  column.  Organic  scohosis  may  be  congenital,  caused  by 
prenatal  deficiencies  or  augmentations  of  the  spinal  column  (see  .Y-rayj . 

There  is  no  pathology,  but  post-mortem  examinations  reveal  a  confirma- 
tion of  Wolfe's  law  that  prolonged  alteration  of  the  normal  functions  always 
results  in  changes  of  anatomic  structures.  In  extreme  cases  the  bones  of  the 
spinal  column  become  extensively  altered  in  shape,  the  ribs  are  altered  in 
coiitour,  and  the  thoracic  and  abdominal  viscera  are  forced  into  unnatural 
positions  and  assume  abnormal  shapes,  their  functions  often  being  materially 
altered. 

Diagnosis. — The  patient  is  usually  taken  to  the  physician  because  of  appar- 
ent elevation  of  one  shoulder,  or  because  one  hip  is  thought  to  be  larger  than 
its  mate,  or  one  mamma  larger  than  the  other.  Dressmakers  and  corset 
makers  are  generally  the  first  ones  to  direct  attention  to  the  faulty  posture 
(as  scoliosis  occurs  in  eight  girls  to  one  boy).  A  patient  suspected  of  having 
scoHosis  should  be  nude  at  the  time  of  inspection,  as  clothing  hampers  the  normal 
action  and  tends  to  conceal  the  movements  of  the  body.  The  accompanying 
diagnostic  table  (page  858)  is  a  condensed  comparative  statement  of  the 
important  features  in  diseases  and  conditions  that  may  resemble  scoHosis  in 
some  respects.  It  is  only  by  carefully  studying  the  symptom-complex  that  a 
definite  decision  can  be  reached.  It  is  frequently  obserA-ed  that  patients 
with  mild  types  of  functional  scoHosis  can  sit  or  stand  erect  for  a  few  minutes 
and  thereby  deceive  even  a  critical  observer.  The  habitual  posture,  as  well  as 
the  rapidity  \\\i\\  which  the  patient  returns  to  the  distorted  position  after  tem- 
porary voluntary  correction,  demand  careful  attention.  Young  children,  when 
chided  by  parents  or  teachers,  often  temporarily  assume  an  approach  to  a 
normal  posture  without  actual  correction.  The  ease  with  which  their  sur- 
rounding joints  peld  in  compensatory  action  is  often  overlooked.  A  patient 
with  contracture  of  the  pectoral  muscles  will  elevate  the  shoulders  into  an 
apparent  correction  of  stoop  or  round  shoulders  instead  of  throwing  the 
shoulders  weU  back,  a  posture  that  is  to  them  impossible. 

Goldthwait  has  directed  attention  to  forward  curves  of  the  scapula  that 
are  often  present  in  patients  who  are  stoop-shouldered  and  has  devised 
an  operation  for  its  correction. 

In  the  same  way,  a  patient  who  has  preternatural  contracture  of  the  ham- 
string tendons,  either  unilateral  or  bilateral,  will  often  conceal  that  condition 


86o  Surgery  of  the  Spine 

by  bending  the  knee  or  knees  enough  to  permit  tlie  pelvis  and  trunk  to  bend 
forward. 

Treatment  consists  especially  of  removing  the  cause.  If  the  eyes  produce 
head-tilting,  proper  refraction  will  be  necessary.  Adenoids  should  be  re- 
moved. The  clothing  should  be  regulated  to  avoid  constriction  and  the 
shoulder  straps  should  fit  close  to  the  neck  and  not  be  allowed  to  shp  on  to  the 
shoulder-joint. 

Contractures  of  the  pectoral  muscles  should  be  stretched  by  corrective  ma- 
nipularions.  Hamstring  contracture  should  be  removed  by  correcdve  manipu- 
lation. Hoke  ("A  Study  of  a  Case  of  Lateral  Curvature  of  the  Spine:  \  Report 
on  an  Operation  for  the  Deformity,"  "American  Jour.  Ortho.  Surg.,"  vol.  i, 
November,  1903,  p.  169)  has  de\ised  an  operation  of  rib  resection  for  cosmetic 
purposes.  Every  effort  should  be  made  to  prevent  the  occurrence  of  scoliosis. 
The  successful  treatment  of  scoUosis  depends  on  preventing  its  progress.  It 
is  essential  that  it  should  be  fully  understood  that  braces  of  any  kind,  as  corsets 
and  constricting  clothing,  are  not  only  useless  and  irrational,  but  positively  harm- 
ful. Especially  injurious  are  the  ready-made  varieries  of  braces  and  spinal  sup- 
ports. Each  individual  patient  requires  careful  study  to  determine  the  special 
characteristics  that  may  be  present.  Remedial  measures  should  be  employed 
that  meet  the  pecuHar  individual  requirements  of  each  case. 

School  gymnastics  are  generally  more  harmful  than  beneficial  in  cases  of 
scoliosis.  No  one  but  a  physician  should  prescribe  the  gymnastic  work.  The 
soft  bones  may  be  still  further  distorted  by  injudicious  exercises. 

The  first  requirement  in  the  application  of  applied  physical  culture  is  to 
secure  the  hearty  cooperation  of  the  patient.  Without  such  cooperation  prog- 
ress cannot  be  expected. 

No  gymnastic  apparatus  of  any  kind  is  required  when  the  patient  can  be 
instructed  in  the  proper  methods  of  autoresistance.  There  are  over  four 
thousand  movements  of  the  body  that  may  be  employed  in  remedial  physical 
culture.  From  this  vast  assortment  those  may  be  selected  that  are  suitable  to 
the  peculiar  conditions  of  the  patient.  At  first  the  least  tiresome  forms  are  to 
be  employed,  and  gradually  and  progressively  others  are  resorted  to  until  the 
patient  presents  a  strong  robust  personality.  Usually  about  a  year  is  required 
for  the  purpose,  as  the  progress  must  be  essentially  educational.  Training 
in  developing  muscle  action  goes  hand  in  hand  ^^dth  instruction  in  walking,  in 
sitting,  and  in  all  the  postures  assumed  by  the  human  body  in  the  various  occu- 
pations of  the  patient. 

In  organic  scoUosis,  where  the  distortion  is  more  or  less  of  a  permanent 
character,  much  can  be  accomphshed  in  preventing  the  progress  of  the  condi- 
tion as  well  as  in  aiding  correction  by  removing  any  rigidity  that  may  be  pres- 
ent. By  increasing  the  flexibihty  we  faciUtate  muscular  development  in  much 
the  same  manner  as  in  functional  scoliosis. 

When  rigidity  is  present  it  must  be  considered  in  the  same  light  as  rigidity 
of  any  other  joints.  Its  presence  prevents  muscular  development.  Manipu- 
lative measures  are  similar  in  effect  to  those  employed  in  fibrous  ankylosis  of 
any  joint,  and  are  pecuhar  to  the  parts  involved.  In  the  majority  of  cases  the 
force  for  manipulative  correction  must  be  apphed  through  the  interposition  of 
the  ribs,  and  the  great  danger  of  producing  fractures  of  these  structures  should 
be  reaHzed.     One  famihar  \^^th  the  dangers  as  well  as  the  technic  will  have 


Angular  Curvature  86i 

little  difficulty  in  avoiding  the  former  and  applying  the  latter.  In  no  instance 
is  a  layman  warranted  in  undertaking  the  procedures  that  are  necessary,  and 
only  a  physician  with  experience  in  scoliosis  will  successfully  carry  such  cases 
to  a  satisfactory  termination. 

In  severe  cases  of  organic  scoliosis  plaster-of-Paris  jackets  and  other 
forms  of  fixation  appliances  are  occasionally  applied  for  definite  purposes 
during  the  developmental  stages.  Such  appliances  should  be  made  to  order 
to  fit  the  peculiarities  of  the  patient  and  should  never  be  the  shop-kind  that 
are  extensively  advertised.  Much  valuable  time  is  often  lost  during  the  use 
of  unmechanical  and  unsuitable  apparatus,  during  which  the  bony  changes 
become  permanent  and  beyond  repair. 

Anteroposterior  curvature  (not  from  spinal  caries  or  from  hip-joint 
disease)  is  an  increase  of  the  normal  anteroposterior  curves.  Increase  of  the 
dorsal  curve  is  posterior  curvalure,  kyphosis,  or  excurvation  (Fig.  481,  a);  in- 
crease of  the  lumbar  curve  is  anterior  curvature,  lordosis,  or  saddle-back  (Fig. 
481,  b).  Both  lordosis  and  kyphosis  are  apt  to  be  present.  Scoliosis  has 
nearly  always  some  anteroposterior  curvature  associated  with  it.  Lordosis  is 
apt  to  be  compensatory,  to  prevent  the  center  of  gravity 
going  too  far  forward.  Lordosis  is  found  in  pregnant 
women  and  in  very  fat  men.  In  an  old  man  kyphosis 
arises  from  flattening  out  of  the  vertebral  discs  from 
pressure.  Rheumatic  gout  may  cause  anteroposterior 
curvature.  Anteroposterior  curvature  is  often  due  to 
paralysis  of  the  erector  spinas  mass  (from  infantile  paral- 
ysis).    Pseudohypertrophic  paralysis  causes  lordosis. 

Symptoms  and  Treatment. — The  symptoms  of  antero- 
posterior curvature  are  as  follows:  the  thorax  is  flattened 
or    pigeon-breasted;     the    shoulder-blades     are     widely      „. 

^  °     ,  ,     V  ,  ,  .  1  ,    ,  Fig.  481.— Kyphosis 

separated  and  the  scapular  angles  project;  the  abdomen  (a)  and  lordosis  (b). 
is  protuberant;  the  patient  complains  of  backache  and 
soon  tires.  A  recent  kyphosis  disappears  when  the  patient  lies  upon  his 
stomach.  The  facts  that  the  erector  spinae  muscles  are  soft,  and  that 
pain  is  absent  on  concussion  transmitted  to  the  back,  separate  kyphosis 
from  caries.  Lordosis  is  unmistakable.  When  the  spine  is  movable,  em- 
ploy the  same  plan  of  treatment  as  in  lateral  curvature,  suiting  the  gym- 
nastics to  the  deformity  (Roth).  In  painful  kyphosis  with  partial  ankylosis 
endeavor  to  make  the  ankylosis  complete  in  order  to  prevent  pain,  obtain- 
ing this  result  by  applying  a  plaster  jacket  which  laces  up  and  letting  the 
patient  wear  it  for  several  years. 

Angular  curvature  {spinal  caries;  spondylitis;  PotVs  disease)  is  usually 
due  to  tuberculous  caries  of  the  vertebral  bodies,  and  occurs  particularly 
in  children  who  are  predisposed  to  tuberculosis,  but  it  may  arise  at  any  age. 
Any  portion  of  the  spinal  column  may  be  attacked.  The  dorsolumbar  region 
is  most  prone  to  suffer.  The  chief  cause  is  tuberculosis,  but  syphilis  and  sec- 
ondary cancer  of  the  vertebrae  are  occasional  causes,  and  acute  osteomyelitis 
is  a  very  rare  cause  (page  856).  Blows  or  strains  may  act  as  exciting  causes. 
Angular  curvature  may  develop  after  an  exanthematous  fever. 

The  cancellous  tissue  of  the  anterior  portion  of  the  vertebral  body  becomes 


862  Surgery  of  the  Spine 

primarily  carious,  or  the  inflammation  begins  in  an  intervertebral  disc. 
(The  changes  of  tuberculous  osteitis  have  previously  been  set  forth — pages  229, 
256,  and  505.)  The  body  of  the  vertebra  and  the  vertebral  disc  are  destroyed, 
and  the  process  extends  to  adjacent  vertebrae.  The  weight  which  rests  upon 
the  spinal  column  causes  softened  bone  to  crumble,  compresses  the  diseased 
vertebrae  and  discs,  and  produces  angular  deformity  (the  anterior  part  of  the 
column  formed  by  the  vertebral  bodies  is  shortened,  the  posterior  part  is  not, 
and  hence  the  spines  project).  In  some  cases  the  disease  is  spontaneously 
arrested  by  organization  of  inflammatory  products,  and  ankylosis  (fibrous  or 
bony)  in  deformity  is  nature's  cure.  In  most  cases,  however,  the  disease 
spreads  and  caseous  pus  is  formed,  which,  according  to  the  point  of  formation 
and  the  route  it  takes,  causes  lumbar  abscess,  dorsal  abscess,  psoas  abscess, 
or  post-pharyngeal  abscess  (pages  161  and  162).  In  some  cases  the  spinal 
cord  is  compressed,  but  in  most  cases  it  is  not,  and  even  when  it  is  compressed, 
paraplegia  is  rare  and  is  usually  temporary.  Compression  of  the  cord  may 
be  caused  by  the  displaced  vertebrae  or  by  inflammatory  material  or  caseous 
matter  between  the  bone  and  dura  mater,  but  is  most  often  due  to  pachymen- 
ingitis. Caries  of  the  cervical  region  constitutes  a  more  dangerous  disease 
than  caries  of  either  the  dorsal  or  the  lumbar  region  {dangerous  pressure 
occurs  more  easily).  Death  may  be  caused  by  exhaustion,  sepsis,  hemorrhage, 
amyloid  disease,  pneumonia,  peritonitis,  pleuritis,  tuberculous  dissemination, 
pressure  upon  the  cord,  or  inflammation  of  the  cord  or  its  membranes. 

Symptoms. — The  sufferer  from  Pott's  disease,  if  a  child,  grows  tired 
easily,  his  disposition  alters,  he  becomes  moody  and  irritable,  and  complains 
of  vague  pains  in  many  places,  is  disposed  to  lean,  rest,  or  lie  down,  and 
walks  with  the  back  rigid,  which  produces  a  peculiar  gait.  A  painful  spot 
is  found  by  pressing  upon  the  spines.  Faradism  to  the  back  causes  pain. 
Spasm  of  the  erector  spinae  mass  is  detected  (Hilton,  Golding-Bird).  It 
is  not  proper  to  seek  to  develop  pain  by  jarring  the  back  or  by  pressing  the 
head  downward.  The  posture  of  the  child  and  the  rauscular  rigidity  prove 
the  existence  of  inflammation,  and  to  seek  to  develop  pain  by  the  methods 
referred  to  may  do  harm,  and  at  best  can  only  call  attention  to  what  is  already 
known.  Pain  in  the  back,  which  is  increased  by  motion,  by  pressure,  and 
by  vertebral  jars,  may  be  absent  until  late  in  the  case.  Distinct  pain  and 
tenderness  in  the  back  often  mean  abscess-formation.  Neuralgic  pains  pass 
into  distant  parts  (sciatica,  intercostal  neuralgia)  and  are  often  linked  with 
muscular  spasm.  A  chronic  bilateral  pain  in  the  trunk  or  extremities  is 
suggestive  of  Pott's  disease.  "Chronic  bilateral  belly-aches  in  children  are 
almost  diagnostic"  (Jordan  Lloyd).  The  pain  of  dorsal  caries  can  be  re- 
lieved by  lifting  the  shoulders;  the  pain  of  cervical  caries,  by  traction  on 
the  head.  Cramp  in  the  legs  occurs  in  dorsal  and  in  lumbar  caries.  The 
presence  of  the  knuckle  due  to  bending  the  spine  at  an  acute  angle  is  a  very 
important  sign  of  the  disease.  In  many  cases  angular  deformity  appears 
late;  in  some  cases  it  does  not  appear  at  all.  An  angular  deformity  is  detected 
sooner  in  those  regions  where  the  normal  curves  are  posterior  than  where  the 
normal  curves  are  anterior  (Jordan  Lloyd).  The  deformity  appears  early 
in  the  dorsal  region,  but  late  in  the  cervical  and  lumbar  regions.  In  some 
rare  cases  lateral  deformity  occurs.  Rigidity  is  an  early  sign  of  great  impor- 
tance.    It  is  always  present.     Rigidity  is  manifest  very  early  in  cervical 


Angular  Curvature 


863 


caries,  tolerably  early  in  lumbar  caries,  late  in  dorsal  caries.  Lloyd  gives 
the  following  practical  rules  to  enable  us  to  detect  rigidity.*  In  the  cervical 
region:  seat  the  patient  in  a  chair  and  tell  him  to  nod  the  head  affirmatively. 
Stiffness  in  nodding  points  to  occipito-atloid  disease.  Tell  him  to  look  far 
to  the  right  and  then  far  to  the  left.  Stiffness  of  these  motions  suggests 
atlo-axoid  disease.  Tell  him  to  place  his  shoulders  against  the  back  of  the 
chair  and  carry  his  eyes  back  along  the  ceiling.  Stiffness  in  this  movement 
indicates  disease  below  the  second  cervical  vertebra.  It  is  practically  useless 
to  examine  the  dorsal  region  of  an  adult  for  rigidity,  but  such  an  examination 
can  be  made  in  a  child.  Place  the  patient  prone  on  an  adult's  lap,  mark  the 
tip  of  each  spinous  process  with  an  anilin  pencil,  then  make  the  child  stand  up 
straight  on  the  floor,  and  observe  if  any  of  the  pencil  marks  fail  to  come  nearer 
together.  If  it  is  seen  that  two  or  more  marks  do  not  approach  each  other,  there 
is  rigidity  which  prevents  approximation.     To  test  for  rigidity  in  the  lumbar 


Fig  4S2  —Plaster  of  Pans  jacket  (Sajre). 


Fig.  483.— Plaster-of-Paris  jacket  and  jur>'-mast 
applied  (Sayre). 


region  lay  the  naked  patient  prone  upon  a  couch.  Grasp  the  patient's  ankles 
and  raise  the  pelvis  from  the  couch.  If  the  lumbar  spine  is  flexible,  the 
pelvis  can  be  lifted  without  raising  the  chest  from  the  bed,  and  the  maneuver 
deepens  the  hollow  of  the  loin.  If  the  lumbar  spine  is  stiff,  the  maneuver 
hfts  the  trunk  and  produces  no  alteration  in  the  vertical  outline  of  the  lumbar 
spines.  If  a  child  with  Pott's  disease  is  asked  to  pick  up  something  from 
the  ground,  because  of  rigidity  or  pain  on  movement  he  will  not  bend  the 
back,  but  wiU  bend  the  knees  or  get  upon  the  knees.  Paralysis  may  exist, 
and  it  is  due  to  pachymeningitis  more  often  than  to  pressure  from  bone. 
Cervical  caries  causes  dyspnea  and  torticollis,  the  head  requiring  support 
with  the  hands.  Dysphagia  indicates  abscess.  In  adults  the  first  signs  of 
Pott's  disease  to  attract  attention  are  headache,  backache,  neuralgia,  girdle- 
pain,  cramp,  or  even  paralysis.  In  abscess  due  to  caries  of  the  dorsolumbar 
vertebras  the  pus  usually  enters  the  psoas  muscle  and  passes  out  of  the  pelvis 
below  the  junction  of  the  middle  and  outer  thirds  of  Poupart's  ligament. 
*  Birmingham  Med.  Review,  April,  1897. 


864  Surgery  of  the  Spine 

It  may  point  here  or  may  pass  to  the  inner  aspect  of  the  thigh  and  point 
a  httle  below  the  spot  where  a  femoral  hernia  is  met  with  if  it  exists.  In 
a  psoas  abscess  a  mass  is  always  felt  in  the  iliac  fossa  above  Poupart's  lig- 
ament; in  a  hernia  no  such  mass  exists  (J.  T.  Rugh).  In  sacral  caries  there 
is  no  deformity  and  frequently  no  pain.  The  diagnosis  becomes  apparent 
when  bilateral  abscess  is  detected  in  the  buttocks  or  groins  (Jordan  Lloyd). 
If  an  abscess  due  to  spinal  caries  opens  spontaneously,  healing  will  not  occur, 
but  mixed  infection  takes  place  and  death,  as  a  rule,  soon  follows. 

Treatment  of  Caries  of  the  Spine. — When  recent  caries  of  the  spine  is 
active  and  affects  a  child;  when  it  is  accompanied  by  pain  and  fever;  and 
when  paralysis  threatens,  insist  upon  perfect  rest.  Place  the  child  supine 
on  a  hard  mattress,  and,  if  possible,  take  it,  while  in  a  rolling  bed,  out  of 
doors  daily.  Leeches,  blisters,  or  the  hot  iron  over  the  area  of  pain  may 
do  good.  When  the  activity  of  the  process  abates,  apply  a  fixation  apparatus. 
In  diseases  at  or  near  the  vertebro-occipital  articulation,  as  long  as  dyspnea 
persists,  keep  the  patient  supine  with  a  small  hard  pillow  under  the  nape 
of  the  neck  (Hilton)  and  a  sand-bag  on  each  side  of  the  head  and  neck.  After 
several  months  mechanical  support  can  be  given  by  Furneaux  Jordan's 
method.  Jordan  applies  his  support  as  follows:  The  patient  Hes  on  a  flat, 
hard  table,  his  arms  are  raised  al)0ve  his  head,  and  traction  is  made  upon 
the  head  by  means  of  a  pulley  and  a  weight.  Cotton  pads  arc  placed  over 
the  ears,  the  back  of  the  neck,  and  the  clavicles,  and  are  held  in  place  by 
a  flannel  bandage  appHed  as  a  figure-of-eight  on  the  head,  neck,  and  chest. 
The  flannel  bandage  is  overlaid  with  plaster-of- Paris  bandages.*  In  disease 
of  the  cervical  region  below  the  axis,  or  of  the  dorsal  region  above  the  seventh 
vertebra,  use  Sayre's  jury-mast  (Fig.  483),  or  some  other  form  of  head  support. 
Instead  of  the  jury-mast  a  steel  upright  may  be  used  to  hold  the  head  rigid. 
Sayre's  appliance  relieves  the  spine  frorh  the  weight  of  the  head  and  acts 
admirably.  In  most  cases  of  dorsal  and  lumbar  caries  a  steel,  leather,  or 
plaster  jacket  as  a  fixation  apparatus  must  be  employed.  The  best  of  all 
fixation  apparatus  is  Sayre's  plaster-of-Paris  jacket  applied  while  the  patient 
is  suspended  (Fig.  482),  or  better,  while  the  column  is  in  hyperextension. 
The  Sayre  apparatus  applied  in  this  manner  is  used  for  the  treatment  of  caries 
of  the  lumbar  region  and  the  lower  half  of  the  dorsal  region.  When  all 
subjective  signs  cease,  substitute  for  Sayre's  jacket  a  felt  or  sole-leather 
jacket  which  laces  down  the  front.  Caries  of  the  upper  half  of  the  dorsal 
region  is  often  treated  by  a  Sayre's  jury-mast  (Fig.  483) ;  but  if  the  jury-mast 
fails,  it  may  be  necessary  to  place  the  patient  horizontally  in  "an  open  cuirass, 
fitted  to  the  back  from  occiput  to  sacrum,  and  combined  with  pulley  extension 
to  the  head  and  pelvis."  f 

During  the  course  of  caries  of  the  spine  have  the  patient  eat  fat-forming 
and  nutritious  food,  insist  on  a  plentiful  supply  of  fresh  air,  and  administer 
tonics  and  antituberculous  drugs.  Sea-air  is  very  beneficial.  When  all 
active  disease  ceases  and  only  angular  curvature  remains,  use  an  apparatus 
to  combine  extension  with  mechanical  support,  the  plaster  jacket  being 
generally  employed. 

Spinal  abscesses  are  treated  as  indicated  on  pages  163,  164,  and  707. 

*  See  "  Children's  Deformities,"  by  Walter  Pye. 

t  Jordan  Lloyd,  in  Birmingham  Med.  Review,  April,  1897. 


Forcible  Correction  of  Angular  Deformity  865 

Paralysis  in  Pott's  Disease. — Partial  or  complete  motor  and  sensory 
paralysis  may  develop  in  the  course  of  vertebral  caries.  It  may  be  due  to 
the  pressure  of  tuberculous  material  or  to  pachymeningitis  with  thickening 
of  the  membrane.  In  only  2  per  cent,  of  cases  of  paralysis  is  the  paralysis 
due  to  the  pressure  of  angled  bone  (Willard).  The  paralysis  may  come  on 
gradually.  There  are  weakness  in  walking  or  actual  inability  to  walk,  exag- 
gerated reflexes,  muscular  rigidity,  and  impaired  sensation  in  the  legs,  and 
loss  of  control  of  the  bladder  and  rectum.  Caries  in  the  high  dorsal  region 
is  more  apt  to  result  in  paralysis  than  in  any  other  region,  because  of  the  small 
size  of  the  canal.     Pressure  in  the  cervical  region  is  highly  dangerous. 

Treatment. — We  must  remember  that  angulation  is  the  rare  cause,  tubercu- 
lous masses  the  common  cause.  Treatment  for  paralysis  due  to  tuberculous 
masses  is  the  full  open-air  treatment  of  tuberculosis,  with  rest,  fixation,  and 
progressive  straightening  of  the  spine.  The  patient  is  kept  in  bed  (see  Treat- 
ment of  Tuberculosis,  page  246)  on  a  Bradford  frame  and  with  his  head 
overextended  (Willard).  If  after  one  year  the  condition  is  not  notably 
improved,  do  laminectomy  and  clear  away  tuberculous  masses.  If  angula- 
tion is  the  cause  of  the  paralysis,  we  consider  gradual  correction,  forcible 
correction,  and  laminectomy. 

Gradual  Correction  of  Angular  Deformity. — Pressure  is  made  upon  the 
hump  with  the  hand,  and  while  the  hand  is  thus  held  the  weight  of  the  body  is 
allowed  to  bear  upon  it  above  and  below.  Something  is  perhaps  gained  and 
then  plaster-of-Paris  is  applied,  somewhat  later  a  little  more  gain  is  obtained, 
and  so  on.     This  method  is  safer  and  more  satisfactory  than  forcible  correction. 

Forcible  correction  of  angular  deformity  is  advocated  by  Chipault 
and  Calot  in  cases  of  Pott's  disease  without  abscess.  Forcible  correction  is 
only  used,  if  used  at  all,  in  angular  deformity  of  the  middle  and  lower  part 
of  the  dorsal  region.  It  is  not  used  in  the  cervical,  upper  dorsal,  or  lumbar 
regions.  Before  it  is  used  a  skiagraph  should  be  taken,  to  show  if  bony  anky- 
losis exists  or  if  there  is  an  abscess.  If  there  is  an  abscess,  it  must  be  treated 
surgically,  and  must  heal  before  forcible  correction  is  attempted.  If  bony 
ankylosis  exists,  it  must  not  be  broken  down.  Only  recent  cases  are  suited 
for  this  treatment,  and  only  cases  in  which  very  few  vertebrae  are  involved 
(Gabaert).  The  operation  is  unjustifiable  if  any  organs  are  tuberculous, 
and  if  a  patient  is  in  very  poor  health.  It  is  said  by  its  advocates  to  be  par- 
ticularly indicated  when  the  deformity  interferes  with  respiration  or  digestion, 
or  when  there  is  paraplegia,  especially  if  paraplegia  is  due  to  disease  of  the 
mid-dorsal  region.  The  advocates  of  the  operation  claim  that  it  does  not 
injure  the  cord  or  its  membranes.  The  operation  is  not  entirely  safe,  and  a 
number  of  deaths  have  been  reported.  Chloroform  must  not  be  given,  as 
it  seems  to  possess  special  dangers  in  this  condition.  Gabaert  *  points  out 
certain  disasters  which  may  follow  forcible  correction;  they  are:  death 
during  anesthesia;  rupture  of  an  abscess;  subsequent  paralysis  of  the  legs 
and  bladder;  disseminated  tuberculosis;  and  shock  with  convulsions  and 
death.  Forcible  correction  can  be  carried  out  as  follows:  the  patient  is 
anesthetized  with  ether  and  is  placed  face  down;  one  assistant  holds  the 
feet,  another  the  head,  another  supports  the  abdomen,  and  another  the 
pelvis.  While  strong  traction  is  made  on  the  head  and  feet  the  surgeon 
*  Ann.  de  la  Soc.  Beige,  July  15,  1898. 


866  Surgery  of  the  Spine 

makes  forcible  pressure  on  the  projection.  After  the  correction  of  the  defor- 
mity a  plaster-of-Paris  support  is  apphed  so  as  to  include  the  neck,  trunk, 
and  pelvis,  the  site  of  the  gibbosity  being  left  exposed  in  order  to  avoid 
ulceration.  A  plaster-of  Paris  support  is  used  for  at  least  six  months.  After 
forcible  correction  a  large  gap  exists,  and  this  does  not  fill  up  with  bone,  but 
with  dense  fibrous  tissue,  and  in  some  cases  the  spines  and  laminae  ankylose. 
When  the  support  is  first  removed,  there  is  usually  a  reappearance  of  the 
deformity  to  some  degree.  In  some  cases  Cabot  resects  the  spines  and  laminae 
of  the  diseased  vertebrae,  and  performs  osteotomy  of  the  ankylosed  vertebral 
bodies.*  Personally  I  do  not  believe  in  forcible  correction  and  I  do  believe 
that  the  alleged  dangers  are  real  dangers  and  that  the  operation  is  unsafe. 

Laminectomy  is  warmly  advocated  by  some  surgeons  for  paraplegia 
from  spinal  caries.  This  operation  is  rarely  necessary,  but  in  some  few 
cases  is  imperatively  demanded.  Many  cases  recover  from  paraplegia  with- 
out oDeration — operation  in  these  cases  has  a  very  heavy  mortality  (25  per 
cent.);  and  many  are  not  benefited  at  all  by  it.  If  degeneration  of  tracts 
in  the  cord  has  occurred,  operation  cannot  help  the  paralysis.  Nevertheless, 
in  some  cases  laminectomy  has  certainly  cured  palsy  and  saved  life. 

Laminectomy  should  not  be  undertaken  until  treatment  by  rest  and  fixa- 
tion and  extension  has  been  applied  for  at  least  one  year.  Laminectomy  may 
become  necessary  in  cervical  caries  to  prevent  asphyxia.  The  operation 
enables  the  surgeon  to  remove  masses  of  inflammatory  material  which  make 
pressure  on  the  cord,  and  also  to  free  the  cord  from  pressure  due  to  angulation. 
The  dura  should  not  be  opened  unless  there  is  evidently  trouble  beneath  it,  in 
which  case  it  is  incised  and  any  tuberculous  area  removed,  the  dura  being 
subsequently  sutured.  Menard  removes  the  transverse  processes  of  the 
diseased  vertebras  and  the  heads  and  necks  of  the  associated  ribs  in  order  to 
give  the  surgeon  access  to  diseased  vertebral  bodies. 

Spondylitis  Deformans  {Bechterew^s  Disease). — This  is  the  name 
usually  applied  to  osteoarthritis  of  the  spine  (page  650).  In  this  disease 
osteophytic  formation  takes  place  at  the  vertebral  borders,  and  the  vertebrae 
become  ankylosed.  The  vertebral  bodies,  as  a  rule,  are  most  affected  by  the 
disease,  but  any  portion  of  a  vertebra  may  be  attacked,  and  often  the  heads 
of  the  ribs  are  anchored  to  the  spine  by  bone. 

The  disease  may  begin  in  infancy,  childhood,  youth,  adult  life,  or  old  age. 

Symptoms. — There  are  decided  and  persistent  pain  and  tenderness  of 
the  spine,  and  occasionally  evidence  of  pressure  on  the  nerve-roots.  Early 
in  the  case  deformity  is  apt  to  occur,  because  at  this  period  there  is  inflam- 
matory softening.-)-  The  deformity  is  not  angular,  but  is  usually  a  total 
kyphosis,  the  column  being  bent  forward  from  above  and  made  into  a  single 
curve.  Lateral  curvature  may  occur.  In  many  advanced  cases  and  in  some 
comparatively  recent  cases  the  spine  becomes  rigid  and  ankylosed,  and  when 
it  does,  there  may  be  evidences  of  irritation  of  the  posterior  nerve-roots.  In 
this  condition  there  is  rigidity  of  part  or  of  the  entire  spine,  other  joints 
escaping.  If  the  entire  spine  is  involved,  there  is  rigid  cervico-dorsal  kypho- 
sis, a  condition  which  causes  the  neck  to  stick  forward  and  the  head  to 
appear  as  if  forcibly  driven  down  between  the  shoulders.  If  the  entire 
spine  is  involved,  the  lumbar  spine  is  rigid  and  the  normal  lumbar  curve  dis- 

*F.  Cabot,  in  Archiv  Prov.  de  Chirurgie,  Feb.,  1897. 
t  J.  Jackson  Clarke's  book  on  "  Orthopedic  Surgery." 


Injuries  of  Spinal  Ligaments  and  Muscles  867 

appears.  As  a  consequence  the  j^atient  stands  in  an  unnatural  attitude, 
the  hips  and  knees  being  partly  flexed,  and  the  legs  and  feet  being  in  a 
condition  of  external  rotation.  In  Bechterew's  disease  there  are  compres- 
sion of  the  posterior  nerve-roots,  severe  pain,  muscular  atrophy,  and  ascend- 
ing degeneration  of  the  cord.  What  Marie  calls  spondylitis  rhizomeliqtie 
is  said  by  Osier  to  be  a  form  of  arthritis  deformans.  There  is  rigidity  of 
the  spine,  shoulders,  and  hips,  but  no  nervous  lesions,  as  in  Bechterew's 

disease. 

Treatment.— Cure  is  impossible,  but  amelioration  can  be  obtained. 

The  local  and  constitutional  treatment  is  as  for  osteo-arthritis  in  any 
region  (page  652) .     If  curvature  begins,  a  mechanical  support  must  be  applied. 

Injuries  of  spinal  ligaments  and  muscles,  which  may  complicate 
more  serious  injuries  or  may  exist  alone,  are  caused  by  wrenches,  twists, 
and  violent  muscular  efforts  (as  in  lifting) .  Railway  accidents  may  be  respon- 
sible for  these  sprains  and  strains.  The  injury  is  called  "  railway  spine  "  when 
it  is  caused  by  a  railway  accident. 

Symptoms.— Injuries  of  the  back,  even  without  cord-injury,  are   fre- 
quently linked  with  very  deceptive  nervous  symptoms.     Symptoms  are  often 
severe,'  but  are  usually  temporary.     In  some  few  cases  the  symptoms  are 
persistent.     Secondary  disease  of  the  cord   is  extremely  rare.     Any  region 
may  be  affected,  but  the  lumbar  is  most  usually  injured,  and  the  entire  spine 
may  suffer.     The  three  marked  symptoms  are  pain,  tenderness,  and  stiffness 
of  the  back.     At  the  time  of  injur)^  and  for  a  while  after,  there  is  often  marked 
shock,   and  hysterical  excitement  is  occasionally  observed.     The  cardinal 
symptoms  mav  arise  very  soon,  but  may  not  become  severe  for  a  day  or 
two.     The  pain  is  not  acute  when  at  rest,  but  becomes  acute  on  movement.* 
The  pain  is  felt  in  the  back,  and  sometimes  darts  into  the  extremities.     The 
muscles  of  the  back  are  rigid,  the  spasm  being  due  to  pain.     The  patient 
is  very  careful  not  to  twist  or  bend  the  spine,  because  to  do  so  increases 
pain.     In  a  one-sided  injury  the  rigidity  is  unilateral,  and  this^  symptom 
cannot  be  simulated.     Often,  but  by  no  means  always,  the  region  of  the 
back  is  swollen  and  the  skin  is  discolored.     The  tenderness  is  not  of  the 
skin,  but  of  the  muscles.     Firm  pressure  on  a  spot  of  real  tenderness  causes 
rapid  pulse   (Mannkopff).     The  vertebral  spines  are   regular   and  are  not 
mobile.     There  is  no  distant  paralysis  or  hyperesthesia  unless  the  cord  is 
damaged  (though  in  some  rare  cases  the  bladder  and  the  rectum  are  paralyzed 
when ''no  cord-lesion  can  be  detected,  and  hyperesthesia  may  exist  over  the 
spines).     MouUin  tells  us  that  the  extremities  feel  weak  because  they  are 
deprived  of  proper  support  on  account  of  the  immobility  of  the  muscles 
of  the  back.     For  the  same  reason  the  action  of  the  abdominal  muscles 
is  interfered  with,  and  the  power  of  micturition  and  of  defecation  is  impaired 
(there  are  constipation  and  difficulty  in  emptying  the  bladder). 

The  treatment  of  recent  injuries  comprises  rest,  the  application  of  an 
ice-bag,  and  leeching  over  the  painful  area.  After  a  day  or  two  hot  fomenta- 
tions, tincture  of  iodin,  compression  by  adhesive  strips,  and  inunctions  of 
ichthyol  and  lanolin  are  used;  and,  later  still,  massage,  douches,  and  frictions 
with  a  stimulating  liniment  are  employed.  Phenacetin  helps  to  relieve  pain, 
though  in  some  cases  opium  is  necessary. 

*  Moullin  on  "  Sprains." 


868  Surgery  of  the  Spine 

Traumatic  neurasthenia  is  apt  to  arise  after  the  immediate  effects  of  the 
accident  subside.  In  this  condition  the  patient  grows  tired  easily  and  com- 
plains of  pains  and  aches  in  the  back  and  loins,  interfering  with  or  preventing 
work;  paresthesia  and  numbness  exist  in  the  extremities;  in  many  cases 
sexual  intercourse  is  impossible  because  of  premature  ejaculation  or  of  inca- 
pacity for  erection;  there  are  dyspepsia,  eye-strain,  insomnia,  loss  of  mem- 
ory, rapid  and  irregular  pulse,  cardiac  palpitation,  and  mental  depression 
or  confusion.  The  reflexes  are  usually  exaggerated,  but  they  can  be  ex- 
hausted more  easily  than  can  the  exaggerated  reflexes  of  organic  cord  dis- 
ease (because  of  irritable  weakness).  Some  rigidity  and  tenderness  exist  in 
the  back,  and  the  skin  over  this  region  is  often  hyperesthetic.  Attacks  of 
retention  of  urine  may  occur.     Hypochondriasis  is  not  unusual. 

Treatment  of  Traumatic  Neurasthenia. — Employ  rest,  tonics,  massage, 
douches,  and  frictions  to  the  back.  Secure  sleep,  and  endeavor  to  bring 
about  a  gain  in  weight.  If  sexual  incapacity  or  seminal  emissions  worry 
the  patient,  dilate  the  urethra  with  steel  sounds. 

Traumatic  hysteria  develops  only  in  those  predisposed  by  a  neuropathic 
hereditary  tendency;  traumatic  neurasthenia  may  arise  in  any  one.  In  the  first- 
named  disease  the  accident  is  only  the  exciting  cause;  in  the  second  disorder 
it  is  the  cause.  Many  cases  of  so-called  "railway  spine"  are  really  examples 
of  traumatic  hysteria.  Traumatic  hysteria  and  neurasthenia  may  be  asso- 
ciated. Neurasthenia  is  a  condition  of  exhaustion  associated  with  a  number 
of  chronic  disorders;  it  forms  a  foundation  on  which  hysteria  is  apt  to  build 
its  structure.  The  structure  of  hysteria  is  made  up  of  morbid  impression- 
ability, hyperesthesia  of  centers,  lowered  self-control,  and  sensitiveness  of 
the  peripheral  nervous  system.  The  accident  plays  a  double  part  in  pro- 
ducing traumatic  hysteria — first,  by  its  effect  on  the  mind  (psychical  trau- 
matism); second,  by  its  effect  on  the  body,  which  anchors  the  attention  to 
one  point.  An  area  of  pain  or  stiffness  often  serves  as  an  autosuggestion 
which  undergoes  morbid  magnification  when  viewed  through  the  distorting 
medium  of  hysteria.  Erichsen  taught  that  the  symptoms  of  what  he  named 
"railway  spifte"  arose  from  inflammation  of  the  cord  and  its  membranes, 
a  view  now  abandoned.  A  blow  given  to  a  hysterical  person  causes  a  feeling 
of  numbness,  and  thus  negative  sensation  from  local  shock  may  establish 
the  idea  of  paralysis,  or  traumatism,  acting  as  a  suggestion,  may  inhibit 
motor  representations  and  destroy  the  normal  ideas  of  motion  and  feeling 
(Charcot  and  Pitre).  Terror  always  causes  a  feeling  of  loss  of  power  in 
the  legs,  and  the  terror  of  the  accident  may  thus  develop  the  idea  of  para- 
plegia. The  site  of  a  traumatism  may  localize  symptoms;  for  instance,  a  blow 
upon  the  eye  may  cause  amaurosis  or  blepharospasm.  It  is  important  to 
remember  Charcot's  saying  that  a  hysteria  long  latent  and  unrecognized 
may  be  awakened  into  obvious  activity  by  a  blow  or  an  accident.  Pitre 
shows  the  same  to  be  true  of  epilepsy.  A  not  unusual  lesion  is  hysterical 
traumatic  monoplegia,  not  coming  on  at  once  after  the  accident,  but  usually 
some  days  afterward,  and  presenting  flaccid  muscles,  the  electrical  reactions 
and  reflexes  remaining  normal,  but  the  muscular  sense  being  lost  (Pitre). 
The  muscles  usually  waste.  The  skin  of  the  paralyzed  limb  is  anesthetic 
or  analgesic.  There  may  be  anesthesia  limited  to  a  limb,  hemianesthesia, 
or  general  anesthesia.*  Hysterical  paralysis  is  usually  associated  with  the 
*  J.  Mitchell  Clarke,  in  Brain. 


Contusion  of  the  Spinal  Cord  869 

permanent  stigmata  of  hysteria — concentric  contraction  of  the  visual  field, 
pharyngeal  anesthesia,  convulsive  seizures,  and  hysterogenic  zones  (Clarke 
and  Pitre).  The  permanent  sdgmata  may  be  latent.  Hysteric  phenomena 
lack  regularity  of  evoludon,  and  they  may  be  produced,  altered,  or  abolished 
by  mental  influences  or  by  physical  forces  which  produce  no  effect  on  organic 
disease.  In  most  hysteric  condidons  the  general  health  is  not  profoundly 
impaired.*  In  making  a  diagnosis  of  hysteria  we  must  be  most  careful  to 
exclude  both  mahgnant  disease  and  imposture,  because  hysteria  is  a  sort  of 
diagnostic  waste-basket  into  which  we  cast  most  things  which  we  fail  to  under- 
stand. Babinsky  proposes  that  we  should  call  phenomena  hysteric  only 
when  they  can  be  produced  or  can  be  cured  by  suggestion  ("Brit.  Med. 
Jour.,"  Jan.  23,  1909,  p.  234). 

Treatment. — By  moral  means  chiefly.  Gain  the  confidence  of  the  patient. 
Suggestion  is  of  great  value.  In  many  cases  separation  from  family  and  friends 
is  necessary  and  isolation  is  desirable.  The  Weir  Mitchell  rest-cure  is  often 
the  best  plan  of  treatment,  and  all  its  details  should  be  carried  out  faithfully. 

Malingering. — Persons  often  pretend  to  suffer  from  maladies  of  the 
spinal  cord  or  column  as  a  result  of  accident,  which  diseases  do  not  exist  in 
them.  Some  get  well  upon  the  rendering  of  a  favorable  verdict  by  a  jury 
(litigation  backs).  In  any  case  always  examine  carefully,  so  as  to  be 
able  to  exclude  malingering.  Note  the  patient's  behavior  and  motions  when 
his  attention  is  diverted  from  his  disease.  Meningomyelitis  can  be  excluded 
if  there  be  no  spasm,  paralysis,  hyperesthesia,  paresthesia,  or  anesthesia  at  a 
distance  (A.  Pearce  Gould).  If  pain  has  lasted  for  months;  if  pressure  down- 
ward upon  the  head  or  shoulders  does  not  increase  pain;  if  the  vertebrae  are 
movable  and  there  is  no  angular  displacement,  exclude  caries.  Gould  states 
that  when  there  are  wasted  muscles,  when  moderate  spine  movement  is  pain- 
less, but  effort  in  bringing  the  body  erect  causes  pain  in  the  erector  spinae 
region,  the  trouble  is  a  strain  of  the  erector  spina;  muscle.  If  the  muscle  is  not 
wasted  and  the  pain  is  in  bending  forward  rather  than  in  straightening  up,  the 
vertebral  ligaments  are  the  seat  of  trouble.  Unilateral  spasm  cannot  be  simu- 
lated. The  administration  of  ether  may  dispose  of  a  pretended  paralysis,  the 
patient  moving  the  suspected  extremity  while  drunk  from  the  anesthetic. 

Concussion  of  the  Spinal  Cord. — This  term  has  no  definite  patho- 
logical meaning.  It  is  probable  that  the  condition  is  one  of  laceration  of 
capillaries  and  of  cord-substance. 

The  symptoms  are  shock,  intense  pallor,  nausea,  often  vomiting,  and 
sometimes  syncope.  With  this  condition  special  symptoms  may  be  linked — 
as  temporary  paralysis,  a  girdle-sensation,  numbness  and  loss  of  power  in 
the  limbs,  hiccough,  torticollis,  coarse  tremors,  pains  in  the  back  and  limbs, 
areas  of  anesthesia  and  analgesia — depending  on  the  portion  of  cord  lacerated. 

Treatment. — The  treatment  in  concussion  of  the  spinal  cord  is  the  same 
as  that  for  sprains.  Traumatic  neurasthenia  and  hysteria  or  organic  cord- 
disease  may  follow  this  injury. 

Contusion  of  the  spinal  cord  may  arise  from  a  blow  or  a  sprain,  but 
it  is  usually  due  to  extreme  flexion  of  the  spine.  It  causes  hemorrhage  into 
the  gray  matter  of  the  cord  {hematomyelia).  The  symptoms  are  motor  and 
sensory  palsy  and  diminished  reflexes.     Some  cases  recover,  but  others  end 

in  myelitis. 

*  Read  the  works  of  Thorburn  and  Pitre. 


Sjo  Surgery  of  the  Spine 

Wounds  of  the  spinal  cord  are  rare  and  are  usually  fatal.  A  knife 
is  sometimes  thrust  in  between  the  occiput  and  atlas.  Wounds  above  the 
origin  of  the  phrenic  nerves  cause  almost  instant  death.  Gunshot- wounds  are 
the  most  usual  form,  the  cord  being  damaged  by  the  bullet  and  by  bone-frag- 
ments. 

In  the  American  Civil  War  gunshot  injuries  of  the  cord  were  very  rare  {{  of 
I  per  cent,  of  all  wounds) ,  but  at  the  present  day  in  war  they  represent  more 
than  ^  of  I  per  cent,  of  all  wounds,  the  increase  in  frequency  being  due  to  the 
increased  penetrating  power  of  the  modern  military  bullet  (Surgeon-General 
Robert  M.  O'Reilly,  in  "Keen's  Surgery,"  vol.  iv).  The  mortahty  is  about 
60  per  cent. 

A  revolver  bullet  or  a  small-caHber  bullet  fired  at  long  range  may  produce 
vertebral  fracture  without  cord  injury  and  any  bullet  may  fracture  a  process 
of  a  vertebra  without  cord  injury.  If  the  laminae  are  fractured  the  cord  is 
almost  sure  to  be  injured.  The  cord  may  be  concussed,  lacerated,  or  cut 
across  by  bone  or  bullet,  or  compressed  by  bone  or  blood.  The  bullet  may 
lodge  or  may  perforate. 

Treatment. — In  a  suspected  wound  of  the  cord  do  an  exploratory  laminec- 
tomy, arrest  hemorrhage,  and  if  the  cord  is  divided,  suture  it.  If  a  bullet  is 
lodged,  remove  it. 

Compression  of  the  spinal  cord  maybe  due  to  blood  or  to  inflammatory 
■exudate,  as  well  as  to  displaced  bone  (page  872).  Compression  from  blood  may 
be  due  to  extramedullary  hemorrhage  or  to  intramedullary  hemorrhage.  Ex- 
tramedidlary  hemorrhage  causes  sudden  pain  in  the  back,  the  pain  radiating 
from  compressed  nerve-roots;  hyperesthesia  and  paresthesia  in  the  area  of  the 
radiated  pain;  spasm  of  vertebral  muscles  supplied  by  the  compressed  nerves, 
sometimes  of  muscles  whose  nervous  supply  is  below  the  lesion;  tremors; 
•convulsions;  retention  of  urine;  paralytic  symptoms  following  the  signs  of 
irritation,  but  no  absolute  paralysis  (Mills).  A  girdle-sensation  is  usual. 
Intramedullary  hemorrhage  causes  pain,  a  girdle-sensation,  abolition  of  re- 
flexes, and  paralysis.  Spasms,  rigidity,  and  paralysis  come  on  early.  Bed- 
sores may  form,  and  retention  of  urine  and  incontinence  of  feces  may  be  ob- 
served. Paralysis  from  hemorrhage  is  rapidly  progressive  from  below  upward 
(crawling  paralysis). 

Treatment. — If  paralysis  from  spinal-cord  bleeding  extends  rapidly  and 
life  is  endangered  through  the  probable  involvement  of  a  vital  center,  per- 
form a  laminectomy,  remove  the  clot,  and  arrest  the  hemorrhage.  It  is  wise 
always  to  open  the  dura  and  inspect  the  cord.  Extramedullary  hemor- 
rhage may  be  arrested  by  sutures  or  by  packing.  Intramedullary  hemorrhage 
may  be  arrested  by  suture-ligatures  or  by  packing.  If  an  extramedullary 
clot  is  extensive,  it  is  proper  to  make  a  second  laminectomy  near  the  lower 
end  of  the  spinal  column  in  order  to  permit  the  surgeon  to  wash  it  out 
thoroughly.  The  dura  must  be  sutured  and  drainage  is  to  be  employed.  If 
there  is  paraplegia,  complete  anesthesia  of  the  paralyzed  parts,  and  entire 
abolition  of  the  deep  reflexes,  operation  is  probably  useless,  but  it  is  justi- 
fiable to  try  it  because  of  a  possibility  that  the  cord  is  not  completely  divided. 
In  some  cases  with  persistent  paraplegia  the  operation  should  be  under- 
taken. If  operation  is  not  undertaken,  have  the  patient  lie  upon  his  side, 
apply  a  spinal  ice-bag,  and  give  morphin  hypodermatically.     If  hemorrhage 


Fractures  and  Dislocations  of  the  Spine 


871 


continues  in  the  cord  and  if  the  patient  be  plethoric,  perform  venesection. 
To  promote  absorption  of  the  clot  and  exudate  give  a  combination  of  carbo- 
nate and  acetate  of  ammonium,  or- 
der pilocarpin,  and  employ   spinal 
galvanism  and  not  douches. 

Fractures  and  dislocations 
of  the  spine  are  very  rare.     The 
spinal  regions  most  liable  to  injury 
are  the  atlo-axial,  the  cervicodorsal, 
and  the  dorsolumbar  (Treves).     A 
vertebra  may  be   fractured   alone, 
but    dislocation    without    fracture, 
except  in  the  upper  cervical  region, 
very    rarely    occurs.      These    two 
lesions,  dislocation  and  fracture,  are 
so  often  associated  that   the    term 
fracture-dislocation  is  used  by  many 
surgeons    to    include    them    both. 
The  causes  of  fracture  and  dislo- 
cation are  direct  force  (seldom)  and 
indirect  violence    (commonly).     In 
fracture  by  direct  force  the  laminae 
and  spinous  processes  are  most  apt 
to  suffer.     In  most  cases  the  frag- 
ments are  not  greatly  displaced.     A 
fracture  by  indirect  force  may  result 
from  a  fall  on  the  shoulders,  from  a 
weight  falling  on  the  shoulders,  or 
from  a  fall  on  the  buttocks.     Forced 
flexion  or  overextension  is  the  com- 
monest  cause.     In   fractures   from 
indirect  force  the  cord  generally  suf- 
fers.    In   some  cases  the  displace- 
ment of  the  vertebrae  lacerates  the 
cord,  the  vertebrae  return  into  place, 
and    no    deformity    is    detectable. 
Fracture-dislocation      from     direct 
force  may  occur  at  any  part  of  the 
column,   and   in  this    accident  the 
posterior    vertebral    segments    are 
driven  together,  and  the  cord,  as  a 
rule,  escapes  injury.     Fracture-dis- 
locations from  indirect  force   most 
commonly  happen  in  the  dorsolum- 
'  bar  region,  but  are  met  vdth  in  the 
cervical  and  dorsal  regions.     In  the 
cervical  region  reduction  can  usually 
be  secured,  but  in  the  lumbar  region  reduction  is  impossible. 

Symptoms.— In  fracture-dislocation  great  displacement  is  unusual,  but 


Fig.  484. —  Spine  sawed.  Fracture  of  the 
spinous  processes  of  the  seventh  cervical  and  first 
and  second  dorsal  vertebrae.  Fracture  of  the 
bodies  of  the  fifth,  sixth,  and  seventh  cervical  ver- 
tebrae with  displacement  backward  of  the  upper 
fragment.  Total  crush  of  the  cord.  The  section 
passes  a  little  to  one  side  of  the  cord,  which  is  seen 
in  place,  and  the  staining  of  the  cord  by  hemor- 
rhage into  its  substance  shows  plainly  through  the 
membranes  even  in  photograph.  The  spinous 
processes  of  the  second  and  third  dorsal  vertebrae 
were  found  fractured  at  the  operation,  and  were 
removed  (Thomas). 


872 


Surgery  of  the  Spine 


some  is  almost  always  recognizable  (irregularity  of  the  spines  or  angular 
deformity).  There  are  pain  (which  is  increased  by  motion),  tenderness, 
ecchymosis,  and  motor  and  sensory  paralysis.  Priapism,  cystitis,  and  reten- 
tion of  urine  often  occur.  Horsley  has  pointed  out  that  in  many  cases 
paralysis  passes  away  only  to  recur  subsequently,  the  recurrence  being  due  to 
edema  of  the  cord.  In  some  cases  of  spinal  injury  there  is  temporary  paral- 
ysis due  to  shock.  Persistent  paralysis  may  be  due  to  laceration  of  the  cord, 
division  of  the  cord,  or  compression  of  the  cord  by  bone,  blood-clot  (Fig. 
485),  or  products  of  inflammation.     The  extent  of  paralysis  depends  on  the 

seat  of  the  cord  injury.  We  must  al- 
ways try  and  decide  if  the  spinal  cord 
is  completely  divided  or  hopelessly 
crushed  (Fig.  484).  When  the  symp- 
toms are  not  immediate  in  onset;  when 
all  the  muscles  below  the  seat  of  injury 
are  not  completely  paralyzed;  when 
there  is  some  retention  of  sensation; 
when  reflexes  are  present  and  muscular 
rigidity  exists,  we  may  be  sure  that  the 
cord  is  not  completely  divided.  When 
the  cord  is  completely  divided  the 
symptoms  are  immediate,  there  are  ab- 
solute flaccid  motor  paralysis  and  com- 
plete sensory  paralysis  (loss  of  appre- 
ciation of  pain,  touch,  and  temperature). 
The  Hne  of  anesthesia  is  definite  and 


Fig.  485. — Fracture  of  the  cervical  spine, 
cord  compressed  by  bone  and  blood.  Hem- 
orrhage into  the  cord  at  the  seat  of  the  lesion 
and  below  the  lesion  (Warren  Museum). 
(From  Scudder's  "  Treatment  of  Frac- 
tures."    Drawn  by  Byrnes.) 


Fig.  486. — Lesion  of  spine  between  fifth  and 
sixth  cervical  vertebrae.  Note  position  of  arms, 
due  to  paralysis  of  subscapularis.  Brachialis 
anticus,  supinator  longus,  and  deltoid  muscles 
intact.  Elbow  flexed,  shoulders  abducted  and 
rotated  outward  (after  Thorburn). 


suddenly  terminates  (Walton).  The  bladder  and  rectum  are  paralyzed  and 
there  may  be  priapism.  All  the  reflexes,  superficial  and  deep,  except  per- 
haps the  plantar,  have  disappeared.  There  is  no  pain,  there  are  no  muscular 
spasms,  there  is  vasomotor  paralysis  with  sweating  of  the  paralyzed  parts, 
and  the  symptoms  persist  and  do  not  vary  (J.  J.  Thomas,  in  "Boston  Cit}' 
Hospital  Med.  and  Surg.  Reports").  There  is  usually  tympanites  (Walton). 
If  this  latter  symptom-group  is  due  to  shock,  it  will  usually  be  temporary', 
but  occasionally,  even  when  so  caused,  it  persists  .some  considerable  time. 


Fractures  and  Dislocations  of  the  Spine  873 

It  is  also  probable  that  concussion  of  the  cord  may  in  some  cases  simulate 
complete  division.  As  Walton  says,  no  symptoms  prove  a  hopeless  crush  of 
the  cord:  it  is  the  persistence  of  the  sym{)toms  which  does  prove  it  ("Jour. 
Nervous  and  Mental  Diseases,"  Jan.,  1902);  I  would  add  the  unchanging 
persistence  of  the  symptoms  j)roves  it. 

A.  J.  McCosh  ("Jour.  Amer.  Med.  Assoc,"  Aug.  31  and  Sept.  7,  1901) 
points  out  that  definite  pressure  is  indicated  by  marked  symptoms  and  ab- 
sence of  reflexes.  When  there  is  not  definite  pressure,  the  symptoms  are 
irregular;  there  is  incomplete  palsy,  or  muscles  of  the  same  group  show 
different  degrees  of  paralysis;  anesthesia  is  partial;  signs  of  irritation  are 
not  distinct,  and  there  are  patches  of  hyperesthesia  and  zones  of  paresthesia. 
If  in  doubt,  at  the  end  of  twelve  hours  perform  an  exploratory  operation. 

The  prognosis  depends  on  the  amount  of  damage  done  to  the  cord. 
Fracture-dislocations  in  the  cervical  region  produce  obvious  deformity,  stiff- 
ness of  the  neck,  and  irregularity  of  the  spines,  and  a  displaced  vertebra 
may  occasionally  be  detected  by  a  finger  in  the  pharynx.  Crepitus  can 
rarely  be  detected  unless  a  spinous  process  is  fractured.  The  Rontgen  rays 
aid  diagnosis.  The  seat  of  cord  injur)'  may  be  determined  by  a  study  of 
the  palsy  and  other  symptoms. 

Fracture-dislocation  of  the  atlas  or  axis  usually  causes  instant  death. 
When  the  displacement  is  only  trivial,  the  patient  may  actually  recover, 
but  will  probably  die  of  secondary  cord  disease.  Dr.  N.  J.  Blackwood  of  the 
U.  S.  Navy  records  a  case  of  fracture  of  the  atlas  and  axis  and  forward  disloca- 
tion of  the  occiput  on  the  spinal  column,  hfe  having  been  maintained  for  thirty- 
four  hours  and  forty  minutes  by  artificial  respiradon,  during  which  time 
laminectomy  was  performed  on  the  third  cervical  vertebra  ("Annals  of  Sur- 
gery," May,  1908).  Lofton  has  recorded  a  case  of  recovery  after  dislocation 
of  the  anterior  arch  of  the  atlas  on  to  the  odontoid  process  ("N.  Y.  Med. 
Jour.,"  April  18,  1908).  In  injur)'  of  the  third  cervical  vertebra  the  phrenic 
nerve  is  involved,  the  diaphragm  is  paralyzed,  and  death  soon  occurs.  In 
fracture-dislocation  of  the  fifth  cer\'ical  vertebra  the  subscapularis  mus- 
cles are  paralyzed,  but  the  biceps,  brachialis  anticus,  supinator  longus,  and 
deltoid  escape,  and  the  patient  assumes  a  characteristic  attitude  (Fig.  486). 
In  Jones'  case  of  fracture  of  the  fifth  cervical  vertebra  no  operation  was 
performed,  but  the  patient  partly  recovered  and  became  able  to  walk,  but  with 
a  spastic  gait  ("Lancet,"  Nov.  28,  1903).  If  the  sixth  cervical  vertebra  is  dis- 
located, there  is  palsy  of  the  muscles  of  the  hand.  In  injuries  below  the 
sixth  vertebra  no  muscle  of  the  arm,  forearm,  or  hand  is  paralyzed  at  first, 
although  after  some  days  paralysis  may  develop.  Damage  to  the  cord  above 
the  sixth  cer\ncal  vertebra  produces  anesthesia  of  the  body  below  the  in- 
jury and  of  the  entire  upper  extremity  except  the  shoulder.  In  injury  just 
above  the  upper  level  of  the  seventh  cervical  there  are  body-anesthesia  and 
anesthesia  of  the  outer  surfaces  of  the  arms  and  ulnar  margins  of  the  fore- 
arms and  hands.  In  any  cervical  injury  there  are  body-anesthesia  and 
diaphragmatic  respiration,  and  in  cases  without  paralysis  of  the  arms  there 
is  sure  to  be  pain.  Injuries  of  the  dorsal  spine  can  be  accurately  located. 
There  is  paralysis  of  motion  and  sensation  up  to,  or  almost  up  to,  the  seat 
of  injury.  The  arms  are  not  paralyzed.  Very  great  pain  in  the  legs  occurs 
if  the  lumbar  enlargement  is  involved.     In  injury  of  the  twelfth  dorsal  or 


874  Surgery  of  the  Spine 

upper  lumbar  vertebra  there  are  paralysis  of  the  bladder  and  rectum,  an  incom- 
plete anesthesia,  and  a  partial  motor  paralysis  of  the  limbs. 

Treatment  of  Fracture-dislocations. — When  dislocation  of  the  body 
of  the  vertebra  obviously  exists,  the  surgeon  may  attempt  reduction  by  exten- 
sion and  rotation.  The  maneuver  is  very  dangerous  in  the  cervical  region, 
and,  as  deaths  have  happened,  some  eminent  surgeons  advise  against  reduc- 
tion when  the  injury  aiJects  that  region.  Walton's  plan  for  a  unilateral  cervical 
dislocation  is  as  follows:  Give  the  patient  ether  and  hold  him  erect  and 
sitting  on  a  chair.  The  surgeon  stands  behind  the  patient  and  holds  the  head 
with  both  hands.  The  first  motion  is  a  slight  degree  of  rotation  to  carry  the 
dislocated  process  forward  and  "unlock"  it.  The  head  is  then  rocked  toward 
the  sound  side  and  somewhat  backward  and  finally  the  process  is  replaced  by 
rotation.  No  force  is  used  (Clopton,  in  "Interstate  Med.  Jour.,"  Jan., 
1908.  Quoted  in  General  Surgery  by  John  B.  Murphy,  1909).  After 
reducing  a  fracture-dislocation  of  the  cervical  region,  place  the  patient  in  bed, 
elevate  the  head  of  the  bed  a  few  inches,  and  immobilize  the  neck  and  head. 
In  fracture-dislocation  of  the  dorsal  or  lumbar  region  the  traditional  plan 
is  to  straighten  the  spine,  gently  if  possible,  and  to  put  the  patient  upon  his 
back  upon  a  water-bed  or  upon  air-cushions.  Empty  the  bladder  every 
six  hours  with  a  soft  catheter,  which  is  kept  strictly  aseptic.  Take  every 
precaution  to  prevent  bed-sores.  Some  surgeons  advocate  reduction  of  the 
deformity  by  extension  and  counter-extension,  and  the  application  of  a  firmly 
fitting  but  removable  jacket  with  the  suspension  collar  (as  used  in  Pott's 
disease).  If  this  plan  is  employed,  the  head  of  the  bed  is  raised  and  the 
collar  is  fastened  to  it.  Every  day  extension  is  made  gently — from  the  shoulders 
in  dorsolumbar  fracture  and  from  the  chin  and  occiput  in  cervical  fractures. 
Extension  may  be  maintained  permanently  until  cure.  Surgeons  have  come 
rather  slowly  to  a  belief  in  laminectomy.  One  deterrent  factor  has  been 
the  high  mortality:  Lloyd  collected  the  records  of  159  operations  and  found 
that  59  patients  died  almost  at  once  and  39  died  later.  Some  employ  purely 
expectant  treatment  in  vertebral  fractures.  My  own  feeling  is  that  when 
sirnply  a  spinous  process  or  some  other  part  is  fractured,  and  there  are  no 
cord  symptoms,  we  may  treat  the  patient  expectantly,  following  Burrell's 
advice,  and  fixing  the  patient  in  bed  on  a  Bradford  frame  and  having  him 
carefully  nursed  and  watched.  Reduction  by  extension  and  counter-ex- 
tension is  dangerous  and  unjustifiable  if  there  is  marked  kyphosis  and  if 
cord  symptoms  exist.  I  agree  with  Burrell  that  it  should  only  be  done  if 
operation  is  refused,  or  if  there  are  no  cord  symptoms  and  no  marked  ky- 
phosis ("Annals  of  Surgery,"  Oct.,  1905).  If  it  is  attempted  it  must  be  done 
slowly  and  as  gently  as  possible  because  it  may  cause  grave  or  even  irreparable 
damage  to  the  cord.  I  fear  to  delay,  and,  with  Burrell,  Lloyd,  Walton,  and 
others,  operate  when  the  patient  recovers  from  shock,  if  there  seems  to  be  even  a 
gleam  of  hope  that  operation  may  help  him.  To  wait  when  pressure  exists 
means  that  during  every  hour  of  delay  the  pressure  is  damaging  the  cord. 
Another  reason  for  operating  is  that  we  cannot  know  the  condition  of  the  cord 
without  direct  inspection.  The  operation  to  be  performed  is  laminectomy.  As 
before  stated,  this  is  to  be  done  even  if  we  suspect  division  or  hopeless  crush 
of  the  cord.  In  some  cases,  it  is  true,  we  may  commit  the  error  of  operating 
when  there  is  only  concussion,  but  such  a  mistake  is  less  grave  than  to  fail  to 


Treatment  of  Fracture-dislocations  875 

operate  when  there  is  bone-pressure  or  hemorrhage.  An  objection  filed  by  the 
neurologist  against  laminectomy  is  that  portions  of  cord  above  and  below  the 
level  of  the  fracture  may  be  damaged  (Fig.  485),  but,  as  Lloyd  says,  this  fact 
does  not  forbid  operation,  but  renders  it  necessary  to  make  a  wider  explora- 
tion than  has  been  the  custom.  In  many  cases  after  prompt  laminectomy 
we  get  some  considerable  improvement,  and  this  improvement  may  be  suffi- 
cient to  enable  a  man  to  earn  a  living.  It  is  true  that  statistics  would  indicate 
that  late  operations  have  been  more  successful  than  early  ones,  but  these 
figures  must  be  analyzed  in  the  light  of  the  knowledge  that  many  of  the  fatali- 
ties after  early  operation  would  have  occurred  if  no  operation  had  been  done, 
and  some  improvements  after  late  operation  would  have  occurred  to  as  great 
or  a  greater  degree  after  early  operation.  The  prognosis  of  any  operation, 
early  or  late,  is  never  gratifying,  and  Thorburn  feels  no  confidence  in  obtain- 
ing improvement  except  in  injuries  of  the  laminae,  hemorrhage,  or  injuries  of 
the  Cauda  equina,  as  he  says  laminectomy  in  the  cervical  region  is  followed 
by  death,  and  laminectomy  in  the  dorsal  region,  though  not  commonly  fatal, 
is  seldom  followed  by  recovery  of  function.  Our  statistics  of  early  laminec- 
tomy will  show  fewer  deaths  and  fewer  useless  operations  if  we  do  not  operate 
till  shock  abates.  As  Lloyd  says  ("Phil.  Med.  Jour.,"  Feb.  5,  1902):  "It 
is  therefore  evident  that  if  we  operate  immediately  after  the  injury  we  will 
have  failures  that  should  not  be  charged  against  the  operation  itself,  and,  if 
possible,  we  should  wait  before  operating  until  the  question  can  be  settled 
whether  the  patient  will  overcome  the  shock  or  will  succumb  directly  to 
the  effects  of  the  injury."  All  surgeons  operate  for  compound  fracture, 
for  hemorrhage,  and  for  cases  with  marked  bone-pressure.  If  early  oper- 
ation were  not  performed  and  if  pachymeningitis  arises,  operation  is  called 
for. 

My  own  convictions  are  that  if  symptoms  are  significant,  we  should 
explore,  as  soon  as  shock  has  passed  away,  even  if  we  think  it  probable  that 
the  cord  has  been  divided;  and  if  it  is  found  divided,  it  should  be  sutured. 
If  in  any  case  we  are  in  doubt  twelve  hours  after  the  injury  as  to  whether  or 
not  pressure  exists,  we  should  explore.  If  soon  after  the  accident  we  think 
pressure  by  bone  exists,  we  should  operate.  If  the  case  is  improving,  we 
should  not  operate  even  if  there  are  pressure-signs,  unless  there  is  a  chance 
that  pressure  is  due  to  bone,  in  which  case  we  should  operate.  As  McCosh 
says,  pressure  by  blood  or  inflammatory  exudate  may  pass  away;  pressure 
by  bone  cannot.  Even  long  after  an  injury  laminectomy  may  be  productive 
■of  some  benefit. 

The  rather  radical  views  set  forth  above  regarding  the  advisability  of 
-operating  even  if  the  symptoms  point  to  complete  division  of  the  cord  arose 
largely  from  a  knowledge  of  the  well-known  case  operated  upon  by  Stewart 
for  total  division  of  the  cord.  In  a  case  of  gunshot-wound  of  the  dorsal 
spine  treated  at  the  Pennsylvania  Hospital  by  Francis  T.  Stewart,  and  reported 
by  Francis  T.  Stewart  and  Richard  H.  Harte  ("Phila.  Med.  Jour.,"  June 
7,  1902),  an  exploratory  incision  made  three  hours  after  the  injury  showed 
that  the  spinal  cord  was  completely  divided.'  There  was  a  fracture  of  the 
laminae  of  the  seventh  dorsal  vertebra.  The  spines  and  laminae  of  the  seventh 
and  eighth  dorsal  vertebrae  were  removed.  The  bullet-hole  was  recognizable 
in  the  membranes,  and  the  bullet  and  some  bone-fragments  were  removed. 


876  Surgery  of  the  Spine 

When  the  dura  was  opened,  the  ends  of  the  completely  divided  dorsal  cord 
were  found  to  be  three-quarters  of  an  inch  apart.  Stewart  freshened  these 
ends  and  brought  them  together  with  two  sutures  of  chromicized  catgut. 
In  this  case  a  considerable  degree  of  restoration  of  function  took  place.  At 
the  time  of  the  operation,  three  hours  after  the  injury,  there  were  complete 
paralysis  and  absence  of  reflexes  below  the  seat  of  injury;  but  sixteen  months 
later  the  patient  was  able  voluntarily  to  flex  the  toes,  flex  and  extend  the  legs, 
flex  and  extend  the  thighs,  and,  while  sitting,  lift  an  extended  leg  from  the 
floor.  The  movements  of  the  lower  extremity  became  more  forcible  when 
reinforced  by  contracting  the  muscles  of  the  upper  extremity  while  making 
them.  The  patient  could  stand  with  one  hand  resting  on  the  back  of  a  chair, 
and  could  get  herself  from  her  bed  to  her  chair  by  sliding.  The  bowels  were 
under  perfect  control,  and  there  was  no  incontinence  of  urine  when  she  was 
awake,  although  there  was  occasionally  some  when  she  was  asleep.  There 
were  occasional  cramp-like  pains  in  the  lower  limbs.  The  sense  of  touch, 
temperature,  pain,  and  position  were  perfect  all  over  the  previously  para- 
lyzed parts.  Below  the  knee  the  localization  of  sensation  was  not  so  accu- 
rate. There  was  a  slight  amount  of  muscular  rigidity;  and  on  each  side, 
an  ankle  and  patellar  clonus,  which  was  easily  exhausted.  When  the  sole 
of  the  foot  was  tickled,  the  big  toe  flexed,  the  thigh  abducted,  and  there  was 
slight  contraction  of  the  anterior  tibial,  the  hamstring,  and  the  tensor  vagina? 
femoris  muscles.  There  were  no  reactions  of  degeneration  and  no  trophic 
changes.  There  had  never  been  any  bed-sores.  George  Ryerson  Fowler 
("Annals  of  Surgery,"  Oct.,  1905)  operated  on  a  gunshot-wound  of  the 
dorsal  spine  eleven  days  after  the  injury.  He  removed  the  laminas  of  the 
tenth,  eleventh,  and  twelfth  dorsal  vertebrae  and  found  the  cord  divided,  the 
bullet  lying  between  the  severed  ends.  A  piece  of  dura  one-eighth  of  an  inch  wide 
was  intact.  The  bullet  and  blood-clot  were  removed.  The  cord  was  sutured 
with  three  sutures  of  chromicized  gut,  which  included  the  dura,  and  more  sutures 
were  taken  through  the  dura  only.  The  ends  of  the  cord  were  easily  approxi- 
mated. The  patient  recovered  from  the  operation.  Twenty-six  months 
later  voluntary  motion  was  found  to  be  practically  lost  in  the  area  below 
the  injury,  although  when  supported  by  the  hands  he  could  stand  and  when 
in  a  frame  could  move  a  little  by  a  swinging  movement.  He  is  able  to  tell 
when  his  bowels  or  bladder  are  about  to  move,  and,  if  furnished  promptly 
with  a  utensil,  does  not  soil  himself.  Wlien  asleep,  he  passes  urine  involun- 
tarily. Both  legs  exhibit  spastic  rigidity,  but  there  are  no  reactions  of  de- 
generation. Patellar  reflex  on  each  side  exaggerated.  Ankle  clonus  is  found 
on  one  side,  but  not  on  other.  There  is  complete  anesthesia  of  the  affected  area, 
except  in  a  region  five  inches  in  length  on  the  outer  side  of  the  right  thigh. 
Touch  is  appreciated  but  not  correctly  localized.  In  connection  with  the  fore- 
going important  cases  we  would  note  that  Dr.  Estes,  of  Bethlehem,  has  also 
operated  upon  a  case  of  complete  division  of  the  spinal  cord,  in  which  suturing 
was  followed  by  some  restoration  of  function. 

In  the  light  of  these  positive  reports  we  must  ask  ourselves  if  we  have  not 
been  wrong  in  the  view  that  the  spinal  cord  cannot  regenerate.  If  there 
is  even  a  chance  that  we  have  been  wrong,  we  must  reverse  our  former  con- 
servative treatment  and  follow  a  radical  plan.  The  three  cases  strongly  sug- 
gest the  possibility  of  some  regeneration,  but  do  not  prove  it.     The  cord  may 


Operations  on  the  Spine  877 

have  appeared  to  be  completely  divided  and  yet  minute  undivided  bundles 
may  have  escaped  recognition.     Again,  as  Fowler  suggests,  there  may  be  a 
nerve  anastomosis  through  uninjured  portion  of  the  dura  or  between  adja- 
cent nerve-trunks  which  arise  above  and  below  the  lesion.     At  my  request 
Dr.  Samuel  Lloyd,  of  New  York,  kindly  wrote  me  a  personal  communication 
setting  forth  his  views  on  this  important  subject.      They  are   as   follows: 
"  The  question  of  the  regeneration  of  the  spinal  cord  after  traumatism  of  the 
spine  deserves  careful  consideration  in  all  cases  that  are  operated  upon.     Up 
to   the    present    time,   however,   although    a    number    of    operators    have 
reported  improvement  following  suture  of  the  spinal  cord  in  these  cases, 
a  careful  analysis  does  not   substantiate   the   fact   that   that   improvement 
is  due  to  an  actual  regeneration.     It  is  a  recognized  fact  on  the  part  of 
all  who  have  had  experience  with  the  surgery  of  the  spinal  cord  that  in 
almost  every  instance  a  certain  amount  of  improvement  is  noted  during  the 
first  few  months.     This  is  probably  due  to  the  fact  that  at  the   time   of 
the   injury   minute   hemorrhages   occur   into   the   adjoining  segments,   and 
that  pressure  is  also  increased  in  those  portions  of  the  cord  by  the  inflamma- 
tory exudate  and  edema.     Within  a  short  time  after  the  injury  these  condi- 
tions improve,  and  there  seems  to  be  an  improvement  in  function;    but  in 
every  case  of  spinal  suture  yet  reported  the  amount  of  improvement  may  be 
explained  by  these  facts.     In  no  instance  has  there  been  a  complete  recovery 
of  function,  but  in  every  one  there  has  remained  more  or  less  permanent  dis- 
ability.    This,  however,  should  not  discourage  attempts  at  spinal  suture, 
and  in  every  case  operated  upon  the  dura  should  be  opened  and  the  condition 
of  the  cord  examined.     In  those  cases  where  a  complete  destruction  has 
occurred  and  where  the  extent  of  it  is  not  over  three-quarters  of  an  inch,  it 
may  be  possible  to  cut  out  the  lacerated  portions  and  coaptate  the  surfaces 
by  a  series  of  sutures  placed  in  the  dura.     In  all  these  cases  the  patient  should 
be  put  up  in  a  plaster  retaining  bandage  in  extreme  extension,  even  the  head 
being  thrown  back  so  as  to  relax  as  much  as  possible  the  tension  on  the  line 
of  suture.     The  operator  should  be  very  sure,  however,  that  there  are  no 
undestroyed  fibers  traversing  the  lacerated  area,  for  the  destruction  of  these 
in  case  regeneration  did  not  occur  would  increase  the  amount  of  paralysis. " 
With  the  views  of  Lloyd  I  am  in  entire  agreement,  and  in  future  I  shall 
follow  this  plan,  bearing  in  mind  that  it  is  often  impossible  to  tell  whether  the 
spinal  cord  is  completely  divided  or  seriously  damaged  without  examining  it, 
and  it  can  be  examined  only  by  exploratory  operation;  therefore,  if  the  serious 
symptoms  already  indicated  exist  after  shock  has  passed  away,  exploratory 
operation  should  be  performed;    if  pressure  exists,  it  should  be  removed; 
and  if  the  spinal  cord  is  found  to  be  completely  divided,  it  should  be  sutured. 
It  is  well  to  remember  that  Abbe's  experiments  have  shown  that  there  may 
be  great  difficulty  in  bringing  the  divided  ends  of  the  cord  into  apposition. 
In  order  to  effect  this  it  may  be  necessary  to  resect  a  vertebra. 

Operations  on  the  Spine.— Operation  for  Spina  Bifida.— A.  W. 
Mayo  Robson  maintains*  that  operation  is  not  demanded  when  the  sac  is 
of  small  size  and  is  well  protected  by  sound  integument;  that  operation  is 
improper  when  a  large  portion  of  the  column  is  fissured,  or  when  paraplegia  or 
hydrocephalus  exists;  that  operation  is  advisable  only  in  meningocele,  in 
*  Annals  of  Surgery,  vol.  xxii,  No.  i. 


878  Surgery  of  the  Spine 

cases  in  which  the  integument  is  thin  and  translucent,  in  cases  in  which  the 
cord  is  flattened  out  or  the  nerv^es  are  fused.  Robson  has  closed  the  osseous 
defect  by  transplanting  periosteum. 

Instruments  Required. — Scalpels,  dissecting  and  hemostatic  forceps,  scis- 
sors, mouse-toothed  forceps,  rongeur  forceps,  dural  separator,  Hagedom 
needles  and  needle-holders,  silk,  silkworm-gut  or  catgut. 

Operation. — Surround  the  sac  by  elliptical  incisions.  Find  the  neck  of 
the  sac,  and  if  it  contains  no  visible  nerves,  ligate  it  and  cut  off  the  protrusion. 
Push  the  stump  into  the  canal.  Freshen  the  bone-margins  and  spring  a 
piece  of  celluloid  beneath  them  to  close  the  gap  (Park).  Suture  over  the 
stump  with  small  sutures  of  catgut.* 

Treves's  Operation  for  Vertebral  Caries. — (See  page  707.) 

Laminectomy. — The  instruments  required  for  laminectomy  are  Horsley's 
bone-cutter,  dissecting,  mouse- toothed,  and  hemostatic  forceps;  scalpels;  bone- 
cutting  forceps;  rongeur  forceps;  a  dry  dissector;  a  periosteum-elevator; 
sequestrum  forceps;  small  scissors,  straight  and  curved  on  the  flat;  a  chisel 
and  mallet;  retractors;  blunt  hooks;  a  probe;  tenaculum  forceps;  a  spoon- 
curet;  a  sand-pillow;  fine  needles,  curved  and  straight,  large  needles,  and  a 
needle-holder. 

In  the  operation  of  laminectomy  the  patient  lies  prone  and  a  sand-pillow 
is  placed  under  the  lower  ribs.  Make  a  vertical  incision  over  and  down 
to  the  vertebral  spines,  the  middle  of  the  incision  corresponding  to  the  seat 
of  injury  or  disease.  The  sides  of  the  spinous  processes  and  the  laminae 
are  cleared.  The  periosteum  is  incised  in  the  angle  between  the  laminae 
and  spines,  and  is  lifted  away  from  the  arches.  The  spinous  processes  are 
cut  off  close  to  their  bases  by  means  of  the  bone-cutter  forceps,  the  laminae 
are  removed  on  each  side  with  the  same  instrument  or  the  rongeur,  and  the 
dura  is  exposed.  In  some  cases  of  fracture  fragments  will  be  found  on  ex- 
posing the  vertebra,  or  a  blood-clot  will  be  seen  between  the  dura  and  the  bone; 
in  other  cases  the  dura  must  be  opened  with  scissors  vertically  in  the  middle 
Hne  while  it  is  grasped  with  mouse-toothed  forceps.  After  reaching  and 
removing  the  compressing  cause,  or  after  failing  to  find  or  remove  it,  it  is 
best  not  to  close  the  dura  completely,  because  if  we  do  so,  cord  pressure  may 
result  from  hemorrhage.  The  dural  wound  is  left  open  or  is  partly  closed. 
I  used  to  insert  a  drain  of  rubber  tissue,  but  have  given  it  up.  Horsley  shows 
that  it  is  not  necessary,  and  if  we  refrain  from  draining  we  lessen  the  tendency 
to  headache,  temporary  pyrexia,  and  rapid  pulse,  which  frequently  follow 
laminectomy.  The  superficial  parts  are  stitched  with  silkworm-gut  and  dress- 
ings are  applied. 

Puncture  of  the  spinal  meninges,  or  lumbar  puncture,  was  devised 
by  Quincke,  and  has  been  carefully  tested  by  many  surgeons.  It  is  the  opera- 
tion for  withdrawing  cerebrospinal  fluid  from  the  subarachnoid  space  of  the 
cord.  It  is  employed  as  a  means  of  diminishing  cerebral  pressure  in  hydro- 
cephalus, cerebral  tumor,  uremia,  and  tuberculous  meningitis,  but  in  these 
cases  it  has  proved  of  little  or  only  of  temporary  therapeutic  value.  It  may 
be  of  some  service  in  cerebrospinal  meningitis.  The  condition  of  a  patient 
with  a  fracture  of  the  base  of  the  skull  is  sometimes  temporarily  improved  by 

*  A  full  consideration  of  the  various  plans  of  operating  will  be  found  in  an  article  by 
Marcy,  in  Annals  of  Surgery,  March,  1895. 


Puncture  of  Spinal  Meninges,  or  Lumbar  Puncture  879 

the  operation.  Pain  is  often  temporarily  relieved.  In  the  performance  of  a 
brain  operation  the  brain  may  bulge  so  that  the  dura  cannot  be  sutured. 
Lumbar  puncture  makes  suturing  possible.  Puncture  is  the  prehminary 
step  of  spinal  anesthesia.  In  some  cases  the  examination  of  the  fluid  has  been 
of  great  diagnostic  value.  The  fluid  is  not  only  subjected  to  a  naked-eye 
study,  it  is  also  studied  microscopically  and  bacteriologically.  If  the  fluid 
from  the  puncture  gives  no  positive  finding,  the  operation  should  be  repeated 
(Lorgo).  When  a  diagnostic  tap  is  made  we  must  know  the  appearance, 
nature,  and  pressure  of  the  fluid  normally. 

Normally  the  fluid  is  clear,  transparent,  and  alkaline  under  a  pressure  of 
from  40  to  60  miUimeters  of  mercury  (Dana),  its  specific  gravity  is  from  1.006 
to  1.008,  and  from  5  to  10  cc.  will  flow  out  at  a  tap.  It  contains  a  very 
few  endothelial  cells  and  leukocytes.  In  cases  of  increased  tension  it  flows 
out  more  forcibly,  rapidly,  and  profusely  (brain  tumor,  hydrocephalus,  menin- 
gitis, and  some  infectious  conditions).  When  there  is  meningeal  inflammation 
the  specific  gravity  is  increased.  In  apoplexy  and  other  hemorrhages  beneath 
the  cerebral  arachnoid,  in  fracture  of  the  base  of  the  skull,  and  in  hemorrhage 
beneath  the  arachnoid  of  the  cord,  the  fluid  contains  blood.  Laceration  of 
the  brain  tissue  without  subarachnoid  or  ventricular  hemorrhage  does  not 
make  the  fluid  bloody.  The  fluid  is  turbid  in  purulent  meningitis  of  the  cord 
or  brain.  Lumbar  puncture  is  of  great  diagnostic  use  in  the  cerebral  hemor- 
rhage of  the  newborn  and  in  some  fractures  of  the  base  of  the  skull. 

The  chemical  study  of  the  fluid  is  sometimes  of  value. 

In  intracranial  tumor,  purulent  meningitis,  subarachnoid  hemorrhage 
of  the  brain  or  cord,  and  apoplexy  albumin  is  increased.  The  normal  fluid 
contains  a  substance  resembling  or  identical  with  glucose.  This  is  often  absent 
in  meningitis  and  is  increased  in  saccharine  diabetes. 

In  uremia  the  chlorids  are  diminished. 

Cytodiagnosis  (a  microscopic  study  of  the  cells  of  the  fluid)  may  furnish 
useful  information.  Lymphocytosis  suggests  a  tuberculous  lesion  rather  than 
an  acute  meningeal  inflammation.  Lymphocytosis  occurs  also  in  syphilis  of 
the  brain  and  cord,  locomotor  ataxia,  paresis,  and  uremia. 

Bacteriologic  study  by  cover-glass  preparations  or  cultures  may  give  im- 
portant information.  •  In  over  75  per  cent,  of  cases  of  tuberculous  meningitis 
of  the  brain  membranes  the  fluid  contains  bacilh.  Stadelmann  has  reported 
37  cases  in  which  tubercle  bacilli  were  found  in  the  fluid.*  In  tuberculous 
meningitis  the  fluid  may  or  may  not  contain  tubercle  baciUi.  In  cerebrospinal 
meningitis  the  cerebrospinal  fluid  contains  the  meningococcus.  In  this  disease 
lumbar  puncture  is  unnecessary  if  the  nasal  mucus  contains  the  diplococcus 
intracellularis.  The  operation  of  lumbar  puncture  is  simple,  and  if  done  with 
proper  precautions,  is  harmless.  The  back  should  be  carefully  sterilized  and 
thorough  asepsis  must  be  preserved  in  every  detail.  The  patient  may  lie  on  the 
right  side  with  the  left  knee  well  drawn  up,  may  lie  prone,  vdth  a  pillow  under 
the  belly,  or  may  sit  in  a  chair,  with  the  body  bent  forward.  The  site  of  the 
intended  puncture  may  be  frozen  with  ethyl  chlorid,  but  no  general  anesthetic 
is  required.  A  Pravaz  syringe  is  employed.  The  needle,  which  should  be 
3  inches  in  length,  is  guarded  by  the  surgeon's  index-finger  and  the  point 
is  inserted  J  inch  to  the  right  of  the  median  line  and  between  the  third 
*  Berliner  klinische  Wochenschrift,  July  8,  1895. 


88o  Surgery  of  the  Spine 

and  fourth  lumbar  vertebra?.  It  is  pointed  upward  and  a  httle  inward 
under  a  spinous  process.  In  a  child  the  needle  enters  the  canal  at  a  depth  of 
from  2  to  3  centimeters;  in  an  adult,  at  a  depth  of  from  4  to  6  centimeters.  The 
fluid  is  permitted  to  fall  drop  after  drop  into  a  sterile  test-tube.  In  some  cases 
but  a  few  drops  of  fluid  will  be  obtained;  in  other  cases  many  cubic  centi- 
meters may  be  removed.  It  is  not  wise  to  draw  for  diagnostic  purposes  over 
5  CO.  from  a  child  and  10  cc.  from  an  adult.  If  we  evacuate  too  much  cere- 
brospinal fluid,  the  ventricles  are  emptied  and  compression  of  the  cerebellum 
may  arise.  The  flow  should  be  spontaneous  and  suction  ought  not  to  be 
used.  Sometimes  nausea,  vertigo,  and  severe  headache  follow  the  operation, 
and  sudden  deaths  have  been  reported.  For  a  number  of  hours  after  tapping 
the  patient  should  remain  recumbent. 

Horsley's  Operation  for  Chronic  Spinal  Meningitis. — Sir  Victor 
Horsley  ("Brit.  Med.  Jour.,"  Feb.  27,  1909)  states  that  during  the  past  ten 
years  he  has  operated  on  a  number  of  cases  for  what  he  calls  chronic  spinal 
meningitis.  Such  cases  are  commonly  confused  with  tumor,  are  much  more 
frequent  than  tumors,  and  are  often  cured  or  greatly  improved  by  operation. 
The  first  pubKshed  case  of  this  sort  was  reported  by  Spiller,  Musser,  and 
Martin  ("Univ.  of  Penn.  Med.  Bulletin,"  March,  1903).  Martin  performed 
laminectomy,  found  a  "circumscribed  meningitis, "  and  cured  the  patient. 
In  these  cases  a  fluid  accumulation  is  found  and  this  fluid  is  stagnating  and 
under  pressure.  The  cord  passes  into  a  condition  of  sclerogliosis.  The 
symptoms  are  pain,  advancing  loss  of  power  in  the  legs,  perhaps  shght  kypho- 
sis, and  eventually  progressive  and  fatal  paraplegia  (compression  paraplegia) . 

The  pain  in  these  cases  involves  an  extensive  area,  not  as  in  extramedullary 
tumor  a  small  area  supplied  by  one  or  two  nerve-roots,  and  there  may  be 
hyperesthesia  over  an  entire  extremity,  which  does  not  occur  in  extramedullary 
tumor  (Horsley,  Ibid.).  Horsley  has  never  seen  absolute  abolition  of  tactile 
sense.  The  operation  consists  in  laminectomy,  opening  the  theca,  washing 
it  out  with  mercurial  solution  (i  :  500  followed  by  i  :  2000),  and  closing 
without  drainage. 


Inflammation  and  Abscess  of  the  Antrum  of  Highmore 


XXV.    SURGERY    OF   THE    RESPIRATORY  ORGANS. 

Diseases  and  Injuries  of  the  Nose  and  Antrum. 

Foreign  bodies  in  the  nose  are  usually  introduced  through  the 
anterior  nares,  but  in  rare  instances  they  enter  by  way  of  the  posterior  nares. 
Small  particles  are  often  expelled  spontaneously;  larger  pieces  collect  mucus 
and  epithelium  and  become  fixed.     Some  materials  swell  after  lodgment. 

Treatment . — In  many  cases  anesthesia  is  required.  Illuminate  the  nostril, 
and,  if  the  foreign  body  can  be  seen,  insert  a  hook  back  of  it  and  ei^ect  its 
removal  by  means  of  forceps.  Some  foreign  bodies  require  to  be  pushed 
back  into  the  nasopharynx.  Occasionally  expulsion  may  be  effected  by 
inserting  a  rubber  tube  into  the  unblocked  nostril  and  telhng  the  patient 
to  blow  forcibly  through  the  tube.  In  serious  cases  a  specialist  should  be 
summoned  to  remove  a  portion  of  the  turbinated  bone  or  to  perform  whatever 
operation  he  thinks  best. 

Inflammation  and  Abscess  of  tiie  Antrum  of  Highmore  (of  the 
Maxillary  Antrum). — The  source  of  this  disease  may  be  inflammation  of 
the  nose  or  periostitis  around  the  roots  of  the  teeth.  In  some  cases 
the  natural  opening  into  the  meatus  is  patent;  in  other  cases  it  is  partly 
or  completely  blocked.  Caries  and  necrosis  may  arise.  The  symptoms 
are  pain,  edematous  swelHng  of  the  face,  and  thinning  of  the  bone  so 
that  it  may  crepitate  under  pressure.  When  pus  has  formed,  if  the 
antral  opening  is  patent,  certain  positions  of  the  head  will  cause  a  puru- 
lent flow  from  the  nose,  and  if  a  speculum  is  inserted  pus  may  be  seen 
as  it  flows  into  the  nose.  The  opening  of  the  maxillary  antrum  into 
the  nasal  channel  is  at  the  summit  of  the  antrum;  hence  the  antrum 
drains  when  the  head  is  inverted.  The  ethmoidal  cells  and  frontal  sinus 
drain  best  when  the  patient  is  upright.  Wipe  the  interior  of  the  nose  and 
place  the  patient  with  his  head  between  his  knees.  If  the  nostril  fills 
with  pus,  it  comes  from  the  antrum  (Cobb).  In  severe  cases  the  jaw  expands, 
the  eye  protrudes,  and  great  tenderness  of  the  alveolus  exists.  Percussion 
exhibits  a  dull  note.  In  making  a  diagnosis  it  is  well  to  take  the  patient 
into  a  dark  room,  insert  an  electric  light  into  the  mouth  and  note  the  diminu- 
tion of  Hght-transmission  on  the  diseased  side  as  contrasted  with  the  sound 
side.  Transillumination  may  be  easily  practised  by  the  use  of  a  cautery 
electrode,  protected  by  a  small  glass  vial.  Any  cautery  battery  may  be 
employed  (plan  suggested  by  Ohls).  Exploratory  puncture  wiU  settle  a 
doubtful  diagnosis.  This  may  be  by  way  of  the  lower  meatus,  the  canine 
fossa,  or  the  alveolar  process.* 

Treatment. — Before  pus  forms  order  the  use  of  hot  fomentations  and 
remove  any  diseased  teeth.  When  pus  has  formed,  evacuate  it  at  once. 
Before  performing  a  severe  operation  try  the  effect  of  opening  into 
the  antrum  from  the  nose,  by  means  of  Krause's  trocar,  followed  by 
insufflation  of  iodoform.  If  this  procedure  fails,  other  means  may  be  em- 
ployed. If  the  disease  arises  from  a  carious  tooth,  pull  the  tooth  and  push 
a    trocar    through    its    socket    into    the   antrum.     If  the  teeth    are   sound, 

*  Cobb,  in  Boston  Med.  and  Surg.  Jour.,  May  7,  1896. 
56 


882  Surgery  of  the   Respiratory   Organs 

bore  a  hole  with  a  large  gimlet  or  with  a  bone-drill  above  the  root  of  the 
second  bicuspid  tooth  and  one  inch  above  the  edge  of  the  gum.  A  counter- 
opening  should  be  made  into  the  inferior  nasal  meatus.  A  drainage-tube  is 
pulled  from  the  first  opening  into  the  nose  and  is  allowed  to  protrude  from 
the  nostril.  Irrigate  daily  with  normal  salt  solution.  In  three  or  four  days 
discontinue  through-and-through  drainage,  but  prevent  the  first  opening 
closing  until  the  discharge  ceases  to  be  purulent.  In  severe  cases  make  a 
free  incision  through  the  canine  fossa  by  means  of  a  chisel. 

Distention  and  Abscess  of  the  Frontal  Sinus.— The  usual  cause  is  an 
injury  which  may  long  antedate  the  symptoms.  This  injury  causes  or  leads 
to  blocking  of  the  infundibulum;  secretion  accumulates  and  distends  the  sinus; 
and  in  some  cases  pus  forms.  In  many  cases  the  fluid  slowly  accumulates,  and 
it  requires  years  to  produce  marked  symptoms.  In  other  cases  infection  takes 
place,  and  the  symptoms  are  positive  and  violent.  If  the  outlet  into  the  nose  is 
not  permanently  blocked,  the  fluid  may  discharge  itself  from  time  to  time.  In 
the  chronic  cases  there  is  rarely  much  pain.  The  chief  sign  is  a  swelling  of  the 
inner  or  upper  part  of  the  orbit,  which  swelling  progressively  increases  and 
finally  displaces  the  eye.  If  at  any  time  acute  .symptoms  supervene,  there  will 
be  pulsatile  pain,  discoloration,  and  tenderness. 

Treatment. — In  some  cases  it  is  possible  to  pass  a  trocar  upward  from  the 
nose  into  the  sinus,  and  so  drain  and  irrigate.  In  most  cases  an  incision  should 
be  made  through  the  soft  parts,  and  the  sinus  opened  by  a  trephine  or  chisel. 
After  the  sinus  has  been  opened  it  must  be  curetted.  The  opening  into  the 
meatus  should  be  restored  and  enlarged,  and  a  drainage-tube  must  be  passed 
from  the  forehead  incision  into  the  nostril.  I  usually  prefer  to  open  the 
sinus  by  making  an  osteoplastic  flap  in  the  anterior  wafl. 

Diseases  and  Injuries  of  the  Larynx  and  Trachea. 

Edema  of  the  Larynx  (Edema  of  the  Glottis). — The  causes  of  edema 
of  the  larynx  are:  acute  laryngitis;  chronic  diseases,  such  as  tuberculosis, 
malignant  disease,  or  syphilis;  inflammatory  disorders,  such  as  diphtheria  and 
erysipelas;  acute  infectious  diseases;  Bright's  disease;  aneurysm;  whooping- 
cough;  pneumonia;  quinsy;  wounds  of  the  larynx;  wounds  of  the  neck;  scalds 
and  burns  of  the  larynx,  and  the  inhalation  of  irritating  vapors,  such  as  those 
of  ammonia  and  sulphur.  The  symptoms  are  sudden  and  rapidly  increasing 
dyspnea,  respiratory  stridor,  huskiness  of  the  voice,  and  finally  aphonia.  The 
swollen  epiglottis  may  be  fell  with  the  finger  and  may  be  seen  with  the  help  of 
a  mirror. 

Treatment. — In  cases  in  which  edema  of  the  larynx  is  not  excessively  acute, 
introduce  a  gag  between  the  teeth,  hold  the  mouth  open,  lake  a  knife  wrapped 
to  within  one-quarter  of  an  inch  of  its  point,  make  multiple  punctures  into  the 
epiglottis,  and  favor  bleeding  by  the  inhalation  of  steam.  In  severe  cases  per- 
form intubation  or  tracheotomy. 

Wounds  and  Injuries  of  the  Larynx. — The  larynx  may  be  injured 
internally  by  foreign  bodies,  and  externally  by  blows  and  cuts.  A  condition 
often  met  with  is  cut  throat,  the  result  usually  of  a  suicidal  attempt  on  the  part 
of  the  patient  or  a  homicidal  effort  on  the  part  of  an  assailant.  The  cut  of  the 
suicide  is  usually  in  front;  as  a  rule,  it  misses  the  great  vessels,  but  divides  the 


Foreign   Bodies  in  the  Air-passages  883 

cricothyroid  or  thyrohyoid  membrane.  The  epiglottis  may  be  incised,  or 
even  be  cut  off.  If  a  large  vessel  is  cut,  death  rapidly  occurs.  The  immediate 
dangers  of  cut  throat  are  hemorrhage,  suffocation  by  blood  in  the  windpipe 
and  bronchi,  or  by  displacement  of  parts,  and  entrance  of  air  into  veins.  The 
secondary  dangers  are  pneumonia,  infection  and  sepsis,  exhaustion,  and 
secondary  hemorrhage.  The  remote  dangers  are  stricture  and  fistula  (Keet- 
ley). 

Treatment. — In  wounds  of  the  throat  arrest  hemorrhage,  remove  clots 
from  the  larynx  and  trachea,  bring  about  reaction,  asepticize  the  parts  as  well 
as  possible,  suture  the  deeper  structures  with  silver  wire,  catgut,  or  kangaroo- 
tendon,  and  the  superficial  parts  with  silkworm-gut,  dress  antiseptically,  and 
place  a  bandage  around  the  head  and  chest  so  as  to  pull  the  chin  toward  the 
sternum.  If  laryngeal  breathing  is  much  interfered  with,  perform  tracheo- 
tomy. Feed  the  patient  through  a  tube  until  union  is  well  advanced.  The  old 
method  of  leaving  the  wound  open  is  to  be  condemned.  When  sutures  are 
used,  primary  union  may  be  obtained.    This  fact  was  proved  by  Henry  Morris. 

Scalds  of  the  Glottis. — (See  section  on  Burns  and  Scalds.) 

Foreign  Bodies  in  the  Air=passages. — The  lodgment  of  foreign 
bodies  in  the  air-passages  is  a  frequent  accident.  Small  soHd  bodies  are 
usually  expelled  by  coughing.  Liquids  and  sohds  rarely  pass  beyond  the 
larynx  (except  in  laryngeal  disease  or  palsy,  wounds  of  the  floor  of  the  mouth, 
cut  throat,  and  in  people  unconscious  or  very  drunk) .  In  vomiting  during  or 
after  the  administration  of  an  anesthetic,  or  in  the  vomiting  of  drunkards,  the 
vomited  matter  may  find  its  way  into  the  larynx  or  lungs.  There  is  great 
danger  of  this  accident  in  an  operation  upon  a  patient  with  intestinal  obstruc- 
tion who  has  stercoraceous  vomiting.  In  most  instances  of  foreign  bodies 
lodged  in  the  air-passages  it  will  be  found  that  the  object  was  being  held  in  the 
mouth  when  a  sudden  deep  inspiration  was  taken  (often  during  laughter). 
The  symptoms  are  immediate,  due  to  obstruction  by  the  body  and  to  spasm, 
and  secondary,  due  to  the  situation  of  the  body  and  the  changes  it  undergoes 
or  induces. 

Lodgment  in  the  pharynx  causes  violent  dyspnea.  The  body  can  be  seen 
or  felt. 

Lodgment  in  the  Larynx. — In  a  severe  case  the  patient  fights  madly  for  air; 
his  face  becomes  livid  and  cyanotic;  his  veins  stand  out  prominently;  speech 
is  impossible,  though  he  may  make  noises  and  utter  harsh  cries;  violent  cough- 
ing begins,  and  then  vomiting;  he  tries  to  force  a  finger  down  his  throat  and 
clutches  at  his  neck;  sweat  pours  from  him;  he  feels  a  sense  of  impending  dis- 
solution, and  he  falls  unconscious,  with  incontinence  of  feces  and  urine.*  In  a 
less  severe  case  violent  dyspnea  gradually  departs  and  the  patient  lies  ex- 
hausted; but  dyspnea  and  cough  are  liable  to  recur  suddenly  at  any  time  be- 
cause of  spasm,  and  they  may  be  induced  by  a  change  of  position.  These 
attacks  of  fierce  spasmodic  cough  are  not  at  first  linked  with  expectoration,  but 
after  inflammation  begins  there  is  a  profuse  and  often  bloody  expectoration. 
Inflammation  follows  more  rapidly  the  lodgment  of  a  sharp  or  irregular  body 
than  it  does  that  of  a  round  or  smooth  body.  Inflammation  is  apt  to  produce 
edema  of  the  glottis,  bronchopneumonia,  or  ulceration  and  necrosis  of  the 
larynx.     Any  sort  of  foreign  body  in  the  larynx  may  at  any  moment  produce 

*  See  Moullin's  graphic  description  in  his  "Treatise  on  Surgery." 


884  Surgery  of  the   Respirator}-   Organs 

spasmodic  dyspnea,  and  is  always  very  liable  to  cause  edema  of  the  glottis. 
The  body  if  bony  or  metallic  can  be  detected  by  the  .r-rays. 

Lodgment  in  the  Trachea. — The  immediate  symptoms  of  a  foreign  body 
in  the  trachea  depend  on  the  shape  and  weight  of  the  body,  and  whether  it  be- 
comes fixed  in  the  mucous  membrane  or  moves  to  and  fro  with  the  air-current. 
A  smooth,  heavy  body  falls  to  the  tracheal  bifurcation,  and,  if  it  does  not  enter 
a  bronchus,  moves  with  every  breath,  and  by  its  movement  causes  violent  laryn- 
geal spasm,  cough,  and  whooping  inspiration  without  aphonia.  The  patient  is 
often  conscious  of  the  movements  of  the  foreign  body,  and  the  surgeon  may 
detect  them  with  the  stethoscope.  The  foreign  bod}-  may  be  found  with  the 
Rontgen  rays.  A  foreign  body  in  the  trachea  is  liable  to  cause  death  by 
dyspnea,  or  it  may  ascend  so  as  to  be  caught  in  the  larynx,  or  may  even  be 
expelled.  Irregular  or  sharp  bodies  lodge  in  the  mucous  membrane,  produce 
inflammation,  frequent  cough,  and  expectoration,  and  finally  lead  to  ulcera- 
tion. Bodies  which  swell  from  heat  and  moisture  tend  to  lodge  and  to  become 
fixed  (seeds  may  sprout). 

Lodgment  in  a  Bronchus. — Foreign  bodies  in  the  bronchi  seriously  en- 
danger life.  They  usually  lodge  in  the  right  bronchus.  When  a  small  lung- 
area  is  obstructed  the  obstructed  side  shows  diminished  respiratory  movement 
and  murmur  with  occa.sional  whisthng  sounds  and  large  moist  rales;  the  per- 
cussion-note is  normal.  When  an  entire  lobe  is  obstructed  all  respiratory 
sounds  are  absent  over  it,  and  over  the  unobstructed  lung  respiration  is  exag- 
gerated; the  percussion-note  over  the  obstructed  area  is  at  first  resonant,  but 
becomes  dull.  The  ^v-rays  will  enable  the  surgeon  to  detect  some  foreign 
bodies  in  a  bronchus.  Lodgment  in  a  bronchus  may  cause  bronchopneu- 
monia, abscess,  hemorrhage,  and  even  gangrene.  In  some  cases  the  body  has 
been  expelled  spontaneously.  In  rare  instances  people  have  lived  for  years 
with  lodged  foreign  bodies.  If  death  does  not  soon  follow  the  lodgment  of  a 
foreign  body,  an  abscess  is  very  apt  to  form. 

Treatment. — If  a  foreign  body  lodges  in  the  pharynx,  try  to  pull  it  for- 
ward ;  if  this  fails,  push  it  back  into  the  esophagus.  In  lodgment  in  the  larynx 
or  below,  if  the  symptoms  are  very  urgent,  at  once  perform  a  quick  laryn- 
gotcmy.  If  the  symptoms  are  not  so  urgent,  get  a  complete  history  of  the  acci- 
dent and  find  out  the  nature  of  the  foreign  body.  Be  sure  a  foreign  body  is 
retained  in  the  respiratory  tract,  and  determine  what  its  situation  may  be. 
Often  a  laryngologist  can  remove  a  foreign  body  from  the  larynx  by  means  of 
forceps,  a  mirror  and  lamp  being  used  for  illumination.  The  fauces  and  upper 
portion  of  the  larynx  should  have  cocain  applied  to  them  to  lessen  pain  and 
spasm.  If  the  surgeon  fails  in  extraction  by  forceps,  and  laryngotomy  has 
been  performed,  continue  the  search  through  the  opening  in  the  cricothyroid 
membrane;  if  laryngotomy  has  not  been  performed,  let  the  lar}-nx  be  opened 
by  thyrotomy  (a  vertical  incision  between  the  alae  of  the  thyroid  cartilage,  and 
the  separation  of  these  ah-e  to  permit  of  exploration).  After  a  thyrotomy 
suture  the  perichondrium  with  catgut.  If  the  foreign  body  is  in  the  trachea, 
perform  ordinary  tracheotomy;  if  it  is  in  a  bronchus,  perform  low  tracheotomy. 
Tracheotomy  prevents  suffocation  from  laryngeal  spasm  or  edema  of  the 
glottis.  It  may  be  possible  to  remove  the  body  in  the  bronchus  through  the 
incision  of  a  low  tracheotomy,  and  this  ought  to  be  tried.  By  this  method  I 
succeeded  in  removing  a  pin,  a  bone,  a  bean,  a  tack,  and  a  broken  tracheotomy 


Treatment  of  Foreign  Bodies  in  the  Air-passages 


885 


tube  from  the  right  bronchus.  The  foreign  body  may  be  expelled  through 
the  tracheotomy  wound;  if  it  is  not  expelled,  search  the  trachea  and  bronchi 
with  Gross's  forceps,  with  probes,  with  hooks,  or  with  the  finger.  If  the 
foreign  body  cannot  be  found,  put  the  patient  to  bed  and  maintain  a  moist 


Fig.  487. — Author's  case  of  pin  in  bronchus  removed  by  operation. 

atmosphere  in  the  room.  As  a  rule,  when  the  foreign  body  is  not  found,  insert 
a  tube.  If  the  foreign  body  be  extracted,  do  not  insert  a  tube  (unless  edema 
of  the  glottis  exists  or  is  hkely  to  come  on) ,  do  not  suture  the  wound,  but  cover 
it  with  moist  gauze  and  let  it  heal  by  granulation.     Morphin  and  sedative 


Fig.  488. 


-Gibbons'   case  of  tack  in  the  right  bronchus   removed  by  low  tracheotomy,  child 
six  years  old. 


cough-mixtures  are  given.  Gross  says  that  even  when  a  foreign  body  has  long 
been  retained  an  operation  should  be  performed  if  the  air-passages  are  not 
seriously  diseased.  What  shall  be  done  when  a  foreign  body  is  lodged  in  a 
bronchus  and  we  are  unable  to  extract  it  through  a  tracheotomy  wound 
or  by  tracheobronchoscopy?     True  said  if  "the  patient  is  in  danger  of  death" 


886 


Surgery  of  the  Respiratory  Organs 


cut  through  the  chest-wall  and  attempt  to  remove  the  body.  He  said  this  with 
a  full  knowledge  of  the  difficulty  of  locating  the  body.  This  difficulty  has  been 
partly  overcome  by  the  :x;-rays,  and  it  seems  now  more  certainly  our  duty  to 
operate  than  it  was  a  short  time  ago.  Nasiloff  proposed  to  reach  the  ob- 
struction by  the  posterior  route  after  rib  resection.  Curtis  attempted  this, 
and  though  the  patient  died,  his  operation  proves  that  the  method  is  feasible. 
An  operation  by  the  posterior  route  should  be  performed  at  once  if  low  trache- 
otomy fails.  The  danger  of  pulmonary  collapse  will  be  abolished  by  the  use 
of  a  suitable  apparatus  to  prevent  it  (page  901). 

Tracheobronchoscopy. — Dr.  Chevaher  Jackson  of  Pittsburg  has  devised 
a  tracheobronchoscope  through  which  he  has  succeeded  in  removing  foreign 
bodies  from  the  trachea  and  from  a  bronchus.  In  10  cases  of  foreign  body 
in  the  bronchus  he  removed  the  offender  in  7.  In  7  cases  of  foreign  body  in 
the  trachea  he  was  successful  in  each  case,  but  2  of  the  cases  required  tra- 
cheotomy. Whenever  there  is  dyspnea  he  always  prepares  to  do  tracheotomy 
("Annals  of  Surgery,"  March,  1908).  In  Jackson's  trained  hands  the  instru- 
ment is  most  useful,  but  an  untrained  man  with  it  would  be  like  an  untrained 
man  with  a  cystoscope. 


Operations  on  the  Larynx  and  Trachea. 

Tracheotomy. — The  instruments  required  in  this  operation  are  scalpels, 
dissecting  forceps,  a  dry  dissector,  hemostatic  forceps,  scissors,  a  tenaculum, 
aneurysm-needle,  tubes,  tapes,  Paquelin  cautery,  needles,  needle-holder,  a 

mouth-gag,  tongue-forceps,  foreign-body  for- 
ceps, retractors,  and,  if  membrane  is  present, 
feathers  and  a  solution  of  bicarbonate  of 
sodium.  In  a  formal  operation  give  chloro- 
form, but  in  an  emergency  case  this  cannot  be 
done.  The  patient  may  be  placed  supine 
with  a  sand-pillow  under  the  neck  and  with 
the  head  thrown  over  the  end  of  the  table. 
If  a  child,  Liston  used  to  wrap  it  up  to  the 
neck  in  a  sheet  to  prevent  movements  of  the 
limbs,  would  seat  himself  on  a  chair,  place 
the  child  upon  the  nurse's  lap,  and  takes  its 
head  between  his  knees.  The  head  must 
be  exactly  in  the  middle  hne,  and  extended 
(in  an  adult  this  gives  two  and  three-quarters 
inches  of  trachea  above  the  manubrium;  in  a 
child  of  ten,  two  and  a  quarter  inches;  in  a 
child  of  six,  about  two  inches).  The  operator 
stands  to  the  right  side  when  the  patient  is 
supine.  If  bleeding  is  profuse  when  the  surgeon  is  ready  to  open  the  trachea, 
place  the  patient  in  the  Trendelenburg  position  with  the  neck  extended.  The 
trachea  may  be  opened  above  or  below  the  isthmus  of  the  thyroid  gland. 
The  isthmus  in  an  adult  usually  lies  over  the  second  and  third  rings  (Fig.  490). 
The  isthmus  in  a  child  usually  lies  over  the  first  ring  or  even  over  the  space 
between  the  cricoid  cartilage  and  the  first  ring.     The  high  operation  is  always 


Fig.  489. —Blood-supply  of  the  lar- 
ynx and  trachea  ( Esmarch  and  Kowal- 


High  Tracheotomy  887 

chosen  except  in  cases  where  it  is  desired  to  search  for  a  foreign  body  in  a 
bronchus. 

High  Tracheotomy. — High  tracheotomy  is  preferred  because  in  this 
region  the  muscles  are  distinctly  separated  (Fig.  49°),  the  main  vessels  of  the 
neck  and  the  inferior  thyroid  vessels  are  not  encountered,  the  anterior  jugular 
veins  are  small  and  have  very  few  transverse  branches,  and  the  trachea  is  near 
the  surface  (Treves).  The  surgeon  accurately  locates  the  cricoid  and  thyroid 
cartilages.  An  incision  is  begun  at  the  upper  border  of  the  cricoid  cartilage, 
and  is  carried  down  precisely  in  the  middle  line  for  about  one  and  a  half  inches. 
Treves  advises  the  operator  to  steady  the  skin  of  the  neck  with  the  fingers  of 
the  left  hand  and  to  cut  with  the  unsupported  right  hand  (if  the  hand  be  sup- 
ported, the  respirations  will  interfere  with  the  operation).  The  skin,  the 
superficial  fascia,  and  the  anterior  layer  of  the  cervical  fascia  are  incised,  the 
sternohyoid  and  sternothyroid  muscles  are  separated,  and  the  fascia  over  the 
trachea  is  divided.  This  fascia  is  attached  above  to  the  cricoid  cartilage,  and 
it  divides  below  into  two  layers  to  invest  the  thyroid  body  and  its  isthmus.  If 
veins  are  in  the  line  of  the  incision,  they  are  pushed  aside, .but  it  is  not  necessary 
to  take  the  time  to  apply  double  hgatures.  Even  if 
bleeding  is  profuse,  as  soon  as  the  trachea  is  opened  and 
air  enters  freely  into  the  lungs,  venous  congestion  is  re- 
heved  and  bleeding  is  apt  to  cease.  If  hemorrhage  be 
violent  and  the  veins  are  not  at  once  caught  by  forceps, 
it  may  be  well  to  place  the  patient  in  the  Trendelenburg 
position  before  incising  the  windpipe,  in  order  to  prevent 
the  entrance  of  blood  into  the  lungs.  Before  opening 
the  trachea  the  isthmus  of  the  thyroid  gland  is  pushed 
downward ;  if  it  cannot  be  pushed  down  sufficiently,  a 
tran.sverse  incision  is  made  through  the  fascia  at  the 
upper  border  of  the  cricoid  cartilage,  and  the  fascia,  and 
the  isthmus  with  it,  is  hfted  off  the  trachea  (Bose's 
method).  A  tenaculum  is  inserted  into  the  cricoid  car- 
tilage in  order  to  steady  the  tube.  The  back  of  the  knife  posed  m  tracheotomy  {Es- 
is  turned  toward  the  sternum,  a  finger  being  held  upon  march  and  Kowaizig). 
the  blade  to  prevent  too  deep  a  cut  being  made.     The 

knife  is  plunged,  as  if  it  were  a  trocar,  into  the  mid-Une  of  the  trachea  above 
the  isthmus,  and  two  or  three  rings  are  divided  from  below  upward.  The  hook 
is  not  removed  until  the  operation  is  completed.  If  a  foreign  body  is  present, 
an  attempt  is  made  to  remove  it;  if  success  attends  the  effort,  no  tube  need  be 
worn ;  but  if  the  body  is  not  found,  a  tube  must  be  used.  In  croup  or  diphtheria 
remove  membrane  (by  means  of  a  feather  and  a  solution  composed  of  bicar- 
bonate of  sodium  oij,  glycerin  §],  water  ox — Parker)  and  insert  a  tube.  The 
edge  of  the  cut  is  grasped  with  the  dissecting  forceps,  the  mucous  membrane 
being  included  in  the  bite;  the  head  is  placed  erect,  the  tube  is  introduced,  and 
the  tenaculum  is  removed.  Secure  the  tube  by  tapes,  and  suture  the  wound 
below  the  tube.  Remove  the  tube  at  the  first  moment  consistent  with  safety. 
In  croup  or  diphtheria  put  a  screen  around  the  bed ;  have  the  air  kept  moist 
by  steam;  remove  the  inner  tube  and  clean  it  everv'twoor  three  hours  at  first; 
clean  the  outer  tube  whenever  required.  Clean  the  larynx  and  trachea  from 
time  to  time  by  means  of  a  feather  and  Parker's  solution.  A  steam  spray 
atomizer  may  be  used  with  advantage. 


Surgery  of  the  Respiratory  Organs 

Quick  laryngotomy  must  never  be  attempted  upon  a  child  under  thir- 
teen years  of  age,  because  of  the  small  size  of  the  cricothyroid  space  before  this 
age  (Treves).  In  view  of  the  difficulty  of  introducing  a  tube  and  of  wearing  it 
so  near  the  vocal  cords,  laryngotomy  should  not  be  performed  for  croup,  diph- 
theria, or  for  any  condition  in  which  a  tube  must  be  long  worn.  The  operation 
is  performed  as  follows:  Make  an  incision  an  inch  and  a  quarter  in  length 
in  the  middle  line,  from  above  the  lower  edge  of  the  thyroid  to  below  the  lower 
border  of  the  cricoid  cartilage.  Divide  the  skin,  superficial  fascia,  and  deep 
fascia,  separate  the  cricothyroid  and  sternoth\Toid  muscles,  divide  the  deep 
layer  of  fascia,  and  cut  the  cricoth}Toid  membrane  horizontally  just  above 
the  cricoid  cartilage.  The  tube  must  be  shorter  than  the  ordinary  tracheotomy 
tube.  An  operation  which  opens  vertically  the  cricothyroid  membrane, 
the  cricoid  cartilage,  and  the  upper  rings  of  the  trachea  is  called  ''/aryngo- 
tracheolomy. " 

Intubation  of  the  larynx  (O'D-djer's  Operation).— Bouchot  con- 
ceived the  idea  of  intubation;  0'D\\yer  perfected  it  and  made  it  a  genuine 
scientific  proceeding.  The  instruments  required  for  the  performance  of  this 
operation  are  a  mouth-gag,  an  instrument  to  hold  the  tube  and  introduce 
it,  and  an  instrument  for  extracting  the  tube.  The  collar  of  the  tube  has  a 
perforation  through  which  a  piece  of  silk  is  fastened  to  draw  out  the  tube. 
The  child  is  wrapped  in  a  sheet  to  secure  the  limbs,  is  seated  in  a  nurse's 
lap,  and  its  head  is  held  by  an  assistant.  The  jaws  are  opened  and  held 
apart  by  the  self-retaining  mouth-gag.  The  surgeon  sits  in  front  of  the 
patient,  wraps  a  piece  of  rubber  plaster  about  the  index-finger  of  his  left  hand, 
and  passes  the  finger  into  the  child's  mouth  until  its  tip  touches  the  epiglottis. 
He  introduces  the  holder  and  tube  (observing  if  the  silk  is  free)  along  the  sur- 
face of  the  tongue  until  the  obturator  touches  the  epiglottis;  raises  the  epiglottis 
with  the  left  index-finger,  and  passes  the  tube  into  the  larynx;  places  the  left 
index-finger  against  the  tube,  and  withdraws  the  holder  with  the  right  hand. 
The  silken  thread  is  tied  to  the  ear,  and  the  nurse  is  directed  to  employ  the 
thread  to  remove  the  obturator  if  it  becomes  obstructed  or  is  coughed  up.  The 
tube  is  removed  in  two  or  three  days;  if  breathing  is  easy,  it  is  not  reintroduced; 
but  if  dyspnea  recurs,  it  is  replaced  for  two  or  three  days  more.  If,  in  intro- 
ducing the  tube,  a  mass  of  false  membrane  is  pushed  before  it  into  the  trachea, 
breathing  ceases,  and,  if  the  mass  is  not  at  once  coughed  up,  tracheotomy  must 
be  performed.  Feed  these  patients  on  semisolids  rather  than  upon  Hquids 
(mush,  soft  eggs,  and  corn-starch);  and  if  trouble  occurs  in  swallowing  these 
articles,  feed  by  the  rectum  or  by  means  of  a  nasal  or  an  oral  tube.  In  opium- 
poisoning,  in  asphxyia,  in  acute  traumatic  pneumothorax,  and  in  cerebral  inju- 
ries, intubation  may  be  associated  with  the  use  of  Fell's  apparatus  (page  894). 

Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs. 

Traumatic  Asphyxia  (Pressure  Stasis;  The  Ecchymotic  Mask).— This 
is  a  condition  that  occasionally  arises  when  the  trunk  is  subjected  to  sudden 
and  violent  compression.  The  compression  may  be  upon  the  chest,  the  abdo- 
men, or  both;  and  in  the  majority  of  cases  it  has  been  very  temporary. 
The  ecchymotic  condition  arises  immediately,  and  is  manifested  over  the 
head  and  neck  down  to  and  sometimes  below  the  clavicle.     The  hue  is  a 


Pleuritic  Effusion  889 

violet  lividity.  There  are  a  great  many  spots  in  the  skin  in  which  the 
color  is  much  deeper,  which  have  been  supposed  to  be  hemorrhage,  and  simi- 
lar spots  exist  on  the  aural,  palatine,  and  pharyngeal  mucous  membranes. 
In  some  cases  blood  has  been  effused  into  the  orbit.  There  has  never  been 
a  reported  instance  of  intracerebral  hemorrhage. 

If  death  occurs,  it  results  from  associated  injuries.  The  condition  in 
the  cases  without  severe  associated  injuries  has  soon  disappeared,  and  entire 
recovery  has  followed.  The  view  generally  taught  is  that  traumatic  asphyxia 
is  the  result  of  compression  of  the  abdominal  veins,  causing  distention  of  the 
superior  cava  and  its  tributary  veins,  this  region  oT  the  body  showing  the  effect 
more  than  the  limbs,  because  of  the  comparative  feebleness  of  the  valves 
(Villemin).  One  thing  is  sure,  and  that  is  that  the  condition  is  particularly 
apt  to  arise  if  the  patient  violently  struggles  to  free  himself  from  the  compres- 
sion; and  many  observers  have  held  the  opinion  that  actual  vascular  rup- 
tures take  place.  There  are  certainly  some  cases,  however,  in  which  there  is 
simply  great  venous  and  capillary  distention  in  the  skin  without  rupture, 
because  pieces  of  skin  have  been  excised  and  microscopic  examination  has 
indicated  that  there  had  been  no  blood  effused.  (See  Winslow,  "Medical 
News,"  Feb.  4,  1906;  Birge,  "Cleveland  Medical  Journal,"  Sept.,  1905; 
Beach  and  Cobb  in  "Annals  of  Surgery,"  April,  1904;  and  Villemin,  "  Bull, 
et  mem.  de  la  Soc.  Chir.  de  Paris,"  No.  9,  1906.) 

Pleuritic  effusion  may  arise  from  the  lodgment  of  foreign  bodies,  from 
injury  by  fragments  of  a  broken  rib,  from  tumors,  and  from  inflammation  of  the 
lung,  but  most  usually  is  due  to  pleuritis.  '  The  commonest  cause  of  primary 
pleuritis  is  tuberculosis.  Inflammatory  effusion  is  nearly  always  unilateral 
(except  in  tuberculous  pleuritis,  but  even  this  form  is  often  one-sided  in 
origin). 

The  signs  of  pleuritic  effusion  are:  dulness  on  percussion  over  the  area  of 
effusion,  this  dulness,  when  the  patient  is  erect,  being  at  the  lower  part  of  the 
chest  and  ascending  higher  posteriorly  than  anteriorly  (alteration  of  position 
alters  the  situation  of  the  dulness);  the  intercostal  spaces  are  widened,  the 
intercostal  depressions  are  obliterated,  the  intercostal  muscles  are  rigid,  and 
their  rigidity  lessens  the  mobility  of  the  ribs  (Przewalski) .  No  breath-sounds 
can  be  detected  in  the  area  of  percussion  flatness  when  the  collection  of  fluid 
is  large,  but  in  small  effusions  deeply  situated  the  breath-sounds  are  often 
audible;  the  percussion-note  above  the  liquid  is  hyperresonant  or  tympanitic, 
and  is  often  associated,  at  the  edge  of  the  liquid,  with  a  friction-sound;  pos- 
teriorly, high  up  and  near  the  spine,  there  are  bronchial  respiration  and  bron- 
chophony. In  cases  of  pleurisy  with  effusion  pain  almost  or  quite  disappears 
with  the  advent  of  effusion,  dyspnea  comes  on,  and  the  patient  lies  upon  the 
diseased  side.  Cough  always  exists  if  there  is  pleuritic  effusion,  and  fever  is 
usually  present.  In  serous  effusions  the  diagnosis  may  be  confirmed  by  the 
aseptic  introduction  of  a  clean  aspirating-needle. 

The  treatment  in  this  stage  is  to  discontinue  arterial  sedatives  and  to 
stimulate  if  the  circulation  calls  for  it.  The  exudation  is  removed  by  the 
administration  of  salines,  compound  jalap  powder,  or  elaterium.  If  these 
means  fail,  if  the  effusion  is  excessive,  or  if  it  is  producing  dyspnea,  at  once 
aspirate.  Aspiration  should  be  performed  for  an  effusion  which  fills  the  whole 
chest,  which  produces  great  dyspnea,  or  which  has  lasted  for  three  weeks.  In 
tuberculous  pleuritis  early  aspiration  is  not  advisable,  but  aspiration  should  be 


890  Surgery  of  the  Respiratory  Organs 

performed  if  the  fluid  becomes  purulent,  if  the  eflfusion  displaces  the  heart 
considerably,  and  if  it  adds  notably  to  the  dyspnea.  If  an  effusion  becomes 
purulent,  the  proper  procedure  is  incision,  resection  of  a  portion  of  a  rib, 
and  drainage. 

Empyema  is  a  collection  of  pus  in  the  pleural  cavity.  It  may  begin  sud- 
denly, but  rarely  does  so.  Among  the  causes  of  empyema  are  those  of  serous 
effusion.  Empyema  is  due  to  infection  of  the  pleura,  and  in  every  case  a 
bacteriological  study  should  be  made  of  the  pus  to  discover  the  causative 
bacterium.  The  pneumococcus  is  the  causative  micro-organism  in  many  of 
the  cases  which  follow  pneCimonia.  Pneumococci  hve  but  a  short  time,  and 
in  empyema  due  to  pneumococci  these  micro-organisms  may  not  be  discov- 
erable when  the  pus  is  evacuated.  In  most  cases  of  empyema  streptococci  or 
staphylococci  can  be  found  in  the  pus.  These  micro-organisms  may  appear 
in  an  empyema  induced  originally  by  pneumococci  (Stephen  Paget).  In 
empyema  developing  during  or  after  typhoid  fever  typhoid  bacilli  may  be 
discovered.  In  putrid  empyema  various  bacteria  are  found.  Bouchard 
thinks  acute  empyema  has  a  special  organism.  Bacilh  of  tuberculosis  are  pres- 
ent for  a  time  at  least  in  tuberculous  empyema,  but  may  disappear,  and  are 
particularly  apt  to  after  mixed  infection  with  pyogenic  bacteria.  Empyema 
may  be  due  to  a  wound  or  contusion,  an  attack  of  pneumonia,  tuberculous 
pleuritis,  phthisis,  influenza,  pyogenic  infection  of  a  serous  effusion,  caries  of 
a  rib,  specific  fevers,  especially  typhoid,  peritonitis,  abscess  of  the  liver,  sup- 
purating hydatid  cyst  of  the  liver,  subphrenic  abscess,  malignant  disease  of  the 
pleura,  gangrene  of  the  lung,  and  pneumothorax. 

Acute  Empyema. — The  signs  are  in  reality  those  of  pleuritis  with 
effusion — viz.,  dulness  on  percussion,  absent  breath-sounds  over  the  puru- 
lent matter,  bulging  of  the  intercostal  spaces,  and  sometimes  edema  of  the 
skin  of  the  chest.  The  symptoms  of  acute  empyema  are  dyspnea,  pallor, 
cough,  sweats,  chills,  and  usually  irregular  fever,  but  fever  may  be  absent. 
There  is  marked  leukocytosis.  The  fingers  may  become  clubbed.  An 
empyema  may  pulsate,  particularly  an  empyema  of  the  left  side.  The  cause 
of  pulsating  empyema  has  been  much  debated.  The  most  probable  expla- 
nation is  that  of  W.  J.  Calvert  ("Am.  Jour.  Med.  Sciences,"  Nov.,  1905). 
He  says  the  requirements  for  such  a  condition  are:  "A  firmly  fixed,  pulsat- 
ing organ;  distention  of  the  pleural  sac  with  fluid  or  air  or  solid  material; 
and  a  collapsed  condition  of  the  lung."  In  all  probability  the  thoracic 
aorta  is  the  "fixed  pulsating  organ."  The  left  parietal  pleura  is  in  close 
relation  with  the  aorta,  and  most  pulsating  empyemas  are  left-sided.  The 
right  parietal  pleural  may  be  "pushed  against  the  aorta. "  If  a  lung  contains 
air,  it  is  elastic  and  compressible  to  a  degree  that  enables  it  to  absorb  the 
aortic  impulse;  if  it  is  collapsed  and  solid  it  cannot,  and  aortic  pulsations  are 
transmitted  to  fluid  in  the  pleural  cavity  and  the  thoracic  wall  pulsates.  A 
neglected  empyema  may  break  into  the  lung,  esophagus,  or  pericardium, 
through  an  intercostal  space,  or  may  point  in  the  lumbar  region.  When 
an  empyema  is  pointing  externally,  the  condition  is  called  empyema  necessi- 
tatii's.  A  total  empyema  is  a  condition  involving  the  entire  pleural  sac.  In 
a  partial  or  localized  empyema  the  purulent  matter  is  encapsuled.  After 
an  empyema  ruptures  spontaneously  it  rarely  heals  without  surgical  inter- 
ference, a  pleural  fistula,  as  a  rule,  persisting.     A  subphrenic  abscess  may 


Treatment  of  Empyema  891 

follow  an  empyema.  When  an  empyema  ruptures  into  a  bronchus,  pneu- 
mothorax arises,  as  a  rule.  Empyema  may  cause  death  by  compression  of 
the  heart  and  lung,  pulmonary  embolism,  pericarditis,  peritonitis,  cerebral 
embolism,  cerebral  abscess,  septicemia,  exhaustion,  or  rupture  into  a  bronchus. 

A  small  empyema  due  to  pneumococci  occasionally,  though  very  rarely, 
undergoes  spontaneous  cure,  the  pus  being  absorbed  (Stephen  Paget). 

A  small  empyema  is  occasionally  cured  by  encapsulation  with  fibrous  tissue. 

Under  exceptional  circumstances  even  a  large  empyema  may  be  cured  by 
breaking  externally  or  into  a  bronchus. 

Empyema  is  so  rarely  cured  spontaneously  that  it  does  not  do  to  trust  to 
nature,  and  practically  almost  every  case  will  die  without  surgical  treatment. 

Double  empyema  is  a  rare  and  extremely  fatal  condition. 

Chronic  empyema  may  follow  an  acute  empyema,  or  the  condition  may  be 
chronic  from  the  beginning.  In  chronic  empyema  the  lung  is  compressed, 
shrunken,  and  strongly  adherent,  and  the  pleura  is  very  thick.  In  some  cases 
the  pleura  is  over  an  inch  thick.  This  thickening  is  brought  about  by  the 
deposition  of  layer  after  layer  of  fibrin.  In  not  a  few  cases  a  chronic  empyema 
succeeds  an  acute  one  or  is  itself  maintained  because  a  drainage-tube  has 
slipped  into  the  pleural  cavity  and  remains  lodged. 

A  closed  empyema  is  one  in  which  no  opening  has  been  made  by  the  sur- 
geon and  no  opening  has  formed  spontaneously.  In  a  closed  empyema  the 
pus  is  rarely  putrid;   in  an  open  empyema  the  pus  is  often  putrid. 

Treatment  of  Empyema. — The  treatment  is  purely  surgical,  and  the 
earlier  it  is  applied  the  better.  To  delay  allows  the  pleura  to  thicken  and  per- 
mits adhesions  to  form,  conditions  which  prevent  lung  expansion  and  retard  or 
even  prevent  cure.  The  results  of  operation  are  better  in  children  than  in 
adults;  in  small  collections  than  in  large;  in  recent  than  in  advanced  cases;  in 
pneumococcus  empyema  than  in  empyema  due  to  other  organisms.  The 
surgical  methods  comprise  aspiration,  incision,  rib-resection,  the  operation  of 
Schede,  the  operation  of  Estlander,  and  the  operation  of  Fowler  (see  pages 
903  to  908   inclusive). 

In  acute  empyema  general  practitioners  are  very  apt  to  aspirate,  and  yet 
aspiration  is  almost  never  curative.  It  may  cure  a  pneumococcus  empyema 
in  a  child  and  an  encysted  empyema,  but  even  in  these  it  will  usually  fail. 
Aspiration  is  not  to  be  considered  a  method  of  curative  treatment.  It  is  to  be 
regarded  as  the  surgical  treatment  only  in  a  tuberculous  empyema  in  a  young 
person  with  rapidly  progressing  phthisis,  because  in  such  a  case  incision  will 
probably  prove  fatal  (Lockwood).  It  is  a  very  useful  diagnostic  expedient, 
and  enables  the  surgeon  to  prove  the  existence  of  pus,  and  the  pus  which  is 
obtained  can  be  examined  bacteriologically.  In  a  very  large  effusion  it  is  wise 
to  aspirate  and  withdraw  part  of  the  effusion  a  day  or  two  before  operating. 
This  enables  the  patient  to  take  an  anesthetic  with  greater  safety  and  obvi- 
ates the  danger  attending  the  rapid  evacuation  of  a  large  amount  of  pus. 

In  a  recent  empyema  incision  and  drainage  or  rib  resection  and  drainage 
will  often  cure  the  case,  and  yet  many  of  the  results  are  unsatisfactory.  In 
some  cases  the  discharge  ceases  and  yet  pulmonary  function  is  not  completely 
restored.  In  other  cases  a  pleural  fistula  persists.  If  a  profuse  discharge  is 
maintained,  amyloid  disease  may  arise.  An  acute  empyema  is  to  be  drained 
by  intercostal  incision  or  by  resection  of  a  rib  (page  904).     A  chronic  closed 


892  Surgery  of  the  Respiratory  Organs 

empyema  is  drained  in  the  same  manner,  and  if  the  lung  will  not  fully  expand 
and  remains  stationary  for  one  year,  Schede's  or  Estlander's  operation  is  re- 
quired. An  open  chronic  empyema,  in  which  the  lung  will  not  expand, 
requires  the  operation  of  Schede,  Estlander,  or  Fowler  (pages  go6  and  907) . 
Extensive  decortication  is  sometimes  impossible,  and  then  Ransohoff's  opera- 
tion may  be  done.  He  calls  it  discission  of  the  pu/))W)iary  pleura  (page  908). 
When  there  is  an  external  opening  which  persists  and  which  joins  a  long,  narrow 
cavity,  the  condition  is  spoken  of  as  pleural  fistula,  and  pleural  fistula  is 
often  produced  by  the  prolonged  use  of  a  drainage-tube  and  sometimes  by 
caries  of  a  rib.  Even  if  there  is  no  opening  on  the  cutaneous  surface,  there  may 
be  one  into  a  bronchus.  A  pleural  fistula  may  sometimes  be  cured  by  dilata- 
tion of  the  sinus.  If  this  fails,  and  it  usually  does,  it  is  the  custom  to  resect 
one  or  more  ribs. 

Before  resorting  to  operative  treatment  try  the  injection  of  bismuth  paste. 
We  owe  this  method  to  Dr.  Emil  Beck.  This  plan  will  often  succeed.  Ochs- 
ner  has  strongly  commended  it  ("Annals  of  Surgery,"  July,  1909).  The 
injection  is  made  with  a  glass  syringe  and  the  material  should  fill  but  not 
stretch  the  cavity.  After  injecting  the  paste  the  external  opening  of  the  fistula 
is  plugged  with  gauze.  The  treatment  is  begun  with  solution  No.  i  (i  part  of 
subnitrate  of  bismuth  devoid  of  arsenic  and  2  parts  of  yellow  vaselin) . 

This  is  used  every  second  day  until  pus  has  practically  disappeared.  Then 
solution  No.  2  is  substituted  for  it  (30  parts  of  bismuth,  60  parts  of  yellow 
vaselin,  and  10  parts  of  paraffin).  The  injections  are  made  often  enough  to 
keep  the  sinus  and  pocket  full.  They  are  made  at  first  every  day,  then  every 
other  day,  and  so  on  until,  finally,  every  eighth  or  tenth  day  is  often  enough. 
If  poisoning  should  arise  from  these  injections  Beck  advises  the  injection  of  olive 
oil  at  a  temperature  of  110°  F.  to  dissolve  the  paste  and  favor  its  evacuation. 

Non=traumatic  Pneumothorax. — By  the  term  pneumothorax  is 
meant  the  presence  of  air  in  the  pleural  cavity.  As  a  rule,  besides  air  there  is 
serous  fluid  or  pus.  It  may  be  due  to  the  rupture  of  an  empyema  into  a 
bronchus;  to  the  rupture  into  the  pleural  sac  of  a  tuberculous  area,  an  area 
of  gangrene,  an  abscess  of  the  lung,  an  air-cell  in  a  state  of  emphysema,  or  of 
pulmonary  tissue  softened  because  of  hemorrhagic  infarction.  The  im- 
mediate effect  of  the  entrance  of  air  into  the  pleural  sac  is  to  compress  the  lung, 
the  degree  of  compression  being  in  proportion  to  the  amount  of  air  present. 
In  severe  cases  the  lung  is  squeezed  against  the  vertebral  column,  and  the  heart, 
the  diaphragm,  and  even  the  liver  are  displaced.  In  some  cases,  where  the 
admission  of  air  does  not  continue,  the  amount  set  free  in  the  pleural  sac  is 
absorbed.     In  most  cases  pyopneumothorax  (empyema)  follows. 

Symptoms. — The  symptoms  usually  arise  suddenly,  and  consist  of  dis- 
tressing dyspnea,  pain  in  the  chest,  lividity,  and  rapidity  and  weakness  of  the 
pulse.  In  some  cases  of  phthisis  the  symptoms  are  not  very  severe.  It  has 
been  pointed  out  that  occasionally  in  phthisis  pneumothorax  seems  actually  to 
benefit  the  tuberculous  area  in  the  lung.  The  physical  signs  of  pneumothorax 
are  as  follows:  The  affected  side  of  the  chest  is  bulged  and  immobile,  and  the 
heart  is  displaced,  especially  if  the  condition  affects  the  left  side.  Palpation 
discovers  that  vocal  fremitus  is  lessened  or  absent.  On  auscultation  it  is 
found  that  the  breath-sounds  are  very  feeble  or  absent.  The  voice  is  trans- 
mitted as  a  metallic  sound,  the  rales  sound  metallic,  and  on  coughing  there 


Acute  Traumatic  Pneumothorax  893 

may  be  metallic  tinkling.  The  percussion-note  is  tympanitic.  In  some  rare 
cases  the  percussion-note  is  dull.  When  fluid  gathers,  there  is  a  positively 
dull  note  on  percussion  over  the  fluid. 

Treatment.— Osier  says  the  treatment  should  be  the  same  as  that  of 
pleurisy  with  effusion.  In  many  cases  it  is  wise  to  perform  paracentesis 
without  suction  to  remove  air  and  serous  effusion.  If  pus  forms,  a  rib  should 
be  resected  and  a  tube  inserted  (see  Empyema).  In  pneumothorax  occur- 
ring during  chronic  phthisis  operation  is  of  great  service.  In  cases  with 
rapidly  progressive  phthisis  it  is  practically  useless. 

If  the  opening  into  a  bronchus  or  air-cell  remains  patent,  aspiration  will 
not  get  rid  of  air;  the  air  will  enter  into  the  pleura  as  rapidly  as  the  aspirator 
removes  it.  Incision  has  dangers  of  its  own:  the  diaphragm  is  flapping  dur- 
ing respiration  and  may  be  injured  (Fowler),  and  when  the  pleura  is  opened, 
there  is  a  great  alteration  produced  in  the  air-pressure  in  the  chest,  and  the 
patient  may  "drown  in  his  own  secretions. "  After  incision  irrigation  is  not  justi- 
fiable, because  the  fluid  may  enter  a  bronchus  and  produce  suffocation  (Fowler) . 
West's  rules  are  those  I  follow* — West  says  early  incision  is  dangerous. 
In  an  early  stage  use  paracentesis  without  suction.  This  will  often  relieve  the 
patient.  If  paracentesis  does  relieve  him,  wait  a  while  and  perhaps  repeat  the 
operation  if  the  symptoms  again  become  severe.  If  paracentesis  does  not 
reheve,  incise,  resect  a  portion  of  a  rib,  and  drain.  If  pus  forms,  an  incision 
must  be  made  and  a  portion  of  a  rib  resected,  to  afford  exit  to  the  fluid. 

Fowler  points  out  that  if  the  lung  is  bound  down  by  adhesions,  incision  is 
dangerous  but  justifiable.  Operation  at  the  proper  time  often  prevents  the 
lung  being  bound  down  by  adhesions. 

Acute  Traumatic  Pneumothorax.— This  is  produced  by  the  sudden 
admission  of  a  quantity  of  air  into  the  pleural  cavity  as  a  resuh.  of  a  wound  of 
the  chest-wall.  A  small  quantity  of  ak,  or  the  gradual  introduction  of  con- 
siderable air,  does  not,  as  a  rule,  produce  very  serious  symptoms.  The  sudden 
admission  of  a  quantity  of  air  causes  very  dangerous  symptoms,  and  even 
death.  A  quantity  of  air  may  be  admitted  rather  suddenly  as  a  result  of  an 
accident  or  during  the  performance  of  a  surgical  operation  which  opens  the 
pleura.  It  sometimes  arises  during  the  removal  of  tumors  from  the  chest- wall, 
during  operations  upon  the  lung,  and  during  empyema  operations.  As  a  rule, 
when  puknonary  adhesions  exist,  dangerous  symptoms  do  not  arise,  even  when 
the  pleura  is  widely  opened,  and  adhesions  exist  in  25  per  cent,  of  empyema 
cases  seen  by  the  surgeon.f 

It  was  formerly  taught  whenever  the  pleura  is  opened  there  is  a  strong 
tendency  to  the  development  of  pneumothorax,  but  West  has  shown  that  the 
surfaces  of  the  pleura  often  cohere  with  a  force  superior  to  puhnonary  elas- 
ticity, and  in  such  cases  pneumothorax  does  not  arise. 

In  surgical  operations  in  which  it  is  necessary  to  open  the  pleura  widely 
(as  in  operation  for  sarcoma  of  the  chest-wall)  the  surgeon  endeavors  to 
prevent  acute  pneumothorax  which  may  prove  fatal.  This  may  be  done 
by  operating  in  the  Sauerbruch  negative  pressure  chamber  (page  901),  or  by 
applying  positive  pressure  (page  902). 

Symptoms.— When  the  pleura  is  opened  during  an  operation  or  by  an 

*  British  Medical  Journal,  Nov.  27,  1897. 

t  Rudolph  Matas,  Annals  of  Surgery,  April,  1899. 


894 


Surgery  of  the  Respiratory  Organs 


injury,  the  symptoms  may  be  trivial  and  transitory,  may  be  tolerably  severe, 
may  be  extremely  grave,  and  the  patient  may  quickly  die  (Quenu  and  Longuet) . 
Rudolph  Matas  sets  forth  the  symptoms  as  presented  by  the  French  observers:* 
The  mild  symptoms  are  a  weak,  slow  pulse  and  irregular,  noisy  respiration. 
The  severe  symptoms  are  slow  pulse,  slow  and  irregular  respiration,  and 
dyspnea,  continuing  after  the  anesthetic  has  been  withdrawn. 

The  grave  symptoms  are  cyanosis;  collapse;  small,  weak  pulse;  shallow 
and  noisy  respiration;  and  spells  of  syncope.  Death  may  occur  suddenly 
from  inhibition,  or  later  from  mechanical  asphyxia  (Matas) . 

Treatment. — Various  plans  have  been  adopted:  suturing  the  opening  in 
the  pleura;  plugging  the  opening;  pulling  the  diaphragm  into  the  wound  in  the 

chest- wall  and  suturing  it;  and  grasping 
the  lung  and  suturing  it  to  the  wound. 
Whenever  the  pleura  is  to  be  widely 
opened,  use  a  positive  pressure  apparatus, 
and  when  the  operation  is  complete,  suture 
the  lung  to  the  margin  of  the  opening  in 
the  pleura  with  a  continuous  catgut  suture. 
Parham,  Keen,  and  the  author  have  fol- 
lowed this  plan,  using  the  Fell-0'Dwyer 
apparatus,  and  the  lung  was  kept  from 
collapsing,  f 

The  Fell-O'Dwyer  apparatus  is  shown 
in  Fig.  491. 

O'Dwyer's  tube  is  introduced  into  the 
glottis  as  is  the  tube  in  intubation,  and  is 
attached  to  a  bellows,  the  lung  is  in- 
flated, respiration  is  maintained  by  the 
use  of  the  bellows,  and  collapse,  with  all 
its  dangers,  is  avoided.  The  modern  pos- 
itive pressure  apparatus  is  better  (page 
902). 

Contusions  and  Wounds  of  the 
Chest. — Contusions. — A  contusion  may 
be  trivial  and  limited  to  the  superficial 
parts  of  the  chest- wall;  it  may  involve  the 
muscles;  it  may  be  associated  with  frac- 
ture of  the  ribs  or  sternum  or  with  vis- 
ceral injury. 

Symptoms. — In  an  ordinary  contu- 
sion without  visceral  injury  there  are  con- 
siderable pain,  discoloration,  and  often 
much  swelling.  The  patient  prefers  to  He  upon  the  back  and  the  respiration 
is  abdominal.  After  a  severe  blow  upon  the  chest  there  is  great  shock  and 
may  even  be  instant  death.  The  condition  of  shock  so  produced  is  called  con- 
cussion of  the  chest.     After  a  severe  blow  upon  the  chest  a  limited  area  of 

*  Annals  of  Surgery,  April,  iSgg. 

t  F.  W.  Parham's  paper  on  "Thoracic  Resection  for  Tumors  Growing  from  the 
Bony  Walls  of  the  Chest."  Read  before  the  Southern  Surgical  and  Gynecological  Asso- 
ciation, November,  1898. 


Fig.  491.— The  Fell-O'Dwyer  appa; 
ratus.  This  illustration  shows  an  early 
model;  since  then  the  bellows  has  been 
improved  by  the  addition  of  a  strong 
wooden  frame,  which  holds  it  steadily,  and 
is  provided  with  a  long  arm  that  acts  as  a 
powerful  foot -piece  for  compressing  the 
machine  with  the  least  amount  of  muscular 
effort. 


Treatment  of  Contusions  of  the  Chest  895 

inflammation  may  arise  in  the  pleura  {traumatic  pleuritis).  Severe  visceral 
injury  is  announced  by  positive  symptoms.  A  contusion  of  the  lung  causes 
pain,  cough,  expectoration  of  bloody  mucus,  dyspnea,  and  possibly  distmct 
hemoptysis.  Over  the  contused  region  the  percussion-note  is  dull  and  on 
auscultation  crepitus  is  audible.  A  traumatic  pneumonia  always  follows. 
This  involves  a  limited  area  of  lung  tissue,  but  genuine  croupous  pneumonia 

may  arise.  i.        ^^     ^ 

In  rupture  of  the  lung  the  physical  signs  are  dependent  on  the  extent 
and  situation  of  damage.  A  minute  rupture  would  not  produce  defimte 
physical  signs.  If  the  lung  is  ruptured  and  the  pleura  is  not,  there  will  not  be 
pneumothorax,  but  there  may  be  cellular  emphysema  first  becoming  evident  at 
the  root  of  the  neck.  If  the  pleura  is  torn  as  well  as  the  lung,  there  will  be 
pneumothorax  and  hemothorax,  the  amount  of  hemorrhage  depending  upon 
the  situation  and  extent  of  the  injury. 

Le  Conte  ("Annals  of  Surgery,"  March,  1908)  points  out  five  ways  in 
which  rupture  may  be  caused:  (i)  Bruising  (simply  causes  subpleural  ec- 
chymosis) ;  (2)  bursting  (violent  force,  and  a  lung  unable  to  empty  itself  of  air 
is  broken  as  an  inflated  paper  bag  is  broken  by  a  sharp  blow).  The  question 
as  to  whether  the  glottis  must  be  closed  for  such  an  injury  to  occur  is  not  set- 
tled- (i)  penetration  by  a  green-stick  fracture  of  a  rib ;  (4)  compression  of  the 
lung  against  some  resistant  structure;  (5)  tearing,  when  the  lung  has  previously 
been  adherent  to  the  wall  of  the  chest. 

These  five  causes  might  be  sententiously  designated  as  brmsing,  bursting, 
puncturing,  squeezing,  and  tearing. 

The  svmptoms  are  shock,  dyspnea,  cough  with  or  without  bloody  expectora- 
tion rapid  and  irregular  pulse,  cyanosis,  emphysema  (appearing  first  over  the 
region  of  injury  if  a  broken  rib  penetrated  the  lung,  and  first  at  the  root  of  the 
neck  if  the  lung  is  ruptured,  but  the  pleura  is  not) ,  and  in  some  cases  pneumo- 
thorax and  hemothorax  (see  Robt.  G.  Le  Conte,  Ibid.). 

Rupture  of  the  diaphragm  causes  pain,  dyspnea,  and  often  vomiting. 
The  stomach  or  intestine  may  pass  into  the  pleural  sac.  If  this  happens,  there 
will  be  a  tympanitic  percussion-note  over  the  displaced  viscus  and  symptoms 
will  vary  with  the  viscus  involved.  Such  a  diaphragmatic  herma  may  be- 
come strangulated.  (Seepage  1146.)  In  a  case  in  the  Jefferson  Medical 
Colle'^e  Hospital,  in  which  the  stomach  passed  into  the  left  pleural  sac,  there 
were  persistent  vomiting,  violent  pain  in  the  chest  and  upper  abdomen,  great 
thirst,  and  displacement  of  the  apex-beat.  The  condition  may  be  confused 
with  pulmonary  rupture  causing  pneumothorax,  but  in  rupture  of  the  dia- 
phragm nausea  and  vomiting  are  prominent  features,  whereas,  in  pulmonary 
.  rupture,  if  they  exist  at  ah,  they  are  early  and  temporary;  further,  in  rupture  o 
the  diaphragm  the  tympanitic  percussion  note  is  not  found  over  the  p  eural 
apex,  but  in  pulmonary  rupture  with  pneumothorax  a  tympamtic  note  is  found 
all  over  the  entire  pleural  cavity  (Le  Conte,  Ibid.) .  .    ,       ,      .       „ 

Treatment  of  Contusions  of  the  Chest.-A  contusion  of  the  chest-wall 
is  treated  as  directed  in  the  section  on  Contusions  (page  259),  and  the  chest  is 
strapped  with  adhesive  plaster,  as  in  the  treatment  of  fractured  ribs,  in  con- 
cussion of  the  chest  the  treatment  for  shock  is  apphed.  It  may  be  necessary 
to  employ  artificial  respiration  for  a  time.  If  a  diaphragmatic  herma  is  diag- 
nosticated, the  abdomen  should  be  opened,  the  displaced  viscera  restored  to 


896  Surgery  of  the  Respiratory  Organs 

their  proper  abode,  and  the  diaphragm  sutured.  The  diaphragm  may  also  be 
reached  by  resectmg  several  ribs  and  opening  the  pleural  sac.  In  contusion 
of  the  lung  cold  is  appUed  to  the  chest,  and  any  inflammation  which  arises  is 
treated  according  to  general  rules.  In  rupture  of  the  lung  the  case  may  be 
treated  expectantly,  but  dangerous  and  continued  bleeding  or  pneumothorax 
may  render  surgical  interference  necessary.  For  pneumothorax  paracentesis 
without  suction  is  employed.  If  this  fails,  it  may  be  repeated.  If  it  fails  again, 
resect  a  portion  of  a  rib  and  put  in  a  tube.  If  bleeding  is  dangerously  profuse 
resect  a  portion  of  a  rib  and  insert  a  drainage-tube  into  the  pleural  cavity. 

Wounds  of  the  Chest. — Non-penetrating  wounds  are  not  particularly 
grave,  and  are  treated  according  to  general  principles,  the  chest  being  immo- 
bilized. Penetrating  wounds  are  extremely  grave,  as  viscera  are  apt  to  be 
injured.  In  such  a  wound  an  intercostal  artery  may  be  severed  or  the  internal 
mammary  artery  may  be  divided.  An  intercostal  artery  is  rarely  divided 
unless  a  rib  is  broken.  The  surgeon  should  always  examine  carefully  in  order  to 
determine  whether  an  intercostal  artery  or  the  internal  mammary  artery  has 
been  divided,  and,  in  doing  so,. should  bear  in  mind  the  admonition  of  Matas — 
that  is,  the  bleeding  from  these  vessels  may  be  internal,  the  blood  collect- 
ing in  the  pleural  sac.  The  pericardium  or  heart  may  be  injured  (page  401). 
A  wound  of  the  pleura  is  usually,  but  not  always,  associated  with  a  wound  of 
the  lung.  If  the  lung  is  injured,  there  are  usually  great  shock,  pain  in  the 
chest,  dyspnea,  and  cough.  In  a  large  wound,  damage  to  the  lung  will  be 
indicated  if  air  is  sucked  into  the  wound  during  inspiration  and  expelled  during 
expiration,  and  blood  is  forced  out  of  the  wound  by  coughing.  The  lung  may 
be  visible  or  may  protrude  {protrusion  oj  the  lung).  In  a  small  wound  it  is  often 
difficult  and  sometimes  impossible  to  determine  whether  the  lung  has  been 
injured.  Pneumothorax  with  pulmonary  collapse  proves  it  has.  Severe 
hemothorax  strongly  suggests  it.  Spitting  blood  does  not  prove  it.  In  some 
severe  cases  there  is  no  hemoptysis;  in  some  slight  bruises  the  amount  of  blood 
coughed  up  is  large.  Emphysema  about  the  wound  does  not  prove  lung 
injury.  An  incised  wound  of  the  lung  is  apt  to  produce  rapid  death  from 
hemorrhage,  especially  if  the  wound  is  at  the  root  of  the  lung.  A  pistol-bullet 
or  a  sporting-rifle  bullet  is  not  usually  productive  of  great  primary  hemorrhage; 
but  infection  probably  follows,  and  secondary  hemorrhage  is  apt  to  occur. 
The  modern  military-rifle  ball  passes  through,  rarely  lodges,  is  aseptic,  and 
often  produces  astonishingly  little  trouble.  A  pistol-bullet  and  an  old-time 
rifle  bullet  may  lodge  or  may  perforate. 

Treatment. — Bring  about  reaction  as  previously  directed  (page  264) . 

An  incised  wound  of  the  chest,  if  large,  should  be  carefully  inspected. 
If  the  wound  is  small,  cut  down  layer  by  layer  until  the  depths  of  the 
wound  are  reached.  Disinfect  the  wound  and  arrest  hemorrhage.  If  the 
pleura  is  not  open,  proceed  according  to  general  rules.  If  the  pleura  is  found 
to  have  been  opened,  suture  it  with  catgut,  close  the  superficial  wound,  dress 
with  gauze,  and  immobilize  the  chest-wall. 

The  above  proceeding  should  be  carried  out  whether  it  is  or  is  not  believed 
that  the  lung  has  been  damaged,  provided  there  is  no  pneumothorax  and  no 
violent  hemorrhage.  What  course  shall  be  pursued  if  the  lung  has  been 
injured  by  a  stab?  If  hemorrhage  does  not  threaten  life  and  there  is  no  pneu- 
mothorax, the  patient  is  kept  at  rest  and  observed.     If  pneumothorax  occurs, 


Occluding  Pulmonary  Embolism  897 

the  pleural  sac  must  be  drained  by  means  of  a  tube,  because  clots  must  be 
evacuated  and  infection  should  be  anticipated.  If  hemorrhage  into  the  pleural 
sac  persists,  active  measures  become  necessary.  The  use  of  ice-bags  and  drugs 
is  but  waste  of  time.  Some  surgeons  believe  that  the  mere  closure  of  the 
external  wound  leads  to  arrest  of  hemorrhage,  blood  accumulating  and  making 
pressure.  It  is  true  that  hemorrhage  often  ceases  after  suturing  or  plugging  a 
wound  and  strapping  the  chest,  but  it  is  not  probable  that  it  ceases  because  of 
these  measures.  Blood  in  the  pleura  usually  remains  unclotted  for  several  or 
many  days.  Further,  as  Le  Conte  shows,  as  the  blood  is  forced  against  the 
root  of  the  lung,  the  right  heart  is  engorged,  the  blood-pressure  is  raised,  and 
the  bleeding  continues.* 

Bleeding  from  the  lung  can  often  be  arrested  by  inserting  the  end  of  a 
drainage-tube  into  the  pleural  sac.  In  cases  where  a  drainage-tube  is  inserted 
into  the  pleural  cavity  and  free  drainage  established,  the  pleura  is  immediately 
filled  with  air,  and  the  muscles  of  respiration  are  kept  from  acting  on  the  lung. 
The  lung  contracts  by  its  own  elastic  tissue,  as  well  as  by  the  pressure  exerted 
by  the  pneumothorax,  and  at  the  same  time  the  presence  of  the  air  favors 
clotting  in  the  severed  vessels. f  If  the  insertion  of  a  tube  fails,  or  if  the  bleed- 
ing is  rapid  and  obviously  seriously  threatens  life,  several  ribs  must  be  rapidly 
resected  and  the  bleeding  part  explored.  In  some  cases  the  bleeding  may  be 
arrested  by  ligation,  in  some  cases  by  packing  a  small  wound  with  gauze,  in 
some  cases  by  the  suture  ligature.  In  a  violent  secondary  hemorrhage  follow- 
ing a  gunshot-wound  of  the  lung  the  author  packed  the  entire  pleural  cavity 
with  sterile  gauze  to  obtain  a  base  of  support,  and  arrested  the  bleeding 
by  carrying  iodoform  gauze  directly  against  the  oozing  surface.  J  I  did  the 
same  thing  recently  on  a  Chinaman  suffering  from  a  gunshot  wound  of  the 
lung.  The  hemorrhage  was  arrested  and  he  lived  three  weeks,  dying  finally 
from  pericarditis.  i\f  ter  directly  arresting  hemorrhage  from  the  lung,  turn  clots 
out  of  the  pleural  sac  and  insert  a  drainage-tube.  In  a  perforating  wound 
inflicted  by  a  bullet,  reaction  m.ust  be  brought  about,  the  wgund  dressed  anti- 
septically,  the  chest  strapped,  and  the  patient  kept  quiet.  If  pneumothorax 
occurs,  the  pleura  should  be  drained  with  a  tube.  If  hemorrhage  occurSj  it 
should  be  met  as  directed  above.  In  a  wound  in  which  the  bullet  has  lodged, 
an  examination  should  be  made  to  see  if  the  bullet  is  under  the  skin,  and  if  it 
is,  it  is  removed  after  the  patient  has  reacted.  It  should  always  be  borne  in 
mind  that  a  pistol-bullet  may  be  deflected  by  a  rib  or  may  pass  from  the  front 
to  the  back  part  of  the  chest  by  making  a  burrow  under  the  skin  {a  contour 
wound).  If  a  bullet  is  lodged,  no  attempt  should  be  made  to  remove  it  unless 
an  operation  must  be  done  for  bleeding,  unless  the  bullet  causes  trouble,  or 
unless  it  is  felt  under  the  skin.  Under  no  circumstances  conduct  a  long  seai'ch 
for  a  bullet.  If  emphysema  of  the  chest-walls  is  moderate,  strapping  or 
a  bandage  wiU  control  it;  if  it  is  great,  make  multiple  punctures  and  then 
apply  pressure.  In  protrusion  of  a  portion  of  the  lung  try  to  restore  the  pro- 
trusion; but  if  restoration  is  impossible  or  if  gangrene  seems  likely  to  occur, 
ligate  the  base  of  the  protrusion  with  silk  and  cut  away  the  mass. 

Occluding  Pulmonary  Embolism. — By  this  term  we  mean  an  embolism 
which  completely  blocks  the  pulmonary  artery  or  some  of  its  chief  branches. 

*  Annals  of  Surgery,  April,  iSqg. 

t  Le  Conte,  in  Annals  of  Surgery,  April,  1899.  J  Annals  of  Surgery,  Jan.,  1898. 

57 


898  Surgery  of  the  Respiratory  Organs 

Such  cases  occasionally  follow  a  surgical  operation.  The  clot  is  derived 
from  a  vein.  The  calamity  is  most  apt  to  occur  between  the  second  and  fourth 
weeks  after  an  operation  (Bartlett  and  Thompson,  in  "Annals  of  Surgery," 
May,  1908).  If  the  pulmonary  artery  is  completely  blocked  death  occurs  at 
once.  If  one  branch  only  is  blocked  the  patient  may  recover  if  the  heart  is 
sound  and  strong.  If  the  artery  proper  is  partly  blocked,  the  patient  has  a 
period  of  suffering  and  dyspnea  before  death,  but  death  is  sure  to  occur  from 
subsequent  complete  blocking. 

Bartlett  and  Thompson  (Ibid.)  report  22  cases  of  occlusive  pulmonary 
emboHsm,  20  of  which  were  fatal.  The  greatest  cause  in  a  surgical  operation 
seems  to  be  varicose  veins,  especially  about  an  abdominal  or  pelvic  tumor. 

The  symptoms  are  sudden  collapse,  cyanosis  or  pallor  with  livid  lips, 
the  pulse  at  the  wrist  is  absent  or  very  rapid,  and  irregular.  There  are  pain 
in  the  chest,  intense  dyspnea,  dilated  pupils,  and  early  unconsciousness. 
The  surgeon  must  bear  in  mind  the  danger  of  embolism  and  endeavor  to 
prevent  it  in  operations  by  handUng  and  exposing  viscera  as  little  as  possible, 
by  applying  ligatures  above  all  clots  in  veins  and  all  varicosities,  and  removing 
the  affected  structures. 

Treatment. — There  is  nothing  to  do  medically. 

Trendelenburg  of  Leipzig  suggests  surgical  treatment  ("German  Congress 
of  Surgery,"  1908).  He  points  out  that  death  is  not  always  sudden  (in  7  cases 
out  of  9  the  victim  lived  from  ten  minutes  to  one  hour) ,  and  advises  opening  of 
the  pulmonary  artery  and  removal  of  the  embolus.  It  was  tried  three  times. 
One  died  on  the  table;  one  died  in  fifteen  hours  from  cardiac  failure;  one  lived 
for  thirty-seven  hours  and  died  of  reactionary  bleeding  from  the  internal 
mammary  artery. 

Abscess  of  the  lung  may  follow  ordinary  pneumonia.  It  is  apt  to 
follow  aspiration-pneumonia.  It  is  usually  caused  by  streptococci  or  staphy- 
lococci, but  it  may  result  from  pneumococci  or  colon  bacilli.  These  germs 
may  reach  the  pulmonary  tissue  by  direct  entrance  from  adjacent  organs, 
by  way  of  the  blood  or  by  way  of  the  bronchi  and  alveoli.  Osier  tells  us 
that  pulmonary  abscess  may  result  from  the  aspiration  of  septic  particles 
after  "wounds  of  the  neck,  operations  upon  the  throat,"  and  suppurative 
lesions  of  the  nose,  larynx,  or  ear.*  Aspiration-pneumonia  may  develop 
when  there  is  difficulty  in  swallowing  from  any  cause,  when  there  is  profound 
exhaustion,  and  when  there  is  palsy  or  incoordination  of  any  of  the  muscles 
of  deglutition.  Cancer  of  the  esophagus  may  be  a  cause;  so  may  perforation 
of  the  lung  by  an  abscess,  wound  of  the  lung,  impaction  of  a  foreign  body 
in  the  lung,  suppuration  about  a  focus  of  tubercle  or  a  metastatic  abscess.  A 
pulmonary  abscess  may  be  of  trivial  size  or  it  may  be  very  large,  involving  an 
entire  lobe.  There  may  be  one  abscess,  several,  or  many.  When  sup- 
puration results  from  aspiration-pneumonia  or  blood-infection,  there  are 
usually  multiple  abscesses. 

Symptoms. — The  expectoration  is  not  frequent,  but  is  profuse,  and 
during  a  paroxysm  mouthfuls  are  coughed  up  in  rapid  succession.  The 
expectorated  matter  is  sour  or  very  offensive  in  odor  and  contains  fragments 
or  shreds  of  pulmonary  tissue,  which  can  be  identified  as  such  by  the  micro- 
scope. The  patient  Hes  upon  the  diseased  side  in  order  to  keep  the  pus 
*See  Osier's  "Practice  of  Medicine." 


Treatment  of  Pulmonary  Tuljerculosis  899 

from  running  into  the  bronchi  and  causing  cough.  When  the  cavity  fills 
and  pus  reaches  the  bronchi,  violent  cough  and  expectoration  begin,  continue 
until  the  cavity  is  partly  or  entirely  emptied,  and  then  subside,  perhaps  for 
several  hours.  If  the  abscess-cavity  is  large  and  full  of  pus,  an  area  of  dul- 
ness  on  percussion  can  be  mapped  out.  When  the  pus  is  coughed  out  and 
the  air  enters,  physical  signs  of  a  cavity  are  clear.  The  .r-rays  often  show 
the  situation  of  such  a  cavity. 

The  course  of  abscess  of  the  lung  is  usually  acute.  There  are  fever  of 
the  hectic  type,  rapid  loss  of  weight,  weakness  and  rapidity  of  circulation, 
dyspnea,  pallor,  sleeplessness,  and  great  weakness.  Gangrene  may  arise; 
empyema  or  pyopneumothorax  may  develop;  very  rarely  the  abscess  breaks 
through  the  chest-wall;  recover}'  may  follow  spontaneous  evacuation  or 
drainage  by  coughing  up  pus;  death  may  result  from  exhaustion  or  secon- 
dary septic  lesions.  If  operation  is  performed,  from  50  to  60  per  cent,  of 
the  patients  will  recover. 

The  treatment  is  purely  surgical  {pneumotomy).  Make  an  incision 
over  tne  cavity.  Resect  a  portion  of  one  or  more  ribs.  Expose  the  pleura. 
If  the  two  layers  of  the  pleura  are  not  adherent,  suture  them  together  and 
wait  two  days.  If  they  are  adherent,  proceed  at  once.  Search  for  the  abscess 
with  an  aspirating  needle.  When  the  cavity  is  found,  open  into  it  with  the 
cautery  and  insert  a  drainage-tube  (page  908). 

Gangrene  of  the  Lung. — This  term  means  the  putrefaction  of  a 
devitalized  portion  of  pulmonary  tissue.  The  tissue  is  devitalized  by  the 
action  of  pvogenic  micro-organisms.  Gangrene  may  follow  abscess,  bron- 
chitis, or  pneumonia,  or  may  be  due  to  diabetes,  to  embolism  of  the  pul- 
monary artery,  bronchiectasis,  tuberculosis,  malignant  disease,  wounds,  or  the 
lodgment  of  foreign  bodies.  Gangrene  may  be  circumscribed  or  diffused. 
There  may  be  one  cavity,  small  or  large,  or  multiple  cavities  may  form.  The 
gangrenous  area  putrefies,  softens,  and  the  softened  matter  may  be  expector- 
ated, a  gangrenous  cavity  being  formed.  In  the  rare  cases  which  undergo 
spontaneous  cure  the  cavity  is,  after  a  time,  surrounded  by  fibrous  tissue  and 
obUterated  by  granulations. 

Symptoms. — Expectoration  occurs  only  now  and  then,  but  at  each 
seizure  a  great  quantity  of  matter  is  brought  up  and  this  matter  is  extremely 
oflfensive.  Occasionally  there  is  no  expectoration.  The  patient,  as  in  lung 
abscess,  lies  upon  the  diseased  side.  The  expectorated  matter  is  mucopurulent, 
contains  particles  or  shreds  of  pulmonary  tissue,  bacteria,  and  altered  blood. 
The  fetor  of  the  pus  is  much  greater  than  is  the  fetor  of  the  pus  of  an  abscess. 
The  breath  is  very  foul.  Physical  signs  may  indicate  either  consolidation  or  a 
cavity.  There  are  hectic  fever,  great  exhaustion,  deathly  pallor,  and  diarrhea. 
Pulmonary  hemorrhage  is  not  unusual,  and  complications  spoken  of  in  the 
article  upon  Abscess  may  occur  (page  898).  Recovery  sometimes  ensues,  the 
cavity  closing  by  granulation.  Death  may  take  place  in  a  few  days.  Often 
the  patient  lives  for  weeks,  being  sometimes  better  and  sometimes  worse,  dying 
finally  from  exhaustion  or  from  the  effects  of  a  complication. 
The  treatment  is  to  operate  as  for  pulmonary  abscess. 
Treatment  of  Pulmonary  Tuberculosis.— Surgical  Treatment.— 
For  the  past  decade  surgical  thought  has  been  actively  directed  toward 
placing   on   a    scientific  footing    operations  for  pulmonary  phthisis.     The 


900  Surgery  of  the  Respiratory  Organs 

matter  is  still  in  a  transition  stage,  and  operations  at  present  have  a  very 
limited  field  of  application,  although  Sonnenberg  and  others  have  reported 
cures.     Baghvi,   in    1643,  endeavored    to   tap   and   inject   tuberculous  cavi- 
ties.    Hastings  and  Stucke  did  the  same  thing  in  the  eighteenth  century. 
Mosler,  a  number  of  years  ago,  attempted  to  treat  cavities  by  introducing  a 
trocar  into   the  cavity  and  injecting  permanganate  of  potassium   solution 
through  the  cannula.     Patients  were  not  benefited  by  this  procedure.     The 
plan  was  revived  by  Pepper  in  1874.     The  results  are  bad  and  the  operation 
is  dangerous.     Hillier  tried  injection  of  corrosive  sublimate  into  the  lung- 
parenchyma,  but   the  effect   of    the   injections   was    disastrous.     Vidal   ad- 
vocates counter-irritation  by  the  actual  cautery  and  maintains  that  congestion 
improves   nutrition.     When  the  strength  of  the  patient  is    well    preserved 
and  the  pulmonary  lesion  is  circumscribed  and  slowly  progressive,  it  may 
be  justifiable  to  perform  an  operation,  open  the  cavity,  and  treat  it  directly 
{pneumotomy) .     That  pneumotomy  might  be  performed  successfully  was  sug- 
gested to  surgeons  by  observing  that  some  patients  recovered   after  sword- 
thrusts  into   the  lung.     Fowler  says  it  is  not  justifiable  to  operate  if  the  dis- 
ease has  come  "  to  a  standstill."     The  same  surgeon  states  that  the  only  acces- 
sible region  is  bounded  above  by  the  clavicle,  to  the  inner  side  by  the  manu- 
brium, to  the  outer  side  by  the  lesser  pectoral  muscle,  and  below  by  the 
second  rib.*     This  operation  does  not  cure  any  one,  but  it  may  cause  dis- 
tinct improvement  when  there  is  hectic  from  an  ill-drained  cavity  contain- 
ing the  products  of  a  mixed  infection.     In  an  advanced  case  there  is  usually 
more  than  one  cavity,  and  then  the  operation  is  contraindicated.     Before 
attempting  it,  be  sure  the  case  is  advanced  and  not  incipient  and  that  the  cavity 
is  single.     Locate  the  cavity  by  auscultation,  percussion,  and  the  x-rays.     (See 
Willard,  "Jour.  Amer.  Med.  Assoc,"  Sept.  20,  1902.) 

Mauclaise  says  that  pneumotomy  is  justifiable  only  in  circumscribed 
tuberculous  cavities  without  peripheral  infiltration  and  in  pulmonary  ab- 
scesses.f  Bronchiectatic  cavities  are  usually  multiple;  they  are  exceedingly 
difficult  to  locate,  and  treatment  by  pneumotomy  should  not  be  attempted. 
In  the  treatment  of  pulmonary  tuberculosis  resection  of  the  diseased  area 
has  been  proposed  \pneumectomy).  Tuffier  successfully  performed  this 
operation.  Surgeons,  as  a  rule,  do  not  believe  in  pneumectomy.  Reclus 
voices  the  general  opinion  when  he  says  the  operation  is  not  required  if  the 
area  of  disease  is  very  limited,  as  such  a  condition  is  frequently  curable  by 
medicinal  means,  and  it  does  no  good  if  the  area  of  disease  is  extensive.J 

It  has  long  been  known  that  pneumothorax  might  benefit  a  tuberculous 
lung.  Attempts  have  been  made  by  Farlanini  and  IVlurpby  to  cure  phthisis 
by  the  deliberate  production  of  artificial  pneumothorax.  Murphy  injects 
nitrogen  gas  into  the  pleural  sac,  and  believes  that  the  method  is  of  great  value. 
It.  is  maintained  that  Murphy's  operation  occludes  the  lymph-channels,  pre- 
vents bleeding,  compresses  the  lung,  favors  the  development  of  fibrous  tissue, 
and  leads  to  healing  of  cavities.  Every  third  or  fourth  week  120  c.c.  of  nitrogen 
gas  are  injected  into  the  pleural  sac.  (See  Willard  in  "Jour.  Amer,  Med. 
Assoc,"  Sept.  20,  1902;   Murphy's  paper  before  Amer.  Med.  Assoc,  in  1898; 

*See  the  very  full  and  thoughtful  article  by  George  Ryerson  Fowler  on  "The  Surgery 
of  Intrathoracic  Tuberculosis,"  Annals  of  Surger}%  Nov.,  i8g6. 

t  La  Tribune  medicale.  Sept.  21,  1893.  %  Revue  de  Chirurgie,  Nov.  11,  1895. 


Operations  on  Pleura  and  Lungs  901 

Lemke,  in  "Jour.  Amer.  Med.  Assoc,"  Oct.  14,  21,  28,  1899.)  The  operation 
is  not  dangerous,  but  its  value  is  greatly  diminished  if  there  are  adhesions. 
The  more  numerous  the  adhesions  the  less  the  usefulness  of  the  method. 
Adhesions  prevent  pulmonary  collapse.  The  method  is  valuable  in  hemop- 
tysis. 

AUis  suggested  that  in  extensive  unilateral  tuberculosis  of  the  lung  resection 
of  a  number  of  ribs  will  favor  cure  by  permitting  retraction  of  the  chest-wall* 
This  operation  is  founded  on  the  belief  that  the  chief  element  in  effecting  a 
cure  is  the  formation  and  contraction  of  fibrous  tissue.  Pulmonary  collapse 
and  abolition  of  movements  favor  the  formation  of  fibrous  tissue.  In  this 
operation  the  pleura  is  not  opened.  Quincke,  Landerer,  and  others  remove 
portions  of  ribs  with  periosteum  along  the  axillary  line.  Some  surgeons 
remove  portions  of  ribs  and  periosteum  from  directly  over  the  lesion.  Free; 
man  removes  portions  of  ribs  without  periosteum  and  appUes  a  truss  to  push 
in  the  chest  wall  ("Annals  of  Surgery,"  July,  1909).  Friedrich,  of  Marburg, 
removes  all  the  ribs  from  the  second  to  the  tenth  inclusive  and  mobilizes  the 
first  rib  {thoracico plastic  pleuro pneumolysis  with  subcostal  apicolysis).  The 
pleura  is  not  opened.  He  used  to  remove  the  periosteum,  but  does  so  no 
longer.  He  now  leaves  the  periosteum  so  that  after  a  time  enough  bone  will 
reform  to  prevent  lung  bulging  on  coughing. 

Operations  on  Pleura  and  Lungs. 

Intrathoracic  Operations  Under  Positive  or  Negative  Air=pres= 

sure.— When  under  ordinary  conditions  the  chest  wall  is  widely  opened  the 
lung  often  rapidly  collapses  and  the  patient  is  placed  in  deadly  peril  (see 
Acute  Traumatic  Pneumothorax  on  page  893).  The  reality  of  the  danger  has 
to  a  great  extent  retarded  progress  in  the  surgery  of  the  heart,  lungs,  and  lower 
portion  of  the  esophagus.  Of  late,  however,  methods  have  been  devised  for 
maintaining  normal  respiratory  movements  and  preventing  pulmonary  col- 
lapse during  operations  which  open  the  pleura.  There  are  two  forms  of  pres- 
sure apparatus  and  each  form  finds  warm  advocates.  Negative  pressure  is 
the  form  that  is  advocated  by  Sauerbruch.  In  Sauerbruch's  negative  pressure 
chamber  the  lung  is  kept  from  collapse  by  suction  exerted  upon  its  exposed 
surface.  Positive  pressure  is  advocated  by  Brauer.  Posidve  pressure  keeps 
the  lung  from  collapsing  by  distending  it  from  within.  The  two  methods  act 
similarly  in  many  respects.  Clinical  observations  and  numerous  experiments 
seem  to  prove  that  "emphysema,  persistent  pneumothorax,  difficulty  of  narcosis, 
and  infection  of  the  pleura  are  not  dangers  associated  with  the  use  of  positive 
pressure  as  such"  (Samuel  Robinson  and  George  Adams  Leland,  in  "Surg., 
Gynecol.,  and  Obstet.,"  March,  1909). 

The  Sauerbruch  Chamber.— This  is  an  air-tight  cabinet.  The  sides  are 
of  boards  covered  with  tin,  the  corners  being  soldered.  The  roof  is  of  glass. 
The  sides  contain  air-tight  windows.     There  is  one  air-tight  door. 

The  room  is  lighted  by  electricity  and  contains  a  telephone.  The  larger 
chambers  have  a  communicating  room.  Instruments  which  are  wanted 
*  Allis,  to  State  Med.  Soc.  of  Penna.  in  1891. 


902 


Surgery  of  the  Respiratory  Organs 


can  be  placed  in  this  room  so  that  the  surgeon  may  get  them.  The  patient's 
head  projects  outside  of  the  cabinet  and  a  tightly  fitting  rubber  collar  is  placed 
around  the  neck.  The  body  and  legs  are  surrounded  by  a  canvas-covered  rub- 
ber sac  the  interior  of  which  is  in  communication  with  the  external  air. 

The  chamber  is  sufficiently  large  to  hold  the  patient,  the  surgeon,  and  the 
assistant.  By  means  of  an  electric  suction  air  pump,  the  valve  of  which  is  in  the 
wall,  negative  pressure  is  obtained  and  is  continuously  maintained  in  the 
cabinet.  The  patient's  thorax  is  exposed  to  the  suction  of  negative  pressure, 
but  the  bronchioles  are  subjected  to  ordinary  atmospheric  pressure,  hence, 


Fig.  492. — Sauerbruch's  cabinet  :  Position  of  patient  in  chamber  ready  for  operation   under 

negative  pressure. 


even  when  a  wide  opening  is  made  in  the  chest- wall,  the  lung  does  not  collapse. 
The  operator  does  not  suffer  from  the  negative  pressure. 

The  Positive  Pressure  Apparatus. — Numerous  apparatuses  have  been 
devised. 

This  used  to  be  done  by  the  Fell  O'Dwyer  apparatus  (Fig.  491).  The 
larynx  was  intubated  and  bellows  were  used.  It  can  be  done  with  this,  but  it 
is  uncertain  and  difficult  to  use. 

Brauer  advocated  the  following  plan:  When  the  patient  has  been  anes- 
thetized and  the  surgeon  is  ready  to  open  the  pleura,  a  glass  case  is  placed  over 
the  patient's  face  and  the  air  in  the  case  is  condensed  by  means  of  an  apparatus. 

Bauer  subsequently  modified  the  head  chamber  so  that  the  hands  and 
wrists  of  the  anesthetist  are  admitted  within  it.  Some  surgeons  have  given 
compressed  air  by  the  nose,  the  mouth  being  sealed.  Some  give  it  by  intuba- 
tion from  the  mouth.  The  trouble  with  this  method  in  man  is  that  no  com- 
pletely satisfactory  tube  has  yet  been  made.  As  a  general  thing  the  best  way 
to  give  it  is  by  a  well-fitting  face  mask.  A  small  motor  runs  a  small  rotary 
air  pump  and  thus  we  dispense  with  the  trouble  and  uncertainty  of  clumsy 


Paracentesis  Thoracis 


903 


reservoirs  Robinson  and  Leland*  state  that  any  positive  pressure  apparatus 
consists  of  four  elements:  (i)  A  supply  of  compressed  air;  (2)  an  anesthetizing 
segment;  (3)  a  device  for  introducing  air  and  ether  into  the  respiratory  tract; 
(4)  a  means  of  varying  the  resistance  of  exhaled  air  (Fig.  493). 

Exploratory  Puncture  of  the  Pleural  Sac— Puncture  often  gives 
valuable  information  as  to  the  existence  of  fluid  in  the  pleural  sac  and  as 


Fig.  493. —Scheme  of  apparatus  for  the  maintenance  of  distention  of  the  lung  by  positive 
pressure  (Robinson  and  Leland). 


to  the  nature  of  the  fluid.  The  operation  must  be  performed  with  aseptic 
care,  otherwise  a  serous  effusion  might  be  converted  into  a  purulent  effusion, 
and 'either  a  serous  or  a  purulent  effusion  might  be  rendered  putrid.  A 
large  hypodermatic  syringe  with  a  long  and  strong  needle  is  used  for  explor- 
atory puncture.  A  slender  needle  breaks  easily  and  is  unsafe.  In  order 
to  prevent  breaking  of  the  needle  impress  upon  the  patient  the  absolute 
necessity  of  keeping  quiet  and  avoiding  any  violent  respiratory  or  general 
movement  during  the  operation.  It  is  not  desirable  to  stick  the  lung,  although 
harm  rarely  resuhs  from  such  an  accident.  If  no  fluid  is  found  in  the  pleura 
on  one  trial,  several  other  punctures  should  be  made.  What  is  known  as 
a  dry  tap  may  be  due  to  the  entire  absence  of  fluid,  to  encapsulation  of  fluid 
in  a  region  not  invaded  by  the  needle,  to  the  lodgment  of  the  point  of  the 
needle  in  thickened  pleura  or  in  an  adhesion,  or  to  blocking  of  the  lumen 
of  the  needle  with  coagula.  Fowler  points  out  that  if  a  person  has  been 
recumbent  for  a  long  time,  the  upper  layer  of  fluid  may  be  clear  while  the 
lower  layer  is  purulent,  t  The  fluid  should  be  collected  in  a  sterile  glass 
tube  and  subjected  to  a  careful  bacteriological  study. 

Paracentesis  Thoracis.— The  operation  of  tapping  with  a  simple 
trocar  and  allowing  the  fluid  to  flow  out  through  the  cannula  is  no  longer 
practised  except  in  an  emergency,  when  an  aspirator  cannot  be  obtained, 
or  in  an  early  stage  of  non-traumatic  pneumothorax.  An  aspirator  is  a  much 
better  instrument. 

Aspiration.— Aspiration  consists  in  the  introduction  into  the  pleural 
sac  of  the  tip  of  a  hollow  needle,  the  other  end  of  which  is  attached  by  means 
of  a  rubber  tube  to  a  bottle  from  which  the  air  has  been  exhausted.  ^  The 
fluid  does  not  run  out,  but  is  sucked  out,  air  is  excluded,  and  bacteria  do 
not  enter  the  pleural  sac.  Fig.  379  shows  a  pneumatic  aspirator.  No  anes- 
thetic is  required.     The  patient's  skin,  the  instruments,  and  the  surgeon's 

*  "  Surg.  Gynecol,  and  Obstet.,"  March,  1909. 
t  "  Annals  of  Surgery,"  November,  1896. 


904  Surgery  of  the  Respiratory  Organs 

hands  must  be  thoroughly  asepticized.  The  patient  is  given  a  Httle  whisky, 
and,  unless  he  is  very  v\?eak,  he  assumes  a  semi-erect  attitude,  M^ith  the  arm 
hanging  by  the  side.  The  trocar  is  introduced  in  the  fifth  interspace,  just 
in  front  of  the  angle  of  the  scapula.  The  surgeon  marks  the  upper  bor- 
der of  the  sixth  rib  with  the  index-finger,  and  plunges  in  the  trocar  just  above 
the  finger,  thus  avoiding  the  intercostal  artery,  which  lies  along  the  lower 
border  of  the  rib  above.  He  guards  the  needle  with  the  index-finger  to  pre- 
vent its  going  in  too  far.  The  fluid  is  withdrawn  rather  slowly  in  order 
that  the  patient  may  escape  syncope  and  violent  cough.  If  the  patient  becomes 
very  faint,  the  operation  should  be  abandoned.  All  the  fluid  present  should 
not  be  removed  at  one  sitting — complete  removal  of  a  large  effusion  is  not 
safe.  The  operation  can  be  repeated  if  necessary.  After  withdrawing  the 
cannula  place  iodoform  collodion  over  the  opening  in  the  chest.  In  an  early 
stage  of  non-traumatic  pneumothorax  perform  paracentesis  without  suction. 
In  non-purulent  pleuritic  effusion,  if  the  lungs  will  not  expand  after  tappings, 
perform  thoracotomy.  In  some  cases  aspiration  is  followed  by  pulmonary 
embolism  or  embolism  at  a  distance.  Syncope  is  a  not  unusual  result.  Con- 
vulsions occasionally  occur.  In  rare  cases  the  sudden  withdrawal  of  a  large 
effusion  is  followed  by  allniminoiis  expectoration,  as  was  pointed  out  by 
Pinault  in  1853.  It  usually  begins  from  a  few  minutes  to  half  an  hour  after 
aspiration.  When  this  complication  arises,  the  pulse  is  very  weak,  there 
are  severe  dyspnea,  cyanosis,  cough,  and  the  expectoration  of  quantities  of 
a  yellow,  frothy  fluid.  Riesman  ("Amer.  Jour,  of  Med.  Sciences,"  April, 
1902)  demonstrates  that  the  condition  is  due  to  pulmonary  edema  and  not 
to  puncture  of  the  lung.  The  sudden  withdrawal  of  fluid  by  aspiration 
relieves  the  pressure  which  was  compressing  the  lung,  the  lung  becomes  con- 
gested with  blood  {congestion  by  recoil,  Riesman  calls  it),  the  blood  dis- 
tends weakened  vessels,  and  profuse  transudation  takes  place  into  the  air- 
cells.  Most  cases  recover  in  a  few  hours  or  a  day  or  two.  Severe  cases 
die  from  asphyxia.  Terrilon  collected  23  cases  with  2  deaths.  If  albu- 
minous expectoration  arises,  dry  cup  the  chest  and  counterirritate  with 
mustard  plasters.  Perform  venesection.  Give  oxygen  by  inhalation.  Ad- 
minister atropin  hypodermatically.  Employ  artificial  respiration  if  neces- 
sary. 

Thoracotomy  is  an  incision  into  the  cavity  of  the  pleura.  It  may 
be  merely  an  intercostal  incision,  or  may  be  an  opening  into  the  chest  after 
resecting  a  portion  of  a  rib.  Often  in  a  child  with  empyema  good  drainage 
can  be  obtained  by  an  intercostal  incision,  but  in  most  children  and  in  all 
adults  a  rib  should  be  resected.  The  instruments  required  for  rib  resec- 
tion and  thoracotomy  are  a  scalpel,  a  grooved  director,  forceps  (hemostatic 
and  dissecting),  scissors,  a  periosteum  elevator,  retractors,  a  costotome  or 
metacarpal  saw,  rongeur  forceps,  drainage-tubes,  and  needles. 

If  there  is  very  little  dyspnea,  ether  can  be  given.  If  there  is  considerable 
dyspnea,  chloroform  should  be  given.  If  there  is  severe  dyspnea,  no  general 
anesthetic  is  admissible.  In  severe  dyspnea  the  patient  is  using  certain 
voluntary  muscles  to  aid  him  in  obtaining  air.  A  general  anesthetic  abolishes 
the  activity  of  the  voluntary  muscles  of  respiration,  and  so  might  cause  suffo- 
cation.    In  such  cases  the  operation  can  be  done  with  fair  satisfaction  after 


Thoracotomy  905 

the  injection  of  eucain  or  after  infiltrating  the  superficial  tissues  of  the  chest 
wall  with  Schleich's  fluid,  or,  what  is  better,  preliminary  aspiration  can 
be  performed.  Aspiration  will  permit  of  the  subsequent  administration  of 
a  general  anesthetic.  The  patient  on  whom  thoracotomy 
is  to  be  performed  is  placed  supine,  the  diseased  side  being 
at  or  over  the  edge  of  the  table.  He  must  never  be  placed 
on  the  sound  side,  because  he  breathes  only  with  that  side, 
and  pressure  on  it  may  be  dangerous. 

The  arm  of  the  diseased  side  should  be  elevated  to  a 
right  angle  with  the  body.  If  the  surgeon  desires  to  ob- 
tain only  intercostal  drainage,  he  should  make  a  longitudi- 
nal incision  about  three  inches  in  length  at  the  upper  bor- 
der of  the  sixth  or  seventh  rib,  and  the  middle  of  this  inci- 
sion should  correspond  to  the  midaxillary  hne.  This  inci- 
sion is  carried,  layer  by  laver,  to  the  pleura.     If,  as  will       ,  Fig.  494.-Resection 

,,,,,'.,"  .  -        .,  of  a  nb  (Esmarch  and 

usually  be  the  case,  he  wishes  to  remove  a  portion  of  a  rib,  Kowaizig). 
he  will  make  an  incision  about  three  inches  in  length  di- 
rectly upon  the  outer  surface  of  the  rib  he  wishes  to  remove,  and  the  middle  of 
this  incision  corresponds  to  the  midaxillary  hne.  Some  surgeons  resect  a  por- 
tion of  the  fifth  rib,  some  remove  a  bit  of  the  eighth  rib,  and  Alunro  *  shows 
that  at  the  level  of  the  eighth  rib  there  is  no  danger  of  injuring  the  diaphragm. 
By  many  operators  a  portion  of  the  seventh  or  eighth  rib  is  removed  in  front 
of  the  line  of  the  posterior  axillary  fold. 

I  agree  with  Ilutton  that  a  portion  of  the  sixth  rib  in  the  midaxillary 
Kne  should  be  removed,  f  The  reasons  given  by  Hutton  for  the  selection 
of  this  rib  are:  (i)  It  is  over  the  portion  of  the  lung  which  expands  last. 
An  empyema  is  drained  only  partly  by  gravity,  and  the  fluid  is  really  forced 
out  and  the  cavity  obliterated  by  lung  expansion.  If  an  incision  is  made 
anterior  or  posterior  to  this  point,  the  expanding  lung  will  block  the  drainage- 
opening,  and  a  pus-cavity  without  drainage  will  remain  in  the  midaxillary 
line.  (2)  Such  an  incision  permits  a  patient  to  he  on  his  back  without  mak- 
ing pressure  on  the  drainage-tube. 

The  periosteum  of  the  outer  surface  of  the  rib  must  be  divided  in  the 
same  direction  as  the  superficial  incision.  The  exposed  rib  is  stripped  of 
periosteum  front  and  back  by  means  of  a  periosteal  separator,  and  with 
the  periosteum  at  the  lower  border  of  the  rib  the  intercostal  artery  is  hfted 
out  of  harm's  way.  The  rib  can  be  divided  by  means  of  cutting  forceps, 
a  chain-saw,  or  a  GigH  saw.  I  prefer  a  costotome,  as  it  accomplishes  the 
section  most  rapidly.  The  usual  method  is  to  push  a  periosteal  separator 
under  the  rib,  and  saw  the  bone  in  two  places  by  means  of  a  metacarpal 
saw  (Fig.  494)-  An  inch  or  more  of  the  rib  should  be  removed.  The  inter-' 
costal  artery  is  hgated  at  each  end  of  the  incision,  the  periosteum  is  removed, 
and  the  pleura  is  opened.  The  object  of  removing  the  periosteum  is  to 
prevent  the  rapid  formation  of  bone  which  might  narrow  the  opening  and 
interfere  with  drainage.  The  actual  opening  of  the  pleura  is  carried  out  in 
the  same  way  in  intercostal  incision  and  after  rib-resection.     A  grooved  direc- 

*  Medical  News,  Sept.  2,    1899. 

I  See  W.  Menzies  Hutton  on  "  Empyema,"  in  Brit.  Med.  Jour.,  Oct.  29,  1898. 


9o6  Surgery  of  the  Respiratory  Organs 

tor  is  pushed  into  the  pleural  sac,  and  the  opening  is  enlarged  by  means 
of  the  forceps  and  the  finger. 

The  finger  removes  all  masses  of  tuberculous  material  or  aplastic  lymph 
within  reach.  If  the  finger  finds  the  lung  firmly  bound  down  by  dense  ad- 
hesions so  that  it  cannot  expand,  simple  rib-resection  will  not  cure  the  patient, 
and  Estlander's,  Schede's,  or  Fowler's  operation  should  be  done.  Some  sur- 
geons advocate  immediate  irrigation  after  opening  an  acute  empyema,  but  this 
procedure  is  unsafe.  It  is  true  that  in  most  cases  irrigation  does  no  harm, 
but  in  no  case  will  it  sterilize  the  cavity,  and  in  some  cases  it  is  very  dangerous. 
The  pleura  is  very  susceptible  to  the  action  of  irritants.  This  is  especially 
true  of  young  children.  It  happens  occasionally  that  the  injection  of  the 
blandest  fluid  is  followed  by  intense  dyspnea,  great  shock,  disturbances 
of  respiration  and  circulation,  convulsions,  and  even  death  (Quenu).  The 
convulsions  which  occasionally  follow  pleural  irrigation  were  called  by  de 
Cerenville  pleural  epilepsy.  In  putrid  empyema  it  is  proper  to  irrigate. 
Irrigation  will  remove  part  of  the  actively  poisonous  putrid  matter,  and 
the  retention  of  putrid  matter  is  a  greater  danger  than  irrigation.  It  was 
formerly  a  common  custom  to  make  a  counter-opening  by  cutting  down 
upon  the  long  probe  pushed  against  the  chest-wall  after  being  introduced 
through  the  incision,  but  a  counter-opening  is  of  no  particular  use.  A  drain- 
age-tube about  two  inches  in  length  is  introduced  and  stitched  in  place. 
The  tube  must  not  be  long  enough  to  touch  against  the  lung.  A  safety- 
pin  is  clamped  upon  the  tube  to  keep  it  from  slipping  into  the  chest.  A 
tape  should  be  fastened  to  each  side  of  the  tube  and  tied  about  the  chest 
to  prevent  it  from  slipping  out.  Arrest  bleeding,  suture  the  skin,  dress 
with  gauze,  wood-wool,  and  a  binder,  and  have  the  dressings  changed  as 
soon  as  they  become  soaked  at  one  point.  Several  times  a  day  change  the 
patient's  position.  At  each  change  of  dressings  direct  him  to  lie  on  the  dis- 
eased side  with  the  foot  of  the  bed  raised  for  half  an  hour.  Healing  takes  place 
by  ascent  of  the  diaphragm,  expansion  of  the  lung,  and  retraction  of  the  chest- 
wall.  Expansion  of  the  lung  is  favored  by  expiratory  acts;  hence  cause  the 
patient  several  times  a  day  to  blow  through  a  rubber  tube  into  a  one  gallon 
Woulff  bottle  filled  with  water.  The  water  is  blown  into  another  bottle  at- 
tached to  the  first  by  a  tube.  Remove  the  drainage-tube  when  the  dis- 
charge becomes  thin  and  scanty  (about  the  eighth  or  tenth  day,  as  a  rule). 
If  an  empyema  ceases  to  improve  and  remains  stationary  for  months  after  it 
has  been  drained,  firm  adhesions  exist.  If  after  one  year  has  passed  a 
cavity  still  exists  and  there  is  a  flow  of  pus,  the  surgeon  must  perform  the 
operation  of  Schede,  Estlander,  Fowler,  or  Ransohoff. 

Thoracoplasty  (Estlander's  operation)  is  employed  in  old  cases  of 
'  empyema  in  which  drainage  has  failed,  and  in  cases  with  retracted  chest-wall, 
collapsed  lung,  thickened  pleura,  and  cavities  whose  rigid  walls  will  not  col- 
lapse. The  procedure  recognizes  the  fact  that  after  pus  is  evacuated,  if  the 
lung  is  adherent,  it  cannot  expand  to  fill  the  space  once  occupied  by  fluid,  and 
that  the  rigid  chest-wall  cannot  fall  in  as  a  substitute  for  the  lung.  It  seeks 
to  destroy  the  rigidity  of  the  chest-wall  and  to  permit  it  to  collapse  and  thus 
obliterate  the  cavity  of  the  empyema.  When  the  surgeon  resects  a  rib  and 
finds  a  cavity  with  uncollapsible  walls,  or  a  lung  bound  down  with  firm 


Total  Pleurectomy  or  Pulmonary  Decortication 


907 


Fig.  495 . — Incision  for  Schede's  oper- 
ation of  thoracoplasty  (Esmarch  and 
Kowalzig). 


adhesions,  he  should  perform  thoracoplasty.  This  operation  causes  the 
obliteration  of  the  cavity  by  collapsing  that  portion  of  the  chest-wall  overly- 
ing it.  The  cavity  is  usually  in  the  upper  or  central  part  of  the  pleural  space. 
The  instruments  required  are  the  same  as  those  for  resection  of  a  rib.  The 
position  is  the  same  as  that  for  rib- 
resection.  The  length  of  the  incision 
depends  on  the  size  of  the  cavity.  The  sur- 
geon usually  removes  portions  of  the  second, 
third,  fourth,  fifth,  sixth,  and  seventh  ribs. 
Make  a  transverse  incision  along  the  center 
of  an  intercostal  space,  and  through  this 
incision  remove  the  ribs  above  and  below  by 
the  method  set  forth  on  page  904  (the  re- 
moval of  six  ribs  will  require  three  incisions) . 
Instead  of  this  incision,  we  can  make  a  ver- 
tical incision  or  a  U-shaped  flap.  Always 
take  away  the  periosteum  in  order  to  pre- 
vent reproduction  of  the  ribs.  In  cavities 
which  are  surrounded  by  firm  adhesions, 
and  in  old  cases  in  which  the  pleura  is  greatly 
thickened,  irrigation  is  safe.  If  the  cavity 
is  small,  it  should  be  packed  with  iodoform 
-gauze  and  allowed  to  granulate;  if  large, 
it  should  be  drained  by  a  large  tube,  the  skin 
being  sutured  by  silkworm-gut. 

Schede's  Operation. — Schede  showed  that  when  the  pleura  is  much 
thickened,  even  Estlander's  operation  will  not  permit  the  chest- wall  to  col- 
lapse and  fill  the  cavity  once  occupied  by  the  fluid.  The  instruments  used 
are  the  same  as  for  Estlander's  operation.  A  U-shaped  flap  is  made  from 
the  level  of  the  axilla  in  front  to  the  level  of  the  second  rib  and  between  the 
scapula  and  spine  behind.  The  lowest  level  of  this  incision  corresponds 
to  the  lowest  limit  of  the  pleura  (Fig.  495)-  The  flap  is  loosened  and  raised 
and  the  scapula  is  lifted  with  it.  The  ribs  from  the  second  rib  down  and 
from  the  costal  cartilages  to  the  tubercles  are  removed,  along  with  the  inter- 
costal muscles  and  the  pleura.  This  is  accomplished  by  cutting  with  bone- 
shears  and  scissors.  Hemorrhage  is  arrested.  The  pleura  is  cureted. 
A  drainage-tube  or  a  piece  of  iodoform  gauze  is  introduced,  and  the  raw 
flap  is  laid  against  the  visceral  layer  of  the  pleura.  The  superficial  inci- 
sion is  sutured,  except  at  the  point  where  the  tube  of  the  gauze  emerges.  The 
mortaHty  from  Schede's  operation  is  from  15  to  20  per  cent. 

Total  Pleurectomy  or  Pulmonary  Decortication  (Fowler's  Oper- 
ation).— In  the  spring  of  1893  ^^  Lorme  performed  some  experiments  on 
dogs  looking  to  the  development  of  the  operation.  In  October,  1893,  George 
Ryerson  Fowler,  having  no  knowledge  of  de  Lorme's  investigation,  operated 
on  a  man  and  cured  a  chronic  empyema.  The  French  surgeon's  first  opera- 
tion was  months  later.  Extensive  rib-resection  is  practised.  This  is  better 
than  de  Lorme's  trap-door  flap,  which  causes  pneumothorax.  The  thickened 
pleura  is  removed  from  the  chest- wall,  lung,  pericardium,  and  diaphragm, 
any  sinus  is  extirpated,  and  all  granulation  tissue  is  taken  away.     Fowler 


9o8  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

maks  a  report  of  30  cases.  Eleven  cases  were  completely  cured.  In  17 
cases  the  empyema  was  cured,  but  6  of  them  had  tuberculosis.  There 
were  3  deaths.  The  combined  statistics  of  Fowler,  de  Lorme,  and  Cestan 
show  35.7  per  cent,  cured,  19.7  per  cent,  improved,  33.9  per  cent,  not  cured, 
and  10  per  cent,  died  (Kurpjweit,  in  "Beitrage  zur  klinischen  Chirurgie," 
Bd.  xxxiii,  H.  3). 

Discission  of  the  Pulmonary  Pleura  (Ransohoff's  Operation).— 
This  operation  can  be  employed  when  decortication  is  impossible,  and  it 
may  be  used  as  a  substitute  for  decortication  in  certain  cases.  It  is  founded 
on  the  observation  that  if  the  thickened  pleura  over  a  shrunken  lung  is  incised 
the  cut  widens  with  each  respiration  and  quickly  becomes  a  groove  (Ranso- 
hoff,  in  "Annals  of  Surgery,"  April,  1906).  The  pulmonary  pleura  is  divided 
by  numerous  parallel  incisions  one-quarter  of  an  inch  apart,  and  then  similar 
incisions  are  made  to  cross  these.  An  incision  is  also  carried  through  the 
costal  side  of  the  angle  of  reflection  of  the  pulmonnry  and  costal  pleura. 

Pneumotomy  for  Abscess  of  the  Lung.— Give  chloroform  or  use  a 
local  anesthetic.  Place  the  patient  recumbent  with  the  shoulders  a  little  raised. 
Make  a  U-shaped  flap  over  the  seat  of  disease.  Resect  a  portion  of  a  rib. 
If  it  is  found  that  adhesions  do  not  exist  between  the  pulmonary  and  costal 
layers  of  the  pleura,  stitch  these  layers  together  with  catgut  and  postpone 
further  operation  for  forty-eight  hours.  If  adhesions  exist,  proceed  at  once. 
Chloroform  can  be  put  aside  when  pleura  is  exposed.  Fowler  calls  attention 
to  the  fact  that  lung  tissue  is  so  insensitive  that  the  administration  of  an  anes- 
thetic can  be  suspended  as  soon  as  the  pleura  has  been  opened.  Incise  the 
agglutinated  layers  of  the  pleura,  and  pass  an  aspirating  needle  into  the 
lung  in  various  directions.  When  the  abscess  is  located,  open  it  with  the 
cautery.  Carry  the  Paquelin  cautery  slowly  into  the  lung  in  the  direction 
of  the  abscess-cavity.     The  cautery  knife  should  be  at  a  dull-red  heat. 

When  the  cautery  opens  the  cavity  of  the  abscess,  withdraw  the  instrument 
and  insert  a  drainage-tube,  and  suture  the  flap  of  superficial  tissue.  If  the 
abscess  is  not  found  after  one  or  two  punctures  with  the  aspirating  needle, 
abandon  the  attempt. 

Tuffier  explores  for  an  abscess  by  what  he  calls  decoUement  of  the  parietal 
pleura.  He  exposes  the  parietal  layer  of  the  pleura,  passes  his  hand  between 
this  layer  and  the  chest-wall,  strips  the  pleura  off  over  a  considerable  area, 
and  is  able  to  feel  the  lung  below  and  thus  determine  its  condition. 


XXVI.    DISEASES    AND  INJURIES  OF  THE  UPPER  DIGESTIVE 

TRACT. 

Injuries  and  Diseases  of  the  Face,  Nose,  Mouth,  Salivary  Glands, 
Tongue,  Jaws,  and  Esophagus.— -Wounds  of  the  Salivary  Glands.— An 

aseptic  wound  usually  heals  and  rarely  results  in  a  salivary  fistula,  although 
after  healing  it  is  not  unusual  for  an  encysted  collection  of-  saliva  to  gather 
under  the  skin.  Such  a  collection  of  sahva,  if  it  does  not  disappear  spontane- 
ously, can  usually  be  gotten  rid  of  by  continued  pressure.  When  a  wound  of 
a  salivary  gland  is  infected,  a  single  fistula  or  multiple  fistulaj  may  be  left  as 
a  legacy.    A  salivary  fistula  is  very  annoying,  because  the  saliva  flows  con- 


Parotitis 


909 


stantly.  A  fistula  usually  heals  spontaneously  after  a  long  time,  but  heal- 
ing can  be  quickly  brought  about  by  touching  the  orifice  with  the  Paquelin 
cautery. 

Wound  oj  Steno's  duct  is  apt  to  cause  a  fistula,  and  the  condition  is  often 
difficult  to  cure.  In  this  condition,  when  the  duct  was  cut  across,  the  central 
end  grows  fast  to  the  cutaneous  surface.  Fistula  of  Steno's  duct  may  also  be 
caused  by  obstruction  an']  rupture  nf  the  duct  and  by  suppurative  or  gan- 
grenous processes. 

In  wounds  of  the  duct  the  ends  .-h(juld  be  brought  as  near  together  as 
possible  with  catgut  sutures  which  do  not  enter  the  lumen  of  the  duct;  an 
incision  should  be  made  through  the  mucous  membrane  to  permit  drainage 
of  saliva,  if  the  mucous  membrane  is  not  already  opened,  and  the  skin  should 
be  sutured.  In  some  cases  the  central  end  of  the  duct  may  be  carried  into  the 
mouth  and  sutured  to  the 
mucous  membrane.  If,  after 
an  injury  of  Steno's  duct, 
saliva  gathers  under  the  skin, 
make  an  incision  through  the 
mucous  membrane,  to  give  a 
route  for  the  saliva  to  enter  the 
mouth,  and  apply  pressure  ex- 
ternally. When  a  fistula 
forms,  it  may  be  cured  by  the 
cauterv  and  pressure,  but,  if 

the    peripheral  portion  of    the  Fig.  496.-DeGuise-s  operation  for  salivary  fistula 

1         '     _  ^  (Esmarchand  Kowalzig). 

duct  is  obliterated,  which  can 

be  determined  with  a  sound,  an  operation  must  be  performed.  Tillmanns  ad- 
vocates cutting  out  the  external  portion  of  the  fistula  by  two  elliptical  incisions. 
A  trocar  is  passed  through  the  bottom  of  the  wound  in  two  places,  about  half  a 
centimeter  apart;  a  piece  of  stout  silk  is  drawn  through  the  holes  and  tied  tightly 
and  the  superficial  incision  is  closed.  The  silk  cuts  through  and  makes  an 
internal  fistula.  Another  method  is  to  make  an  incision,  find  and  isolate  the 
central  end  of  the  duct,  open  the  mucous  membrane,  suture  the  duct  to  it,  and 
close  the  superficial  wound. 

De  Guise's  operation  is  shown  in  Fig.  496,  He  threads  a  piece  of  silk 
through  two  needles  and  carries  the  needles  into  the  mouth  so  that  the  silk 
w-ill  embrace  a  bit  of  tissue  half  a  centimeter  in  length.  The  silk  is  tied  tightlv 
within  the  mouth,  the  ends  are  cut  ofi^,  and  the  margins  of  the  fistula  at  the 
surface  are  freshened  and  sutured. 

Parotitis. — Mumps,  or  epidemic  parotitis,  is  treated  by  the  physician. 
In  this  condition  the  submaxillar}'  and  subHngual  glands  are  usually  involved 
as  well  as  the  parotid.  In  pyemia  metastatic  abscesses  may  form  in  the  par- 
otid gland.  Great  swelling  arises,  respiration  is  often  embarrassed,  and  early 
incision  is  necessary.  Parotid  inflammation  other  than  mumps  is  usually  due 
to  the  passage  of  bacteria  up  Steno's  duct,  the  source  of  the  microbes  being  a 
foul  condition  of  the  mouth,  particularly  noma  or  stomatitis.  Hence  such 
inflammation  is  most  common  during  the  existence  of  acute  infectious  diseases 
and  sepsis.  Suppuration  or  even  gangrene  may  occur.  As  a.  rule,  only  one 
gland  is  attacked,  but  both  may  be.     It  is  a  well-known  fact  that  occasionally, 


Qio  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

though  very  rarely,  after  an  abdominal  operation  inflammation  of  the  ])ar()tid 
gland  occurs.  The  condition  is  more  common  in  adults  than  in  children. 
This  form  of  parotids  may,  of  course,  be  due  to  sepdc  metastasis  and  may  be 
produced  by  trauma,  but  I  am  satisfied  that  most  cases  result  from  foul 
mouths,  the  infection  ascending  from  the  mouth  along  the  duct.  Oral  clean- 
liness strongly  tends  to  prevent  the  so-called  '^sympathetic'^  parotitis.  In  about 
one-third  of  the  cases  the  condition  is  not  to  be  distinguished  from  mumps  and 
is  recovered  from  in  seven  or  eight  days.  Mild  cases  seldom  suppurate,  and 
if  they  do,  the  pus  flows  down  the  duct  and  into  the  mouth.  In  nearly  (me-half 
of  the  cases,  according  to  Marchetd  ("Epitome  of  Surgery,"  in  "Brit.  Med. 
Jour.,"  March  6,  1909),  there  is  phlegmonous  inflammadon  with  necrosis  and 
suppuradon  of  the  tissues  and  formation  of  a  sahvary  fistula.  In  non-sup{)ura- 
tive  parotitis  there  are  pain,  tenderness,  obvious  swelling,  and  hyperemia  of  the 
skin,  and  it  is  difficult  to  open  the  mouth  or  swallow.  When  suppuration 
occurs,  all  of  the  above  symptoms  are  intensified,  the  discoloration  becomes 
dusky,  the  skin  becomes  shiny  and  edematous,  the  constitutional  symptoms 
of  pus-formation  exist,  and  there  is  usually  delirium. 

Treatment. — In  the  non-suppurative  form  apply  an  ice-bag  over  the  gland 
for  the  first  twenty-four  hours  and  then  substitute  heat.  Wash  the  mouth 
out  frequently  with  an  antiseptic  wash  and  apply  ichthyol  and  lanolin  to 
the  swollen  region.  In  the  suppurative  form  make  several  openings  by 
Hilton's  method,  seeking  for  points  of  softening;  apply  hot  antiseptic  fomenta- 
tions, wash  the  mouth  frequently  with  an  antiseptic  fluid,  and  combat  sepsis 
by  appropriate  constitutional  treatment. 

Salivary  Concretions. — The  sahva  contains  in  solution  certain  salts 
which  may  deposit.  Deposited  on  the  teeth,  they  constitute  tartar.  Depos- 
ited in  a  sahvary  duct  or  the  acini  of  a  gland  they  constitute  a  calculus.  The 
salts  deposited  are  carbonate  and  phosphate  of  lime.  A  calculus  may  consist 
purely  of  these  two  salts  or  there  may  be  a  foreign-body  nucleus.  A  cal- 
culus is  a  possible  result  of  an  inflammation  which  blocks,  constricts,  or 
roughens  a  duct  or  acinus  and  decomposes  saliva.  Small  concretions  are  often 
passed.  Concretions  the  size  of  a  bean  are  retained.  A  concretion  may 
attain  the  size  of  an  English  walnut.  A  concretion  does  not  block  a  duct 
continuously,  but  does  so  now  and  then,  causing  swelling  and  tenderness  of  the 
gland.  A  retained  calculus  can  be  palpated  by  a  finger  in  the  mouth  and  a 
finger  externally. 

Treatment. — A  calculus  in  a  duct  is  extracted  by  making  an  incision  through 
the  mucous  membrane.  If  a  very  large  calculus  forms  in  the  submaxillary 
gland,  the  gland  should  be  removed  through  an  external  incision. 

Harelip  and  Cleft  Palate. — Harelip  is  a  congenital  cleft  in  the  upper 
lip  due  to  defective  development.  Clejt  palate  is  a  congenital  fissure  in 
the  soft  palate  or  in  both  the  hard  and  soft  palates.  In  harelip  the  cleft 
is  usually  complete,  through  the  entire  lip  into  the  nostril,  but  in  rare  cases 
it  may  show  only  as  a  furrow  in  the  mucous  edge  or  as  a  split  from  the  nostril 
partly  into  the  lip.  It  is  most  common  on  the  left  side.  In  double  harelip  the 
central  portion  of  the  lip  is  often  adherent  to  the  tip  of  the  nose.  Double 
harelip  may  be  free  from  complication,  but  is  often  associated  with  a  malforma- 
tion of  the  alveolus  and  palate.  Median  harelip  is  exceedingly  rare.  In  cleft 
palate  the  septum  of  the  nose  is  usually  adherent  to  the  palatine  process 


HareHp  and  Cleft  Palate  911 

opposite  the  side  upon  which  the  fissure  exists.  In  those  rare  cases  of  cleft 
palate  double  in  front,  the  nasal  septum  is  attached  only  to  the  premaxillary 
bone,  and  the  premaxillary  is  not  attached  at  all  to  the  superior  maxiilar}- 
bone.  In  harelip  there  is  frequently  a  cleft  in  the  alveolus,  and  almost 
always  flattening  of  the  corresponding  side  of  the  nose.  Harelip  is  often 
associated  with  cleft  palate,  talipes,  and  other  deformities.  It  is  a  great 
deformity,  and  interferes  with  sucking,  swallowing,  and  articulation. 

Operation  for  harelip  uncomplicated  by  cleft  palate  should  be  performed 
between  the  third  and  sixth  months  of  life  in  a  child  in  good  health,  free  from 
stomach  trouble,  cough,  or  coryza,  but  operation  is  not  advisable  in  the  early 
weeks  of  life.  Always,  if  possible,  operate  before  dentition  begins  (seventh 
month).  If  the  child  is  in  poor  health,  postpone  the  operation  until  restora- 
tion has  so  far  advanced  as  to  render  operation  safe.  While  waiting  for  opera- 
tion be  sure  the  child  is  getting  enough  food.  If  it  cannot  suck,  feed  it  with 
a  spoon.  If  a  cleft  exists  in  the  palate,  we  sometimes  operate  first  upon  the 
lip,  because  the  pressure  of  the  parts  after  the  edges  of  the  gap  are  approxi- 
mated aids  in  the  closure  of  the  bony  cleft.  In  other  cases  we  operate  first  on 
the  palate.  Cleft  palate  interferes  with  sucking,  deglutition,  mastication,  and 
articulation.  In  severe  cases  the  food  passes  into  the  nose  and  excites  inflam- 
mation. Loss  of  control  of  the  palate-muscles  always  exists,  and  liquids  and 
solids  are  liable  to  pass  into  the  ■wandpipe.  Clefts  in  the  hard  palate  should 
not  be  operated  on  until  the  second  year,  but  should  be  operated  upon  then, 
otherwise  speech  will  be  permanently  affected.  Some  surgeons  refuse  to  oper- 
ate until  the  tenth  or  twelfth  year,  but  operation  done  this  late  will  not  correct 
speech-defect.  The  patient  at  the  period  of  operation  should  be  well  and  free 
from  cough.  In  many  cases  the  passage  of  food  and  drink  into  the  nose  can 
largely  be  prevented  by  the  use  of  a  diaphragm. 

Operation  for  Harelip. — The  instruments  required  are  a  tenotome  and 
scalpel,  toothed  forceps,  hemostatic  forceps,  scissors  cur\'ed  on  the  flat  and 
pointed,  straight  blunt-pointed  scissors,  needles  (straight  and  curved),  silver 
wire  or  silkworm-gut  and  silk  sutures,  a  mouth-gag  and  tongue-forceps,  a 
needle-holder  and  sequestrum-forceps,  each  blade  protected  by  a  rubber  tube. 
Wrap  the  child  in  a  sheet;  place  it  in  the  Trendelenburg  position,  and  rest  the 
head  upon  a  sand-pillow.  The  surgeon  stands  to  the  right  side  of  the  patient. 
Ether  or  chloroform  is  given.  For  single  harelip,  separate  with  the  scissors 
the  upper  lip  from  the  bone  on  each  side  of  the  cleft  until  approximation  of  the 
cleft  can  be  effected  without  tension.  If  the  premaxillary  bone  of  one  side 
projects  more  than  its  fellow,  grasp  it  with  sequestrum-forceps  and  bend  it  back 
(Jacobson  and  Treves).  Clamp  the  upper  lip  at  each  angle  of  the  mouth  to 
prevent  hemorrhage.  If  the  edges  are  of  equal  or  nearly  equal  length,  and  if 
the  gap  is  not  verv-  wide,  perform  "Malgaigne's  operation.  This  is  performed  as 
follows :  a  flap  is  detached  on  each  side,  the  detachment  beginning  at  the  upper 
angle  of  the  gap;  each  flap  is  detached  above,  but  remains  attached  below. 
The  flaps  are  separated  from  the  bone,  and  are  drawn  downward  so  as  to  form 
a  prominence  at  the  vermilion  border  (Fig.  497).  If  the  edges  are  pared  so 
that  in  closure  the  vermilion  border  is  even,  when  the  parts  are  healed  a  gutter 
will  be  visible  at  the  line  of  union.  The  edges  are  approximated  by  an  assis- 
tant, and  silkworm-gut  sutures  or  silver  wires  are  passed  by  means  of  a  straight 
needle.     Each  suture  goes  down  to  the  mucous  membrane.     The  first  suture 


912  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

is  passed  through  the  middle  of  the  lip,  one-third  of  an  inch  from  the  cleft. 
Three  or  four  main  sutures  are  passed  through  the  thickness  of  the  lip,  and  are 
tied  and  cut  off.  Two  or  three  fine  silk  or  catgut  sutures  are  passed  by  a 
curved  needle  through  the  vermilion  border  of  the  Hp  and  the  mucous  mem- 
brane of  the  mouth,  and  are  tied  and  cut  off.  A  small  piece  of  gauze  is  placed 
over  the  hp  and  is  held  in  place  by  straps  of  rubber  plaster.  After  operation 
prevent  the  child  crying  by  feeding  it  often  and  giving  it  small  doses  of  lau- 
danum. Heath  orders  two  drops  of  laudanum  in  one  ounce  of  distilled  water, 
a  teaspoonful  to  be  given  every  two  or  three  hours.  About  the  sixth  day  one- 
half  the  sutures  are  taken  out,  and  on  the  eighth  or  ninth  day  the  remaining 
ones  are  removed.  In  many  cases  no  further  procedure  is  necessary,  but  if 
after  some  weeks  the  prominence  at  the  lip-border  does  not  shrink,  it  can  be 
readily  clipped  away.  Harelip-pins  are  not  used  at  the  present  time,  and  are 
not  needed  if  the  hp  is  weU  separated  from  the  bone.  If  the  edges  of  the  cleft 
are  of  unequal  length,  Edmund  Owen's  operation  can  be   performed  (see 


Fig.  497  — M,ilt;.iiL,Mit's  op-         Fig.  498. — Incisions  for  double  hare-        Fig.  499. — Mirault's  operation 
eration  for  harelip.  lip  (Esmarch  and  Kowalzig).  for  single  harelip  (Esmarch). 

below,  under  Double  Harelip),  or  we  can  perform  Mirault's  operation,  as 
shown  in  Fig.  499- 

In  double  harelip  the  operation  is  similar  to  that  for  single  harelip.  If  the 
intervening  piece  is  vertical  and  is  covered  with  healthy  skin,  complete  each 
operation  as  for  single  harelip,  closing  both  fissures  at  once  with  silver  wire  in  a 
strong,  healthy  child,  closing  them  at  intervals  of  three  weeks  in  one  not  so 
lusty  (Fig.  498).  Excise  the  septum  if  it  is  deformed.  The  premaxillary  bone 
should  in  most  instances  be  removed,  the  skin  over  it  being  preserved.  Sir 
Wm.  Fergusson  was  accustomed  to  incise  the  mucous  membrane  and  shell  out 
this  bone.  The  premaxillary  bone  can  be  forced  back  into  line,  being  held,  if 
necessary,  by  catgut  suture  of  the  periosteum;  but  if  saved,  it  is  liable  to  necrose 
and  its  teeth  soon  decay.  Heath  removes  this  bone  two  weeks  before  operat- 
ing on  the  lip.  If  there  is  much  hemorrhage  after  removal  of  the  bone,  arrest 
it  with  a  hot  wire  or  with  Horsley's  wax.  Fig.  498  shows  incisions  for  double 
hareHp.  Edmund  Owen's  operation  is  very  useful  (Figs.  500  and  501).  In 
this  operation  very  thick  flaps  are  cut.  The  prolabium  and  incisive  bone  are 
removed.  The  flaps  are  cut  as  shown  in  Fig.  500,  on  one  side  by  a  Hne  ab, 
and  on  the  other  side  the  piece  cde  is  removed;  a  is  brought  to  e,  b  is  brought 
to  d,f\s  brought  to  c,  and  sutures  are  appUed  (Fig.  50.1). 

Operation  for  Cleft  Palate. — It  is  true  that  during  the  early  years  of  its 
growth  a  cleft  diminishes  in  size  and  particularly  if  a  harelip  is  closed; 
but  to  wait  too  long  before  we  operate  means  permanent  speech  impairment. 
Bony  clefts  should  be  operated  upon  early  in  the  second  year.     Clefts  of  the 


Harelip  and  Cleft  Palate 


913 


soft  palate  only  may  be  operated  upon  during  the  first  six  months  of  life.  If 
both  the  hard  and  soft  palates  are  cleft,  close  both  at  one  operation.  In  an 
ill-nourished  child  in  which  the  covering  of  the  bone  is  obviously  thin,  it  is  best 
to  postpone  any  operation  upon  a  bony  cleft  until  the  end  of  the  third 
year.  I  agree  with  Berry  that  operation  is  justifiable  up  to  the  age  of  twenty, 
but  early  operation  is  highly  desirable.  Edmund  Owen  has  recently  put 
forth  a  convincing  plea  for  early  operation.*  He  says  he  is  operating  earlier 
and  earher,  and  quotes  Chilton  as  the  gentleman  who  led  him  to  do  so.  Owen 
maintains  that  if  speech  is  to  be  improved,  operation  must  be  done  early, 
and  he  formulates  some  very  valuable  rules  for  preparation  and  care.  I  have 
never  been  convinced  that  operation  in  early  infancy  is  entirely  safe  and 
has  any  notable  advantages.  When  one  comes  to  treat  congenital  clefts  of  the 
lip,  the  alveolar  process,  and  the  hard  and  soft  palate,  the  necessities  one  should 
seek  to  obtain  are  the  surgical  closure  of  the  clefts,  the  establishment  of  the 
function  of  the  involved  tissues,  the  correction  of  the  congenital  deformity, 
and  the  prevention  of  postoperative  or  acquired  deformity.  There  are  few 
if  any  cases  of  cleft  palate  that  cannot  be  successfully  treated  by  surgical 


^X 


Fig.  500. — Double  harelip,  the  prolabium   and 
incisive  bone  having  been  removed  (Owen). 


Fig.  501.— The  two  sides  of   the  lip   drawn 
together  and  secured  by  sutures  (Owen). 


means;  and  it  is  a  very  unusual  thing  for  a  case  really  to  need  any  mechanical 
appUance,  such  as  the  obturator  and  velum. 

In  deciding  upon  the  time  for  operating  and  the  nature  of  the  operation, 
the  safety  of  the  patient  should  be  the  first  consideration.  One  must  care- 
fully consider  his  physical  condition,  especially  with  respect  to  nutrition.  An 
operative  method  that  has  a  greater  mortality  than  is  incident  to  minor  sur- 
gery ought  not  to  be  selected,  and  no  operation  should  be  performed  until  the 
condition  of  the  patient  justifies  it.  Having  considered  the  physical  condi- 
tion of  the  patient  and  the  relative  safety  of  different  operative  plans,  a  care- 
ful study  of  the  individual  case  should  be  made;  and  in  this  study  each  of 
the  four  requirements  above  set  forth  must  be  attentively  regarded.  If  we 
succeed  in  closing  the  cleft  without  establishing  the  function  of  the  tissues, 
without  correcting  congenital  deformity,  and  without  preventing  postoperative 
or  acquired  deformity,  we  leave  the  patient  worse  off  than  he  was  before,  and 
perhaps  renders  subsequent  satisfactory  treatment  impossible. 

We  should  attempt  to  secure  closure  of  the  cleft  with  the  least  possible 
formation  of  cicatricial  tissue.  The  simplest  technique  is  the  best,  and  we 
should  endeavor  to  avoid  all  additional  traumatism,  such  as  incisions  to  re- 

*  Lancet,  Jan.  4,  1896. 
58 


914  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

lieve  tension  and  to  permit  of  approximation.  One  should  refrain  from  pass- 
ing additional  approximation-sutures,  from  bruising  the  tissues  by  overten- 
sion  or  by  traction-forceps,  and  from  using  large  needles  and  coarse  suture 
materials,  which  make  large  suture-cicatrices.  The  amount  of  scar  tissue 
bears  directly  upon  the  functional  result.  In  addition,  when  deahng  with  the 
lip,  and  especiall}  with  the  soft  palate,  one  must  seek  to  avoid  incisions  that 
involve  muscles,  and  particularly  the  nerve-supply  of  muscles. 

The  periosteal-flap  operation  separates  portions  of  the  soft  palate  from  the 
palatine  bones.  A  large  amount  of  cicatricial  tissue  is  necessary  to  effect  re- 
pair, and  this  mass  of  new  tissue  lessens  the  good  functional  results.  In  the 
periosteal-flap  operation  the  repaired  soft  palate  is  anterior  and  inferior  to  the 
position  secured  by  the  osteoplastic  method  and,  to  that  extent,  interferes  with 
the  closure  of  the  nasopharynx.  Nevertheless,  in  my  opinion,  the  operation 
which  uses  the  soft  tissues  only  is  by  far  the  safest  and  is  the  one  I  usually 
employ.  In  cases  of  complete  cleft  associated  congenital  deformities  are 
especially  manifest  in  the  nose,  lips,  premaxilla,  and  maxillae. 

To  correct  congenital  deformities  and  to  prevent  postoperative  or  acquired 
deformities  is  the  most  neglected  and  the  least  understood  phase  of  the  sub- 
ject; and  it  is  a  very  complicated  question  to  hope  to  make  clear  in  a  brief 
statement.  The  key  to  the  difficulty  is  the  normal  contour  of  the  face  as 
established  by  the  proper  occlusion  of  the  permanent  teeth.  In  finding  this 
out  there  is  no  better  guide  than  the  rules  laid  down  by  Dr.  Angle  in  the 
latest  edition  of  his  Orthodontia.  He  maintains  that  every  tooth  must  be 
held  in  its  proper  relation  and  occlusion;  and  that  if  any  teeth  are  lost  they 
must  be  replaced  in  order  to  establish  or  restore  the  proper  expression  and 
contour  of  the  face.  To  comply  with  the  foregoing  requirements  one  should 
avoid  any  operation  that  would  not  maintain  or  would  fail  to  replace  the 
normal  position  of  the  premaxilla  and  the  maxillae  and  their  future  comple- 
ment of  teeth.  If  the  premaxilla  is  only  slightly  in  advance  of  its  normal 
position,  the  early  closure  of  the  cleft  of  the  lip  will  help  to  replace  it.  If, 
however,  the  premaxilla  is  far  in  advance  of  its  normal  position,  it  is  hopeless 
to  expect  the  pressure  of  a  reunited  lip  to  restore  it  to  position.  In  such  a 
case  sufficient  of  the  nasal  septum  posterior  to  the  premaxilla  must  be  re- 
sected, and  the  premaxilla  must  be  carried  back  and  sutured  in  position;  but 
this  operation  should  be  done  after  the  closure  of  the  cleft  soft  and  hard  palates, 
and  seldom  at  the  same  operation.  If  the  cleft  is  unilateral  in  relation  to  the 
premaxilla  and  that  bone  is  swung  to  the  opposite  side,  and  anterior  to  its 
normal  position,  the  pressure  exerted  by  an  early  repaired  lip  will  often  cor- 
rect the  condition.  Until  the  deciduous  incisors  have  erupted  it  is  difficult 
to  determine  how  far  the  intermaxillary  bone  really  protrudes;  and  it  is  often 
surprising  to  observe  how  little  correction  is  needed  in  what  had  appeared  to 
be  marked  protrusion  of  the  premaxilla  in  a  unilateral  or  bilateral  cleft.  If 
in  doubt  about  this  point  it  is  better  to  wait  until  the  eruption  of  the  decidu- 
ous incisors,  when  one  may  decide  with  certainty  whether  there  is  enough 
anterior  protrusion  to  warrant  the  closure  of  the  lip  before  operation  on  the 
palate.  Early  closure  of  the  cleft  of  the  lip  brings  very  considerable  pressure 
to  bear,  especially  in  double  cleft  or  the  typical  harehp,  as  the  lateral  portions 
are  comparatively  short  and  the  lip  is  usually  quite  tense.  Sometimes  this 
pressure  is  quite  efficient,  when  exerted  upon  these  cases  of  protrusion  of  the 


Harelip  and  Cleft  Palate  9^5 

premaxilla,  which  are  frequent,  and  of  lateral  separation  of  the  maxilla;,  which 
are  infrequent;  but  when  such  pressure  is  exerted  upon  cases  without  protru- 
sion or  separation,  it  produces  an  unfortunate  postoperative  deformity,  and 
one  that  is  too  frequently  encountered.  It  causes  the  alveolar  arch  to  lose  its 
parabolic  curve,  and  what  should  be  an  arch  is  frequently  V-shaped  or  tri- 
angular, and  not  infrequently  the  cuspid  teeth  are  closely  approximated.  One 
thus  gets  marked  flattening  of  the  anterior  lateral  region  of  the  face  or  cheek, 
with  loss  of  contour  and  position  of  the  upper  lip  and  apparent  protrusion  of 
the  lower  lip  and  chin.  It  is  true  that  such  a  postoperative  deformity  can  be 
corrected  by  modern  orthodontic  methods,  but  it  is  better  to  prevent  it  than  to 
be  obliged  subsequently  to  correct  it. 

From  the  preceding  remarks  it  is  evident  that  it  is  to  be  regarded  as 
advisable  in  many  cases  to  close  the  cleft  in  the  soft  and  hard  palates  before 
operating  upon  the  lip.     The  best   time  for  operating  is   just  before  the 
patient  begins  to  employ  articulate  speech.     In  most  cases  the  cleft  in  the 
alveolar  process,  including  the  floor  of  one  or  both  nares,  should  be  repaired 
separately,  and  subsequently  to  the  repair  of  the  hard  and  soft  palates.     A 
comparatively  short  time  after  operating  upon  the  palate  the  lip  may  be 
repaired;  and  the  lip  also  should  be  repaired  before  the  establishment  of 
articulate  speech.     An  advantage   in  operating  with    the   harelip   still   un- 
closed is  that  one  can  see  better  and  work  better  during  the  operation  on 
the  palate,  and  can  give  the  palate  better  local  care  after  the  operation. 
Unfortunately,  however,  many  children  with  cleft  palates  are  never  brought 
for  advice  until  they  have  cultivated  articulate  speech.     It  is  always  very 
difficult  and  often  impossible  to  correct   the  manner  of  speaking  that  they 
have  taught  themselves.     Only  long  training  and  much  perseverance  is  of 
any  avail.     The  earlier  the  operation  is  performed,  the  better  will  be  the 
result— not  only  from  the  functional  standpoint  but  also  as  regards  the  cor- 
rection of  existing  deformitv  and  the  prevention  of  future  deformity.     So 
far  as  obtaining  good  surgical  results  go,  there  is  practically  no  set  age  limit 
If  operation  is  refused  for  cleft  of  the  hard  palate,  if  it  offers  no  real 
hope,  or  if  it  is  verv  dangerous,  an  obturator  must  be  worn.     An  obturator 
is  made  by  a  dentist.     In  preparing  a  child  for  operation  I  follow  Edmund 
Owen's  rules,  viz.:  Have  the  child  in  the  best  condition,  free  from  cough  and 
stomach  disorder.     Operate  in  summer.     Place  the  child  under  the  charge  of 
a  nurse  several  days  before  the  operation. 

operation  for  Suture  of  the  Soft  Palate  {Staphylorrhaphy). -The  operation 
of  staphylorrhaphy,  which  is  applied  to  clefts  of  the  soft  palate  alone,  is  a 
comparatively  easy  procedure.  In  performing  this  operation^  the  patient 
should  be  anesthetized  and  be  placed  in  the  Trendelenburg  position,  or  else 
with  the  head  hanging  over  the  end  of  the  operating  table.  The  mouth  is 
held  open  with  Whitehead's  gag,  and  an  assistant  holds  an  electric  light  and 
a  reflector  to  illuminate  the  oral  cavity.  If  the  patient  is  not  a  young  child, 
the  operation  may  be  done  under  cocain,  with  the  subject  sitting  erect  in  a 
chair  and  the  surgeon  sitting  directly  in  front  of  him. 

The  surgeon  should  have  at  hand  several  knives  of  different  shape,  itie 
double-edged,  pointed  knife  is  an  excellent  one  for  freshening  the  margins 
of  the  palate.  Special  forms  of  needle-holders  have  been  devised  for  the 
purpose  of  carrying  the  needle.  The  heavy,  curved,  sharp-pointed  bis- 
toury is  the  best  instrument  for  dividing  the  muscles  of  the  palate;    and  a 


9i6  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


sharp  hook  should  be  at  hand,  in  order  lo  catch  the  edge  of  the  cleft,  if 

necessary. 

The  surgeon  first  of  all  separates  the  soft  palate  from  the  posterior  edge 

of  the  palate  bones  and  from  the 
nasal  mucous  membrane  (Fig. 
503).  This  step  is  necessary  in 
order  that  the  edges  may  meet  in 
the  middle  line  (Berry).  One 
edge  of  the  cleft  uvula  is  now- 
grasped  with  a  pair  of  forceps  or 
a  sharp  hook,  and  is  pulled  upon 
to  make  it  tense.  This  edge  is 
then  pared  from  below  upward, 
the  piece  being  continuous  from 
the  base  to  the  apex  of  the 
cleft.  This  piece  is  severed,  and 
then  the  other  margin  of  the 
cleft  is  pared  in  the  same  way. 
It  is  now  advisable  to  free  the 
margins  of  the  wound  from  ten- 
sion. These  lateral  incisions  not 
only  relieve  tension,  but  tempor- 
arily paralyze  the  soft  palate. 
Figs.  503  and  504  show  the  in- 
cisions    as     recommended     by 

Berry.     These  incisions  divide   the   tendons  of  the  levator  palati  and  the 

palatopharyngeus  muscles,  and  temporarily  paralyze  the  palate.     The  impair- 


Fig.  502.— Longitudinal  vertical  section  through  the 
hard  and  soft  palates,  a.  Before  operation,  b.  Pal- 
atine mucoperiosteum  detached  and  brought  down. 
Blades  of  scissors  introduced  to  cut  attachment  of  soft 
palate  to  the  bony  palate  and  to  the  nasal  mucous  mem- 
brane, c.  The  same  after  the  cut  has  been  made  and 
the  soft  palate  thus  brought  down  (Berry). 


Fig.  503. — Cleft  of  soft  and  part  of  hard 
palate.  Shows  exact  situation  in  which  the  lat- 
eral incisions  should  be  made  (Berry). 


Fig.  504. — Semi-diagrammatic  view  of  complete 
left  cleft  palate.  The  septum  nasi  is  attached  to 
the  palate  on  the  (patient's)  right  side."  The  mu- 
cous membrane  on  the  left  side  of  the  septum  may 
be  detached  and  brought  down  if  necessary  to 
help  in  the  closure  of  the  anterior  half  of  the  cleft. 
Shows  exact  situation  in  which  the  lateral  incisions 
should  be  made  (Berry). 


Harelip  and  Cleft  Palate  917 

ment  of  palate  function  is  not  permanent,  as  the  nerves  to  the  muscles  are 
not  cut. 

The  sutures  are  inserted  by  means  of  a  special  needle-holder,  so  arranged 
that  the  needle  may  be  directed  in  many  different  positions  when  grasped. 
The  sutures  are  introduced  from  below  upward,  silkworm-gut  being  used 
for  the  uvula  and  the  lower  part  of  the  velum,  and  silver  wire  for  the  balance 
of  the  cleft.  Each  suture,  as  it  is  passed,  is  so  tied  or  twisted,  and  it  is  not 
cut  off  until  the  next  suture  is  inserted,  and  thus  serves  as  a  handle.  If  there 
is  too  much  tension  to  allow  of  the  sutures  being  tied  as  they  are  inserted,  all 
the  sutures  are  passed  and  lightly  twisted  before  one  is  tied. 

Closure  0}  Clefts  in  the  Hard  Palate  {Uranoplasty). — As  previously  stated, 
the  best  time  to  perform  these  operations  is  during  the  second  year  of  life. 
In  some  few  cases  we  postpone  the  operation  until  the  end  of  the  third  year. 
If  the  child  learns  to  talk  with  the  palate  cleft,  articulation  will  never  be  very 
greatly  improved,  even  by  operation.  One  should,  therefore,  try  to  operate 
before  the  child  learns  to  talk.  Even  after  the  closure  of  the  cleft  the  speech 
does  not  become  entirely  normal;  in  fact,  as  Berry  says,  it  never  becomes 
even  very  good.  One  should  exercise  the  greatest  care  in  forming  the  soft 
palate,  because  good  articulation  is  largely  dependent  upon  a  well-formed  soft 
palate  (Berry,  in  "  Brit.  Med.  Jour.,"  Oct.  7,  1905).  The  surgeon  may  be  able 
to  close  the  entire  gap  at  one  operation;  or,  owing  to  undue  tension,  he  may 
be  forced  to  close  it  but  partly,  completing  the  closure  at  some  subsequent 
period. 

The  operation  that,  to  my  mind,  is  the  best  is  one  that  uses  the  soft  tissues 
alone — such  a  one  as  is  advised  by  Berry.  I  have  entirely  abandoned 
the  operation  of  wedging  the  bone  over  with  a  chisel.  I  am  satisfied  that 
it  is  far  more  dangerous  than  is  the  other  method;  it  is  more  liable  to  fail; 
and,  if  it  fails  because  of  necrosis,  it  is  difficult  or  impossible  to  cure  the  defect 
by  a  second  operation.  The  essence  of  a  successful  operation,  using  the 
soft  tissues  alone,  is,  as  Berry  insists,  the  complete  detachment  of  the  soft 
palate  from  the  posterior  edge  of  the  palate-bone  (Fig.  502);  because,  if  one 
fails  to  secure  this,  the  edges  of  the  gap  will  not  approximate  in  the  median 
line.  One  should  also  separate  the  soft  palate  from  the  mucous  membrane 
of  the  nose  (Fig.  502). 

A  second  very  important  point  is  the  imperative  necessity  of  making  inci- 
sions to  the  sides,  to  relieve  tension,  and  to  paralyze  for  a  time  the  soft  palate. 
The  incisions,  as  recommended  by  Berry,  are  shown  in  Figs.  503  and  504. 
The  cut  is  close  to  the  teeth,  and  is  taken  as  far  posterior  as  the  middle 
of  the  soft  palate,  at  the  junction  of  that  structure  with  the  lateral  pharyn- 
geal wall.  In  this  cut  there  is  some  risk  of  dividing  the  anterior  palatine 
artery;  but  hemorrhage  from  this  vessel  can  be  arrested  by  pressure. 
Berry  insists  that  the  incision  need  not  go  forward  more  than  the  level  of  one 
or  two  premolar  teeth;  or,  in  older  children,  to  the  first  or  second  molars. 
The  edges  of  the  fissure  are  pared  on  each  side,  from  the  tip  of  the  uvula  to 
the  top  of  the  gap.  Strips  of  the  mucoperiosteum  are  lifted  up  on  each  side  of 
the  gap  and  shifted  toward  the  cleft,  and  at  this  stage  the  posterior  border  of 
the  soft  palate  is  separated  from  the  posterior  border  of  the  hard  palate 
(Fig.  502). 

The  parts  are  sutured  with  silver  wire,  following  the  advice  of  Edmund 


918  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

Owen  to  twist  and  cut  each  wire,  leaving  an  end  one-eighth  of  an  inch  in  length. 
This  procedure  causes  the  child  to  keep  his  tongue  from  the  suture  line. 

For  the  first  twenty-four  hours  only  water  is  given.  After  this  period 
the  patient  is  fed  with  jelly  and  liquids.  Only  fluid  or  soft  food  is  used  for 
two  or  three  weeks.  Talking  is  forbidden.  A  day  or  two  after  the  operation 
the  child  should  be  taken  into  the  open  air  and  kept  in  it  all  day.  As  Owen 
shows,  this  greatly  stimulates  vital  resistance  and  lessens,  to  a  considerable 
extent,  the  danger  of  sloughing  of  the  suture  line.  The  mouth  is  washed  fre- 
quently, and  always  after  taking  food,  with  Condy's  fluid.  The  sutures  are 
allowed  to  remain  between  two  and  three  weeks. 

Fergusson's  Operation. — In  this  operation  the  mucous  edges  are  pared, 
the  bones  are  drilled  for  wires,  and  the  sutures  are  inserted,  but  not  tied.  An 
incision  is  made  on  each  side  of  the  cleft  down  to  the  bone,  each  incision  being 
midway  between  the  cleft  and  the  corresponding  alveolus.  The  bone  is 
divided  on  each  side,  by  means  of  a  chisel,  to  the  full  length  of  the  incision; 
and  the  chisel  is  used  as  a  lever  to  force  each  half  of  the  bone  toward  the  gap. 
The  sutures  are  tied,  and  each  lateral  incision  is  plugged  with  iodoform  gauze, 

Brophy's  Operation. — This  operation  is  employed  particularly  for  children 
under  three  months  of  age,  and  cannot  be  used  when  the  child  is  over  six  months. 
In  this  operation  the  palate  is  closed  before  the  harelip  is  touched.  Operat- 
ing at  this  time,  the  bones  are  soft,  and  by  leaving  the  harelip  untouched 
the  surgeon  has  more  room  to  work.  The  author  of  the  operation  believes 
that  when  it  is  performed  at  this  early  age  the  palate-muscles  do  not  atrophy, 
but  develop,  and  that  the  patient  does  not  form  the  evil  habit  of  talking  through 
the  nose. 

In  performing  this  operation  the  very  strong-handled  needles  of  Brophy 
are  necessary.  The  patient  is  anesthetized  and  put  into  the  Trendelenburg 
position  and  a  strong  piece  of  silk  is  put  through  the  tip  of  the  tongue  as  a 
traction-suture.  The  edges  of  the  cleft  in  the  hard  palate  are  pared,  a  little 
of  the  bone  being  taken  away  with  the  paring.  Then  the  edges  of  the  cleft  in 
the  soft  palate  are  pared.  The  needle  is  threaded  with  strong  silk:  the  cheek 
is  lifted;  and  the  threaded  needle  is  forced  through  the  superior  maxillary 
bone  from  without  inward,  starting  just  back  of  the  malar  process  and  just 
above  the  palate.  As  the  needle  shows  in  the  cleft  the  thread  is  picked  up 
with  a  pair  of  forceps,  and  the  needle  is  pulled  out,  the  loop  of  thread  remain- 
ing in  the  cleft.  Through  a  part  of  the  opposite  superior  maxillary  cor- 
responding with  this  first  point  of  entrance  the  needle  is  entered  again  and 
another  loop  is  got  into  the  cleft.  The  second  loop  is  caught  into  the  first 
loop,  and  when  the  former  is  pulled  out,  it  carries  the  latter  with  it.  This 
thread  now  passes  through  both  the  superior  maxillary  bones  and  usually 
through  the  nasal  septum  as  well.  This  thread  is  used  to  pull  a  piece  of  strong 
silver  wire  through.  One  other  silver  wire  is  introduced  in  the  same  manner 
more  to  the  front.  The  silver  wire  ends  are  threaded  through  perforated  lead 
plates,  which  fit  the  external  outline  of  the  bones  on  each  side.  The  wires  are 
tightened  and  twisted.  For  instance,  on  one  side,  the  end  of  the  anterior 
wire  is  twisted  to  the  end  of  the  posterior  wire,  and  so  on.  The  thumbs  are 
used  to  jam  the  two  ends  of  the  maxillar}-  bones  forcibly  together,  thus  closing 
the  cleft,  and  then  the  wires  are  twisted  more  firmly  to  hold  the  edges  in  con- 
tact.    The  cleft  in  the  soft  palate  is  then  sutured,  although  the  surgeon  may 


Carcinoma  of  the  Lower  Lip  919 

deem  it  advisable  to  wait  one  day  before  doing  so.     After  the  palate  heals  the 
harelip  is  closed. 

Carcinoma  of  the  Lower  Lip. — Cancer  commonly  arises  in  the  lower 
hp,  very  rarely  in  the  upper  lip.  Males  suffer  frequently,  but  females 
are  not  very  often  attacked.  In  some  cases  it  seems  to  arise  in  smokers  at 
the  point  on  the  hp  where  the  pipe  habitually  rested.  A  short-stemmed  clay 
pipe,  which  grows  hot  when  it  is  smoked,  is  particularly  apt  to  lead  to  the 
growth  of  cancer.  The  region  of  the  lip  which  is  most  liable  to  cancer  is  the 
junction  of  the  skin  and  mucous  membrane.  The  growth  may  begin  in  a  fis- 
sure or  abrasion,  may  start  in  an  eczematous  area,  but  most  frequently  arises 
as  an  indurated  area  which  quickly  ulcerates.  After  a  cancer  has  existed  for 
a  variable  time  the  submental  and  submaxillary  lymphatic  glands  become  dis- 
eased. These  glands  are  always  involved  within  three  months  of  the  beginning 
of  the  cancer.  In  a  case  of  my  own  they  were  found  to  contain  carcinoma 
cells  in  less  than  three  months  after  the  origin  of  the  carcinoma  of  the  lip.  This 
involvement  cannot  be  detected  by  external  manipulation  in  the  earliest 
stages;  hence  it  is  not  proper  to  conclude  that  the  glandular  involvement 
is  absent  simply  because  it  cannot  be  palpated.  It  occasionally  happens 
that  glands  enlarge  because  of  septic  absorption,  and  this  enlargement  may 
even  precede  carcinomatous  involvement.  From  an  operative  point  of  view 
the  glands  should  always  be  regarded  as  carcinomatous.  If  cancer  is  not  oper- 
ated upon,  it  destroys  the  lip,  involves  the  glands  of  the  neck  extensively,  the 
floor  of  the  mouth,  the  periosteum  and  the  lower  jaw,  and  produces  death  in 
from  three  to  five  years.  If  the  jaw  is  involved,  the  prognosis  is  bad  and  it  is 
practically  hopeless  if  the  floor  of  the  mouth  is  involved. 

Treatment. — The  treatment  consists  in  the  early  and  thorough  removal  of 
the  growth  with  the  knife,  and  also  in  the  removal  of  the  fatty  tissue  and  gland 
from  the  submaxillary  triangles  and  from  the  submental  region.  The  growth 
must  be  thoroughly  removed — that  is,  the  incision  must  be  at  least  half  an  inch 
wide  of  the  disease.  For  many  years  a  favorite  operation  has  been  the  V- 
shaped  incision,  the  skin-edges  being  sutured  by  silkworm-gut,  the  sutures  be- 
ing passed  almost  to  the  mucous  membrane  and  being  inserted  so  as  to  com- 
press the  vessels  when  tied,  and  the  mucous  membrane  being  sutured  with  fine 
silk  or  catgut.  The  V-shaped  incision  should  be  used  only  for  a  very  small  and 
very  recent  growth.  After  the  removal  of  the  growth  from  the  lip  a  vertical  in- 
cision is  made  from  the  point  of  the  V  over  the  cricoid  cartilage,  and  from  the 
origin  of 'this  incision  incisions  are  made  in  each  direction  along  the  under  surface 
of  the  body  of  the  jaw.  The  glandular  area  is  thus  exposed,  and  after  the  re- 
moval of  the  fat  and  glands  the  wound  is  sutured  with  silkworm-gut.  Far  better 
than  the  V-shaped  incision  is  the  operation  devised  by  W.  W.  Grant,  of  Den- 
ver.*    In  this  operation  the  growth  is  removed  and  cheiloplasty  is  performed. 

GranVs  Operation  for  Cancer  0}  the  Lip. — This  operation  gives  a  useful 
mouth  and  a  more  natural-looking  lip  than  does  the  ordinary  operation,  and 
there  is  decidedly  less  tension  on  the  suture-line.  Furthermore,  the  suture- 
line  in  a  man  is  soon  covered  with  a  beard.  The  procedure  has  great  advan- 
tages over  the  ordinary  V-shaped  operation,  which  greatly  lessens  the  size 
of  the  mouth,  making  it  what  is  known  as  a  sucker-mouth;  and  the  new  Up 
is  rigid  and  ugly. 

*  Medical  Record,  May  27,  1899. 


920 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


In  Grant's  operation  two  vertical  incisions  are  made,  one  on  each  side  of 
the  growth,  and  these  are  connected  with  a  horizontal  incision  at  the  base 
(Figs.  505  and  506).  Thus,  a  quadrangular  gap  is  formed,  which  must  be 
filled  by  flaps.  An  incision  is  made  on  each  side  from  each  inferior  angle  of 
the  wound,  obliquely  downward  and  backward  beneath  the  maxilla,  on  a  line 
about  midway  between  the  angle  of  that  line  and  the  apex  of  the  chin  (Fig.  505 1. 
Its  further  extension  is  determined  by  the  amount  of  lip  removed  and  by  the 
degree  of  glandular  involvement. 


Fig.  505. — Grant's  method  for   removal  of  car- 
cinoma of  the  lower  lip.     The  incision. 


Fig.  506. — Grant's  method  for  removal  of  car- 
cinoma of  the  lower  lip.  Second  step.  The  mass 
removed. 


Fig.  507.— Grant's  method  for  removal  of 
carcinoma  of  the  lower  lip.  Dissection  pre- 
liminary to  suturing. 


Fig.  508. — Grant's  method  for  removal  of 
carcinoma  of  the  lower  lip.  The  wound  su- 
tured. 


The  submaxillary  lymph-glands  are  removed  through  these  incisions. 
The  glands  in  the  midline,  however,  beneath  the  chin  may  require  a  separate 
incision.  If  the  lip  is  extensively  involved,  the  cheek  ought  to  be  completely 
separated  from  the  inferior  maxillary  bone  to  the  middle  of  the  masseter  mus- 
cle (Fig.  507).     When  the  glands  have  been  removed,  the  triangular  flaps  are 


Ranula  921 

brought  together  and  united,  first  of  all,  in  the  middle  line  (Fig.  508).  If  the 
tension  is  marked,  owing  to  the  amount  of  tissue  excised,  it  is  wise  to  insert 
a  traction  suture,  three-quarters  of  an  inch  from  the  center  line,  and  tie  it 
over  pads  of  gauze  covered  with  muslin.  One  thus  prevents  undue  tension 
upon  the  sutures  in  the  center  of  the  flap.  The  stitches  that  unite  the  cheek 
posteriorly  are  inserted  and  tied,  and  the  entire  thickness  of  the  cheek  must 
be  included.  Silkworm-gut  sutures  are  used.  A  drainage-tube  is  inserted 
in  the  posterior  angle  of  the  wound  on  each  side.  It  is  very  useful  to  use  also 
a  T-drainage-tube  as  advised  by  Grant.  This  tube  is  about  the  diameter  of  a 
lead  pencil  and  the  cross-piece  rests  behind  the  incisor  teeth  or  symphysis  and 
beneath  the  tip  of  the  tongue.  This  tube  drains  away  all  of  the  mouth  secre- 
tions, saves  the  lines  of  incision  from  being  constantly  bathed  in  them,  and 
renders  very  frequent  changes  of  dressing  unnecessary. 

I  have  employed  this  operation  repeatedly,  and  regard  it  as  the  most  use- 
ful method  we  have  for  the  purpose.  Thorough  removal  of  the  carcinoma 
of  the  lip  and  of  the  related  glands  will  cure  from  60  to  70  per  cent,  of  cases. 

Carbuncle  of  the  Upper  Lip. — Ixi  contrast  to  carbuncle  in  other  regions 
of  the  body,  facial  and  lingual  carbuncle  is  most  common  in  young  persons. 
The  condition  is  due  to  staphylococcus  infection  and  begins  as  a  papule. 
Numerous  pustules  appear,  and  sloughing  usually  takes  place.  There  may 
or  may  not  be  serious  constitutional  involvement.  The  condition  is  very 
dangerous,  as  thrombophlebitis  may  arise  and  track  up  into  the  cranium.  I 
have  known  two  persons  to  die  from  carbuncle  of  the  lip. 

Treatment. — Make  a  crucial  incision,  cutting  away  the  corners  and  edges 
with  scissors.  Scrape  out  the  carbuncle  with  a  sharp  and  strong  curet,  swab 
with  pure  carbolic  acid,  pack  with  iodoform  gauze,  and  dress  with  antiseptic 
poultices. 

Tongue-tie  {congenital  ankyloglossia  or  adherent  tongne)  is  a  congenital 
shortness  of  the  frenum,  the  tip  of  the  tongue  adhering  to  the  floor  of  the 
mouth.  It  is  due  to  the  projecting  portion  of  the  tongue  being  incompletely 
developed  from  the  tuberculum  impar.  "In  many  of  the  slighter  cases  the 
development  has  merely  lagged  behind,  and  will  be  completed  as  the  child 
grows  after  birth"  ("Diseases  of  the  Tongue"  by  Henry  T.  Butlin.  Second 
edition).  The  tongue  cannot  be  protruded  beyond  the  incisor  teeth.  Swal- 
lowing is  interfered  with,  and  later  in  life  articulation  is  impeded.  It  is  not 
very  unusual  in  infants,  but  in  the  great  majority  of  cases  disappears  as  the 
child  grows  older.  Persisting  tongue-tie,  Butlin  says,  is  one  of  the  rarest 
of  conditions,  and  my  experience  is  in  absolute  accord  with  this — in  fact,  I 
have  never  seen  a  single  case.  Many  unnecessary  or  even  harmful  operations 
are  done  for  a  condition  which,  if  let  alone,  will  usually  correct  itself.  Im- 
proper operation  may  result  in  fatal  hemorrhage  or  in  "swallowing  of  the 
tongue."  The  operation  usually  done  is  to  tear  up  the  frenum  with  a  thumb- 
nail. This  is  unsurgical  and  makes  a  lacerated  wound.  A  better  way  is  to 
raise  the  tip  of  the  tongue  to  make  the  bands  tense,  and  then  snip  with  the 
scissors  close  to  the  mucous  membrane  of  the  lower  jaw.  The  slit  in  the 
handle  of  the  grooved  director  was  placed  there  to  catch  the  frenum  in,  but  a 
short  frenum  will  not  enter  it  (Butlin). 

Ranula  is  a  retention-cyst  of  the  duct  of  the  submaxillary  or  the  duct  of 
the  sublingual  gland.     A  ranula  when  first  formed  contains  saliva,  but  after  a 


022 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


Fit. 


-Ranula. 


time  the  saliva  undergoes  a  change,  and  in  appearance  comes  to  resemble 
mucus.  Mucous  cysts  occur  in  the  floor  of  the  mouth,  resulting  from  obstruc- 
tion of  the  ducts  of  the  mucous  glands  of  Nuhn  and  Blandin.  These  glands 
lie  on  each  side  of  the  frenum  of  the  tongue.     Such  a  cyst  is  often  spoken  of  as 

a  ranula.  A  cyst  of  the  incisive  gland 
forms  just  back  of  the  lower  jaw 
and  lifts  up  the  frenum.  A  true 
ranula  appears  upon  the  floor  of  the 
mouth  on  one  side  and  pushes  the 
tongue  toward  the  opposite  side. 
The  treatment  of  a  mucous  cyst  is 
by  excision  of  a  portion  of  the  cyst- 
vfdAl  and  cauterization  of  the  interior 
with  pure  carbolic  acid;  or  by  cut- 
ting a  flap  from  the  cyst-wall  and 
stitching  it  aside  so  as  to  keep  a  per- 
manent opening.  Such  an  operation 
may  cure  a  genuine  ranula,  but  will 
often  fail.  In  true  ranula  an  exter- 
nal incision  should  be  made,  and 
through  this  both  the  cyst  and  the  gland  should  be  removed.  This  plan  is 
recommended  by  Mintz.* 

Thyrolingual  or  Thyroglossal  Cysts  and  Sinuses. — In  early  embryonal 
life  the  thyroid  gland  has  a  duct  which  passes  from  the  thyroid  isthmus  to 
the  foramen  caecum  of  the  dorsum  of  the  tongue.  The  duct  may  be  lined  vdth 
one  layer,  two  layers,  or  several  layers  of  epithelium,  and  there  are  mucous 
glands  and  lymph-follicles  in  its  walls,  these  structures  being  derived  from 
the  mucous  membrane  of  the  tongue.  The  wall  of  the  duct  presents  numerous 
irregularly  placed  and  irregularly  shaped  diverticula.  It  is  known  as  the  thyro- 
glossal or  thyrolingual  duct.  The  duct  runs  from  the  base  of  the  tongue  down 
the  mid-line  of  the  neck.  It  is  connected  with  the  body  of  the  hyoid  bone,  with 
the  periosteum  in  front  of  the  bone,  and  with  the  thyrohyoid  bursa  behind  the 
bone.  It  passes  to  the  upper  portion  of  the  front  surface  of  the  trachea,  where  it 
bifurcates,  each  branch  passing  to  a  lateral  lobe  of  the  thyroid  gland.  This  fetal 
structure  under  normal  conditions  begins  to  atrophy  in  the  fifth  week  and  closes 
by  the  eighth  week,  the  foramen  cecum  marking  its  old  orifice  on  the  dorsum  of 
the  tongue.  When  the  duct  is  obliterated,  it  becomes  a  cord  of  epithelium.  In 
more  than  30  per  cent,  of  bodies  the  remains  of  this  primitive  passage  can  be 
found  (Weglowski,  in  "Zentralb.  f.  Chir.,"  1908,  xxxv,  289).  The  duct 
may  persist  between  the  foramen  cecum  and  the  hyoid  bone,  developing, 
it  may  be,  into  a  sublingual  dermoid.  The  portion  behind  and  below  the 
hyoid  may  remain  and  develop  into  a  subhyoid  cyst.  The  part  inferior  to  the 
hyoid  may  persist,  give  origin  to  a  cyst  which  ruptures  and  constitutes  an  in- 
complete median  cervical  fistida.  The  duct  may  remain  open  from  the  mouth 
and  make,  by  bursting  an  opening  in  the  neck,  a  complete  median  cervical  fistula. 
A  patent  duct  may  exist  for  years  and  announce  its  existence  by  some  acute 
inflammatory  process.  .  The  small  diameter  of  a  cervical  fistula  renders  prob- 
ing to  any  depth  impossible.  Some  have  told  us  to  determine  if  a  fistula  is 
*  Zeitschrift  fiir  Chirurgie,  March,  1899. 


Carcinoma  of  the  Tongue  923 

complete  by  injecting  quassia  solution  into  the  lower  end.  The  patient  will 
perhaps  experience  a  bitter  taste.  If  we  inject  a  colored  fluid  we  may  see  it  if 
it  runs  from  the  mouth.  I  have  never  succeeded  in  doing  either.  Tumors 
may  spring  from  the  duct. 

Treatment. — If  a  thyroglossal  cyst  or  tumor  arises  on  the  dorsum  of  the 
tongue  and  if  it  is  increasing  in  size  and  interferes  with  swallowing  and  speech, 
it  must  be  removed  through  the  mouth.  A  general  anesthetic  should  be  given. 
In  some  cases  preliminary  tracheotomy  is  necessary. 

A  cyst,  tumor,  or  fistula  about  the  hyoid  bone  requires  excision,  the  patient 
being  under  the  influence  of  a  general  anesthetic.  A  portion  of  the  cyst- wall 
adheres  strongly  to  the  posterior  surface  of  the  hyoid  bone  and  must  be  care- 
fully removed  even  if  it  is  necessary  to  split  the  bone  to  accomplish  it.  In 
treating  fistula  the  surgeon  makes  an  elliptical  incision  of  the  skin  about  its 
orifice  so  as  to  free  the  fistula  from  the  subcutaneous  tissue.  When  traction 
is  made  upon  the  cutaneous  end  of  the  duct  it  wifl  stand  out  clearly  and  can  be 
dissected  out  (M.  S.  Seehg,  in  "Surg.,  Gynecol.,  and  Obstet.,"  May,  1907). 
It  is  useless  to  try  to  cure  a  fistula  by  cauterization.  A  fistula  requires  the 
complete  removal  of  its  epithehal-hned  walls.  No  lesser  operation  will  cure. 
In  one  case  I  operated  four  times  before  securing  success.  In  a  recent  case 
I  divided  the  bone,  removed  the  fistula,  and  sutured  the  bone  with  chromic  gut. 

Carcinoma  of  the  Tongue. — This  is  one  of  the  most  dreadful  forms 
of  cancer.  It  is  quite  a  common  disease.  In  most  of  the  cases  I  see  it  is  far 
advanced  when  first  brought  to  the  surgeon.  The  only  form  of  cancer  which 
attacks  the  tongue  is  epitheHoma.  It  is  much  more  common  in  men  than  in 
women.  It  is  a  disease  of  adult  Hfe  and  is  very  rare  before  the  age  of  thirty- 
five.  It  begins,  as  a  rule,  near  the  tip,  on  the  side  or  at  the  base  of  the 
anterior  two-thirds  of  the  tongue,  as  a  warty  growth,  as  an  ulcer  having 
at  first  a  papillary  structure,  as  a  fissure  which  indurates,  or  as  an  indurated 
area  which  ulcerates.  The  cause  of  the  growth  may  sometimes  be  traced  to  the 
irritation  of  a  jagged  tooth,  or  to  the  smoking  of  a  pipe,  or  to  holding  nails  in 
the  mouth,  as  is  done  by  those  who  nail  laths.  Cancer  may  follow  a  chronic 
inflammation — leukoplakia,  for  instance.  Chronic  ulcers  are  liable  to  become 
cancerous  and  any  indurated  ulcer  has  potentialities  of  peril  and  should  be' 
promptly  removed.  Fournier  regards  syphilis  as  an  influential  cause  and  states 
that  in  184  cases  of  cancer  of  the  mouth  or  tongue  155  had  had  syphilis.  There 
has  been  no  such  proportion  of  syphilitics  in  my  personal  cases.  In  White- 
head's 104  cases  only  7  had  had  syphiHs.  As  in  cancer  of  the  lip,  men  are 
much  more  frequently  affected  than  women.  In  most  cases  the  disease 
spreads  rapidly;  produces  early  and  extensive  glandular  involvement;  disease 
of  the  floor  of  the  mouth;  dribbUng  of  saliva;  difficulty  in  masticating,  swallow- 
ing, and  talking,  foulness  of  the  breath;  severe  pain  which  usually  radiates  to- 
ward the  ear,  and  often  a  fatal  septic  trouble.  Cases  not  operated  upon  usually 
die  within  two  years.  There  is  a  very  rare  form  of  carcinoma  described  by 
Wolfler,  which  grows  very  slowly  or  even  remains  latent  for  years. 

One  reason  why  cancer  of  the  tongue  grows  so  rapidly  has  been  pointed  out 
by  Heidenhain,  of  Greifswald.  The  Hngual  muscles  are  contracting  almost 
constantly,  and  as  a  result  cancer-cells  are  forced  along  the  lymph-spaces  to 
healthy  areas. 

Treatment. — A  cancer  of  the  tongue  should  be  removed  radically  at  the 


924  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

earliest  possible  moment.  Specific  treatment  for  diagnostic  purposes  should 
not  be  continued  beyond  a  very  few  weeks.  If  in  doubt  as  to  the  nature  of  the 
growth,  remove  it  and  have  a  pathologist  at  hand  to  immediately  study  it 
by  frozen  sections  (Warren,  in  "Annals  of  Surgery,"  Oct.,  1908).  Have 
permission  beforehand  to  proceed  at  once  to  radical  operation  if  conditions 
demand  it.  The  study  of  a  small  piece  is  always  of  uncertain  value,  hence, 
take  out  the  growth.  Whatever  it  is,  it  should  be  removed.  Before  any 
operation  is  undertaken  all  stumps  of  teeth  should  be  extracted,  and  a  dentist 
should  clean  tartar  from  the  teeth.  During  several  days  preceding  an  opera- 
tion the  teeth  should  be  scrubbed  twice  a  day  with  a  brush  and  soap  and  the 
mouth  rinsed  with  hydrogen  peroxid.  The  nares  and  nasopharynx  should 
be  sprayed  with  peroxid  of  hydrogen  and  then  with  boric  acid  solution  every 
second  or  third  hour  when  the  patient  is  awake. 

In  this  disease  not  only  the  tongue  but  also  the  adjacent  lymphatic  glands 
must  be  removed.  Cancer  of  the  tip  of  the  tongue,  as  a  rule,  first  involves  the 
submental  and  sublingual  group  of  glands.  Cancer  of  the  anterior  two-thirds 
of  the  dorsum  of  the  tongue  first  involves  the  lingual  and  submaxillary  lymph- 
nodes.  Cancer  of  the  under  surface  of  the  tip  of  the  tongue  first  involves 
the  submaxillary  glands.  Sooner  or  later  the  superior  deep  cervical  glands 
about  the  carotid  bifurcation  become  involved  in  cancer  of  the  tip  or  edges  of 
the  anterior  portion  of  the  tongue.  In  cancer  of  the  dorsum  the  deep  cervical 
glands  become  involved  as  well  as  the  superficial  nodes.  The  lymphatic 
system  of  the  base  of  the  tongue  is  distinct  from  that  of  the  balance  of  the  organ. 
It  drains  into  the  deep  cervical  groups. 

It  was  my  belief  until  recently  that  in  a  very  recent  and  limited  case  only 
the  glands  on  the  diseased  side  require  removal,  but  that  in  an  advanced 
case  the  glands  must  be  removed  from  both  sides  of  the  neck.  Experience 
has  convinced  me  that  in  any  case  the  glands  on  both  sides  should  be  re- 
moved. Kuttner,  of  Tubingen,  has  demonstrated  that  lymph  from  one 
side  of  the  tongue  may  flow  to  glands  on  the  same  side  of  the  neck,  but  some 
also  may  flow  to  the  opposite  side  of  the  tongue.  Remove  the  obviously 
involved  glands  by  the  ''^ block  dissection"  of  Crile.  In  a  bad  case  everything 
is  removed  but  the  carotid  arteries.  The  sternocleidomastoid  muscle,  the 
omohyoid,  the  jugular  vein,  even  the  pneumogastric  and  phrenic  nerves  of  one 
side  may  be  taken  away.  After  a  week  or  two  the  other  side  of  the  neck  should 
be  operated  upon.  It  seldom  requires  a  wide  removal  of  structures.  If  the 
pneumogastric  or  phrenic  were  cut  on  one  side  they  must  be  preserved  on  the 
other.  The  jugular  can  be  removed  after  a  collateral  circulation  has  been  es- 
tablished subsequent  to  removing  the  jugular  of  one  side.  Two  operations 
are  to  be  considered:  partial  removal  and  complete  removal. 

Partial  Removal  oj  the  Tongue. — This  operation  is  restricted  to  recent  cases 
in  which  one  side  only  of  the  anterior  portion  of  the  tongue  is  involved.  The 
operation  does  not  offer  as  good  a  chance  of  cure  as  complete  excision,  because 
lymph  containing  cancer-cells  may  have  reached  the  opposite  side  of  the 
tongue.  Even  in  partial  removal  the  glands  should  be  removed  from  both 
sides. 

In  performing  the  operation  of  partial  excision  introduce  a  mouth-gag, 
place  a  silk  ligature  on  each  half  of  the  tip  of  the  tongue,  and  draw  the  tongue 
out  of  the  mouth  (Barker).     Place  the  patient  in  the  Trendelenburg  position. 


Carcinoma  of  the  Tongue 


925 


Split  the  tongue  back  in  the  middle  line  with  the  scissors,  and  loosen  the  can- 
cerous side  from  the  floor  and  side  of  the  mouth.  Pass  a  stout  silk  ligature 
through  the  base  of  the  tongue  posterior  to  the  cancer.  Draw  the  organ  out 
and  cut  off  the  diseased  side  in  front  of  the  ligature  but  back  of  the  disease. 
Tie  the  vessels,  remove  the  constricting  and  traction  threads,  and  treat  sub- 
sequently as  in  cases  of  complete  removal. 

Complete  Removal  0}  the  Tongue  (Kocher's  Method). — Kocher  recom- 
mends a  preliminary  tracheotomy  in  tongue-excision,  but  the  Trendelenburg 
position  renders  this  procedure  unnecessary  so  far  as  fear  of  the  passage  of 
blood  into  the  larynx  and  trachea  is  concerned.  The  instruments  required  are 
a  scalpel,  retractors,  a  dry  dissector,  hemostatic  and  dissecting  forceps,  a  tenac- 
ulum, aneurysm-needle,  tenaculum  forceps,  needles,  sutures,  and  scissors.  In 
this  operation  the  patient  is  placed  in  the  Trendelenburg  position,  the  surgeon 
standing  to  the  side.  Ether  or  chloroform  is  given.  Ligate  the  hngual 
artery  on  the  side  opposite  to  the  one  where  the  main  incision  is  to  be  made. 
Remove  the  glands  on  that  side  and  suture  the  wound.  An  incision  is  then 
made  on  the  side  opposite  to  that  on  which  the  artery  was  ligated.  This  in- 
cision passes  from  behind  the  lobe  of  the  ear,  along  the  anterior  edge  of  the 
sternocleidomastoid  to  about  the  middle  of  the  margin  of  this  muscle.  From 
this  point  the  incision  is  carried  to  the  level  of  the  hyoid  bone  and  then  to  the 
symphysis  menti,  along  the  anterior  belly  of  the  digastric  muscle  (Fig.  510). 
The  flap  is  dissected  and  turned  up;  the  facial  and  lingual  arteries  are  ligated; 
"the  submaxillary  fossa  is  evacuated"  (Treves);  the  sublingual  and  sub- 
maxillary glands  are  removed;  the  mylo- 
hyoid muscle  is  divided;  the  mucous  mem- 
brane is  incised  close  to  the  jaw,  and  the 
tongue,  caught  with  tenaculum-forceps,  is 
drawn  through  the  opening.  The  tongue  is 
split  in  the  middle  with  scissors,  and  the  near 
half  is  removed,  bleeding  is  arrested,  the  re- 
maining half  of  the  tongue  is  cut  through,  and 
the  vessels  are  tied.  Stitch  the  mucous  mem- 
brane of  the  stump  to  the  mucous  membrane 
of  the  floor  of  the  mouth  with  catgut  sutures. 
Kocher  does  not  suture  the  skin-wound; 
many  surgeons  do  suture  it  and  employ 
drainage-tubes.     I  follow  the  suggestions  of 

Treves  as  to  after-treatment.  Some  hours  after  the  operation,  when  oozing 
has  ceased,  dust  the  mouth-wound  with  iodoform.  The  patient,  as  soon  as 
possible,  is  propped  up  in  bed,  and  he  must  not  swallow  the  discharges  if 
it  can  be  avoided.  The  mouth,  every  half  hour,  is  sprayed  with  peroxid  of 
hydrogen  and  washed  with  a  carbolic  solution  (i  :  60).  Every  three  hours 
after  washing  the  floor  of  the  mouth  and  the  stump  the  parts  should  be  dried 
with  absorbent  cotton  and  dusted  with  iodoform.  For  twenty-four  hours  after 
the  operation  nothing  is  given  by  the  mouth  except  a  little  cracked  ice,  the 
patient  being  fed  per  rectum.  At  the  end  of  twenty-four  or  forty-eight  hours 
some  liquid  food  is  given  from  a  feeding-cup.  The  patient  will  soon  learn  to 
swallow ;  but  if  he  cannot  swallow  easily,  he  is  fed  with  a  tube.  Treves,  in  his 
clear  and  positive  directions  for  after-treatment,  states  that  nutrient  enemata 


510.— Kocher's  excision  of  tongue 
(Esmarch  and  Kowalzig). 


926  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

are  to  be  continued  until  sufficient  nourishment  is  taken  by  the  mouth;  that 
the  mouth  should  be  flushed  by  irrigation,  and  must  be  washed  immediately 
after  taking  food;  that  morphin  is  to  be  avoided;  and  that  the  patient  can 
usually  leave  the  hospital  in  from  seven  to  ten  days. 

Whitehead's  Operation. — Whitehead  removes  the  entire  tongue  from  within 
the  mouth  by  the  use  of  scissors.  He  passes  a  Hgature  through  the  tip,  cuts  the 
frenum,  draws  the  tongue  strongly  forward,  and  separates  by  a  series  of  clips 
with  the  scissors.  The  lingual  arteries  are  tied  as  cut.  "  The  stump  should  be 
kept  under  control,  as  regards  hemorrhage,  by  a  stout  silk  ligature  passed 
through  the  remains  of  the  glosso-epiglottidean  fold  and  retained  for  twenty- 
four  hours.  "* 

Heath  has  shown  that  if  the  forefinger  be  passed  to  the  epiglottis  and  used 
to  "hook  forward"  the  hyoid  bone,  the  lingual  arteries  are  stretched  and 
portions  of  the  tongue  can  be  removed  almost  without  bleeding.  It  is  rarely 
desirable  in  Whitehead's  operation  to  remove  the  glands  and  the  tongue 
at  one  seance.  To  do  so  increases  shock  and  the  danger  of  death.  The  rule  of 
procedure  set  forth  by  W.  Watson  Cheyne  f  is  eminently  wise.  This  rule  is  as 
follows:  If  glandular  involvement  is  trivial  or  not  detectable,  it  is  perfectly 
proper  to  remove  the  tongue  first,  and  after  a  week  or  so  remove  the  glands. 
If  the  glandular  involvement  is  marked,  growth  in  the  glands  will  be  much  more 
rapid  than  growth  in  the  tongue.  In  such  a  case  the  glands  should  be  removed 
before  the  tongue,  because,  if  the  tongue  is  removed  before  the  triangles  are 
cleared,  in  the  week  or  two  of  waiting  the  case  may  become  inoperable.  In  the 
majority  of  cases  clear  out  the  triangle  before  removing  the  tongue,  doing  the 
other  operation  in  one  or  two  weeks  when  the  wound  in  the  neck  is  healed.  If 
the  disease  in  the  mouth  is  far  advanced,  do  both  operations  at  one  seance. 

Stricture  of  the  Esophagus. — Fibrous  or  cicatricial  stricture  is  due  to  the 
healing  of  an  ulcer,  and  results  from  traumatism,  chronic  inflammation, 
syphilis,  tuberculosis,  chronic  ulcer,  prolonged  vomiting,  variola,  gout,  or  to 
swallowing  a  corrosive  substance  or  a  boihng  liquid.  It  is  commonest  in  the 
young,  and  is  apt  to  be  situated  opposite  the  cricoid  cartilage,  at  the  tracheal 
bifurcation  or  near  the  cardiac  end.  Cicatricial  strictures  are  usually  single, 
but  may  be  multiple.  Stricture  following  impaction  of  a  foreign  body  is 
located  at  the  seat  of  impaction  unless  the  tube  has  been  injured  by  efforts  at 
extraction,  in  which  case  multiple  strictures  may  exist  (Maylard).  Strictures 
which  result  from  swallowing  boiling  fluid  or  corrosive  liquid  are  usually  very 
extensive,  and  may  be  multiple.  Syphihtic  stenosis  is  due  to  the  healing  of  a 
gummatous  ulceration,  but  there  is  nothing  characteristic  in  this  kind  of 
stenosis.     Tuberculous  stenosis  is  extremely  rare. 

Symptoms  of  Cicatricial  Stenosis. — The  condition  may  occur  at  any  age. 
The  chief  symptom  is  difficulty  in  swallowing,  at  first  shght,  but  becoming 
more  and  more  pronounced  until  swallowing  is  almost  or  quite  impossible. 
The  dysphagia  is  first  manifested  to  dry  solids,  then  to  all  sohds,  and  finally 
to  liquids.  In  some  cases  vomiting  occurs  after  swallowing.  If  the  stricture 
is  high  up,  the  vomiting  is  almost  immediate;  if  it  is  low  down,  the  vomiting  is 
delayed,  especially  if  the  canal  is  dilated  above  the  stricture.  From  time  to 
time  the  patient  vomits  independently  of  taking  food,  the  ejected  matter  being 
sahva.     The  vomited  matter  is  not  bloody.     The  patient  feels  weak  and 

*  "American  Text-book  of  Surgery."  f  The  Practitioner,  April,  1899. 


Stricture  of  the  Esophagus  927 

hungry,  becomes  exhausted  and  emaciated,  and  suffers  from  flatulence,  gas- 
tralgia,  and  constipation. 

There  is  occasionally  slight  uneasiness  or  even  pain  in  the  region  of  the 
stricture,  possibly  "about  the  epigastrium  or  between  the  shoulder-blades" 
(Maylard).  The  stricture  may  be  located  with  a  bougie  and  by  auscultation 
over  the  spine  on  a  line  with  the  supposed  obstruction.  While  a  patient 
is  swallowing  water,  the  arrest  of  the  fluid  at  the  seat  of  stricture  may  be 
audible.  Even  if  the  fluid  passes,  it  will  be  delayed  for  a  time  and  the  dura- 
tion of  deglutition  is  thus  prolonged.  In  order  to  determine  the  time  of 
deglutition  put  the  ear  just  below  the  angle  of  the  left  scapula,  put  a  finger 
on  the  patient's  Adam's  apple,  and  hold  a  watch  in  the  other  hand.  Have 
the  patient  take  a  drink  of  water.  Count  the  time  from  the  moment  the 
Adam's  apple  begins  to  rise  until  the  fluid  is  heard  to  gurgle  into  the  stomach 
(Ogston's  method).  It  ordinarily  requires  four  seconds  for  food  to  pass 
from  the  mouth  into  the  stomach  (Maylard) .  If  food  is  retained  for  some  time 
before  it  is  ejected  we  may  be  able  to  locate  the  seat  of  obstruction  by  the  x-rays. 
An  emulsion  of  bismuth  is  swallowed  and  a  skiagraph  is  taken.  The  bismuth 
is  seen  on  the  plate  as  a  black  mass  extending  above  the  seat  of  constriction. 
The  bougie  can  be  passed  until  it  reaches  the  block  and  a  skiagraph  may  be 
taken  with  the  bougie  in  position. 

In  a  case  reported  by  SeeHg  ("Surgery,  Gynecology,  and  Obstetrics," 
Sept.,  1908)  the  patient  was  directed  to  swallow  a  fine  gold  chain  as  thick 
as  ordinary  wrapping  twine.  The  chain  was  about  two  feet  long.  If  a 
diverticulum  exists  the  chain  will  fill  the  sac  and  a  skiagraph  will  show  the 
position  of  the  diverticulum.  If  no  diverticulum  exists  the  plate  will  show  the 
chain  nearly  in  the  middle  line  of  the  body. 

The  history  of  the  case  is  of  much  importance  in  diagnosis.  The  surgeon 
must  inquire  about  impaction  of  a  foreign  body,  or  swallowing  of  acids, 
alkahes,  or  boiling  fluids;  and  must  examine  for  evidence  of  syphiHs.  If 
there  is  no  history  of  injury,  syphilis,  tuberculosis,  variola,  or  prolonged  vomit- 
ing, and  the  patient  is  over  forty  years  of  age,  the  indications  point  to  cancer 
rather  than  cicatricial  stenosis.  The  easy  passage  of  a  bougie  when  the 
patient  is  anesthetized  shows  that  spasm  is  the  cause,  and  not  organic  disease. 
Narrowing  due  to  external  pressure  is  marked  by  positive  symptoms  of  the 
causative  disease.* 

Treatment. — Thiosinamin  is  given  by  some  physicians,  but  I  have  never 
seen  it  accompHsh  the  shghtest  good.  Tellekyf  recommends  it  in  old  scars 
without  inflammation.  He  makes  a  15  per  cent.  alcohoHc  solution  and  injects 
from  one-half  to  one  syringeful  at  a  dose,  throwing  the  fluid  beneath  the  skin 
between  the  scapulae.  He  uses  twenty  doses  in  the  course  of  two  weeks. 
Gradual  dilatation  through  the  mouth  is  a  method  employed  for  at  least  a 
time  in  almost  every  case.  It  is  the  method  of  choice  when  it  can  be  carried 
out,  and  usually  it  can  be  carried  out.  Begin  with  the  largest  bougie  which 
will  easily  pass.  Warm  the  bougie,  oil  it,  pass  it  gently,  and  hold  it  in  position 
for  several  minutes,  prolonging  the  time  of  retention  of  the  bougie  as  treat- 
ment progresses.     Pass  an  instrument  every  second  or  third  day,  gradually 

*  See  the  excellent  article  in  Maylard's  "  Surgery  of  the  Alimentary  Canal." 
fWien.  klin.  Woch.,  Feb.  20,  1902. 


928 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


increasing  the  size.     If  the  stenosis  involves  a  considerable  portion  of  the 
esophagus,  gradual  dilatation  will  almost  certainly  fail  to  cure. 

Symonds  advocates  the  inserdon  of  a  tube  through  the  stricture  and 
leaving  it  in  place  until  there  is  decided  dilatation,  and  then  replacing  the 
tube  with  a  larger  instrument.  The  patient  is  fed  through  the  tube.  Gradual 
dilatation  from  below  has  been  pracdsed  in    cases  where  a  bougie  could 


Fig.  511. ■ — Esophageal  instruments:    a,   b,  Forceps;    c,   horsehair  probang;    d,   coin-catcher; 

E,  esophageal  bougie. 

not  be  passed  from  the  mouth.  A  gastrostomy  is  performed,  and  after  the 
fistula  has  become  sound  the  patient  is  made  to  swallow  "a  shot  to  which 
is  attached  a  silk  thread  "  (May lard).  The  silk  thread  is  brought  out  through 
the  fistulous  orifice  and  is  attached  to  a  bougie,  and  the  dilating  instrument 
is  pulled  up  through  the  esophagus.  Forcible  dilatation  can  be  employed 
through  the  mouth  or  through  a  gastrotomy  opening,  by  means  of  bougies, 
tents,  or  divulsing  instruments.  Electrolysis  is  used  by  Fort  and  others. 
Some  surgeons  perform  internal  esophagotomy  through  the  mouth  with  a 
special  instrument.  A  fibrous  stenosis  in  the  region  of  the  cricoid  cartilage 
which  is  not  cured  by  gradual  dilatation  should  be  treated  by  the  operation 
of  external  esophagotomy.  In  this  operation  the  stricture  is  divided  by  a 
longitudinal  incision;  "funnel-shaped  retraction  of  the  cut  portion  is  caused 
by  adhesion  to  the  external  tissues  divided,  and  it  lessens  future  contraction.  "* 
If  dilatation  fails  in  the  case  of  a  stenosis  above  the  line  of  the  aortic  arch,  the 
esophagus  may  be  opened  above  the  stricture  (external  esophagotomy),  a 
tenotome  is  introduced  through  the  wound,  the  stricture  is  cut  and  well  dilated 
by  the  passage  of  instruments.  This  operation  is  known  as  Gussenbauer's 
combined  esophagotomy. 

*W.  J.  Mayo,  Jour.  Amer.  Med.  Assoc,  July  29,  1899. 


Stricture  of  the  Esophagus 


929 


If  a  stricture  is  impassable  from  above,  the  stomach  should  be  opened 
and  retrogade  dilatation  be  carried  out.  Billroth  showed  years  ago  that  a  stric- 
ture impassable  from  above  may  be  passable  from  below.  This  is  because  the 
esophagus  above  the  stricture  is  basin  shaped  and  immediately  below  the 
stricture  is  funnel  shaped  (Abbe) .  If  a  tine  bougie  is  carried  from  the  stomach 
to  the  mouth  it  is  used  to  carry  a  piece  of  string  through  the  same  route,  and 


Fig.  512. — Abbe's  method  of  cutting  esophageal  strictures. 

this  string  is  used  to  pull  bougie  after  bougie  through  the  stricture.  A  firm, 
non-dilatable  stricture  in  the  thoracic  portion  of  the  esophagus  can  be  treated 
by  Abbe's  method  (Figs.  512  and  513).  He  performs  a  gastrotomy,  sutures 
the  stomach  to  the  abdominal  wound  to  prevent  contamination  of  the  peri- 
toneum, and  seeks  for  the  esophageal  opening  by  two  fingers  passed  \nthin  the 
stomach.  Abbe  points  out  that  finding  the  orifice  would  seem  much  more 
easy  than  it  is.     In  a  recent  case  I  found  it  only  after  a  prolonged  search,  the 


Fig.  513. — The  bougie  engaged  in  the  stricture  while  the  string-saw  is  being  used. 


entire  esophageal  region  feeling  smooth  to  the  touch.  Abbe  says  that  "this 
surface  is  maintained  by  the  circular  sphincteric  muscle  layers,  and  it  is 
not  until  a  moment's  pressure  of  the  finger  at  the  right  place  causes  them 
to  yield  that  it  shps  upward  into  the  esophagus"  (  "Med.  Record,"  Nov.  30, 
1907).  He  then  passes  a  long  filiform  whalebone  bougie  from  the  stomach 
into  the  mouth,  ties  a  piece  of  braided  silk  to  the  bougie,  withdraws  the  instru- 
59 


930  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

merit,  and  leaves  the  silk  in  place.  One  end  of  the  silk  emerges  from  the  mouth 
and  the  other  end  from  the  gastrotomy  wound.  In  some  cases  he  opens  the 
stomach  and  also  opens  the  esophagus  above  the  stricture;  one  end  of  the  string 
comes  out  of  the  esophagotomy  wound  and  the  other  end  out  of  the  gastrotomy 
wound.  A  large  dilating  bougie  is  then  passed  from  the  stomach  into  the 
esophagus  and  pushed  as  forcibly  as  is  safe  into  the  lumen  of  the  stricture. 
The  string  is  used  as  a  string-  or  bow-saw,  and  the  stricture  is  divided,  the  di- 
lating bougie  being  pushed  firmly  upward  while  the  saw  is  being  used.  If 
this  is  not  done  the  saw  will  not  cut.  Only  stretched  tissue  vrill  be  divided. 
When  the  stricture  has  been  divided,  the  silk  is  withdrawn,  full-sized  bougies 
are  passed,  a  temporary  gastrostomy  is  usually  made,  and  the  wound  or  wounds 
are  sutured. 

An  operation  devised  by  A.  J.  Ochsner  is  thus  described  by  Mayo  *:  "  The 
anterior  wall  of  the  stomach  is  drawn  out  of  a  left  oblique  incision  through  the 
abdominal  coverings;  a  small  opening  is  made  into  the  stomach  sufficient  in  size 
to  introduce  the  finger.  A  whalebone  probe,  to  the  tip  of  which  a  silk  string 
guide  has  been  tied,  is  now  passed  through  the  esophagus  either  from  above 
or  retrograde,  as  in  the  Abbe  method.  With  this  guide  a  loop  of  silk  is 
drawn  out  of  the  gastric  incision  in  such  manner  as  to  leave  the  guide  as 
a  third  string.  Into  this  loop  a  small  soft-rubber  drainage-tube  three  feet 
or  more  in  length  is  caught  in  the  middle  by  traction  on  the  ends  of  the  doubled 
thread  through  the  mouth:  this  loop  of  rubber  tube  is  drawn  through  the 
stomach  and  made  to  engage  in  the  stricture. 

"The  greater  the  amount  of  traction,  the  smaller  the  stretched  rubber 
tube,  until  it  is  sufficiently  reduced  in  size  to  enter  the  stenosed  portion; 
by  alternating  the  direction  of  the  pull  the  tube  is  drawn  out  by  its  free  ends 
and  in  by  the  silk  loop.  Increasing  sizes  of  tubes  can  be  employed,  and 
if  necessarv  the  third  string  can  be  used  as  a  string-saw,  after  the  Abbe  plan 
of  procedure. "  In  a  very  severe  case  of  stenosis  gastrostomy  is  performed  to 
keep  the  patient  from  starving.  In  a  case  of  fibrous  stenosis  in  charge  of  the 
author  it  was  found  impossible  to  insert  any  instrument  from  above  or  from 
below.  Gastrostomv  was  performed  by  Kader's  method.  The  patient  was  fed 
through  the  artificial  opening  and  the  esophagus  was  thus  put  at  rest.  Two 
weeks  after  the  operation  it  became  possible  to  pass  a  bougie  from  the  mouth. 
The  gullet  was  gradually  dilated  to  its  normal  caliber  and  the  gastrostomy 
wound  was  closed.  This  case  demonstrates  that  a  stricture  of  the  esophagus, 
like  a  stricture  of  the  urethra,  may  become  temporarily  impassable  from 
inflammation,  edema,  and  spasm;  but,  after  the  part  is  put  at  rest,  will  again 
permit  the  passage  of  an  instrument. 

Carcinoma  of  the  Esophagus. — Cancer  causes  obstruction  of  the  esoph- 
agus. It  arises  in  those  beyond  middle  life,  and  is  far  more  common  in 
men  than  in  women.  The  disease  may  begin  at  any  portion  of  the  gullet, 
but  is  least  often  met  with  in  the  central  portion  (Maylard,  Butlin).  Epithe- 
lioma is  the  usual  form,  but  scirrhus  or  encephaloid  may  occur.  Cancer 
soon  ulcerates,  involves  adjacent  parts,  and  affects  the  deep  cervical  and 
posterior  mediastinal  glands. 

Symptoms  of  Cancerous  Stenosis. — The  patient  is  over  forty  years  of  age, 
is  usually  a  male,  and  presents  the  same  difficulty  of  swallowing  met  with 
*  Jour.  Amer.  Med.  Assoc,  July  29,  1899. 


Spasmodic  Stricture  of  the  Esophagus  931 

in  cicatricial  stenosis.  The  vomited  matter  is  apt  to  contain  blood;  the  use 
of  the  bougie  causes  bleeding;  there  are  generally  decided  pain  and  very 
great  emaciation.  The  seat  of  obstruction  is  located  by  the  bougie  and  by 
listening  over  the  spine  while  the  patient  is  attempting  to  swallow  water. 
The  stomach  is  the  seat  of  pain;  the  mouth  is  dry,  and  there  is  often  great 
thirst.  As  the  disease  infiltrates,  the  involvement  of  adjacent  regions  pro- 
duces other  symptoms.  Dyspnea  may  result  from  tracheal  pressure.  Pleu- 
ritis,  pericarditis,  or  pneumonia  may  arise. 

Treatment. — The  disease  is  of  necessity  fatal,  and  treatment  is  only  pallia- 
tive. Complete  excision  is  scarcely  feasible.  The  patient  should  be  put 
upon  a  soft,  bland  diet,  small  quantities  being  given  frequently.  When  trouble 
is  experienced  in  swallowing  the  bland  and  soft  food,  pass  a  soft  bougie  every 
third  or  fourth  day.  When  the  patient  becomes  entirely  unable  to  swallow 
soft  food,  we  may  insert  a  Symonds  tube  or  do  an  esophagostomy  (if  this  can 
be  performed  below  the  stricture),  or  perform  gastrostomy.  In  every  doubt- 
ful case  of  esophageal  stricture  give  a  course  of  iodid  of  potassium  before  per- 
forming any  operation. 

Spasmodic  Stricture  of  the  Esophagus  (Esophagismns;  Hysterical 
Stricture). — By  this  term  is  meant  a  spasm  of  the  circular  muscular  fibers 
of  the  gullet,  which  is  most  common  near  the  larynx  or  the  cardia.  This 
condition  not  unusually  arises  in  a  hysterical  individual,  in  which  case  it 
will  be  associated  with  the  stigmata  of  hysteria,  especially  globus  hystericus. 
In  some  cases  evidences  of  hysteria  are  wanting,  although  the  patient  is 
neurotic  and  ill-nourished,  and  the  condition  is  due  to  a  reflex  irritation, 
A  spasm  of  the  muscular  fibers  of  the  esophagus  may  be  clonic  or  may  be 
tonic.  A  clonic  spasm  may  arise  during  vomiting  or  from  some  reflex  cause; 
it  may  affect  one  part  of  the  tube  for  a  time  and  then  shift  to  another,  or 
may  develop  only  in  one  particular  region.  Globus  is  a  spasm  which  moves 
upward.  Tonic  spasm  is  in  one  fixed  place.  Most  reflex  spasms  are  tonic 
and  result  from  cancer  of  the  liver,  cancer  of  the  stomach,  tonsillitis,  glossitis, 
pharyngitis,  or  inflammation  of  the  epiglottis  (A.  L.  Benedict,  in  "  Am.  Jour, 
Med.  Sciences,"  August,  1904).  Spasmodic  stricture  may  also  arise  during 
pregnancy  and  as  a  result  of  laryngeal  ulceration.  I  have  seen  two  instances 
due  to  cancer  of  the  stomach.  In  one  of  these  cases  the  esophageal  spasm 
entirely  disappeared  after  the  performance  of  pylorectomy.  It  occasionally 
occurs  in  tetanus,  and  sometimes  in  epilepsy. 

Symptoms  of  Spasmodic  Stenosis. — It  arises  suddenly  in  a  hysterical  or 
neurotic  individual.  It  may  last  for  a  time  and  suddenly  pass  away,  or 
may  persist  for  a  long  time.  The  difl&culty  in  swallowing  is  irregular,  rarely 
interfering  seriously  with  nourishment,  and  sometimes  solids  are  taken  more 
readily  than  fluids,  and  vice  versd. 

There  may  be  regurgitation ;  but  if  it  occurs,  it  does  so  at  once  on  swallow- 
ing food.  Examination  with  a  bougie  detects  the  obstruction.  If  the  bougie 
is  held  firmly  against  it,  in  most  cases  the  spasm  will,  after  a  time,  relax  suddenly 
or  gradually  and  let  the  instrument  pass.  A  medium-sized  instrument  or 
a  large  instrument  may  not  pass  until  the  patient  has  been  anesthetized, 
but  in  every  case  a  bougie  can  be  passed  after  an  anesthetic  has  been  given. 

Treatment. — The  systematic  passage  of  bougies.  Occasionally  the  passage 
of  an  instrument  but  once  will  cure  a  case.     The  general  health  must  be 


932  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

improved,  and  in  persistent  cases  it  may  be  necessary  to  use  electricity  within 
the  esophagus,  employ  cold  locally,  and  administer  the  bromids. 

Diverticula  of  the  Esophagus. — Maylard  tells  us  that  these  pouches 
may  be  due  to  one  of  four  causes — they  may  be  congenital;  may  be  due 
to  stricture;  may  be  caused  by  pressure  from  within,  upon  a  weak  spot  of 
the  wall;  may  be  due  to  traction  from  without,  by  the  healing  and  contrac- 
tion of  an  area  of  inflammation.  To  these  another  cause  should  be  added, 
muscular  weakness  resulting  in  dilatation. 

Symptoms. — When  the  diverticulum  is  in  the  neck,  a  lump  forms  during 
deglutition,  and  this  lump  may  be  obliterated  by  pressure.  Food  will  pass 
into  the  stomach  only  when  the  diverticulum  is  fuU.  A  bougie  cannot  be 
passed  unless  the  pouch  is  full  of  food,  at  which  time  it  may  pass  or  may 
not.  Sometimes  it  enters  the  pouch.  This  latter  symptom,  the  variability 
in  the  passage  of  the  bougie,  is  the  evidence  relied  on  for  diagnosis  in  intro- 
thoracic  diverticula.  By  listening  with  a  stethoscope  fluid  may  be  heard  to 
pass  into  the  pouch.  After  a  patient  swallows  an  emulsion  of  bismuth  or  food 
mixed  with  subnitrate  of  bismuth  a  diverticulum  may  be  skiagraphed.  When 
a  bougie  is  passed  as  far  as  it  will  go  a  skiagraph  should  be  taken  with  the  bougie 
in  position.  The  plate  may  show  that  the  instrument  is  so  much  de\iated 
to  the  side  that  it  must  be  in  a  pouch.  If  a  fine  gold  chain  is  swallowed  it 
may  fill  up  the  pouch,  and  if  it  does,  a  skiagraph  will  indicate  the  diverticulum. 
The  opening  of  the  pouch  may  be  seen  by  means  of  an  esophagoscope. 

Treatment. — Extirpation  and  suture,  as  performed  by  von  Bergmann, 
Hearn,  and  others.  For  five  days  after  operation  no  food  is  given  by  the 
mouth. 

Injuries  of  the  Esophagus  from  Within. — Injuries  of  the  internal  sur- 
face are  more  common  than  injuries  from  without.  Burns  and  scalds  are 
among  these  injuries.  Wounds  may  be  inflicted  by  foreign  bodies.  Injuries 
of  the  gullet  cause  pain  on  swallowing,  and  a  severe  injury  induces  bleeding, 
the  blood  being  both  coughed  up  and  vomited.  A  severe  wound  may  involve 
a  large  vessel  and  cause  violent  or  even  fatal  hemorrhage.  If  the  bronchus 
or  trachea  is  involved,  there  will  be  "  cough  and  expectoration  of  blood,  mucus, 
and  food"  (Maylard).     The  pleural  or  pericardiac  sacs  may  be  perforated. 

Treatment. — Feed  only  by  the  rectum.  Give  morphin  hypodermatically. 
Do  not  feed  by  the  mouth  for  ten  days,  and  even  then  give  only  fluid  food 
and  jelly.  Symptoms  are  met  as  they  arise.  After  burns  by  caustic,  admin- 
ister the  antidote;  give  large  drafts  of  water  and  wash  out  the  stomach.  From 
two  to  four  weeks  after  a  caustic  has  been  swallowed  and  after  a  burn  or 
scald  the  use  of  sounds  should  be  begun,  and  sounding  should  be  persisted 
in  for  a  considerable  time  to  prevent  contraction. 

Injuries  of  the  Esophagus  from  Without,  Other  Structures  not  being 
Seriously  Involved. — Such  injuries  are  rare.  Esophageal  injuries,  as  a  rule, 
are  associated  with  serious  damage  to  adjacent  structures.  These  injuries 
may  be  due  to  stabs  or  to  bullets.  Besides  the  obvious  external  signs  of 
the  injury  there  wiU  be  difficulty  in  swallowing,  cough,  bloody  expectoration, 
or  vomiting;  and  mucus  or  the  contents  of  the  stomach  may  run  out  of  the 
wound. 

Treatment. — Suture  the  wound,  and  feed  by  the  rectum  for  ten  days. 


Foreign  Bodies  Lodged  in  the  Esophagus 


933 


Foreign  Bodies  Lodged  in  the  Esophagus, — These  accidents  occur 
especially  in  children  and  lunatics,  and  women  are  more  apt  to  suffer  from 
them  than  men.  A  list  of  various  bodies  which  have  been  swallowed 
will  be  found  in  Poulefs  elaborate  treatise.  There  are  three  regions  where 
a  foreign  body  is  especially  apt  to  lodge — viz.,  opposite  the  cricoid  cartilage, 


Fig.  514. — Author's  case  of  whistle  in  esophagus  removed  by  external  esophagotomj". 

at  the  level  of  the  diaphragm,  and  at  the  point  where  the  left  bronchus  crosses 
the  gullet.     Small  and  *harp  bodies  may  lodge  anywhere. 

Symptoms. — The  symptoms  are  variable;  if  the  body  is  large,  there  will 
be  pain  and  difficulty  in  swallowing,  and,  in  some  cases,  dyspnea  from  pressure 
upon  the  trachea  or  bronchus.  Occasionally  the  dyspnea  is  such  a  prominent 
feature  that  it  misleads  the  physician  into  the  belief  that  the  foreign  body 
is  lodged  in  the  air-passages.    Death  may  actually  result  from  asphyxia.     In 


Fig. 


-Author's  case  of  jackstone  in  esophagus  removed  by  e.xternal  esophagotomy. 


some  Other  cases  the  symptoms  are  ver}-  sUght.  If  the  body  is  sharp,  there 
will  be  hemorrhage  and  severe  pain.  The  blood  may  be  hawked  up,  or  may 
be  swallowed  and  vomited.  A  patient  may  grow  accustomed  to  a  foreign 
body  and  cease  to  notice  it;  but,  on  the  contrary,  the  foreign  body  may  pro- 
duce inflammation,  and  may  even  ulcerate  into  the  windpipe,  the  pleura, 


934  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

the  pericardium,  or  the  aorta.  In  many  cases  of  impaction  a  patient  makes 
violent  efforts  to  hawk  and  produces  aphonia.  There  may  be  violent  retch- 
ing. Even  after  a  foreign  body  has  been  removed  by  swallowing  or  other- 
wise a  sensation  is  apt  to  remain  as  if  it  were  still  lodged.  The  diagnosis 
is  made  by  the  history,  the  detection  of  the  body  by  external  manipulation, 
by  feeling  it  with  an  esophageal  bougie,  and,  if  bone  or  metal,  seeing  it  with 
the  fluoroscope  or  obtaining  a  skiagraph. 

Treatment. — The  surgeon  should  learn,  if  possible,  the  size,  shape,  weight, 
and  nature  of  the  foreign  body,  and  should  locate  its  point  of  impaction. 
The  exact  point  of  lodgment  of  bone  or  a  metallic  body  is  determined  by 
the  :v-rays.*  An  anesthetic  is  given  before  manipulating  in  a  child,  a  nervous 
woman,  or  a  lunatic,  and  is  sometimes  necessary  for  a  man.  If  the  foreign 
body  is  soft,  external  manipulation  may  succeed  in  altering  its  shape,  so  that 
it  may  be  swallowed  or  ejected.  If  the  foreign  body  is  hard,  external  manipu- 
lation may  shift  its  position.  It  is  usually  impossible  to  reach  the  foreign 
body  through  the  mouth  by  means  of  the  fingers  (when  the  body  is  in  the 
rear  of  the  pharynx  it  may  be  pulled  forward  or  pushed  down).  Sharp 
foreign  bodies  may  be  entangled  and  carried  down  when  the  patient  eats 
mush,  bread,  or  boiled  potatoes.  The  administration  of  emetics  is  an  old 
plan  which  occasionally  succeeds,  but  which  is  too  unsafe  to  be  employed. 
Maylard  says  that  when  a  mass  of  food  is  impacted  it  is  occasionally  possible 
to  soften  and  disintegrate  the  mass  by  administering  a  mixture  containing 
pepsin.  The  horsehair  probang  is  a  very  useful  instrument  (Fig.  511,  c). 
It  may  be  used  to  push  a  body  downward  into  the  stomach,  or  to  catch  the 
body  and  pull  it  up.  When  this  instrument  is  withdrawn,  it  opens  hke 
an  umbrella.  Maurice  H.  Richardson  has  shown  that  in  an  adult  the  dia- 
phragmatic opening  is  about  fourteen  and  one-half  inches  from  the  incisor 
teeth,  a  point  to  be  remembered  in  deciding  whether  to  push  down  or  pull 
up  the  impacted  article.  Esophageal  forceps  (Fig.  511,  A,  b)  are  valuable 
in  some  cases.  The  coin-catcher  (Fig.  511,  d)  is  a  useful  instrument,  Cre- 
quy's  plan  of  removal  is  to  take  a  tangled  mass  of  threads,  tie  a  stout  piece 
of  string  about  the  middle  of  it,  coat  it  with  sugar,  and  have  the  patient  swal- 
low it.  It  may  pass  the  foreign  body;  if  it  does  so,  on  withdrawal  it  may 
entangle  the  object  and  extract  it.  To  remove  a  fish-hook  with  line  attached, 
the  following  plan  may  prove  successful;  stick  the  Hne  which  projects  from 
the  mouth  into  a  metal  catheter,  carry  the  catheter  down  to  the  hook,  and 
push  the  hook  out.  It  is  not  proper  to  allow  a  foreign  body  to  remain  in 
the  esophagus  until  it  causes  ulceration.  Neither  is  it  proper  to  make  pro- 
longed efforts  to  extract  it  through  the  mouth.  Such  efforts  may  do  great 
barm,  and  if  one  careful  and  consistent  effort  fails,  an  operation  should  be 
performed.  If  the  body  is  lodged  anywhere  above  the  lower  third  of  the 
esophagus,  external  esophagotomy  is  performed,  and  usually  on  the  left  side. 
Through  this  wound  the  foreign  body  is  extracted.  The  cut  is  made  on  the 
left  side,  between  the  trachea  and  larynx  in  front  and  the  carotid  sheath 
behind,  the  center  of  the  incision  being  opposite  the  cricoid  cartilage.  After 
the  foreign  body  is  extracted  the  mucous  membrane  is  sutured  with  chromic- 
ized  catgut,  and  the  superficial  structures  are  closed  with  silkworm-gut  after  a 
drainage-tube  has  been  inserted.  The  patient  is  fed  by  the  rectum  for  eight  or 
*  See  cases  of  White,  Keen,  Alfred  Wood,  Maclntyre,  Taylor,  and  others. 


Surgical  Invasion  of  the  Mediastinum  935 

ten  days.  When  a  foreign  body  is  lodged  in  the  lower  portion  of  the  tube,  the 
stomach  is  opened  and  the  body  extracted  by  this  route  (Richardson).  In 
White's  case  of  jackstone  in  the  gullet  gastrotomy  was  performed.  A  string 
was  tied  about  some  rolls  of  gauze,  the  string  was  passed  by  means  of  a 
whalebone  from  the  stomach  into  the  mouth,  and  the  body  was  entangled 
and  drawn  out. 

Surgical  Invasion  of  the  Mediastinum. — The  posterior  mediastinum 
has  been  entered  in  order  to  remove  a  foreign  body  from  the  bronchus  and 
to  extract  a  set  of  false  teeth  wedged  in  the  esophagus.  The  same  method 
can  be  followed  to  reach  suppvurative  processes  in  the  mediastinum,  abscesses 
of  the  lung  otherwise  inaccessible,  and  diverticula  and  carcinomata  of  the  lower 
end  of  the  gullet.  Nassilov  resects  ribs  close  to  the  spine.  The  portion  of  the 
esophagus  above  the  aortic  arch  can  be  reached  after  partial  resection  of  the 
third,  fourth,  fifth,  and  sixth  ribs  of  the  left  side.  The  inferior  portion  of  the 
esophagus  can  be  reached  after  resecting  portions  of  the  lower  third  or  fourth 
ribs  on  the  right  side  (Binnie's  "Operative  Surgery  ") .  The  anterior  mediasti- 
num may  be  entered  to  remove  a  bullet,  to  drain  an  abscess,  to  reach  a  wound 
of  the  heart  or  lung,  and  to  explore  for  the  cause  of  symptoms.  I  explored  the 
anterior  mediastinum  after  rib  resection,  found  a  bullet  imbedded  in  the  aorta, 
and  allowed  it  to  remain.  The  patient  recovered.  M.  H.  Milton*  spUts 
the  sternum  and  separates  the  two  pieces. 

Invasion  of  the  mediastinum  is  much  safer  if  the  operation  is  performed  in 
the  Sauerbruch  chamber  or  with  the  aid  of  positive  pressure  within  the  bronchi. 
Either  of  these  plans  will  prevent  pulmonary  collapse  if  the  pleura  is  opened. 

*  Lancet,  March  27,  1897. 


936  Diseases  and  Injuries  of  the  Abdomen 


XXVn.    DISEASES    AND   INJURIES    OF    THE   ABDOMEN. 

Diagnosis  of  Intra=abdominal  Emergencies. — The  exact  diag- 
nosis is  always  difficuh  and  is  not  unusuahy  impossible.  What  a  surgeon 
must  try  to  determine,  and  what  he  usually  can  determine,  is  whether  he 
is  dealing  with  a  trivial  and  temporary  derangement  for  the  relief  of  which 
an  operation  is  entirely  unnecessary,  or  whether  he  is  confronted  with  a 
grave  calamity  which  imperatively  demands  immediate  surgical  aid.  We 
can  decide  that  a  calamity  exists,  but  the  exact  nature  of  the  lesion  is  often 
doubtful  until  operation  is  performed.  Every  operation  in  such  a  case  is 
exploratory.  Before  the  diagnosis  of  a  calamity  is  made  morphin  should 
not  be  given,  because  it  allays  the  pain,  relieves  the  anxiety,  causes  the  dis- 
appearance of  rigidity,  lowers  the  pulse,  abates  shock,  and  hence  veils  the 
real  situation,  so  that  the  most  discerning  surgeon  will  probablv  be  misled.  If 
shock  is  profound,  diagnosis  is  usually  impossible,  unless  shock  is  due  to 
hemorrhage,  and  immediate  operation  during  shock  is  not  to  be  thought 
of  except  to  arrest  bleeding./ If  excessive  and  continued  hemorrhage  is 
suspected,  immediate  operation  is  indicated./  If  it  is  not  suspected,  the 
patient  should  be  covered  with  blankets  and  surrounded  with  hot-water 
bags,  atropin  should  be  given  hypodermatically,  and  hot  salt  solution 
should  be  administered  by  rectum,  subcutaneously,  or  intra venouslv. 
Suprarenal  extract  is  a  valuable  remedy  to  maintain  blood-pressure  in 
shock  (Crile).  When  the  patient  reacts,  and  he  usually  will  react, 
an  attempt  is  made  to  make  a  diagnosis.  It  is- perfectly  proper  to  give 
a  single  hypodermatic  injection  of  morphin  (gr.  ^)  after  the  effort  has 
been  made  to  diagnosticate  the  condition.  The  danger  of  deluding  the 
surgeon  is  past  and  the  drug  abates  pain,  lessens  peristalsis,  reheves  mental 
anxiety,  and  is  distinctly  beneficial.  Before  the  morphin  was  given  the 
surgeon  came  to  a  conclusion  as  to  the  necessity  for  operation.  After  the 
morphin  has  been  given,  if  an  operation  is  indicated,  it  is  performed  as 
promptly  as  circumstances  admit.  Whenever  it  is  esteemed  consistent  with 
safety,  the  patient  ought  to  be  removed  to  a  hospital  for  operation. 

Contusion  of  the  Abdominal  Wall  without  Injury  of  Viscera. — 

In  some  cases  of  contusion  of  the  abdominal  wall  only  the  parietes  are  dam- 
aged; in  other  cases  the  viscera  or  the  abdominal  tissues  are  injured.  Con- 
tusion may  involve  the  skin  alone,  or  may  involve  the  skin,  muscles,  and 
peritoneum.  In  simple  contusion  there  is  considerable  shock  if  the  injur}^ 
is  severe.  There  is  pain,  increased  by  respiration,  motion,  pressure,  and 
attempts  at  urination  or  defecation.  \\Tien  tenderness  appears  some  days 
after  the  accident  there  is  usually  deep-seated  injury.  Extensive  ecchvmosis 
may  appear.  Even  after  a  severe  contusing  force  has  been  applied  there 
may  be  no  discoloration,  and  it  may  happen  that  after  a  slight  force  there 
is  much  discoloration.  There  is  great  ecchymosis  in  anemic  persons,  victims 
of  hemiplegia,  in  obese  individuals,  opium-eaters,  and  drunkards.  In  severe 
cases  the  tissues  are  pulpified  and  sloughing  inevitably  ensues.  Abscess 
occasionally  follows  contusion.  The  prognosis  after  abdominal  contusion  is 
alvvavs  uncertain. 


Injuries  with  Damage  to  the  Peritoneum  or  Viscera  937 

Treatment  oj  Simple  Contusion. — In  treating  simple  contusion  place  the 
patient  at  rest  in  a  supine  position,  with  the  thighs  flexed  over  a  pillow; 
obtain  reaction  from  the  shock.  Give  morphin  if  pain  is  severe.  After 
shock  has  passed  ofif  it  is  advisable  to  place  an  ice-bag  over  the  seat  of  injury. 
If  much  blood  is  extravasated  into  the  abdominal  wall,  aspirate  and  apply 
a  binder.  After  twenty-four  hours  apply  local  heat  by  means  of  the  hot- 
water  bag,  employ  an  ointment  of  ichthyol,  and  move  the  bowels,  if  neces- 
sary, by  salines.  Regard  every  contusion  as  serious,  and  watch  carefully 
for  the  development  of  signs  of  internal  hemorrhage  or  visceral  injury. 

Muscular  Rupture  from  Contusion. — In  this  injury  there  are  severe 
shock  and  pain  (increased  by  respiration  and  movement).  Separation  be- 
tween the  fibers  of  the  muscle  is  distinct  at  first,  but  it  is  soon  masked  by 
effusion  of  blood.  Such  injuries  may  cause  death,  or  may  lead  to  hernia. 
The  rectus  is  the  muscle  most  apt  to  rupture.  The  rupture  is  due  to  sudden 
contraction  rather  than  to  the  direct  effect  of  a  blow. 

The  treatment  is  the  same  as  for  simple  contusion.  Always  apply  a 
binder.  A  hernia  is  returned  and  a  compress  is  apphed  over  the  opening 
through  which  it  emerged.     If  strangulation  occurs,  operate  at  once. 

Injuries  with  Damage  to  the  Peritoneum  or  the  Viscera.— 

Rupture  of  the  Peritoneum. — The  peritoneum  may  be  involved  in  an 
abdominal  contusion.  It  may  rupture  even  when  there  is  no  visceral  injurv 
or  muscular  contusion.  The  uterine  peritoneum,  the  parietal  peritoneum, 
the  visceral  peritoneum,  or  the  mesentery  may  rupture.  Rupture  of  the 
peritoneum  causes  intra-abdominal  hemorrhage. 

The  treatment  consists  in  opening  the  abdomen,  arresting  the  hemorrhage, 
and  bringing  about  reaction. 

An  injur}'  to  the  peritoneum  creates  a  point  of  least  resistance,  and  at 
such  a  point  peritonitis  may  develop.  The  peritonitis  is  usually  local,  but 
may  become  general.  After  any  severe  intra-abdominal  injury  the  symp- 
toms of  peritoneal  shock  appear  {peritonism),  and  the  patient  may  rapidly 
die.  In  the  condition  of  peritonism  the  temperature  is  subnormal;  the  ex- 
tremities are  cold;  the  face  is  palhd  and  sunken;  the  pulse  is  small,  weak, 
and  very  frequent;  the  respiration  is  shallow  and  sighing;  there  is  great  thirst; 
the  patient  is  restless  and  turns  uneasily,  and  there  is  rigidity  and  dis- 
tention. Vomiting  almost  always  occurs.  In  some  cases  there  is  regurgita- 
tion rather  than  vomiting.  The  abdomen  is  the  seat  of  a  violent,  persistent 
pain.  The  patient  is  fearful  of  impending  death.  As  the  symptoms  develop 
in  a  grave  case  they  will  point  to  one  of  two  conditions — hemorrhage  or 
peritonitis. 

In  intra-abdominal  hemorrhage  the  subnormal  temperature  and  other 
evidences  of  shock  persist.  \"omiting  ceases,  but  nausea  exists.  The  patient 
is  uncontrollably  restless  and  tosses  about  in  bed.  The  thirst  is  great.  The 
abdomen  is  rarely  rigid.  Fainting-spells  occur.  Blood-examination  shows  a 
marked  fall  in  the  percentage  of  hemoglobin.  Percussion  demonstrates  the 
existence  of  an  effusion  which  alters  its  position  as  the  patient's  position  is 
altered,  and  which  gradually  increases  in  amount.  Dulness  is  first  met  with 
in  the  loins.  Digital  examination  of  the  rectum  or  vagina  may  aid  in  diagnosis 
because  in  hemorrhage  blood  gathers  in  the  rectovesical  pouch.  If  peri- 
tonitis develops,  the  vomiting  becomes  worse,  the  pain  intensifies,  and  the 
abdomen  grows  rigid  and  distended. 


938  Diseases  and  Injuries  of  the  Abdomen 

Rupture  of  the  Stomach  without  External  Wound.— The  usual 
cause  of  rupture  is  a  vialent  blow,  although  the  accident  may  happen  while 
washing  out  the  stomach.  Rupture  is  more  apt  to  occur  when  the  stomach 
is  distended  with  food  than  when  it  is  empty.  The  ruptiu"e  may  be  partial, 
the  peritoneal  coat  not  being  torn.  The  rupture  may  be  complete.  Either 
the  anterior  or  the  posterior  wall  may  suffer.  The  region  of  the  pylorus 
is  most  apt  to  be  lacerated.  The  symptoms  of  rupture  are  collapse,  severe 
pain  over  the  entire  abdomen,  great  thirst,  excessive  tenderness,  especially 
over  the  epigastric  region,  occasionally  vomiting,  the  vomited  matter  being 
usually,  but  not  invariably,  bloody;  tympanitic  distention  and  muscular 
rigidity  coming  on  after  a  few  hours.  Austin  Fhnt  pointed  out  years  ago 
that  gas  may  enter  the  abdominal  cavity  and  cause  the  diminution  or  dis- 
appearance of  liver-dulness,  but  the  area  of  liver-dulness  can  be  lessened 
by  great  intestinal  distention,  and  I  have  seen  cases  of  perforation  of  the  stom- 
ach and  intestine  in  which  it  was  not  lessened  at  all.  After  incomplete 
rupture  local  peritonitis  is  frequent;  in  complete  rupture  the  escape  of  food 
into  the  peritoneal  cavity  causes  general  peritonitis.  The  contents  of  the 
stomach  are  not  so  liable  to  escape  after  rupture  of  that  viscus  as  are  the 
contents  of  the  intestine  after  rupture  of  the  gut,  because  of  the  thickness 
of  the  stomach-wall  and  the  tendency  of  the  mucous  membrane  to  evert 
and  block  the  opening.  Perforations  of  the  anterior  wall  are  most  apt  to 
lead  to  extravasation  and  general  peritonitis.  Posterior  laceration  may 
cause  subphrenic  abscess.  To  diagnosticate  between  complete  and  incom- 
plete rupture,  Senn  endeavors  to  distend  the  viscus  with  hydrogen  gas;  in 
incomplete  rupture  the  contour  of  the  dilated  stomach  can  be  made  out 
upon  the  surface;  in  complete  rupture  the  viscus  cannot  be  distended,  and 
the  gas  passes  into  the  peritoneal  cavity,  producing  the  physical  signs  of 
tympanites.  This  maneuver  is  open  to  the  objection  that  it  may  increase 
extravasation  in  a  complete  rupture. 

The  treatment  for  complete  rupture  is  immediate  operation.  Treatment  for 
shock  is  at  once  instituted  and  an  intravenous  infusion  of  salt  solution  is  given 
before  or  during  operation.  In  doubtful  cases  endeavor  to  bring  about  reac- 
tion and  explore.  Open  the  abdomen.  Note  if  gas  emerges  from  the  wound 
or  if  stomach  fluid  appears.  Search  for  the  rupture  in  the  same  manner 
as  we  search  for  the  opening  of  a  perforated  ulcer.  When  the  rupture  is 
discovered,  flush  out  the  stomach  and  the  peritoneal  cavity  with  hot  salt 
solution;  sew  up  the  stomach- wound  with  a  double  row  of  silk  sutures,  the 
first  row  being  buried  and  including  the  muscular  coat  and  mucous  coat, 
the  second  row  being  Halsted  sutures;  drain;  close  the  wound  in  the  parietes 
with  silkworm-gut;  place  the  patient  in  Fowler's  position;  let  salt  water  at  low 
pressure  flow  continuously  into  the  rectum ;  feed  by  the  rectum  for  four  days, 
and  then  begin  the  administration  of  a  very  little  food  by  the  mouth.  In 
incomplete  rupture  the  danger  is  perforation.  The  patient  is  put  to  bed,  and 
after  reaction  has  taken  place,  is  fed  by  the  rectum  for  several  days,  and 
morphin  is  given  hypodermatically.  Cases  of  complete  rupture  not  operated 
upon  occasionally  recover,  adhesions  arising  and  perigastric  suppuration 
taking  place.  The  mortality  is  extremely  large.  In  1896  Petry  collected 
23  cases  in  which  operation  was  not  performed.  The  mortality  was  59  pet 
cent.     This  mortality  is  not  so  large  as  one  would  anticipate.     It  is  not  impos- 


Rupture  of  the  Intestine  without  External  Wound  939 

sible  that  some  of  the  cases  were  not  positively  instances  of  rupture.  Never- 
theless, the  lesion,  for  reasons  previously  stated,  is  not  nearly  so  dangerous 
as  rupture  of  the  intestine.  Another  reason  for  the  greater  danger  of  intes- 
tinal rupture  is  that  fecal  matter  is  much  more  poisonous  than  the  gastric 
contents.  Laparotomy  has  lessened  the  mortahty  of  rupture  of  the  stomach. 
Petry  and  also  Eisendrath  mass  together  operations  for  rupture  of  the  stomach 
and  rupture  of  the  intestine.  Petry  finds  the  group  mortahty  to  be  52.3 
per  cent.,  and  Eisendrath  finds  it  to  be  52.5  per  cent.  Statistics  referring 
to  the  stomach  alone  should  show  a  lower  death-rate. 

Rupture  of  the  Intestine  without  External  Wound.— In  a  great 
majority  of  cases  the  damage  is  produced  by  direct  violence.  In  some  few- 
cases  the  force  is  indirect  (falls  on  the  feet  or  buttocks,  blows  on  the  back 
or  loin).  The  injury  may  result  from  oscillation  or  from  compression  (the 
younger  Senn).  The  common  cause  is  undoubtedly  compression  of  the 
gut  against  the  pelvis  or  vertebral  column,  but  it  is  certain  that  a  gut  con- 
taining fluid  may  be  ruptured  piurely  by  violent  shaking  or  oscillation.  If 
oscillation  produces  the  damage,  the  rupture  is  on  the  portion  of  gut  fur- 
thest from  the  mesentery;  if  compression  is  the  cause,  any  part  of  the  bowel 
may  suft"er.  Rupture  is  most  apt  to  occur  if  the  belly  is  relaxed.  It  is  pre- 
disposed to  by  adhesions,  disease  of  the  wall  of  the  bowel,  and  irreducible 
hernia  (the  younger  Senn).  Most  ruptures  are  complete.  In  a  very  few 
cases  the  tear  extends  only  through  one  or  two  of  the  coats  and  ihe  rupture 
is  incomplete.  A  contusion  of  the  gut  may  l)e  followed  by  rupture  several 
days  after  the  injury.  A  complete  rupture  usually  permits  leaking  of  feces, 
but  in  very  rare  cases  a  small  opening  is  plugged  up  by  pouting  mucous  mem- 
brane. Leaking  may  be  delayed  from  a  rupture  because  intra-abdominal 
pressure  may  for  a  time  keep  the  opening  pressed  against  a  section  of  sound 
gut  (the  younger  Senn),  The  amount  of  damage  to  the  belly  wall  does  not 
convey  any  notion  of  the  amount  of  visceral  injury.  The  belly  wall  may  be 
severely  injured  and  the  viscera  escape.  With  only  a  slight  contusion  of  the 
wall  there  may  be  extensive  visceral  injury.  Homer  Gage  *  collected  85  cases; 
in  75  the  injury  was  due  to  direct  force,  and  in  32  of  these  the  force  was 
inflicted  by  the  kick  of  a  horse  or  of  a  man  In  one  of  mv  cases  it  was  due 
to  the  kick  of  a  horse,  in  one  to  the  kick  of  a  man,  and  in  one  to  a  crush 
inflicted  by  a  cart-wheel.  The  victims  in  the  majority  of  reported  cases  were 
young  men,  probably  because  young  men  are  most  apt  to  be  exposed  to  vio- 
lence. In  78  collected  cases  (Gage)  the  situation  of  the  injury  was  specified: 
The  duodenum,  10;  jejunum,  20;  ileum,  42;  large  intestme,  6,  Curtis  found 
the  large  intestine  injured  in  4  cases  out  of  113,  and  Poland,  in  5  cases  out  of 
64.  In  many  cases  there  is  more  than  one  tear,  and  sometimes  many  tears  exist. 
Both  the  large  and  small  intestines  may  suffer.  Chavasse  collected  106  cases 
in  which  the  ileum  or  jejunum  suffered,  19  in  which  the  large  intestine  did, 
7  in  which  the  duodenum  did,  7  in  which  both  the  large  and  small  intestine 
were  involved,  and  i  case  in  which  the  rectum  was  ruptured  (quoted  by  the 
younger  Senn  in  "Am.  Jour.  Med=  Sciences,''  June,  1904).  As  Alakins 
points  out,  the  portion  of  gut  most  apt  to  be  injured  is  a  portion  hanging  low 
in  the  pelvis,  because  a  loop  in  this  situation  is  most  easily  squeezed  against 
bone  by  a  blow  on  the  belly.  The  mesentery  may  be  lacerated  (in  7  per 
*  Annals  of  Surgery,  March,  1902. 


940  Diseases  and  Injuries  of  the  Abdomen 

cent,  of  cases,  according  to  Gage;  in  i6  per  cent.,  according  to  Curtis).  The 
s}Tnptom5  of  rupture  of  the  intestine  are  profound  shock,  tympanites,  abdom- 
inal pain,  and  rigidity,  rapidly  followed  by  peritonitis  if  the  patient  surv^ives. 
In  some  cases  pain  is  referred  to  the  back.  Vomiting  comes  on  soon  after 
the  accident,  the  vomited  matters  being  possibly  at  first  bloody  and  later  ster- 
coraceous.  The  respiration  is  thoracic,  the  tongue  is  dr\-,  and  great  thirst 
exists.  The  pulse,  which  is  slow  at  first,  becomes  small  and  rapid  and  of 
high  tension.  Blood  in  the  stools  rarely  appears  early  enough  to  be  of  diagnos- 
tic value,  and  there  may  be  diarrhea  or  constipation.  The  respiration  is  costal. 
Dyspnea  exists.  There  may  be  no  marked  5}-mptoms  for  an  hour  or  two 
or  for  many  hours.  Cases  are  on  record  of  people  with  ruptured  intestine 
returning  to  work  perhaps  for  hours.  Holland's  patient  had  no  symptoms 
for  twenty-four  hours,  although  the  jejunum  was  ruptured.  Poland's  patient 
ruptured  the  duodenum  but  walked  one  mile.  The  escape  of  gas  into  the 
peritoneal  cavity  may  cause  the  diminution  or  disappearance  of  liver-dulness. 
After  anesthetizing  the  patient,  hydrogen  gas  insufflated  into  the  rectum 
will  come  from  the  mouth  if  there  is  no  perforation  in  the  stomach  or  the 
intestine;  if  a  perforation  exists,  tympanites  is  much  increased,  and  the  area 
of  liver-dulness  may  disappear.  To  apply  rectal  insufflation  of  hydrogen, 
generate  the  gas  in  a  bottle  by  means  of  zinc  and  sulphuric  acid,  catch  the 
gas  in  a  large  rubber  bag,  and  attach  the  tube  from  the  gas  reservoir  to  a 
tip  which  is  inserted  in  the  rectum.  Give  the  patient  ether  to  relax  the  abdomi- 
nal muscles,  direct  an  assistant  to  press  the  anal  margins  against  the  rectal 
tip,  and  when  the  patient  is  unconscious,  turn  on  the  stopcock  and  press 
upon  the  reser\-oir  (the  elder  Senn). 

It  has  been  suggested  that  ether  vapor,  mixed  with  air,  can  be  used  instead 
of  hydrogen  gas.*  In  this  method  a  little  ether  is  poured  into  the  bottle  of 
an  aspirator,  the  valves  are  opened,  one  tube  is  carried  into  the  rectum, 
the  other  tube  is  attached  to  a  bicycle  pump,  and  by  working  the  pump 
the  ether  vapor  is  driven  into  the  bowel.  If  there  is  perforation,  tympanites 
is  notably  increased.  Most  surgeons  regard  the  rectal  insufflation  test  as 
unsatisfactory'  and  often  dangerous.  Personally  I  am  not  inclined  to  use  it. 
Its  application  requires  considerable  time,  it  must  of  necessity  increase  fecal 
extravasation,  and,  as  Le  Contef  says,  it  "so  distends  the  intestines  that 
it  may  be  impossible  to  return  them  to  the  abdominal  cavity  until  they  have 
been  emptied  of  gas." 

Treatment  of  Rupture  of  Intestine. — If  symptoms  point  to  dangerous 
hemorrhage,  and  in  any  case  in  which  the  patient  does  not  seem  to  be  react- 
ing, but  is  rather  getting  worse,  operate  at  once.  If  in  doubt  as  to  whether 
or  not  rupture  exists,  make  every  endeavor  to  bring  about  reaction,  and  explore. 
Reaction  is  brought  about  as  previously  directed.  Asepticize  and  anesthe- 
tize. Perform  a  laparotomy,  making  the  incision  in  the  middle  line  and 
below  the  umbilicus;  note  if  gas  escapes  when  the  peritoneum  is  opened  or 
if  fecal  material  or  an  inflammator}'  exudate  flows  out;  check  hemorrhage; 
start  at  a  fixed  point  and  conduct  a  careful  search  to  find  the  rent.  When 
the  rent  is  found,  it  should  be  closed  by  Halsted  sutvures  if  possible.  It  is 
only  a  small  rupture,  however,  which  can  be  so  treated.     Most  large  tears 

*  Emerson  M.  Sutton,  of  Geneva,  in  Jour.  Am.  Med.  .Assoc,  July  23,  189S. 
t  Am.  Jour.  Med.  Sciences,  Dec,  1901. 


Identification  of  the  Intestines  941 

make  resection  necessary.  Because  of  the  frequency  of  multiple  lesions 
the  surgeon  must  not  be  sure  he  has  finished  his  work  when  he  finds  and 
closes  one  tear,  but  he  must  determine  by  careful  search  that  no  other  tears 
exist.  The  surgeon  notes  if  there  is  injury  of  the  mesentery  and  if  the  cir- 
culation of  any  portion  of  the  bowel  is  interfered  with.  If  there  is  serious 
impairment  of  circulation  in  any  part  of  the  bowel-wall,  perform  intestinal 
resection,  followed  by  end-to-end  approximation  or  lateral  anastomosis.  In 
some  cases  of  rupture  the  patient  is  so  severely  shocked  that  it  is  impossible 
to  do  a  resection  with  any  hope  of  the  patient  living.  In  such  a  case  stitch 
the  ruptured  portion  of  gut  to  the  belly-wall.  The  opening  in  the  gut  be- 
comes a  fecal  fistula,  and  if  the  patient  survives,  can  be  subsequently  closed 
(Senn).  The  same  procedure  is  proper  if  the  bowel  is  distended  and  paralyzed. 
After  closing  the  opening  in  the  bowel  or  resecting  flush  the  abdominal  cavity 
with  hot  saline  solution,  and  wipe  the  peritoneal  fossae  and  the  space  between 
the  liver  and  diaphragm  with  gauze.  Finney  eviscerates,  wipes  out  the 
abdominal  cavity,  and  wipes  the  intestines  as  he  restores  fiaem.  This  is 
justifiable  if  the  operation  is  done  soon  after  the  rupture,  but  not  in  later 
cases,  in  which  lymph  has  gathered  on  the  bowel.  Whatever  method  is  used 
to  cleanse  the  abdomen,  remember  that  infectious  material  is  apt  to  accumu- 
late between  the  liver  and  diaphragm  and  in  Douglas's  pouch.  Drainage  is 
to  be  used.  Suprapubic  drainage  is  most  advantageous.  Place  the  patient 
semierect  and  employ  continuous  proctoclysis  of  normal  salt  solution  as  directed 
for  peritonitis.  The  value  of  operation  for  intestinal  rupture  is  conclusively 
demonstrated.  Curtis  collected  116  cases  which  occurred  before  1887.  Not 
a  case  was  operated  upon,  and  every  patient  died.  Homer  Gage  collected 
85  cases  since  1887:  45  were  not  operated  upon  and  every  one  died;  40  were 
operated  upon  and  17  recovered.  Eisendrath  collected  40  cases  operated 
upon.  Nineteen  recovered  and  21  died  (52.5  per  cent.).  The  mortal- 
ity of  cases  not  operated  upon  is,  according  to  Eisendrath,  at  least  93  per 
cent.  The  sooner  after  the  injury  operation  is  performed  the  greater  the  chance 
for  success.  The  younger  Senn  points  out  that  in  operations  done  within 
four  hours  the  mortality  is  15.2  per  cent.;  in  those  done  between  five  and 
eight  hours  it  is  44.4  per  cent. ;  in  those  done  between  nine  and  twelve  hours 
it  is  63.6  per  cent.,  and  in  those  done  later  it  is  70  per  cent. 

Identification  of  the  Small  Intestine  and  of  the  Large  Intestine. — 
"In  abdominal  operations  it  is  frequently  imperatively  necessar}-  that  the 
large  intestine  be  recognized  with  certainty  or  the  small  bowel  be  positively 
identified.  The  size  of  the  tube  will  not  always  aid  in  this  recognition,  as 
a  small  intestine  may  be  distended  enormously  and  a  large  intestine  may 
be  contracted  to  the  size  of  a  finger  because  of  obstruction  above.  The 
longitudmal  muscular  fibers  of  the  large  bowel  are  accentuated  in  three  por- 
tions; these  accentuations  constitute  the  three  longitudinal  bands  which 
begin  at  the  cecum  and  terminate  at  the  end  of  the  sigmoid  flexure  of  the 
colon.  Each  band  is  composed  of  a  number  of  shorter  bands,  the  shortness 
of  these  constituent  bands  permitting  the  sacculation  of  the  large  intestine. 
Longitudinal  bands  and  sacculation  are  not  met  with  in  the  small  gut,  their 
presence  or  absence  being  a  means  of  identification  in  many  cases;  but  when 
the  colon  is  much  distended,  the  bands  cannot  be  seen  distinctly  and  the 
sacculation  disappears.     From  the  large  intestine  only  spring  the  appendices 


942  Diseases  and  Injuries  of  the  Abdomen 

epiploicae  (small  overgrowths  of  fat  in  pouches  of  peritoneum),  but  they 
are  sometimes  not  well  marked  except  upon  the  transverse  colon,  and  when 
emaciation  exists  they  may  almost  entirely  disappear.  The  relatively  fixed 
position  of  the  large  intestine  and  the  free  mobility  of  the  small  bowel  are 
important  points  of  distinction.  The  foregoing  indicates  that  it  is  not  always 
easy  to  distinguish  between  colon  and  small  gut,  and  that,  according  to  old 
rules,  it  may  be  often  necessary  to  make  large  incisions,  to  see  as  well  as 
feel,  and  to  handle  a  large  extent  of  the  bowel.  Any  scrap  of  knowledge 
that  will  shorten  an  abdominal  operation,  that  will  permit  of  as  certain  work 
through  a  smaller  incision,  and  that  will  diminish  handling  of  intraperitoneal 
structures,  tends  to  increase  the  chances  of  recovery.  For  these  reasons  the 
writer  suggests  a  method  of  bowel-identification  which  rests  upon  the  facts 
that  each  bowel  has  a  posterior  attachment,  that  the  origin  of  the  attach- 
ment differs  according  to  the  bowel  it  supports,  that  a  single  finger  can  detect 
the  origin  of  the  peritoneal  support  of  any  section  of  the  bowel,  and,  this 
origin  being  known,  the  portion  of  the  bowel  it  supports  is  with  certainty 
deducible.  In  an  exploratory  operation,  for  instance,  the  finger  comes  in 
contact  with  the  bowel:  to  determine  whether  it  is  a  large  or  a  small  bowel,  note 
first  if  the  structure  is  movable  or  is  firmly  fixed;  next,  pass  the  finger  over 
the  bowel  and  let  it  find  its  way  posteriorly.  If  dealing  with  a  small  bowel, 
the  finger  will  reach  the  origin  of  the  mesentery  between  the  left  side  of 
the  second  lumbar  vertebra  and  the  right  sacro-iliac  joint;  if  deahng  with 
the  large  bowel,  the  finger  will  reach  the  origin  of  the  mesocolon,  or  the 
point  where  the  colon  is  fixed  posteriorly  and  to  the  side."* 

Location  of  a  Loop  of  Small  Intestine  (Figs.  516,  517,  518,  and  519. — 
Monks  points  out  a  plan  by  which,  in  most  instances,  we  can  learn  with  approx- 
imate accuracy  what  portion  of  the  small  intestine  we  may  have  hold  of  ("  An- 
nals of  Surg.,"  Oct.,  1903).  He  learns  first  by  observ'ation  of  the  mesenteric 
vessels.  Opposite  the  upper  portion  of  the  bowel  there  are  primary  vascular 
loops  only  with  perhaps  an  occasional  small  secondary  loop.  As  we  descend, 
"secondary  loops  become  more  numerous,  larger,  and  approach  nearer  to  the 
bowel  than  the  primary  loops  in  the  upper  part,"  and  about  the  fourth  foot 
these  secondary  loops  first  become  a  "prominent  feature."  As  we  descend, 
primary  loops  become  smaller,  secondary  loops  become  more  numerous,  and 
nearer  the  bowel,  and  possibly  tertiary  loops  appear.  Opposite  the  lower  por- 
tion of  the  ileum  the  loops  are  not  definite  in  arrangement,  but  are  simply  a 
network.  Monks  points  out  that  opposite  the  upper  bowel  the  vasa  recta, 
when  put  gently  on  the  stretch,  "are  straight,  large,  and  regular,  and  rarely 
give  off  branches  to  the  mesentery,"  and  are  about  5  cm.  long.  In  the  lower 
one-third  they  are  usually  less  than  i  cm.  long,  are  smaller,  are  not  quite  so 
straight,  are  not  so  regular,  and  give  off  numerous  mesenteric  branches. 
Monks  further  shows  that  fat  impairs  the  translucency  of  the  mesentery.  The 
thinnest  mesentery  is  that  connected  with  the  upper  gut.  As  we  descend  the 
mesentery  becomes  thicker  and  thicker,  because  of  fibrous  tissue,  unstriated 
muscle,  and  fat.  Translucency  varies  greatly.  If  a  loop  of  upper  intestine  is 
raised  against  the  light,  one  notices  close  to  the  gut  and  between  the  vasa  recta 
transparent  lunettes.  The  lunettes  become  smaller  and  fatty  as  we  descend, 
and  disappear  at  the  eighth  foot.  In  an  incision  in  the  median  line,  if  the  loop  of 
*  The  author,  in  Medical  News,  June  9,  1894. 


Location  of  a  Loop  of  Small  Intestine 


943 


Fie  .16  -A  loop  of  intestine,  the  middle  of  which  is  exactly  three  feet  from  the  end  of  the 
duodenum  The  gut  is  of  large  size.  The  mesenteric  loops  are  primary  and  the  vasa  recta 
tree  Ze  and  regular  in  disfribution.  The  translucent  spaces  (lunettes)  between  the  vessels 
ie  ex  enfi've  Below,  the  mesentery  is  streaked  with  fat.  The  veins,  which  had  a  distribution 
;  milar  to  the  arteries  are  for  simplicity  omitted  from  this  and  from  the  subsequent  drawings^ 
T^  suiict  from  which  the  specimen  was  taken  was  a  male  of  forty  years,  with  rather  ess  than 
the  usual  amount  of  fat.     The  entire  length  of  the  intestine  was  twenty-three  feet  (Monks). 


Fig  ^17  -A  loop  of  intestine  at  six  feet.  As  compared  with  Fig.  516  the  gut  is  somewhat 
smaller  The  vascularity  of  the  intestine  and  mesentery  is  less.  Secondary  loops  are  a  promt- 
nTn  feature.  The  vasa  recta  are  smaller.  The  lunettes  are  also  present,  but  are  not  so  large  as 
Tpig  S16!  The  subject  was  a  male  of  about  thirty-five  years,  with  an  average  amount  of  fat. 
The  entire  length  of  the  intestine  was  twenty  feet  (Monks). 


944 


Diseases  and  Injuries  of  the  Abdomen 


intestine  is  pulled  downward  we  can  determine  if  "the  hne  of  resistance  from 
above  is  from  the  median  line  of  the  body  or  from  the  left  or  right  of  it." 


Fig.  518.— A  loop  of  intestine  at  twelve  feet.  The  vessels  are  smaller.  The  primary  loops  are 
lost  in  the  fat,  but  secondarj-  and  even  tertiary  loops  are  visible.  The  vasa  recta  are  shorter,  more 
irregular,  and  branching.  The  specimen  came  from  the  same  subject  which  furnished  Figs.  516 
and  5i7(Monks). 


Fig.  519.— A  loop  of  intestine  at  twenty  feet.  The  gut  appears  to  be  thick  and  large.  The 
mesentery  is  quite  fat  and  opaque,  and  large  and  numerous  fat  tabs  are  present.  The  vessels, 
which  are  complicated,  are  seen  with  difBculty,  and  are  represented  by  mere  grooves  in  the  fat. 
The  subject  was  a  stout  woman,  and  the  entire  length  of  the  gut  was  twenty-one  feet  (Monks). 


Penetrating  Wounds  945 

This  resistance  of  the  mesentery  indicates  to  which  point  the  loop  is  attached, 
and  hence  what  portion  of  bowel  the  loop  comprises.     I  have  used  these 
observations  of  Monks  repeatedly  to  great  advantage. 
Rupture  of  the  Liver  (page  1014). 

Rupture  of  the  Qan=bladder  and  the  Bile=ducts  (page  1014). — Rup- 
ture of  the  gall-bladder  or  the  ducts  is  most  apt  to  happen  from  injury  when 
gall-stones  exist.  Peritonitis,  general  or  local,  is  almost  certain  to  follow  such 
a  rupture.  Besides  those  symptoms  common  to  all  severe  abdominal  injuries, 
there  is  often  intense  jaundice. 

Treatment. — Suture  the  laceration  or  make  a  biliary  fistula. 
Rupture  of  the  Spleen  (page  1046). 

Rupture  of  Mesenteric  Arteries. — The  symptoms  are  those  of  hemor- 
rhage. The  superior  mesenteric  artery,  the  inferior  mesenteric  artery,  or 
branches  of  either  or  both  may  be  damaged.  If  branches  of  the  superior  mes- 
enteric artery  are  divided  near  the  bowel,  gangrene  of  the  bowel  will  result,  but 
wound  of  a  branch  far  from  the  intestine  does  not  cause  gangrene.  The  last 
branches  are  terminal  arteries,  hence  the  gangrene.  The  branches  of  the  artery 
divide  and  form  arcades  arranged  concentrically  and  the  terminal  arteries  come 
from  the  peripheral  arcades.  In  wounds  of  the  vessels  far  removed  from  the 
gut  anastomosis  prevents  gangrene  (Labastie,  in  "Archives  Generales  de  Chi- 
rurgie,"  Jan.  25,  1908).  In  most  cases  in  which  there  has  been  rupture  of 
mesenteric  arteries,  death  from  hemorrhage  rapidly  occurs.  If  the  victim 
should  not  die  of  hemorrhage  he  is  in  danger  of  gangrene  and  peritonitis. 
Aldrich*  reported  a  case  in  which  death  occurred  on  the  seventh  day.  The 
treatment  is  immediate  laparotomy.  If  the  wound  is  found  close  to  the  gut 
the  portion  of  gut  supplied  by  the  cut  vessel  should  be  resected.  If  well 
removed  from  the  gut  simply  ligate  the  vessel  (Labastie,  Ibid.).  In  a  wound 
near  the  root  of  the  mesentery  perform  extensive  resection  of  the  gut  and 
remove  also  a  portion  of  the  mesentery. 
Rupture  of  the  Kidney  (page  1278). 
Rupture  of  the  Ureter  (page  1280). 

Wounds  of  the  Abdominal  Wall. — Non-penetrating  wounds  are 
to  be  treated  on  general  principles.  They  are  sutured  with  great  care  and 
are  firmly  supported  externally.     Ventral  hernia  may  follow  a  large  wound. 

Penetrating  Wounds. — The  symptoms  of  penetrating  wounds  of  the 
abdominal  wall  are  usually  those  of  shock  and  hemorrhage,  and  later  of 
septic  peritonitis.  Emphysema  is  apt  to  occur  and  viscera  may  protrude, 
and  often  do  in  the  case  of  a  large  incised  or  lacerated  wound.  Extrava- 
sation of  contents  of  intra-abdominal  viscera  is  very  apt  to  occur,  and  is 
sure  to  occur  if  the  viscus  was  distended  when  injured.  Normal  urine  and 
normal  bile  may  do  little  harm,  but  if  either  excretion  is  septic,  disastrous 
consequences  are  certain  to  ensue.  If  intestinal  contents  escape,  septic  peri- 
tonitis is  certain  to  occur.  Bleeding  is  usually  profuse  and  prolonged,  because 
spontaneous  arrest  of  hemorrhage  from  any  vessel  of  considerable  size  will 
rarely  take  place  within  the  abdomen. 

Treatment. — The  surgeon  endeavors  to  discover  promptly  if  a  wound  of 
the  abdominal  wall  is  or  is  not  penetrating  in  character.     This  fact  may  be 
proved  by  protrusion  of  viscera,  by  the  appearance  of   stomach-contents 
*  Annals  of  Surgery,  March,  1902. 
60 


94^  Diseases  and  Injuries  of  the  Abdomen 

in  the  wound,  or  by  a  flow  of  bile,  urine,  or  feces  from  the  wound.  If  none  of 
the  above  indications  exists,  and  if  there  are  no  signs  of  serious  hemorrhage, 
the  wound  should  be  irrigated  with  hot  salt  solution,  and  should  be  dressed 
with  gauze,  and  every  effort  should  be  made  to  bring  about  reaction;  otherwise 
operation  should  be  immediate. 

When  reaction  is  obtained,  the  wound  should  be  enlarged  layer  by  layer 
until  it  becomes  obvious  whether  or  not  the  peritoneum  is  open.  Madelung, 
of  Strassburg,  points  out  that  incision  layer  by  layer  will  be  of  no  use  in 
settling  the  question  of  penetration  if  the  wound  is  in  the  chest,  the  buttock, 
the  perineum,  or  the  back  of  a  fat  individual.*  If  after  incision  layer  by 
layer  it  becomes  evident  that  penetration  has  not  occurred,  the  wound  should 
be  closed  and  treated  on  general  principles.  If  it  becomes  evident  that  it 
has  occurred,  the  abdomen  should  be  opened  at  the  point  of  penetration, 
and  a  thorough  exploration  of  intra-abdominal  structures  should  be  made 
in  order  to  determine  injury  and  be  able  to  treat  it  properly. 

In  a  case  still  doubtful  after  incision  by  layers,  do  an  exploratt)ry  lapar- 
otomy in  the  middle  Hne.  It  is  impossible  to  affirm  from  the  appearance  of 
the  wound  and  from  the  symptoms  that  visceral  injury  has  not  occurred; 
hence  in  every  penetrating  wound  in  civil  practice  perform  exploratory  lapa- 
rotomy. 

In  every  case  in  which  it  is  evident  that  penetration  has  occurred,  laparot- 
omy is  necessary  in  order  to  detect  and  correct  intra-abdominal  injury,  and 
to  clean  the  peritoneum  by  flushing  with  hot  salt  solution.  If  viscera  protrude, 
they  must  be  washed  off  with  hot  salt  solution  and  covered  with  hot  sterile 
pads,  and  after  the  patient  has  reacted,  the  wound  should  be  enlarged,  the 
condition  of  the  contents  of  the  abdomen  investigated,  hemorrhage  arrested, 
wounds  properly  treated,  and  the  viscera  returned. 

It  is  customary  to  flush  the  belly  with  hot  salt  solution,  some  of  the  fluid 
being  allowed  to  remain.  This  proceeding  mechanically  cleanses  the  perito- 
neum, removes  blood-clots,  and  strongly  combats  shock.  It  is  not  absolutely 
necessary  to  flush  out  the  belly  unless  a  considerable  hemorrhage  has  occurred 
or  feces  or  stomach-contents  have  been  extravasated.  If  extravasation  of 
stomach-contents  or  feces  has  occurred,  not  only  should  flushing  be  practised, 
but  evisceration  should  be  carried  out;  the  fouled  intestine  should  be  wiped  off 
with  gauze  pads  wet  with  hot  salt  solution,  and  be  wrapped  in  hot  moist  towels; 
the  peritoneal  fossae  should  be  rubbed  with  gauze  pads  and  the  space  between 
the  liver  and  diaphragm  should  be  carefully  wiped. 

A  wound  of  the  stomach  should  be  sutured;  a  wound  of  the  bowel  may  be 
sutured,  or  resection  and  anastomosis  or  resection  and  end-to-end  suturing  may 
be  required.  Visceral  injuries  are  treated  by  appropriate  means.  In  a 
punctured  wound  or  a  gunshot-wound  of  the  intestine  rectal  insufflation  of 
hydrogen  gas  when  the  abdomen  is  open  may  disclose  the  situation  of  the 
injury,  but  evisceration  is  usually  practised  instead. 

After  the  completion  of  intra-abdominal  manipulations  the  surgeon 
restores  any  protruding  bowel. 

Drainage  is  required  when  the  contents  of  the  stomach  or  the  intestines  have 
escaped,  when  hemorrhage  is  severe,  or  when  the  liver,  pancreas,  kidney,  or 
spleen  is  found  to  be  damaged.  The  peritoneum  may  be  sutured  with  a  con- 
*  Annals  of  Surgery,  Sept.,  1897. 


Gunshot-wounds  of  the  Abdomen  947 

tinuous  suture  of  catgut,  and  the  muscles,  fascia,  and  skin  with  interrupted 
sutures  of  silkworm-gut,  or  through-and-through  sutures  of  silkworm-gut  may 
be  used.  Active  stimulation  and  artificial  heat  are  needed  immediately  after 
the  operation  to  combat  shock.  In  many  cases  intravenous  infusion  of  hot 
normal  salt  solution  is  of  great  value.  It  may  be  given  both  during  and  after 
operation.  Enteroclysis,  or  high  rectal  injection  of  hot  saline  fluid,  is  useful. 
So  is  hypodermoclysis,  or  the  subcutaneous  injection  of  hot  salt  solution.  The 
after-treatment  consists  of  the  semierect  position,  continuous  proctoclysis  of  salt 
solution,  avoidance  of  food  by  the  stomach  for  forty-eight  hours,  and  the  admin- 
istration of  brandy  and  water  from  time  to  time.  For  two  days  the  patient 
should  be  fed  by  the  rectum.  On  the  appearance  of  the  first  sign  of  peritonitis, 
forty-eight  hours  or  more  after  the  operation,  give  a  saline  cathartic.  It  is  not 
wise  to  purge  during  the  first  forty-eight  hours  after  the  operation,  unless  a 
Murphy  button  was  used.  When  there  is  no  sign  of  peritonitis,  a  purge  should 
not  be  given  until  the  fourth  day.  After  forty-eight  hours  liquid  food  can  usually 
be  given  by  the  stomach.  Solid  food  may  be  given  after  seven  or  eight  days, 
but  the  patient  must  not  leave  his  bed  until  the  wound  is  firmly  united,  because 
of  the  danger  of  ventral  hernia.  A  support  should  be  worn  for  a  long  time. 
E.  D.  Fenner*  reports  39  stab  wounds  of  the  abdomen  operated  upon  in  the 
Charity  Hospital  of  New  Orleans.     There  were  9  deaths  (23.07  per  cent.). 

Qunshot=WOUnds  of  the  Abdomen.— The  bullet  may  penetrate  from 
the  front,  the  side,  the  back,  the  chest,  or  the  perineum.  If  a  bullet  has  pene- 
trated, it  may  or  it  may  not  have  produced  visceral  damage.  A  pistol-bullet  or 
the  bullet  of  a  sporting-rifle  usually  does ;  a  projectile  of  a  modern  military  rifle 
may  not  or  may  produce  wounds  which  can  be  recovered  from  without  operation. 
A  urinary  examination  should  be  made  promptly  to  see  if  blood  is  present. 

In  gunshot-wounds  of  the  belly  shock  is  usually  due  to  hemorrhage,  and  in 
civil  practice  certainly  prompt  operation  is  indicated.  The  incision  is  made 
through  the  belly  even  when  the  shot  entered  the  back.  In  some  cases  the 
opening  is  made  through  the  wound;  in  others  it  is  not;  but  in  every  case  the 
wound  is  explored  and  cleaned.  The  incision  should  be  long  enough  to 
permit  of  thorough  work.  After  opening  the  abdomen  our  first  duty  is  to 
arrest  hemorrhage,  our  next  is  to  look  for  perforations  of  the  viscera  and 
mesentery  and  close  them.  If  the  anterior  wall  of  the  stomach  is  perforated, 
close  the  opening  and  examine  the  posterior  wall  through  an  opening  made  in 
the  gastrocolic  omentum.  If  a  posterior  perforation  is  found,  close  it  and 
insert  posterior  drainage  into  the  lesser  peritoneal  cavity.  As  a  rule,  an 
intestinal  perforation  can  be  closed,  but  occasionally  a  portion  of  the  intestine 
requires  resection.  If  the  bullet  is  encountered  it  is  removed,  but  a  prolonged 
search  for  it  should  never  be  made.  Finally  the  abdominal  cavity  is  cleansed, 
drainage  is  provided  for,  and  the  abdominal  wound  is  closed.  In  one  of  my 
fatal  cases  the  bullet  entered  the  rectum  low  down  and  was  not  found.  In  a 
case  of  mine  with  6  perforations  of  the  small  intestine  recovery  followed  operation. 

E.  D.  Fenner  f  reports  113  gunshot- wounds  of  the  abdomen  operated 
upon  in  the  Charity  Hospital  of  New  Orleans;  there  were  78  deaths  (69  per 
cent.).  In  a  series  of  14  cases  operated  upon  by  Vaughan  the  mortality 
was  64  per  cent.  ("Am.  Jour.  Med.  Sciences,"  Feb.,  1906). 

Military  surgeons  have  shown  that  wounds  inflicted  by  the  modem  hard- 

*  Annals  of  Surgery,  January,  1902.  f  Ibid. 


94^  Diseases  and  Injuries  of  the  Abdomen 

jacketed  projectile  are  not  so  apt  to  involve  fatal  hemorrhage  and  disastrous 
complications;  in  fact,  such  wounds  are  often  recovered  from  without  opera- 
tion, and  sometimes  with  an  entire  absence  of  serious  symptoms.  Again,  it  is 
difficult  or  impossible  to  treat  such  cases  as  in  civil  practice,  even  were  it 
desirable.  In  fact,  in  military  practice  the  results  are  slightly  better  from 
expectant  treatment,  whereas  in  civil  practice  the  reverse  is  true.  Still,  even 
in  war,  if  conditions  permit,  operation  should  be  performed  if  there  is  hem- 
orrhage or  obvious  visceral  injury,  or  if  septic  peritonitis  develops.  Treves 
says  that  in  the  Boer  War  only  40  per  cent,  of  cases  of  gunshot-wounds  of 
the  abdomen  not  operated  upon  died,  but,  as  pointed  out  by  Hildebrandt, 
many  cases  die  on  the  battle-field  and  while  being  taken  to  the  hospital,  hence 
the  mortality  is  much  higher.  In  the  war  between  China  and  Japan  the  mortal- 
ity from  gunshot-wounds  of  the  abdomen  is  said  to  have  been  about  77  per 
cent. 

Qunshot=wounds  of  the  Pregnant  Uterus.— It  is  rarely  that  both 
walls  are  perforated,  as  the  force  of  the  bullet  is  greatly  lessened  by  the  uterine 
contents.  As  a  rule,  there  are  severe  shock  and  hemorrhage,  and  occasionally 
amniotic  fluid  flows  from  the  wound  of  entrance.  The  intestine  may  also  be 
injured.  As  a  rule,  labor  pains  come  on  soon  after  the  injury.  Gellhorn* 
has  collected  18  cases.  In  this  series  there  were  12  recoveries.  The  proper 
treatment  early  in  pregnancy,  if  the  wound  is  small,  consists  in  emptying  the 
uterus  and  closing  the  wound.  A  large  wound,  or  any  wound  late  in  preg- 
nancy, demands  the  Porro  operation — removal  of  the  uterus,  ovaries,  and  tubes. 

Omental  Cysts. — Cysts  may  spring  from  the  outer  surface  of  the  omen- 
tum (escaped  ovarian  cysts,  lymphatic  cysts,  dermoids). 

True  omental  cysts  arise  within  the  cavity  of  the  great  omentum.  There 
are  20  cases  on  record  (Edwin  M.  Hasbrouck,  in  "Annals  of  Surgery,"  August, 
1908).  In  50  per  cent,  of  cases  the  patient  is  an  adult,  but  half  of  the  reported 
cases  were  under  ten  years  old.  (Some  of  these  were  of  congenital  origin.) 
Hasbronck  (Ibid.)  points  out  that  the  condition  is  much  more  common  in 
females  than  in  males,  that  there  are  no  characteristic  symptoms,  that  the  con- 
dition begins  as  omental  endothehoma  between  the  two  surfaces  of  omentum 
which  fuse  because  of  inflammation  and  form  a  closed  sac,  that  hemorrhages 
are  apt  to  occur  into  the  cyst,  and  that  operation  shows  a  mortality  of  6  per 
cent.     The  operation  performed  is  extirpation. 

Mesenteric  Cysts. — These  rare  cysts  are  divided  into  (i)  embryonic, 
(2)  hydatid,  (3)  cystic  mahgnant  disease  (Dowd,  "Annals  of  Surgery,"  1900). 
A  great  majority  of  mesenteric  cysts  are  embryonic.  Moynihan  believes  that 
embryonic  cysts  arise  from  "rests"  from  "the  Miillerian  or  Wolffian  organs  or 
ducts,  or  from  the  ovary,"  which  are  included  between  the  folds  of  mesentery. 
These  rests  undergo  cystic  degeneration.  Mesenteric  cysts  grow  and  pass  along 
between  the  layers  of  mesentery  until  they  reach  the  gut  and  then  compress 
the  gut  and  push  its  wall  ahead  of  them. 

Such  a  cyst  may  contain  embryonal  material,  bloody  fluid,  serous  fluid, 
chylous  fluid,  or  lymph.  In  Harry  C.  Deaver's  report  of  a  case  ("Annals  of 
Surgery,"  May,  1909)  it  is  shown  that  in  40  cases  there  were  25  females  and 
15  males;  that  the  size  varies  from  that  of  a  spHt  pea  to  enormous  dimensions; 
that  there  may  be  a  pedicle  form  in  front  of  the  vertebral  column  or  from  the 
*  St.  Louis  Med.  Review,  Dec.  2  and  9,  1901. 


Foreign  Bodies  in  the  Stomach  and  Intestine  949 

intestinal  wall;  that  the  sac  wall  may  be  exceedingly  thin  or  as  much  as  i  cm.  in 
thickness;  that  in  some  cases  large  veins  are  present  on  the  surface  of  the  cyst; 
that  adhesions  to  the  abdominal  viscera  are  common;  that  intestmal  obstruc- 
tion may  occur  (kinks,  volvulus,  intussusception) ;  that  cysts  are  most  commonly 
found  in  relation  with  the  lower  end  of  the  ileum;  and  that  there  are  no  char- 
acterisdc  svmptoms  except  perhaps  the  rapid  body  wastmg  mentioned  by 
Movnihan  '  Moynihan  points  out  that  the  cyst  fluctuates  and  is  most  promi- 
nent toward  the  navel,  that  it  is  very  mobile,  especially  transversely  (we 
should  add  if  not  anchored  by  adhesions),  and  that  the  cyst  is  surrounded 
by  a  resonant  zone  and  crossed  by  a  resonant  band. 

Treatment.— Incision  and  drainage  if  there  are  numerous  and  farm  ad- 
hesions Enucleation  whenever  possible.  Resection  of  the  involved  portion 
of  gut  with  the  cyst  in  some  cases  of  multiple  cyst  (Harry  C.  Deaver,  Ibid.). 

Stomach  and  Intestines. 
Foreign  Bodies  in  the  Stomach  and  Intestine.— Foreign  bodies 

of  considerable  size  are  rarely  taken  into  the  alimentary  canal  except  by  chil- 
dren, insane  people,  or  drunkards.     Small  bodies  (bits  of  straw,  fragments 
of   bone,  etc.)  are   frequently  swallowed.     Most  foreign   bodies  swallowed 
are  passed  with  the  feces,  but  some  lodge.     Any  body  which  can  pass  the 
esophagus  is  not  too  large  to  pass  through  the  intestines.     Lodgment  is  an 
accident,  not  an  inevitable  consequence— an  accident  which  is  due  to  the 
shape  and  size  of  the  body.     A  foreign  body  may  lodge  in  the  stomach.     In 
some  cases  there  are  no  symptoms.     In  other  cases  symptoms  are  violent.    The 
severity  of  the  symptoms  depends  upon  the  shape  and  character  of  the  body. 
In  some  cases  it   is  possible  to  feel  the  body  from  without.      A  metal 
body  in  the  stomach  will   deflect  a  magnetic  needle  held  over   the  viscus 
(Polaillon) .     Many  foreign  materials  can  be  skiagraphed.     A  body  of  small 
size  may  pass  through  the  entire  canal  and  emerge  without  having  done  any 
harm,  but  it  may  lodge  and  may  cause  perforation.     If  perforation  occurs, 
the  foreign  matter  may  become  encysted,  for  instance,  in  the  mesentery;  may 
cause  an  abscess  or  may  cause  general  peritonitis.     A  fish-bone  may  cause 
an  anal  abscess.     An  epiploic  appendix  may  cause  sacculation  of  the  bowel, 
perforation  may  take  place  in  this  sac,  an  epiploic  abscess  resulting,  which 
may  attain  considerable  size  and  may  be  mistaken  for  carcinoma  (J.  Bland 
Sutton,  in  "Lancet,"  Oct.  24,  1903).     It  is  not  wise  to  attempt  to  recover 
a  foreign  body  from  the  stomach  by  inducing  vomiting.     In  some  cases  gas- 
trotomy  is  necessary.     When  a  small  or  sharp  foreign  body  has  been  swallowed 
and  has  not  caused  perforation,  abscess,  or  obstruction,  the  usual  treatment 
is  as  follows:   a  purgative  should  never  be  given  to  expedite  the  passage  of  a 
foreign  body,  because  increased  peristalsis  means  increased  danger  of  impac- 
tion or  of  perforation.     Endeavor  to  encrust  the  foreign  body,  and  thus  lessen 
the  danger  of  perforation,  by  feeding  with  bread  and  milk  only  for  several 
days,  and  at  the  end  of  this  period  give  a  mild  laxative.     An  exclusive  diet  of 
mush  or  of  mashed  potatoes  has  been  suggested.     Suet  dumplings  may  be  given. 
Pain  is  reUeved  by  opium.     A  foreign  body  rarely  lodges  in  the  duodenum, 
but  may  lodge  lower  down,  and  may  cause  ulceration,  perforation,  abscess, 
or  intestinal  obstruction.     Operation  is  necessary  in  such  cases. 


950  Diseases  and  Injuries  of  the  Abdomen 

Volvulus  of  the  Stomach. — This  condition  is  very  unusual.  Ten  cases 
are  on  record  (Streit,  in  "Am.  Jour.  Med.  Sciences,"  June,  1906).  One-third 
of  the  cases  are  associated  with  diaphragmatic  hernia.  The  symptoms  come 
on  suddenly  with  sudden  abdominal  pain,  distention,  and  collapse.  There 
is  nausea,  but  the  patient  can  neither  vomit  nor  belch.  In  the  upper  left 
abdomen  there  is  a  tender,  tense,  and  tympanitic  area.  The  rotation  of  the 
stomach  may  be  on  its  verdcal  or  on  its  longitudinal  axis.  An  hour-glass 
stomach  may  undergo  twisdng  on  its  verdcal  or  longitudinal  axis.  Bet-g 
operated  successfully  for  volvulus  of  the  stomach.  He  opened  the  abdomen, 
relieved  distention  by  tapping  the  stomach  with  a  trocar,  and  then  easily 
corrected  the  twist.  The  gastrohepadc  omentum  should  be  shortened  by 
Beyea's  operation  (page  1091). 

Carcinoma  of  the  Stomach. — Innocent  tumors  and  sarcomata  occa- 
sionally attack  the  stomach,  but  they  are  infinitely  rare  in  comparison  with 
primary  cancer.  This  disease  is  unusual  before  the  age  of  forty,  and  is  prac- 
tically never  seen  before  the  age  of  thirty.  It  is  more  common  in  men  than 
in  women,  the  proportion  being  as  5  to  4.  In  a  very  few  instances  cancer 
has  been  found  to  have  arisen  from  an  ulcer.  The  forms  of  cancer  which  may 
arise  in  the  stomach  are  the  spheroidal  cell  growth  (either  the  hard  form  known 
as  scirrhus  or  the  soft  form  known  as  medullary  or  encephaloid) ,  the  cylindric 
cell  growth  or  adenocarcinoma,  and  colloid  (due  to  the  myxomatous  degen- 
eration of  either  a  spheroidal  cell  or  a  cylindric  cell  carcinoma).  Scirrhus 
more  than  any  other  form  produces  constriction  of  the  pylorus  and  more 
seldom  than  any  other  form  produces  hemorrhage.  It  may  spread  for  a  con- 
siderable distance  along  the  submucous  coat,  muscular  coat,  and  subserous 
coat  without  apparent  involvement  of  the  mucus  membrane  wide  of  the  pri- 
mary focus  of  disease.  In  some  cases  scirrhus  is  limited  to  the  pyloric  region, 
in  others  it  is  a  limited  tumor  of  some  other  part  of  the  wall  of  the  stomach: 
In  the  condition  known  as  "leather-bottle  stomach"  a  scirrhus  has  invaded 
the  entire  stomach  wall  and  the  wall  of  the  viscus  is  thick  and  rigid. 

Medullary  cancer  and  adenocarcinoma  produce  hemorrhage.  Both  of 
these  forms  most  often  arise  in  the  pyloric  region.  Medullary  cancer  may 
remain  limited,  but,  as  a  rule,  a  cauliflower  growth  arises  and  eventually 
fills  the  stomach  and  portions  of  the  mass  may  slough  away. 

Adenocarcinoma  is  apt  to  spread  along  the  mucous  membrane  instead  of 
"infiltrating  the  deeper  layers"  as  other  forms  are  prone  to  do  ("Cancer  and 
Tumors  of  the  Stomach,"  by  Samuel  Fenwick  and  W.  Soltan  Fenwick). 
Spheroidal  celled  carcinomata  are  twice  as  common  as  cylindric  celled  and 
medullary  cancer  is  about  as  common  as  scirrhus. 

Cancer  may  be  Hmited  to  the  body  of  the  stomach  (either  curvature  or 
either  wall),  the  pyloric  end  or  the  cardiac  end,  but  it  may  involve  two  of  these 
regions,  or  almost  the  entire  stomach,  or,  being  multiple,  may  be  found  in 
many  parts.  Sometimes  there  is  a  primary  cancer  on  one  wall,  and  another 
quite  due  to  contact,  in  a  corresponding  point  of  the  opposite  wall  (contact 
cancer).  All  forms  of  carcinoma  most  frequently  begin  in  the  region  of  the 
pylorus.  In  many  cases  of  gastric  carcinoma  adhesions  form  between  the 
stomach  and  the  liver,  colon,  or  diaphragm.  Even  in  cancer  of  the  pylorus 
the  duodenum  is  seldom  invaded.  Medullary  cancer  not  unusually  passes 
into  the  esophagus.     It  is  usually  fatal  in  from  four  months  to  two  years,  and 


Carcinoma  of  the  Stomach  951 

most  patients  die  within  one  year.  In  60  per  cent,  of  cases  the  pylorus  is 
involved.  In  over  half  of  the  cases  of  cancer  of  the  pylorus  there  is  no  im- 
portant lymphatic  involvement  (McArdle).  In  investigating  any  gastric 
disorder  follow  Mayo's  advice  and  study  the  history,  the  size  and  situation  of 
the  stomach,  determine  the  existence  and  situation  of  pain  and  tenderness,  the 
presence  of  a  tumor,  and  if  the  passage  of  food  is  interfered  with. 

Symptoms. — Examine  with  care  a  patient  in  whom  cancer  is  suspected.  In 
unusual  cases  it  produces  no  symptoms  until  it  has  lasted  for  some  time  and 
has  attained  a  large  size  (latent  cancer).  In  nearly  all  cases  it  does  produce 
symptoms.  The  disease  comes  on  gradually,  usually  with  indigestion  and  physi- 
cal weakness.  The  patient  has  persistent  dragging  pain,  which  is  increased  by 
eating  and  pressure,  and  attacks  of  vomiting  are  frequent.  x\fter  a  short  time 
the  patient  becomes  very  weak  and  exceedingly  anemic,  and  it  is  often  possible 
to  feel  a  tumor  in  the  stomach.  Blood  examination  shows  diminution  of  red 
corpuscles  and  hemoglobin  and  perhaps  absence  of  any  increase  of  leukocytes 
after  a  full  meal.  The  vomiting  of  gastric  cancer  is  at  first  only  occasional,  but 
as  the  case  progresses  it  becomes  more  and  more  frequent.  \'omiting  soon  after 
eating  occurs  when  the  cardiac  region  is  involved;  vomiting  an  hour  or  so  after 
eating  occurs  when  the  pyloric  end  is  involved.  When  the  body  of  the  organ 
is  the  seat  of  disease,  vomiting  may  be  absent.  The  vomited  matter  is  often 
mixed  with  a  small  amount  of  altered  blood  {coffee-ground  vomit).  In  most 
cases  occult  blood  is  found  in  the  feces,  especially  if  hydrochloric  acid  is 
absent  from  the  stomach  contents.  These  symptoms  associated  with  "coffee- 
ground  vomit"  and  lactic  acid  in  the  stomach  contents  are  strongly  indica- 
tive of  cancer  (AVm.  J.  Mayo,  in  "Surg.,  G}Tiec.,  and  Obstet.,"  May, 
1908).  A  test-meal  is  given  and  important  conclusions  are  sometimes  derived 
from  the  presence  or  absence  of  hydrochloric  acid  and  lactic  acid.  It  is  my 
custom  to  have  the  stomach  washed  out  and  then  have  Ewald's  test-breakfast 
given.  This  consists  of  one  roll  of  white  bread  (35  gm.),  400  gm.  of  H^O,  and 
400  gm.  of  tea  without  milk  or  sugar.  In  one  hour  the  stomach  is  emptied  by 
means  of  a  tube  and  a  pump  or  a  tube  and  abdominal  compression,  and  the 
material  is  examined.  If  the  result  of  the  test  seems  out  of  accord  with  the 
other  symptoms,  repeat  the  process  (L.  Boas,  in  "Berlin,  khn.  Woch.,"  No.  440, 
1905).  In  most  cases  free  hydrochloric  acid  is  not  found  in  the  stomach- 
contents,  but  lactic  acid  is  found  and  Oppler's  bacillus  can  often  be  detected. 
There  may  be  red  blood-corpuscles  in  the  fluid.  If  the  cancer  is  not  ulcerated, 
free  hydrochloric  acid  ^\•ill  probably  be  found;  if  it  is  ulcerated,  it  will  usually 
be  absent.*  Free  hydrochloric  acid  may  be  absent  from  the  stomach  because 
of  atrophy  of  glands,  cessation  of  secretion,  or  neutralization  by  the  products 
of  the  cancerous  area.  Free  hydrochloric  acid  may  be  absent  when  cancer 
does  not  exist.  I  have  noted  its  absence  in  two  cases  of  cicatricial  stenosis 
of  the  pylorus. 

It  may  be  absent  in  cancer  of  the  esophagus,  advanced  Bright's  disease, 
cancer  of  the  duodenum,  febrile  conditions,  and  amyloid  disease.  The  con- 
stant presence  of  considerable  quantities  of  hydrochloric  acid  is  strong  e\'i- 
dence  against  the  existence  of  cancer  of  the  stomach.  If  cancer  arises  from 
ulcer,  free  hydrochloric  acid  is  apt  to  be  present  for  a  considerable  time. 

*  Reissner,  in  Miinchen.  med.  Woch.,  Dec.  3,  igor. 


952  Diseases  and  Injuries  of  the  Abdomen 

Distend  the  stomach  with  gas  or  iluid  and  map  out  its  outlines.  Feel  for 
a  tumor.  A  tvunor  can  usually  be  felt  if  it  involves  the  greater  curvature  or 
anterior  wall,  and  a  large  tumor  of  the  pylorus  can  be  palpated,  but  in  other 
regions  the  tumor  can  rarely  be  felt. 

Cancer  of  the  cardiac  end  interferes  with  the  entrance  of  food  into  the 
stomach,  and  in  such  a  case  the  stomach  is  shrunken  and  the  esophagus  is 
dilated  immediately  above  the  growth.  In  cancer  of  the  pylorus  the  food  is 
partially  or  completely  arrested  as  it  passes  to  emerge  from  the  stomach,  and 
the  stomach  becomes  much  dilated.  The  vomited  matter  in  a  case  of  cancer 
rarely  contains  recognizable  fragments  of  the  growth,  but  fluid  with  which 
the  stomach  has  been  irrigated  may  contain  pieces  which  can  be  identified 
as  cancer  (Rosenbach). 

In  cancer  of  the  stomach  the  general  course  of  the  temperature  is  normal, 
but  there  are  occasional  deviations  to  below  or  above  normal.  In  many  cases 
the  urine  contains  albumin,  indican,  acetone,  and  casts.  Occasionally 
cancer  of  the  stomach  produces  spasm  of  the  esophagus.  I  have  seen  this 
in  two  cases.  Cancer  of  the  stomach  is  apt  to  involve  secondarily  adjacent 
l}Tnph-glands,  or  organs  or  other  structures,  especially  the  liver;  in  fact, 
the  liver  is  involved  in  30  per  cent,  of  the  cases  (Welch).  Occasionally  there 
is  enlargement  of  the  supraclavicular  glands  of  the  left  side.  Metastases  are 
usual  and  early,  but  in  cancer  of  the  pylorus  60  per  cent,  of  the  cases  show  no 
distinct  lymphatic  involvement.  In  many  doubtful  cases  exploratory  incision 
is  justifiable. 

Treatment. — The  medical  treatment  consists  in  milk-diet  and  the  use  of 
morphin  and  of  lavage  if  the  pylorus  or  body  of  the  stomach  is  diseased.  Per- 
form lavage  as  follows :  The  tube  for  lavage  should  be  long  enough  to  extend 
about  three  feet  out  of  the  mouth  when  the  other  end  is  in  the  stomach,  it 
should  be  flexible,  should  have  an  opening  in  the  stomach-end  and  another 
opening  on  the  side  about  one  inch  above  the  stomach-end.  The  tube  should 
be  greased  with  glycerin.  The  patient  sits  down,  throws  the  head  back,  opens 
the  mouth  widely,  and  is  directed  to  take  deep  breaths  at  regular  intervals. 
The  tube  is  carried  into  the  pharynx,  the  patient  is  ordered  to  make  efforts  to 
swallow  it,  and  the  tube  is  thus  taken  into  the  stomach.  About  one  quart  of 
fluid  is  poured  into  the  funnel-like  end  of  the  tube,  and  just  before  the  tube 
empties  itself  of  the  last  of  the  water  the  funnel  is  lowered  and  the  fluid  runs 
out.  This  proceeding  is  repeated  till  the  fluid  becomes  clear.  The  best  fluid 
to  use  is  a  solution  of  bicarbonate  of  sodium,  a  teaspoonful  of  the  salt  to  a 
quart  of  warm  water.  Lavage  should  be  practised  before  breakfast,  and 
sometimes  also  at  bed-time. 

The  indications  for  operation  are  well  set  forth  by  Macdonald:*They  are 
progressive  aggravation  of  sjonptoms  in  spite  of  a  rigid  diet  and  medical 
treatment,  loss  of  gastric  mobihty,  progressive  diminudon  of  gastric  peri- 
stalsis, progressive  diminution  of  free  hydrochloric  acid,  emaciation  even 
under  forced  feeding,  progressive  reduction  of  hemoglobin  to  65  per  cent,  or 
under,  and  moderate  leukocytosis. 

Surgical  treatment  aims  to  remove  the  growth  or  to  obviate  the  eff'ect 
of  obstruction  at  one  of  the  orifices  of  the  stomach. 

*  John  B.  Murphy,  in  Chicago  Med.  Recorder,  June,  15,  1902. 


Sarcoma  of  the  Stomach  953 

In  cancer  of  the  body  of  the  stomach,  if  the  growth  is  not  extensive,  exci- 
sion may  be  performed;  if  it  is  extensive,  it  is  useless  to  attempt  it  unless  the 
growth  is  absolutely  non-adherent.  Conner,  of  Cincinnati,  attempted  total 
excision  in  1883,  but  the  patient  died  on  the  table.  In  1897  Schlatter,  of 
Zurich,  successfully  removed  the  entire  stomach.  Brigham,  Richardson,  Mac- 
donald,  Boeckel,  De  Carvalho,  Bardeleben,  Haine,  Gallet,  DoUinger,  Ferry, 
Ribera,  and  others  have  successfully  removed  the  entire  stomach  and  attached 
the  esophagus  to  the  small  intestine  {complete  or  total  gastrectomy).  In  these 
cases  digestion  was  satisfactorily  performed  after  removal  of  the  stomach. 
Very  rarely  will  cases  be  found  suitable  for  such  a  radical  proceeding.  The 
case  suitable  for  this  treatment  is  one  in  which  the  entire  stomach  is  involved 
in  the  growth,  in  which  there  is  no  obvious  glandular  involvement,  and  in 
which  the  stomach  is  not  adherent,  but  is  freely  movable.  Herbert  J.  Patterson 
("The  Hunterian  Lectures  for  1906")  collected  27  cases  of  total  gastrectomy 
for  cancer:  10  died  and  17  recovered.  If  a  small  portion  of  the  fundus  is 
left  the  operation  is  called  subtotal  gastrectomy.  H.  J.  Patterson  (Ibid.) 
collected  20  cases  of  subtotal  gastrectomy  for  cancer  with  6  deaths.  In 
limited  cancer  of  the  body  of  the  stomach  perform  partial  gastrectomy.  In 
cancer  of  the  cardiac  orifice  of  the  stomach  the  surgeon  usually  keeps  the 
passage  open  as  long  as  possible  by  the  frequent  passage  of  a  tube,  and  through 
this  tube  introduces  liquid  food.  Sometimes  a  small  tube  is  introduced 
and  permanently  retained.  When  it  becomes  difficult  to  introduce  a  tube, 
gastrostomy  may  be  performed.  As  a  matter  of  fact,  in  most  cases  gastrostomy 
is  done  as  a  last  resort,  and  it  is  scarcely  worth  doing  in  cancer  of  the  cardiac 
end  of  the  stomach.  It  is  far  more  useful  in  cancer  of  the  esophagus.  In 
cancer  of  the  pylorus,  limited  in  extent  and  without  lymphatic  involvement, 
pylorectomy  may  be  performed;  but  in  cancer  which  has  widely  infiltrated 
the  coats  of  the  stomach  and  has  involved  the  lymphatic  glands,  gastro-enter- 
ostomy  is  performed  as  a  palHative  measure,  the  patient  during  the  rest  of 
his  life  subsisting  upon  liquid  or  semiliquid  foods  and  submitting  to  frequent 
irrigation  of  the  stomach  to  remove  food-residue.  In  cases  of  irremovable 
and  far-advanced  cancer  it  is  often  best  to  refuse  to  operate  and  to  deliber- 
ately create  the  opium-habit  in  the  patient. 

The  most  successful  of  all  the  above  operations  are  pylorectomy  and  partial 
gastrectomy.  The  mortality  is  large.  In  H.  J.  Patterson's  series  of  cases  the 
mortality  was  28  per  cent.  There  are  in  literature  43  cases  which  have  sur- 
vived three  years  or  over  (Macdonald) .  Mayo  reported  2 1  gastro-enterostomies 
for  cancer  with  4  deaths.  The  greatest  prolongation  of  life  was  nineteen 
months.  His  experience  makes  him  question  if  the  operation  is  worth  doing  in 
mahgnant  disease. 

Sarcoma  of  the  Stomach. — Of  recent  years  it  has  been  proved  that 
sarcoma  is  more  common  than  was  once  supposed.  There  are  over  60  cases 
on  record.  It  can  occur  at  any  age,  but  is  more  usual  in  early  life  than  is  car- 
cinoma. It  has  been  estimated  by  Wm.  T.  Howard*  that  37.7  per  cent,  of 
cases  are  under  the  age  of  forty,  and  11.44  per  cent,  are  under  the  age  of 
twenty.  The  pylorus  is  involved  in  about  one-fourth  of  the  cases.  In  most 
cases  the  posterior  wall  and  greater  curvature  are  involved.  Howard  says 
there  is  a  diffuse  growth  in  21.31  per  cent,  of  cases  and  that  the  cardiac  end  is 
*  Jour.  Am.  Med.  Assoc,  Feb.  8,  1902. 


954  Diseases  and  Injuries  of  the  Abdomen 

involved  in  only  4.9  per  cent,  of  cases.  Sarcoma  arises  in  tiie  submucous  coat. 
Any  form  of  sarcoma  may  arise.  It  causes  stenosis  in  less  than  one-tenth  of 
the  cases.     There  is  no  sex  predisposition  in  sarcoma,  as  there  is  in  cancer. 

Symptoms. — A  tumor  forms,  grows  rapidly,  and  often  attains  a  large  size, 
and  not  unusually  actually  causes  a  projection  of  the  abdominal  wall.  If  it 
ulcerates,  there  will  be  hematemesis,  but  it  often  does  not  ulcerate,  and  bleed- 
ing is  much  rarer  than  in  carcinoma.  Not  unusually  this  growth  arises  in  a 
person  under  forty,  and  sometimes  in  one  of  less  than  twenty  years  of  age. 
Stenosis  is  uncommon.  The  liver  is  involved  secondarily  in  only  11.47  P^r 
cent,  of  cases  (Howard) ,  metastases  are  more  rare  than  in  carcinoma,  free  hy- 
drochloric acid  is  usually  absent  from  the  gastric  contents,  and  microscopic 
examinadon  of  washings  from  the  stomach  may  detect  fragments  of  sarcoma. 
Certain  diagnosis  is  impossible  without  exploratory  incision.  Howard  esti- 
mates the  average  duration  of  life  to  be  from  nine  to  ten  months. 

Treatment. — If  the  hver  is  free  and  if  there  are  no  metastases,  partial 
gastrectomy  or  complete  gastrectomy  may  be  ad\nsable.  If  pyloric  stenosis 
should  arise,  gastro-enterostomy  may  be  performed. 

Ulcer  of  the  Stomach. — Ulcer  of  the  stomach  is  a  condition  due  to 
digesrion  of  a  portion  of  the  stomach-wall  by  very  acid  gastric  juice,  the 
destroyed  portion  having  been  the  seat  of  lowered  vitahty.  The  reason  for 
the  lowered  vitahty  of  the  gastric  mucous  membrane  is  uncertain.  Thrombo- 
sis has  been  suggested  as  a  cause,  but  it  is  rare  in  gastric  ulcer.  Embohsm 
is  assigned  by  some  as  a  cause,  but  emboli  are  seldom  found  on  pathologic 
examination.  It  has  been  asserted  that  menstrual  disorders  may  be  respon- 
sible for  ulcer,  that  tight  lacing  may  be,  and  that  habitually  bending  over  (as  in 
making  shoes)  may  be  a  cause.  The  Mayos  are  of  the  opinion  that  the  grind- 
ing action  of  the  pyloric  portion  of  the  stomach  may  be  an  exciting  cause  of 
ulcer  of  that  region.  Some  assert  that  mental  anxiety,  alcohohsm,  and  syphilis 
may  be  causal  (Alderson).  Ulcers  due  to  s\TDhihs  and  tuberculosis  are  not 
peptic  ulcers. 

Robson  believes  that  gastric  ulcer  is  septic  in  origin  and  that  oral  sepsis 
is  responsible  for  its  origin  in  most  cases.  "Mild  sepsis  leads  to  gastritis  and 
hyperchlorhydria,  which  in  its  turn  provokes  and  keeps  up  ulceration"  (A.  W. 
Mayo  Robson,  in  "Keen's  Surgery,"  vol.  iii).  Some  observers  blame  direct 
damage  to  the  mucous  membrane  by  traumatism  or  the  swallowing  of  corrosive 
liquid.  The  question  of  cause  is  involved  in  uncertainty.  What  does  seem  to 
be  certain  is  that  anemia  predisposes  to  the  formation  of  very  acid  gastric  juice 
(hyperchlorhydria)  and  to  ulceration.  In  some  cases  chlorosis  is  associated 
with  ulcer. 

Ulcers  are  far  more  common  in  females  than  in  males,  and  are  more  fre- 
quent in  young  women  than  in  those  of  middle  or  advanced  age.  The  acute 
round  ulcer  is  vastly  more  common  in  women.  The  chronic  indurated  ulcer 
is  most  frequent  in  men.  jMen  about  forty  and  women  between  twenty  and 
thirty  are  particularly  Hable.  There  is  usually  a  single  ulcer,  but  in  one-fifth 
of  all  cases  there  are  two  or  more,  and  when  there  is  an  ulcer  on  the  anterior 
wall,  it  is  not  uncommon  to  find  one  exactly  opposite  on  the  posterior  wall 
("a  kissijig  ulcer"  Moynihan  calls  it).  The  Mayos  di\-ide  ulcers  into  two 
chnical  forms — the  indurated  and  the  non-indurated.  In  the  indurated  ulcer 
all  the  coats  of  the  stomach  are  involved  and  the  mass  of  scar  tissue  indicates 


Symptoms  of  Ulcer  of  the  Stomach  955 

an  effort  at  repair.  The  most  common  situation  for  this  form  of  ulcer  is  the 
region  of  the  pylorus  (Wm.  J.  Mayo,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  21, 
1905).  The  non-indurated  ulcer  involves  the  mucous  coat  only  and  may 
be  of  microscopic  size,  and  even  a  microscopic  ulcer  may  cause  death  from 
hemorrhage  (Wm.  J.  Mayo).  These  non-indurated  ulcers  exhibit  no  sign, 
or  almost  no  sign,  on  the  outer  surface  of  the  stomach,  and  may  not  be  de- 
tected even  when  the  stomach  is  opened  by  the  surgeon.  The  non-indurated 
ulcers  are  divided  into  the  mucous  erosions  of  Dieulafoy,  in  which  the  superfi- 
cial epithelium  only  is  involved,  and  the  true  round  fissured  peptic  ulcers 
(Wm.  J.  ^layo,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  21,  1905).  Both  conditions 
are  rare.  Ulcers  are  also  divided  into  acute  ulcers,  which  progress  rapidly  and 
produce  definite  symptoms,  and  chronic  ulcers,  which  are  usually  chronic 
from  the  beginning,  but  which  may  exhibit  acute  exacerbations,  and  may  have 
periods  of  great  relief  or  apparent  cure  (Wm.  J.  ^Slayo,  in  "Med.  Record," 
August  6,  1904) .  The  most  common  seats  of  ulcers  are  the  posterior  wall  and 
lesser  curvature,  especially  in  the  pyloric  region;  in  fact,  80  per  cent,  occur  in 
the  pyloric  region.  An  ulcer  may  heal  or  may  perforate.  Only  2  per  cent, 
of  ulcers  on  the  posterior  wall  perforate,  as  they  tend  to  form  adhesions  to 
adjacent  structures  (Alderson).  Ulcers  on  the  anterior  wall  are  unusual, 
do  not  tend  to  form  adhesions,  and  are  apt  to  perforate.  It  is  not  uncommon 
to  have  ulcer  of  the  first  portion  of  the  duodenum  associated  with  gastric 
ulcer.  Gastric  ulcer  is  at  least  four  times  as  frequent  in  England  as  in  the 
United  States.  In  2830  autopsies  made  in  the  Philadelphia  Hospital  there 
\Yere  40  gastric  ulcers,  and  in  3763  autopsies  made  in  four  Philadelphia  in- 
stitutions there  were  51  gastric  ulcers — a  percentage  of  1.35  (see  A.  P.  Francine, 
in  "Proceedings  Phila.  Co.  Med.  Soc,"  March  31,  1905). 

Symptoms.- — In  an  acute  ulcer  the  symptoms  are  often  t}'pical;  there  are 
pain,  tenderness  on  pressure,  slight  or  distinct  unilateral  muscular  rigidity^ 
vomiting,  hemorrhage,  and  hyperchlorhydria.  In  a  chronic  ulcer  the  symp- 
toms may  be  clear,  may  be  misleading,  may  be  variable,  and  in  some  cases  even 
absent  {latent  ulcer) .  In  ulcer  dyspepsia  usually  exists.  It  is  usually  but  not 
always  acid  dyspepsia  and  is  associated  with  much  flatulence.  In  most  cases, 
though  not  in  all,  food  aggravates  the  condition.  There  is  a  gnawing  sensation 
(hunger  pain)  when  the  stomach  is  empty,  and  may  be  actual  pain.  The 
taking  of  food  may  temporarily  relieve  pain,  while  as  quantities  of  gastric  juice 
are  poured  out  to  digest  the  food  the  pain  increases.  If  hyperchlorhydria 
disappears  (as  it  may  do  from  chronic  gastritis  and  does  do  from  gastric  dilata- 
tion following  pyloric  obstruction),  pain  may  not  be  increased  during  digestion. 
In  ulcer  of  the  cardiac  and  lesser  curvature  gnawing  uneasiness  is  but  briefly  or 
not  at  all  relieved  by  taking  food  and  pain  develops  immediately  or  almost  at 
once.  In  ulcer  of  the  pyloric  region  the  gnawing  uneasiness  may  be  distinctly 
relieved  by  taking  food,  but  in  two  or  three  hours  pain  is  apt  to  become  severe. 
In  ulcer  the  pain  is  paroxysmal.  It  is  at  times  very  \iolent  in  the  epigastric 
region,  and  also  passes  to  the  back,  being  located  between  the  eighth  and  ninth 
dorsal  vertebrae. 

In  gastric  ulcer  it  is  usual  to  find  distinct  or  severe  tenderness  developed  by 
epigastric  pressure,  and  tenderness  is  associated  with  more  or  less  rigidity.  In 
ulcers  of  the  anterior  wall  tenderness  is  most  acute.  In  many  of  these  patients 
vomiting  occurs  about  two  hours  after  eating.     The  vomited  matter,  as  a  rule. 


956  Diseases  and  Injuries  of  the  Abdomen 

contains  much  hydrochloric  acid.  Vomiting  often  reheves  pain.  Examination 
of  the  gastric  contents  after  the  administration  of  a  test  meal  shows  in  about 
80  per  cent,  of  the  cases  hyperacidity.  Obvious  hemorrliage  from  the  stomach 
occurs  in  less  than  one-half  of  the  cases,  and  from  3  to  8  per  cent,  of  cases 
actually  die  of  hemorrhage.  Wm.  J.  Mayo  states  that  "more  than  90  per  cent, 
of  hemorrhages  from  the  stomach  are  from  chronic  ulcers  with  a  well-marked 
ulcer  history"  ("Surg.,  Gynec,  and  Obstet.,"  May,  1908).  The  blood  may  be 
brought  up  with  food,  and  is  then  black  and  clotted,  or  may  be  vomited  clear 
and  in  large  amount.  Blood  may  be  present  in  vomited  matter  or  stools  in 
such  small  amount  that  its  presence  is  observed  only  by  the  microscope.  The 
demonstration  in  the  feces  of  minute  quantities  of  blood  (occult  blood)  is  im- 
portant diagnostically.  It  may  be  demonstrated  by  the  guaiacum  test  or  the 
aloin  test.  For  two  days  before  this  test  the  patient  must  not  eat  rare  meat, 
sausages,  or  fish.  Blood  in  the  stools  does  not  prove  the  existence  of  gastric 
ulcer.  It  may  come  from  any  spot  from  the  mouth  to  the  anus.  As  Wm.  J. 
Mayo  says  ("Surg.,  Gynec,  and  Obstet.,"  May,  1908):  "Visible  or  occult 
blood  in  the  stool  affords  proof  as  to  the  fact  that  there  is  blood,  but  it  should 
never  be  lost  sight  of  that  it  bears  with  it  no  evidence  as  to  its  exact  gastro- 
intestinal origin.  The  patient  may  have  bleeding  gums  or  hemorrhage  from 
some  shght  abrasion  in  any  part  of  the  many  feet  of  mucous  membrane  which 
exist  between  the  lips  and  the  anus.  If  occult  blood  is  found  by  one  chemical 
test,  it  must  be  corroborated  by  others,  as  some  unsuspected  food  or  drug  may 
give  rise  to  the  reaction. 

"  As  a  matter  of  fact,  hemorrhage  from  ulcer  is  by  no  means  of  frequent 
occurrence.  The  base  of  the  ulcer  is  clean  and  free  from  granulation  tissue,  so 
that  bleeding  may  be  infrequent.  Careful  examination  of  the  stool  for  many 
days  may  be  necessary  to  detect  its  presence." 

In  hemorrhage  from  an  acute  ulcer  a  pint  or  two  maybe  ejected  in  a  few  min- 
utes, and  such  a  patient  presents  all  the  general  symptoms  of  dangerous  hemor- 
rhage. In  some  cases  blood  from  the  stomach  is  passed  by  the  bowels  in 
part  or  wholly.  A  very  large  hemorrhage  may  occur,  and  yet  the  bleeding 
never  be  repeated,  or  a  large  hemorrhage  may  be  followed  by  another  or  be 
the  first  of  three  or  of  a  series.  In  a  great  many  cases  after  a  large  hemorrhage 
there  is  no  further  bleeding  or  there  are  subsequently  a  few  small  hemor- 
rhages. Small  hemorrhages  may  occur  indefinitely,  and  may  after  a  time 
eventuate  in  a  large  hemorrhage.  In  chronic  ulcer  in  which  small  hemor- 
rhages recur  over  a  long  period  the  condition  is  due  to  bleeding  from  con- 
gested mucosa  or  to  the  erosion  of  small  vessels  which  cannot  contract  or 
retract  because  they  are  imbedded  in  fibrous  tissue.  A  large  hemorrhage 
may  be  due  to  the  erosion  of  a  large  vessel,  but  is  often  produced  by  the 
existence  of  a  great  number  of  erosions  of  the  mucous  membrane,  erosions 
perhaps  so  numerous  that  blood  seems  to  pour  from  every  portion  of  the  mucous 
surface.  It  is  usually  stated  that  in  a  sudden  acute  violent  hemorrhage  there 
will  probably  be  no  history  of  antecedent  stomach  trouble,  butWm.  J.  Mayo 
is  of  the  opinion  that  "a  single  hemorrhage  from  a  patient  who  has  not  had 
previous  gastric  symptoms  is  probably  not  due  to  ulcer"  ("Surg.,  Gynec,  and 
Obstet.,"  May,  1908).  It  may  arise  from  rupture  of  veins  about  the  cardia  or 
from  blood  from  hemoptysis  being  swallowed. 


Symptoms  of  Ulcer  of  the  Stomach  957 

In  a  chronic  ulcer  it  is  sometimes,  though  seldom,  possible  to  palpate  the 
indurated  area. 

Constipation  generally  exists.  There  is  usually  very  marked  anemia  aggra- 
vated and,  some  think,  occasionally  caused  by  continued  loss  of  blood.  Indi- 
gestion aggravates  anemia  and  also  may  cause  it.  There  is  loss  of  weight. 
There  is  often  a  tender  area  in  the  back  a  httle  to  the  left  of  the  ninth  and  tenth 
dorsal  spines.  A  triangular  area  of  hyperesthesia  is  often  found  in  the  left 
epigastric  region  (Head). 

If  the  ulcer  does  not  cicatrize,  but  progresses,  causing  pain  and  hemorrhage, 
the  patient  becomes  thinner,  more  anemic,  weak,  and  even  exhausted. 

It  is  certain  that  many  cases  of  gastric  ulcer  are  unrecognized;  in  fact,  as 
Habershon  says,  diagnosis  is  rarely  made  unless  hemorrhage  exists,  and  in 
certain  latent  cases  both  vomiting  and  bleeding  are  absent.  It  is  beheved  by 
some  that  latent  ulcers  are  even  more  common  than  are  ulcers  causing  symp- 
toms. Hall  ("Am.  Jour,  of  Med.  Sciences,"  May,  1909)  says:  "Rather 
than  look  too  narrowly  for  exactly  this  or  that  evidence,  we  should  take  the 
broader  ground  that  ulcer  probably  exists  in  most  patients  complaining  of 
persistent  indigestion,  even  though  not  of  an  acid  character,  if  pain,  tenderness, 
vomiting,  and  rigidity,  or  two  or  three  of  these  phenomena  be  present,  and  even 
though  hyperacidity  be  not  proved." 

A  gastric  ulcer  may  cicatrize  and  thus  be  cured,  but  the  cure  of  the  ulcer 
may  prove  the  ruin  of  the  stomach  by  producing  stenosis  of  one  of  the  stomach 
orifices  or  hour-glass  contraction  of  the  body  of  the  stomach.  An  ulcer  may 
perforate  and  does  so  in  about  15  per  cent,  of  cases  (Robson).  A  perforation 
may  be  acute;  that  is,  the  ulcer  suddenly  breaks  open  when  the  stomach 
contains  food  or  liquid,  and  the  contents  of  the  stomach  are  poured  into  the 
free  peritoneal  cavity.  A  subacute  perforation  occurs  when  the  stomach 
is  empty  or  nearly  empty.  The  opening  is  small  in  size,  there  is  no  escape 
of  stomach-contents  or  the  escape  of  only  a  small  amount,  and  the  opening  may 
be  quickly  closed  by  adhesions  to  an  adjacent  surface  of  peritoneum  or  a 
piece  of  omentum.  If  a  certain  amount  of  stomach-contents  is  extra vasated, 
it  is  usually  surrounded  by  adhesions  or  tracks  slowly  toward  the  pelvis. 
In  what  is  known  as  a  chronic  perforation  the  break  takes  place  usually  in 
the  posterior  wall  into  a  box  of  preformed  adhesions,  the  extruded  gastric 
contents  are  circumscribed  by  these  adhesions,  the  general  peritoneal  cavity 
is  not  invaded,  but  circumscribed  suppuration  is  inaugurated.*  This  condi- 
tion is  known  as  perigastric  abscess,  and  the  subphrenic  form  is  the  commonest. 
In  such  a  case  the  abscess  may  break  into  the  pleural  cavity  or  even  into 
the  lung.  I  recently  operated  on  a  girl  of  sixteen  and  found  a  perigastric 
abscess  and  a  perforation  of  the  anterior  wall  near  the  pylorus,  and  this 
condition  was  tuberculous.     A  fistula  persisted  for  months,  but  finally  healed. 

Perforation  is  usually  brought  about  by  muscular  effort  and  is  most  common 
after  a  full  meal.  The  real  cause  is  spasm  of  the  pylorus  which  causes  tension 
of  the  stomach  walls  and  keeps  the  viscus  from  emptying.  Pyloric  spasm  is 
very  common  in  sufferers  from  ulcer.  In  acute  perforation  food  is  the  most  ac- 
tive cause,  in  chronic  perforation,  muscular  eft'ort.  "The  severity  of  the  symp- 
toms depends  upon  several  conditions:  the  previous  state  of  health,  the  size 
and  number  of  the  perforations,  the  condition  of  the  stomach,  whether  full  or 
*  See  paper  by  B.  G.  A.  Moynihan,  Brit.  Med.  Jour.,  Jan.  31,  1903. 


958  Diseases  and  Injuries  of  the  Abdomen 

almost  empty,  the  bacterial  virulence  of  its  contents,  and  the  occurrence  of 
vomiting."*  The  situation  of  the  ulcer  has  some  influence  on  the  symptoms. 
"If  in  the  fundus,  at  the  cardiac  end,  or  in  the  body  of  the  stomach,  an  acute 
infection  of  the  v^hole  peritoneal  cavity  rapidly  follows;  if  the  ulcer  be  at  the 
pylorus  or  in  the  first  portion  of  the  duodenum,  the  fluid  is  directed  down 
the  right  side  of  the  abdomen,  owing  to  the  hillock  formed  by  the  transverse 
mesocolon  at  the  pyloric  end  of  the  stomach"  (Moynihan,  in  "Brit.  Med. 
Jour.,"  Jan.  31,  1903).  In  such  a  case  the  fluid  may  gravitate  toward  the  right 
iliac  region  and  the  condition  may  be  mistaken  for  appendicitis.  In  a  case  of 
subacute  gastric  perforation  I  operated,  believing  that  appendicitis  existed. 
Alderson  calls  attention  to  the  fact  that  the  sudden  perforation  of  an  ulcer 
may  be  mistaken  for  poisoning,  and  he  cites  the  death  of  Henrietta,  Duchess 
of  Orleans,  in  1670. 

Acute  perforation  can  usually  be  certainly  diagnosticated  if  the  case  is  seen 
early.  Such  an  emergency  has  usually,  but  not  invariably,  been  preceded 
by  positive  and  prolonged  symptoms  of  gastric  disorder.  It  causes  sudden 
and  violent  epigastric  pain,  greatly  increased  by  swallowing  fluids,  by  vomit- 
ing, and  by  pressure.  This  pain  may  radiate  throughout  the  abdomen,  but 
the  chief  tenderness  is  in  the  region  of  the  stomach.  The  seat  of  the  pain 
after  perforation  does  not  of  necessity  correspond  to  the  seat  of  perforation. 
The  collapse  is  usually  profound.  In  some  cases  death  takes  place  quickly, 
but,  as  a  rule,  reaction  occurs  and  peritonitis  develops.  Vomiting  is  rare  after 
rupture.  When  it  does  occur,  it  does  much  harm  by  increasing  shock  and 
by  ejecting  gastric  contents  into  the  peritoneal  cavity.  Vomiting  of  blood 
is  very  unusual.  Board-like  rigidity  exists,  and  it  is  most  marked  in  the  upper 
portion  of  the  abdomen.  The  area  of  liver-dulness  is  in  many  cases  dimin- 
ished or  obliterated.  If  a  patient  with  acute  perforation  is  not  promptly 
operated  upon,  he  will  soon  exhibit  the  symptoms  of  general  peritonitis. 
Subacute  perforation  causes  less  violent  symptoms  and  they  come  on  more 
gradually.  There  is  in  the  beginning  severe  but  not  agonizing  pain,  which 
gradually  abates.  Moynihan  points  out  that  there  is  gastric  uneasiness  for 
several  days  before  the  perforation.  Peritonitis  develops  slowly  and,  as 
Gibbon  says,  the  chief  symptoms  are  often  pelvic.  Chronic  perjoration  gives 
the  signs  and  symptoms  of  perigastric  abscess. 

Treatment. — Medical  Treatment  0}  N on- perforated  Ulcer. — Rest  in  bed. 
It  is  necessary  to  abandon  stomach  feeding  for  a  time.  For  seven  to  ten  days 
give  nothing  whatever  by  the  mouth  and  give  an  enema  of  10  ounces  of  normal 
salt  solution  every  six  hours.  This  is  preferable  to  a  nutritive  enema  because 
every  time  a  nutritive  enema  is  given  a  flow  of  gastric  juice  takes  place  into  the 
stomach  (see  W.  Pasteur,  in  "Lancet,"  May  21,  1904;  and  Seymour  J.  Sharkey, 
in  "Lancet,"  Nov.  10,  1906).  During  this  treatment  the  padent  is  usually 
comfortable  and  is  not  unbearably  disturbed  by  hunger  and  thirst.  At  the 
end  of  a  week  or  ten  days  pancreatinized  or  peptonized  milk  is  cautiously  given 
by  the  mouth,  or  else  nutridve  enemata  are  substituted  for  sahne  enemata  and 
are  given  for  a  few  days  before  stomach  feeding  is  instituted.  After  rectal 
feeding  has  been  abandoned  the  patient  is  placed  on  a  very  bland  diet,  prefer- 
ably pancreatinized  milk,  and  lavage  is  given  twice  a  day.     To  some  cases 

*  Moynihan,  in  Brit.  Med.  Jour.,  Jan.  31,  1903. 


Treatment  of  Ulcer  of  the  Stomach  959 

Carlsbad  salts  are  given  (Ziemssen) ;  to  others  silver  nitrate,  bismuth  sub- 
nitrate,  or  oxalate  of  cerium.  If  pain  is  severe,  opium  may  be  required.  Many 
cases  are  apparently  cured  by  medical  treatment.  Russel's  statistics  show  that 
40  per  cent,  of  cases  were  reported  cured  under  medical  treatment,  but  no  one 
knows  how  many  of  those  reported  cured  again  gave  evidence  of  the  disease 
or  later  perished  of  hemorrhage  or  perforation.  Further,  18  per  cent,  of  the 
500  London  Hospital  cases  under  medical  treatment  died. 

Surgical. — Following  the  Mayos,  we  would  not  advise  surgical  treatment 
in  acute  ulcers  unless  complicated  by  hemorrhage,  perforation,  or  obstruction; 
or  in  chronic  ulcer,  until  careful  medical  treatment  has  failed.  Opera- 
tion is  indicated  for  chronic  ulcer  when  a  mechanical  cause  is  responsible 
for  retention  and  stagnation  of  stomach  contents,  and  in  certain  cases  of 
hemorrhage.  Operation  is  also  indicated  in  chronic  ulcer  with  frequent 
exacerbations,  but  the  surgeon  must  be  very  chary  of  operating  upon  neurotic 
women  with  gastroptosis,  unless,  of  course,  there  is  a  positive  indication  (Wm. 
J.  Mayo,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  21,  1905). 

In  a  chronic  ulcer  if  the  patient  grows  worse  in  spite  of  careful  dietetic 
and  medical  treatment,  if  hemorrhage  has  been  profuse  or  if  there  have  been 
frequent  distinct  hemorrhages,  if  the  pain  is  violent,  or  if  tenderness  is  marked, 
open  the  abdomen  and  inspect  the  stomach.  An  ulcer  with  indurated  edges  is 
easily  found.  The  form,  called  by  the  Mayos  the  non-indurated  ulcer,  gives  no 
evidence  or  little  evidence  of  its  existence  when  the  outer  coat  of  the  stomach 
is  felt  and  inspected  (Wm.  J.  Mayo,  in  ''Jour.  Am.  Med.  Assoc,"  Oct.  21, 
1905).  Even  when  the  stomach  is  opened,  no  ulcer  may  be  found.  Accord- 
ing to  Mikulicz,  in  some  mucous  ulcers  there  is  a  very  little  thickening,  and, 
according  to  Moynihan,  the  mucous  coat  may  be  a  little  adherent  to  the 
muscular  coat,  so  that  it  does  not  shde  easily.  An  enlarged  gland  in  a  portion 
of  the  omentum  may  be  a  sign  of  ulcer  (Lund).  An  indurated  ulcer  may  be 
removed  by  an  elliptical  incision  in  the  long  axis  of  the  stomach,  the  coats  being 
sutured  by  the  usual  method,  and  gastro-enterostomy  being  also  performed. 
In  some  cases  gastro-enterostomy  alone  leads  to  the  cure  of  chronic  ulcer. 
The  Heineke-Mikulicz  operation  is  not  satisfactory  in  ulcer.  Finney's  gastro- 
duodenostomy  is  not  advisable  if  there  is  an  unhealed  ulcer,  because  food  still 
passes  over  the  ulcer  after  its  performance  (Wm.  J.  Mayo). 

Operation  for  Gastrorrhagia  {Hemorrhage  from  the  Stomach). — Rydygier 
proposed  in  1882  to  operate  for  hemorrhage.  The  first  operation  was  done 
by  Mikulicz  in  1887,  and  the  first  successful  operation  was  reported  by  Roux 
in  1893. 

In  an  acute  and  violent  hemorrhage  threatening  Hfe  the  proper  course  to 
pursue  is  somewhat  uncertain.  It  is  not  proper  to  operate  if  there  has  been 
but  one  hemorrhage,  because  the  chances  are  that  the  bleeding  vdll  not  be 
repeated.  Again,  the  chance  of  arresting  such  a  hemorrhage  by  operation  is, 
on  the  whole,  poor.  The  danger  of  waiting  after  one  hemorrhage  is  not  so 
great  as  the  danger  of  immediately  operating,  because  collapse  antagonizes 
renewed  hemorrhage,  but  adds  enormously  to  the  risk  of  an  operation.  In 
over  90  per  cent,  of  cases  the  hemorrhage  ceases  spontaneously.  In  over  18 
per  cent,  of  those  dying  of.  hemorrhage  death  is  so  rapid  that  operation  is 
impossible  (Savariaud) .  If  the  bleeding  is  from  a  distinct  ulcer,  we  may  suc- 
ceed in  excising  the  ulcer  or  in  ligating  the  bleeding-point.     Roux,  of  Lausanne, 


960  Diseases  and  Injuries  of  the  Abdomen 

saved  a  patient  by  excising  an  ulcer  and  ligating  the  bleeding  coronary  artery 
on  each  side  of  it.  As  a  rule,  however,  the  bleeding  is  not  from  a  distinct  point, 
but  from  a  multitude  of  excoriations.  In  the  light  of  our  present  knowledge 
we  may  lay  down  the  following  rule :  Do  not  operate  for  one  acute  hemorrhage. 
Simply  bring  about  reaction  by  gentle  means,  let  the  patient  take  bits  of  ice,  and 
give  suprarenal  extract  by  the  stomach.  If  the  bleeding  recurs  once  or  twice 
in  comparatively  trivial  amounts,  do  not  operate;  but  if  it  recurs  violently,  we 
should  advise  operation.  In  cases  of  ulcer  in  which  bleeding  in  small  amounts 
persists,  operation  is  indicated.  In  operating  for  a  severe  hemorrhage  the  sur- 
geon opens  the  abdomen  while  hot  salt  solution  is  being  thrown  into  a  vein. 
The  stomach  is  opened,  the  clots  washed  out,  and  a  search  made  for  the  source 
of  the  blood.  If  it  is  found  that  the  blood  comes  from  an  area  of  ulceration,  this 
area  may  be  extirpated,  ligated,  or  cauterized  with  the  thermocautery.  Some 
advise  surrounding  it  with  a  purse-string  suture.  Others,  notably  Moynihan, 
simply  perform  gastro-enterostomy,  which  is  of  service  by  draining  and  giving 
rest  to  the  dilated  stomach,  the  hemorrhage  being  perhaps  arrested  by  contrac- 
tion of  the  gastric  walls  and  the  rest  secured  preventing  the  detachment  of 
hemostatic  clot.  Gastro-enterostomy  is  of  most  service  in  ulcer  near  the 
pylorus  and  in  duodenal  ulcer.  If  the  ulcer  is  well  above  the  pylorus  it  should 
be  excised  if  possible.  As  a  rule,  it  will  be  found  that  the  vessels  entering 
the  ulcer  are  varicose.  Excision  is  indicated  because  of  this  varicosity.  If 
excision  is  impossible  "the  main  blood-vessels  leading  into  the  ulcer  should  be 
ligated  and  the  peritoneum  and  muscular  coats  drawn  over  it"  (Wm.  J.  Mayo, 
in  "Surg.,  Gynec,  and  Obstet.,"  May,  1908).  If  it  is  found  that  the  bleed- 
ing comes  from  a  multitude  of  excoriations  and  that  the  stomach  is,  as  Moy- 
nihan expresses  it,  "weeping  blood,"  we  can  do  nothing  but  gastro-enter- 
ostomy, which  in  such  a  condition  is  of  uncertain  value. 

Operation  for  Perforation. — In  acute  and  subacute  perforation  operate  at 
once,  having  all  proper  means  taken  to  bring  about  reaction  from  shock,  while 
the  abdomen  is  being  sterilized  and  while  ether  is  being  administered  (hot 
saline  enemata,  external  heat,  atropin  hypodermatically,  etc.).  I  formerly 
advised  to  wait  until  reaction  was  established  before  operating.  I  now 
believe  such  advice  erroneous.  To  delay  after  an  acute  perforation  is  to  wait 
for  what  may  never  come.  Open  the  abdomen  at  the  point  of  greatest  ten- 
derness, or,  if  there  is  no  such  point,  open  it  in  the  epigastric  region,  a  little 
to  the  right  of  the  midhne.  When  the  abdomen  is  opened,  there  may  be 
an  escape  of  odorless  gas,  and  food  or  fluid  may  be  discovered  in  the  peri- 
toneal cavity.  The  perforation  is  sought  for  and  is  usually  foimd  in  the 
anterior  wall.  When  found,  it  should  be  buried  and  overlaid  by  stomach 
wall,  a  portion  of  which  must  be  inverted  by  two  layers  of  Halsted  sutures. 
I  do  not  believe  that  excision  or  paring  the  edges  is  necessary  or  desirable 
in  a  case  of  perforated  ulcer.  If  no  perforation  is  found  on  the  anterior  wall, 
make  an  opening  into  the  lesser  ]:)eritoneal  cavity  through  the  gastrocolic 
omentum,  e.xplore  the  posterior  wall,  and  close  and  cover  any  perforation 
found.  In  addition  to  closing  the  perforation,  gastro-enterostomy  is  theoret- 
ically indicated  in  order  to  drain  the  viscus.  give  it  rest,  and  lessen  the  tend- 
ency to  recurrence  of  ulceration.  But,  as  a  matter  of  fact,  such  ulcers  seldom 
return.  The  patient  is  usually  too  severely  shocked  to  render  such  an  additional 
operation  justifiable,  and  I  agree  with  Gibbon  that  such  an  operation  should  be 


Cicatricial  Stenosis  of  the  Orifices  of  the  Stomach  961 

performed  only  when  there  are  multiple  ulcers  or  when  there  is  pyloric  con- 
striction (John  H.  Gibbon,  in  paper  before  the  Tri-State  Med.  Assoc,  of 
Virginia  and  the  Carolinas,  Feb.  23-24,  1904).  After  closing  the  perforation 
the  abdominal  cavity  is  irrigated  with  hot  salt  solution  and  the  space  between 
the  liver  and  diaphragm  is  sponged  out  with  a  gauze  pad  wet  with  hot  salt 
solution.  If  the  case  is  operated  many  hours  after  the  perforation,  or  if  the 
peritoneum  was  badly  soiled,  drainage  must  be  used,  but  even  in  other  cases 
it  is  safest  to  use  it.  Drainage  is  obtained  by  means  of  a  strand  of  iodoform 
gauze  passed  to  the  suture  line  in  the  stomach.  In  cases  with  much  extra- 
vasation, especially  if  the  extravasation  has  reached  the  pelvis,  a  suprapubic 
opening  is  made  and  a  tube  inserted.  After  the  patient  has  reacted  from 
the  shock  of  the  operation  he  should  be  placed  in  a  semi-erect  position  to 
direct  the  flow  of  infective  material  to  the  peM?,  and  continuous  proctoclysis 
should  be  employed  as  in  peritonitis  (page  1006).  The  treatment  of  chronic 
perforation  is  the  treatment  of  perigastric  abscess,  and  consists  of  incision 
and  drainage.  Of  late,  a  number  of  cases  of  acute  and  subacute  perfora- 
tion have  been  successfully  operated  upon.  Moynihan  estimates  that  35-40 
per  cent,  of  acute  perforations  recover  after  operation.  T.  Crisp  English 
("Lancet,"  Nov.  28,  1903)  reported  42  consecutive  gastric  perforations 
operated  on  in  St.  George's  Hospital.     Twenty-two  recovered. 

Cicatricial  stenosis  of  the  orifices  of  the  stomach  results 
from  the  healing  of  an  ulcer,  the  swallowing  of  a  corrosive  substance,  or 
traumatism  from  a  foreign  body.  Constriction  of  the  cardmc  orifice  is  indi- 
cated by  gradually  increasing  difficulty  in  swallowing.  After  a  time  the 
esophagus  above  the  stricture  dilates  or  pouches;  the  fluid  food  passes  into 
the  stomach,  but  the  sohd  food  lodges  in  the  esophageal  pouch  and  is 
soon  regurgitated.  The  site  of  the  stricture  is  located  by  a  bougie,  and 
by  having  the  patient  swallow  while  auscultating  over  the  esophagus  and 
cardiac  end  of  the  stomach.  If  the  constriction  be  mahgnant,  the  patient 
will  be  found  to  be  beyond  middle  Hfe,  the  vomit  is  occasionally  bloody, 
emaciation  is  rapid  and  decided,  and  occasionally  the  supracla\'icular  glands 
are  enlarged.  A  tumor  of  the  cardiac  end  of  the  stomach  can  seldom  be 
palpated.  If  the  constriction  be  cicatricial,  the  history  will  indicate  the 
cause.  Constriction  of  the  pyloric  orifice  causes  retention  of  food  and  dilata- 
tion of  the  stomach.  Dyspeptic  symptoms  will  be  found  to  have  been  long 
present.  A  tube  passed  into  the  stomach  permits  of  the  injection  of  fluid 
so  as  to  fill  the  stomach.  \\'hen  the  fluid  runs  out,  it  contains  portions  of 
undigested  food,  which  was  perhaps  eaten  days  bef(?re,  and  measurement  of 
the  liquid  shows  that  the  capacity  of  the  stomach  is  enormously  increased. 
If  hydrogen  be  forced  through  the  tube,  the  outline  of  the  distended  stomach 
is  at  once  made  clear.  The  usual  method  of  distending  the  stomach  is  by  a 
Seidlitz  powder:  two  solutions  are  made*  the  bicarbonate  solution  is  swal- 
lowed at  once,  and  the  tartaric  solution  is  taken  afterward  in  small  amounts 
at  a  time.  Percussion  over  the  distended  stomach  indicates  the  size  of  the 
viscus.  It  is  well  to  remember  that  dilatation  of  the  stomach  can  occur  with- 
out cicatricial  stenosis  when  gastric  ulcer  exists.  The  cause  in  such  a  case  is 
pyloric  spasm  or  perhaps  the  atonic  condition  which  may  result  from  anemia 
and  neurasthenia. 

In  mahgnant  disease  of  the  pylorus  a  tumor  may  often  be  palpated;  there 
61 


962  Diseases  and  Injuries  of  the  Abdomen 

are  tenderness  and  considerable  persistent  pain,  great  cachexia  and  emacia- 
tion, absence  of  free  hydrochloric  acid  from  the  gastric  juice,  diminution  of  red 
corpuscles  and  hemoglobin,  and  no  increase  of  white  corpuscles  after  a  full 
meal.  There  is  sometimes  enlargement  of  the  supraclavicular  glands.  Vom- 
iting of  bloody  fluid  occurs  in  40  per  cent,  of  the  malignant  cases.  Illumina- 
tion of  the  stomach  by  the  gastrodiaphanoscope  may  aid  the  diagnosis,  the 
area  of  malignant  growth  interfering  with  the  transmission  of  light.  In  cica- 
tricial stenosis  of  the  pylorus  there  may  be  paroxysms  of  pain,  there  is  no  ten- 
derness, emaciation  is  not  so  rapid  in  onset,  and  the  supraclavicular  glands 
are  never    enlarged.     Vomiting  occurs,  but  the  ejected  matter  is  not  bloody. 

Treatment. — Cicatricial  cardiac  stenosis  requires  dilatation  with  bougies 
and  the  maintenance  of  the  restored  caliber.  If  dilatation  from  above  is 
unsatisfactory,  perform  a  gastrotomy,  push  a  small  bougie  from  the  mouth 
into  the  stomach,  tie  a  string  to  the  bougie,  draw  the  string  through  the 
stricture,  use  the  string  as  a  saw  to  cut  the  fibrous  bands,  pass  a  full-sized 
bougie,  close  the  wound  in  the  stomach,  and  maintain  the  caliber  of  the 
cardiac  orifice  by  the  repeated  passage  of  dilating  instruments.  If  no  instru- 
ment can  be  passed  through  the  stricture  from  above,  perform  a  gastrotomy, 
introduce  an  instrument  from  below  and  pass  it  into  the  mouth,  tie  a  string  to  it, 
draw  the  string  into  the  stomach,  and  use  Abbe's  string-saw  (page  929) .  If  no 
instrument  can  be  passed  from  below,  convert  the  gastrotomy  into  a  gas- 
trostomy. In  malignant  stenosis  of  the  cardia  gastrostomy,  if  performed  at 
all,  should  be  performed  early.  Cicatricial  pyloric  stenosis  was  once  treated 
by  a  gastrotomy  and  digital  divulsion  of  the  stricture  {Loreta's  operation); 
but  this  operation  is  obsolete,  experience  having  shown  that  recontraction 
is  inevitable.  Pyloroplasty  was  until  recently  advocated  by  many  surgeons. 
This  is  known  as  the  Heineke-Mikulicz  operation.  In  30  per  cent,  of  the 
cases  the  symptoms  are  not  relieved  by  pyloroplasty,  a  condition  which 
renders  gastro-enterostomy  necessary.  Mayo  points  out  that  in  such  cases 
pyloroplasty  fails  because  the  pylorus  is  on  a  higher  level  than  the  gastric 
pouch,  the  degenerated  muscle  of  the  stomach  is  unable  to  lift  the  food 
from  the  pouch  to  the  pylorus,  and  the  symptoms  of  gastric  dilatation  and 
retardation  of  the  passage  of  food  into  the  duodenum  are  not  relieved.  The 
operation  has  been  generally  abandoned.  Finney's  method  of  gastro-duo- 
denostomy  (Figs.  552,  553,  554,  and  555)  is  a  great  improvement  on  pyloro- 
plasty. The  opening  is  large  and  in  a  proper  position  to  afford  satisfactory 
drainage.  Gastro-enterostomy  is  the  most  satisfactory  operation  in  most 
cases  and  usually  effects  a  cure.  Malignant  stenosis  is  treated  by  pylorec- 
tomy  or  gastro-enterostomy.     (See  under  these  heads  respectively.) 

Congenital  or  Infantile  Hypertrophic  Stenosis  of  the  Pylorus.— 
Stenosis  of  the  pylorus  in  adults  is  almost  invariably  due  to  cancer  or  to  ulcer, 
but  in  very  young  children  one  occasionally  meets  with  a  form  that  is  congen- 
ital. The  history  of  such  a  case  is  that  during  the  first  two  or,  three  days 
after  birth  the  child  seems  in  every  way  normal,  but  that  after  several  or  a 
number  of  days  or  weeks  vomiting  suddenly  begins — vomiting  for  which  no 
dietary  cause  seems  responsible,  and  which  persists  irrespective  of  medication. 
After  the  stomach  has  been  emptied  by  vomiting  the  child  seems  much  re- 
lieved, but  when,  after  a  time,  food  is  administered,  vomiting  will  begin 
again,  either  in  a  very  short  time  or  after  an  hour  or  so.      It  has  been  noted 


Perigastric  Adhesions  963 

that  the  vomited  matter  in  congenital  stenosis  of  the  pylorus  never  contains 
any  bile  whatever,  for  obvious  reasons — the  pylorus  is  shut  and  the  bile  can- 
not enter  the  stomach.  A  child  in  this  condition  receives  Uttle  or  no  nour- 
ishment, becomes  quickly  emaciated,  and  soon  dies.  Some  of  these  children 
die  in  a  month;  others,  in  several  months;  and  a  few  may  live  for  five  or  six 
months.  It  may  be  possible,  in  these  cases,  to  palpate  a  thickened  pylorus; 
and  the  outhnes  of  the  dilated  stomach  can  probably  be  made  out.  The 
most  common  symptom  is  gastric  peristalsis.  In  Bunts'  table  gastric  peris- 
talsis was  present  in  84  per  cent.,  and  tumor  in  69  per  cent,  of  cases.  The 
intestines  are  very  much  collapsed,  and  the  child  is,  of  course,  very  much 
constipated.  Cases  have  recovered  after  lavage  carried  out  daily  for  some 
weeks  and  careful  breast  feeding.  A  trial  should  be  given  this  method  unless 
the  condition  of  the  patient  demands  immediate  rehef.  The  delay  in  employ- 
ing surgery  in  hopes  of  lavage  succeeding  must  never  be  so  long  that  the  patient 
emaciates.  If  his  condition  does  not  soon  show  signs  of  improvement,  opera- 
tion is  indicated.  Some  of  the  cases  reported  cured  by  medical  means  may 
have  been  instances  of  pyloric  spasm.  The  operation  for  this  condition  is 
usually  gastro-enterostomy.  The  mortality  after  the  operation  is  apparently 
over  50  per  cent.  It  is  superior  to  pyloroplasty  because  it  enables  us  to  at  once 
feed  the  exhausted  child. 

Perigastric  Adhesions.— That  perigastric  adhesions  are  frequently 
responsible  for  stomach  pain  and  digestive  difi&culty  is  undoubted.  Such 
adhesions  often  arise  in  cases  of  protracted  ulceration  of  the  stomach  or 
duodenum.  A  common  cause  of  perigastric  adhesions  is  gall-stone  disease. 
Tuberculous  peritonitis  causes  dense  adhesions.  In  some  cases  the  adhesions 
are  traumatic,  in  some  they  are  due  to  syphilis,  in  many  the  cause  is  uncertain 
(Fred.  D.  Bird,  "Intercolonial  Med.  Jour,  of  Australasia,"  Dec.  20,  1900). 
Adhesions  may  cause  blocking  or  kinking  of  the  pylorus,  or  may  glue  the 
stomach  to  the  parietal  peritoneum  or  to  some  adjacent  viscus.  In  Fenwick's 
table  of  123  cases  he  finds  that  the  adhesions  usually  cause  the  stomach  to 
adhere  to  the  pancreas  or  to  the  liver.  The  formation  of  adhesions  in  cases 
of  gastric  ulcer  is,  in  many  instances,  conservative,  serving  to  prevent  perfora- 
tion or  to  limit  extravasation  if  perforation  of  the  stomach-wall  occurs. 

Symptoms. — The  symptoms  are  variable.  In  some  cases  the  adhesions 
produce  little  or  no  trouble;  but  in  the  majority  of  cases  they  cause  definite 
symptoms,  and  sometimes  the  condition  becomes  one  of  absolute  disable- 
ment. The  symptoms  may  be  due  to  blocking  of  the  pylorus,  a  condition 
that  is  followed  by  gastric  dilatation.  They  may  be  due  to  dragging  upon 
the  adhesions,  when  the  stomach  contracts  during  digestion,  or  when  peri- 
stalsis occurs  in  an  adherent  piece  of  intestine. 

The  usual  symptom  is  pain,  frequently  of  a  violent  character.  The  pain 
comes  on  in  paroxysms,  and  recurs  over  and  over  again,  it  may  be  during  years. 
H.  Hale  White*  points  out  that  in  these  cases  there  is  usually  some  pain  persist- 
ing, which  is  now  and  then  increased  into  violent  paroxysms;  and  that  the  only 
other  condition  that  produces  persistent  pain  with  violent  exacerbations  is 
cancer.  In  adhesion-dyspepsia,  however,  there  is  no  distinct  loss  of  weight; 
the  condition  may  exist  in  youth,  as  well  as  in  middle  age  or  old  age;  it  is 

*  Lancet,  Nov.  30,  1901. 


964  Diseases  and  Injuries  of  the  Abdomen 

not  increased  by  taking  food;  and  it  very  rarely  causes  death.  If  there  is 
a  history  of  antecedent  gall-stone  disease  or  of  ulcer  of  the  stomach,  it  is  pos- 
sible to  make  the  diagnosis  without  exploratory  operation.  Even  in  other 
cases  the  condition  may  sometimes  be  diagnosticated,  because,  although 
there  are  these  attacks  of  violent  pain,  there  is  no  tenderness.  In  rare  cases 
the  adhering  and  matting  together  with  inflammatory  exudate  produces  a 
palpable  mass.  In  doubtful  cases  of  chronic  and  disabling  stomach  disease 
an  exploratory  operation  should  be  performed;  if  adhesions  exist,  they  will 
then  become  manifest. 

Treatment. — In  some  cases  simply  dividing  an  adhesion  effects  a  cure; 
in  other  cases  it  is  necessary  to  make  extensive  separation  of  adherent  struc- 
tures, covering  the  raw  surface  with  omental  grafts.  In  serious  adhesions 
about  the  pylorus  gastro-enterostomy  is  usually  the  proper  operation. 

Bilocular  Stomach  (Hour=glass  Stomach). — It  is  usually  stated  that 
some  cases  are  congenital,  but  the  writings  of  Mayo  Robson,  Moynihan,  and  H. 
L.  Patterson  cause  us  to  gravely  doubt  if  it  is  ever  congenital.  Even  in  the  so- 
called  congenital  cases  ulcers  are  found,  or  ulcer  scars  exist,  or  ulcer  adhesions 
are  demonstrable.  The  advocates  of  a  congenital  origin  say  that  the  ulcers 
are  secondary  to  the  narrowing,  and  that  ulceration  tends  to  occur,  particularly 
at  the  seat  of  constriction.  Beyond  doubt,  a  very  great  majority,  at  least,  of 
cases  of  bilocular  stomach  result  from  adhesions  produced  by  the  heahng  of  an 
ulcer.  In  hour-glass  stomach  with  a  large  opening  between  the  two  sacs  there 
may  be  no  symptoms.  When  the  opening  is  small,  the  symptoms  resemble 
those  of  pyloric  stenosis.  The  sac  toward  the  cardia  is  frequently  much 
dilated. 

Symptoms. — The  diagnosis  of  cancer  is  often  made.  The  protracted 
gastritis  may  have  caused  free  hydrochloric  acid  to  disappear  and  acids 
of  fermentation  are  usually  found.  The  patient  vomits  from  time  to  time, 
bringing  up  food  which  was  eaten  a  day  or  two  before,  proof  that  food  is 
retained  in  the  stomach  and  not  digested.  Occasionally  perhaps  blood  is 
vomited.  There  is  pain  and  the  patient  is  harassed  with  foul-smelling 
eructations.  Emaciation  is  pronounced.  Cumston  points  out  that  in  a  thin 
belly  distention  of  the  stomach  may  make  the  condition  evident;  further, 
that  if  water  is  thrown  into  the  stomach,  only  a  part  returns,  and  when  the 
stomach  is  emptied  as  much  as  possible  by  a  tube,  a  splashing  sound  can  still  be 
elicited  in  the  stomach  because  the  pyloric  pouch  is  not  empty.  One  cause  of 
death  is  torsion  on  the  axis.* 

Treatment. — The  diagnosis  becomes  certain  only  after  exploratory  opera- 
tion, and  exploration  also  enables  the  surgeon  to  decide  with  certainty  as 
to  what  operation  should  be  performed.  Cumston  gives  us  the  following 
suggestions: 

1.  In  rare  cases  resect  the  stricture  and  suture  the  pouches. 

2.  If  there  is  trivial  ulceration  or  a  shght  scar,  do  gastroplasty,  an  operation 
upon  the  constriction  exactly  similar  to  pyloroplasty. 

3.  The  best  operation  in  most  cases  is  gastrogastrostomy — that  is,  anas- 
tomosis of  the  cardiac  pouch  to  the  pyloric  pouch;  but  this  cannot  be  done 
if  the  pyloric  pouch  is  small.     Then  do  gastro-enterostomy. 

*  Cumston,  in  Med.  News,  Dec.  1901. 


To  Test  the  Motor  Power  of  the  Sj;omach  965 

Other  operations  are: 

4.  Gastroduodenostomy. 

5.  Gastrojejunostomy. 

6.  Gastrolysis.* 

In  malignant  disease  resection  (partial  gastrectomy)  is  indicated.  After 
gastroplasty  recontraction  is  common,  but  I  do  not  believe  in  the  operation. 
Gastro-enterostomy  is  unsatisfactory.  The  ordinary  operation  drains  but  one 
pouch.  Weir  and  Foote  advised  a  double  gastro-enterostomy,  tapping  each 
sac.  In  most  cases  gastrogastrostomy  followed  by  gastro-enterostomy  is  the 
best  procedure. 

Chronic  Dilatation  of  the  Stomach. — A  dilated  stomach,  roughly 
speaking,  is  one  which  can  contain  more  than  1.5  quarts  (Ewald).  Some 
few  cases  of  dilatation  result  directly  from  atrophy  of  the  muscular  coat, 
brought  about  by  drinking  quantities  of  hquid,  especially  beer;  chronic 
catarrh  of  the  stomach;  and  conditions  such  as  cancer,  tuberculosis,  dia- 
betes, etc.  The  common  cause  of  dilatation  is  constriction  of  the  pylorus. 
In  order  to  force  food  by  the  pyloric  narrowing  more  force  is  necessary  than 
is  required  in  a  normal  state  of  affairs  and  the  stomach  muscle  h}'pertro- 
phies.  This  muscular  hypertrophy  is  compensatory,  and  dilatation  does  not 
occur  so  long  as  the  muscle  is  efficient.  But  finally  the  pyloric  opening 
becomes  so  narrow  that  compensation  fails,  the  stomach-contents  accumu- 
late, and  the  stomach  dilates. 

Symptoms  of  Dilated  Stomach. — There  is  annoying  hunger  unless  can- 
cer exists.  Thirst  is  complained  of.  At  intervals  of  a  day  or  two  the  patient 
vomits  enormous  quantities,  and  portions  of  food  may  be  identified  which 
were  eaten  several  days  before.  The  vomited  matter  is  sour  and  foul-smelhng, 
contains  numbers  of  yeasts  and  much  fermentative  acid.  Free  hydrochloric 
acid  is  often  absent.  In  some  cases  vomiting  occurs  two  or  three  hours  after 
each  meal.  The  patient  suffers  from  foul  gaseous  eructations.  There  are  pro- 
gressive emaciation,  constipation,  scantiness  of  xirine;  sometimes  cramp  in 
the  legs,  belly,  and  arms;  tetany  may  occur;  insomnia  is  the  rule;  cardiac 
palpitation  occurs,  and  there  is  dyspnea,  particularly  at  night. 

Physical  Signs  of  Dilated  Stomach. — The  epigastric  region  is  hollow 
and  the  left  side  of  the  abdomen  is  more  prominent  than  the  right.  The 
outline  of  the  greater  curvature  of  the  stomach  can  be  distinguished.  If  the 
stomach  contains  air,  percussion  gives  a  t^-mpanitic  note;  if  it  contains  fluid, 
a  dull  note.  When  it  is  partly  full  of  fluid,  by  altering  the  position  of  the 
patient  we  can  show  by  percussion  that  the  fluid  changes  its  position.  In  a 
doubtful  case  give  a  Hght  meal  in  the  evening,  and  in  the  morning,  before 
the  patient  has  eaten,  introduce  a  tube  and  remove  any  material  contained 
in  the  stomach.     The  presence  of  undigested  food  points  to  dilatation. 

To  Test  the  Motor  Power  of  the  Stomach. — Klemperer's  Test. — Wash 
out  the  stomach.  Introduce  100  c.c.  of  oHve  oil  by  means  of  the  tube. 
After  two  hours  withdraw  the  oil.  The  stomach  cannot  absorb  oil,  and  if  the 
amount  withdrawn  is  subtracted  from  the  amount  introduced,  the  difference 
is  the  amount  which  passed  the  pylorus.  If  the  condition  is  normal,  not 
more  than  from  20  to  40  c.c.  should  be  found  in  the  stomach  after  two 
hours. 

*  Med.  News,  Dec.  7,  1902. 


966  Diseases  and  Injuries  of  the  Abdomen 

The  Salol  Test  0}  Ewald. — Salol  is  not  decomposed  in  the  stomach,  but 
in  the  intestine  is  broken  up  into  phenol  and  saUcyhc  acid.  SahcyHc  acid  is 
absorbed  and  sahcyluric  acid  soon  appears  in  the  urine.  If  salol  cannot  reach 
the  intestine,  sahcyluric  acid  will  not  appear  in  the  urine.  If  salol  reaches 
the  intestine  more  slowly  than  normal,  salicyluric  acid  will  appear  after 
a  longer  interval  than  when  there  is  no  pyloric  block  to  retard  the  emptying 
of  the  stomach.  In  a  normal  person  salicyluric  acid  is  found  in  the  urine 
in  from  three-fourths  of  an  hour  to  an  hour  after  swallowing  a  dose  of  salol. 
In  stenosis  of  the  pylorus  it  appears  much  later.  The  test  is  made  as  follows  : 
The  bladder  is  emptied  and  the  patient  is  given  three  capsules,  each  con- 
taining 5  gr.  of  salol.  The  patient  is  directed  to  pass  water  every  half-hour 
until  he  has  done  so  four  times.  Each  sample  voided  is  examined  for  sah- 
cyluric acid  by  adding  neutral  chlorid  of  iron.  If  salicyluric  acid  is  present, 
a  violet  color  is  noted. 

To  Test  the  Absorptive  Power  of  the  Stomach. — The  absorptive 
power  of  the  stomach  can  be  tested  by  giving  the  patient  a  capsule  containing 
i^  gr.  of  iodid  of  potassium.  Normally  the  drug  should  be  found  in  the 
saliva  in  from  ten  to  fifteen  minutes.  When  absorption  is  deficient,  it  may 
not  appear  for  an  hour  or  longer.  In  order  to  test  for  it,  moisten  starch  paper 
with  the  sahva  and  touch  the  moist  paper  with  a  drop  of  fuming  nitric  acid. 
If  iodin  is  present,  a  blue  color  develops. 

While  the  diagnosis  of  dilatation  of  the  stomach  can  be  certainly  made, 
the  determination  of  the  cause  may  require  an  exploratory  operation. 

Treatment. — Cases  not  due  to  pyloric  obstruction  are  much  improved 
by  lavage,  regulated  diet,  use  of  an  abdominal  belt,  electricity,  aperients, 
and  other  agents  called  for  by  symptoms. 

In  all  cases  where  there  is  pyloric  obstruction,  in  many  doubtful  cases, 
and  in  cases  in  which  medical  treatment  fails,  exploratory  operation  is  indi- 
cated. In  dilatation  without  pyloric  obstruction  some  surgeons  advocate 
gastroplication.  If  pyloric  obstruction  exists,  the  surgeon  may  elect  to  do 
pylorectomy,  pyloroplasty,  or  gastro-enterostomy,  the  method  selected  de- 
pending on  the  condition  discovered.  If  gastroptosis  exists,  gastropexy  or 
Beyea's  operation  may  be  performed. 

Acute  Dilatation  of  the  Stomach.* — This  condition  may  suddenly  arise 
in  the  course  of  chronic  dilatation  or  when  no  previous  dilatation  existed. 
Its  cUnical  features  were  described  by  Brinton  in  1859.  Hilton  Fagge  in  1873 
furnished  us  with  the  first  comprehensive  description  of  the  signs  and  symp- 
toms. The  cause  is  uncertain,  and  is  a  subject  of  active  investigation  at  the 
present  time.  It  is  said  to  be  due  to  degeneration  of  the  gastric  muscle  in 
the  course  of  specific  fevers,  to  paresis  arising  in  the  course  of  chronic  gastritis, 
and  to  the  drinking  of  a  quantity  of  effervescing  hquid.  It  is  occasionally  a 
fatal  sequence  of  abdominal  operations,  particularly  operations  upon  the  gall- 
bladder and  bile-ducts.  The  surgeon  sees  it  in  the  course  of  sepsis  and  during 
shock  from  operations  in  which  a  general  anesthetic  was  used,  and  occasionally 
in  cases  of  spinal  curvature. 

One  set  of  observers  maintains  that  the  condition  is  brought  about  by  actual 
constriction  of  the  duodenum,  the  constricting  cause  being  the  root  of  the 

*  See  Kelling,  in  Archiv.  f.  klin.  chir.,  1901,  Ixiv;  Albrecht,  in  Virchow's  Archiv., 
1899,  clvi;  Conner,  in  Am.  Jour.  Med.  Sciences,  March,  1907. 


Symptoms  of  Acute  Dilatation  of  the  Stomach  967 

mesentery  and  the  superior  mesenteric  artery  and  the  duodenum  being  squeezed 
against  the  vertebral  column  (Rokitansky,  Albrecht,  Robinson,  and  Kundrat) . 
Codman  believes  that  normally  in  man  there  is  more  or  less  tendency  to  such 
constriction  on  standing  erect  or  l)ing  down  and  that  a  trivial  increase  of  the 
constriction  which  may  be  brought  about  by  various  causes  may  completely 
obstruct  the  duodenum  ("Boston  Med.  and  Surg.  Jour.,"  1908).  Conner 
collected  18  fatal  cases  shown  by  necropsy  to  be  due  to  mesenteric  obstruction 
(Lewis  A.  Conner,  in  "Am.  Jour.  Med.  Sciences,"  March,  1907). 

Another  set  of  observers  assert  that  acute  dilatation  is  due  to  lesion  of  the 
nerve  trunks  or  nerve  centers,  resulting  in  paresis  of  the  muscle  of  the  stomach 
wall  and  spasm  of  the  pylorus.  The  cause  of  the  nen^e  lesion  is  variously  held 
to  be  hvperacidity  of  gastric  secretion,  the  absorption  of  the  toxins  of  fermenta- 
tion, the  secretion  of  chloroform  into  the  stomach,  the  overdistention  of  the 
\iscus  with  ether  vapor,  and  the  enormously  great  secretion  of  fluid  into  the 
stomach. 

As  Conner  says  (Ibid.),  the  theor}' of  pyloric  spasm  being  causative  is 
untenable  because  in  most  cases  vomited  matter  contains  bile  and  in  two- 
thirds  of  the  cases  the  duodenum  is  certainly  involved  in  dilatation. 

It  seems  certain  that  some  cases  of  gastric  dilatation  are  associated  with 
mesenteric  constriction  of  the  duodenum,  brought  about  by  the  intestines 
descending  into  the  pelvis.  The  constriction  inaugurates  the  dilatation  and 
is  aggravated  by  the  dilatation.  Conner  points  out  that  the  intestines  enter 
the  pehis  as  a  result  of  dorsal  decubitus,  a  long  mesentery,  and  a  gut  nearly 
empt}'  of  gas  and  feces,  and  is  favored  by  relaxation  of  the  belly  wall  ("Jour. 
Am.  Med.  Assoc,"  March,  1907). 

Symptoms. — The  most  frequent  and  prominent  is  violent  vomiting, 
usually  inaugurating  the  symptoms  and  continuing  throughout  the  illness, 
although  occasionally  it  ceases  for  some  time  before  death.  The  amounts 
vomited  are  large  and  often  enormous.  The  vomitus  is  thin  and  of  a  green 
or  black  hue,  usually  contains  bile  and  sometimes  a  little  blood,  but  very 
seldom  feces. 

In  most  cases,  but  not  in  all,  there  is  epigastric  or  umbilical  pain  and 
tenderness.  Distention  is  the  rule.  Rigidity  is  rare.  In  many  cases  there  is 
no  passage  of  gas  or  feces,  but  in  some  diarrhea  exists.  There  is  great  thirst, 
there  may  be  hiccough,  and  delirium  may  arise  before  death.  The  tem„pera- 
ture  is  nearly  always  normal  or  below  normal.  There  is  seldom  \isible  gas- 
tric peristalsis  (Conner,  Ibid.) ,  and  splashing  sounds  are  obtainable  over  the 
stomach. 

Collapse  arises  early  and  quickly  becomes  profound.  Tetany  occasionally 
occurs.  A  case  of  my  o\vn  died  of  acute  gastric  dilatation  after  an  operation 
for  stone  in  the  kidney.  He  suddenly  developed  attacks  of  violent  and  pro- 
fuse vomiting,  rapidly  went  into  collapse,  hndity  developed  and  hiccough 
arose,  and  he  died  in  forty-eight  hours. 

A  case  may  die  in  less  than  twenty-four  hours  or  may  die  after  ten  days 
or  more.  Conner's  group  of  cases  show  a  mortality  of  72.5  per  cent.  Fluid 
cannot  reach  the  small  intestine,  and  as  none  is  absorbed  from  the  stomach 
and  httle  from  the  duodenum,  the  tissues  starve  for  the  want  of  it  (Laffer,  in 
"Annals  of  Surgery,"  April,  1908).  'The  condition  is  frequently  diagnosticated 
acute  intestinal  obstruction  or  peritonitis  from  perforation. 


968  Diseases  and  Injuries  of  the  Abdomen 

Treatment. — When  the  stomach  has  dilated  greatly  and  when  collapse  is 
profound,  treatment  is  usually  of  no  avail.  When  an  early  diagnosis  is  made 
treatment  is  often  of  the  greatest  value.  The  stomach  must  be  at  once  emptied 
by  the  use  of  a  tube  and  the  treatment  be  repeated  at  intervals  of  a  few  hours. 
Neither  food  nor  drink  should  be  given  by  the  mouth.  Saline  enemata  and  per- 
haps nutritive  and  stimulating  enemata  should  be  given.  The  patient  should 
at  once  be  placed  upon  the  belly  and  kept  there  undl  the  condition  abates,  in 
the  hope  that  this  posture  will  relieve  duodenal  constriction. 

Gastro-enterostomy  has  been  employed,  and  is  advocated  by  Mayo  Robson. 
Byron  Robinson  had  a  successful  case.  I  would  be  disposed  to  employ  it 
in  spite  of  the  reported  failures.  In  a  number  of  cases  the  stomach  has  been 
opened  and  washed  out  \\athout  benefit.  Petit  opened  the  abdomen  and  dis- 
covering a  kink  at  the  junction  of  the  duodenum  and  jejunum,  he  raised  the 
jejunum  and  sutuired  it  to  the  transverse  colon  and  the  patient  recovered 
(Conner,  Ibid.). 

Not  until  we  know  definitely  the  cause  or  causes  of  acute  dilatation  of 
the  stomach  will  we  be  able  to  lay  dowm  with  precision  and  accuracy  the 
treatment  which  is  indicated.  There  is  much  difference  of  opinion  as  to  the 
causation  of  the  condition  and  widely  different  methods  of  treatment  are 
advocated  by  various  surgeons. 

Qastroptosis. — In  this  condition  the  stomach  has  undergone  dis- 
placement downward,  the  greater  curvature  in  many  cases  being  but  little 
above  the  pubic  symphysis  and  the  lesser  curvature  being  between  the  ensi- 
form  cartilage  and  the  umbilicus.  This  condition  is  far  more  common  in 
women  than  in  men,  and  is  especially  common  in  women  who  have  had 
many  children.  It  may  be  produced  by  tight  lacing  and  may  follow  mova- 
bility  of  the  right  kidney,  of  the  liver,  or  of  the  spleen.  It  is  often  associated 
with  enteroptosis  and  is  particularly  prone  to  arise  in  the  anemic  and  tuberculous. 

Symptoms. — There  may  be  no  s>'mptoms  for  a  long  time,  but  sooner 
or  later  dyspepsia  arises  because  the  stomach  cannot  empty  itself.  The 
stomach  becomes  atonic,  its  secretions  are  scanty  and  altered,  and  while 
the  viscus  may  be  normal  in  size  or  even  shrunken,  it  is  usually  dilated. 
The  malposition  can  be  made  out  by  percussion  when  the  stomach  is  dis- 
tended with  air  or  with  fluid. 

And  by  the  :x-rays  after  the  patient  has  drunk  a  pint  of  a  solution  of  mucilage 
of  acacia  containing  subnitrate  of  bismuth.  The  bismuth  lines  the  stomach 
and  intercepts  the  x-rays  and  a  radiograph  shows  the  outlines  of  the  stomach 
and  hence  its  size  and  position.  The  pylorus  descends  to  the  umbilical 
region,  which  it  does  not  do  in  dilatation.  In  dilatation  the  pylorus  is  but 
slightly  lower  than  normal,  but  the  lower  border  of  the  stomach  is  notably 
depressed. 

When  a  patient  mth  gastroptosis  stands  erect  the  bulging  is  most  prominent 
in  the  region  of  the  umbilicus  and  the  epigastrium  is  deepened. 

Gastroptosis  is  not  infrequently  associated  with  chlorosis. 

Treatment. — Lavage,  regulation  of  diet,  improvement  of  the  general 
health,  and  the  wearing  of  an  abdominal  binder.  If  medical  treatment  fails 
and  the  condition  is  producing  grave  impairment  of  the  general  health,  it  may 
be  necessary  to  perform  a  surgical  operation.  Gastro-enterostomy  is  advo- 
cated by  some  on  the  ground  that  the  unpleasant  symptoms  result  from  stag- 


Intestinal  Obstruction  969 

nation  of  gastric  contents.  Good  results  have  been  reported  by  this  plan. 
The  operation  of  Depage  is  unphilosophical.  Buret's  operation  is  objection- 
able (page  1090).     Beyea's  operation  is  usually  preferred  (page  1091). 

Intestinal  Obstruction  (Ileus  or  Enterostenosis).— Intestinal  ob- 
struction is  a  condition  in  which  fecal  movement  is  mechanically  impeded 
or  prevented.  It  may  be  either  partial  or  complete.  Acute  obstruction  is 
due  to  a  sudden  narrowing  or  occlusion  of  the  lumen  of  a  portion  of  the  in- 
testine. Chronic  obstruction  is  due  to  a  gradual  narrowing  of  the  lumen 
of  a  portion  of  the  intestine,  and  it  may  at  any  time  become  acute.  If  ob- 
struction to  circulation  in  the  wall  of  the  bowel  occurs,  the  condition  becomes 
one  of  strangulation.  In  acute  obstruction  the  stagnated  intestinal  contents 
become  charged  with  powerful  poisons  which  act  most  harmfully  on  the  mus- 
culature of  the  intestinal  wall,  and,  after  absorption,  attack  the  heart  and 
nervous  system.  The  inaugural  shock  is  due  to  the  production  of  the  block, 
the  later  increasing  depression  is  due  to  absorption  of  poisons.  Gas  forms  in 
great  amount  in  the  intestine  and  produces  distention.  Distention  impairs 
the  circulation  in  the  wall  of  the  intestine  and  embarrasses  respiration  by  push- 
ing up  the  diaphragm.     Intestinal  obstructions  are  classified*  as  follows: 

I.  Strangulation  by  bands  or  in  apertures,  the  commonest  form,  is  due 
to  peritoneal  adhesions,  but  the  band  may  come  from  the  omentum.  Strangu- 
lation by  baijds  or  in  apertures  usually  involves  the  ileum  and  sometimes  the 
colon.  This  form  of  obstruction  is  identical  with  hernia,  except  in  the  absence 
of  an  external  protrusion.  Obstruction  may  take  place  by  Meckel's  divertic- 
ulum (page  973),  a  structure  due  to  persistence  of  the  viteUine  or  omphalo- 
mesenteric duct,  coming  off  from  the  ileum  from  12  to  36  inches  above 
the  ileocecal  valve,  and  present  in  about  2  per  cent,  of  persons.  The  vitel- 
line duct  should  be  obliterated  in  the  eighth  week  of  fetal  life.  If  it  persists 
the  individual  possessing  it  is  in  constant  and  serious  danger.  The  mortality 
of  a  series  of  cases  of  obstruction  due  to  Meckel's  diverticulum  is  enormous. 
A  Meckel's  diverticulum  usually  has  no  mesentery,  is  from  3  to  10  inches  long, 
and  arises  from  the  convex  side  of  the  gut.  It  may  hang  free  or  may  be  attached 
to  the  umbiHcus  by  its  tip  or  by  a  fibrous  cord  formed  by  the  obliterated  tip. 
In  some  cases  it  remains  open  at  the  umbihcus  (page  398).  In  other  cases  a 
cord  runs  from  the  umbihcus  to  the  gut  or  the  tip  of  the  diverticulum  or  is 
adherent  to  another  portion  of  the  intestine.  The  diverticulum  may  become 
strangulated,  may  enter  a  hernial  sac,  may  ulcerate  or  perforate  Hke  an  ap- 
pendix (W.  Sheen,  in  "Bristol  Medico-Chir.  Jour.,"  Dec,  1901,  gives  an  ad- 
mirable account  of  "Some  Surgical  Aspects  of  Meckel's  Diverticulum";  see 
also  article  on  "Obstruction  of  the  Bowels  by  Meckel's  Diverticulum,"  by 
James  E.  Moore,  in  "Journals  of  Am.  Med.  Assoc,"  Oct.  4,  1902,  and  on 
"Abdominal  Crises  Caused  by  Meckel's  Diverticulum,"  by  Miles  F.  Porter, 
in  "Jour,  of  Am.  Med.  Assoc,"  Sept.  23,  1905).  Strangulation  of  the  diver- 
ticulum may  take  place  beneath  an  adherent  appendix,  a  Fallopian  tube,  a 
portion  of  mesentery,  or  the  pedicle  of  an  ovarian  tumor,  or  it  may  take  place 
in  an  omental  or  a  mesenteric  aperture.  Gangrene,  inflammation,  or  twist- 
ing may  occur.  Obstruction  may  be  due  to  invagination  of  the  diverticulum 
into  the  bowel.  H.  Tyrrell  Gray  collected  39  cases  of  invagination  and  added 
one  of  his  own,  40  in  all  ("Annals  of  Surgery,"  Dec,  1908).  Gray  shows  that 
*  After  Treves,  in  "  Heath's  Dictionary." 


970  Diseases  and  Injuries  of  the  Abdomen 

the  average  age  at  which  the  final  attack  occurs  is  fifteen  years — that  such  cases 
show  a  history  of  previous  abdominal  crises  due  to  twisting,  inflammadon  or 
slight  invagination — that  the  acute  attack  is  apt  to  begin  when  the  padent  is 
active  rather  than  when  he  is  at  rest — that  nearly  70  per  cent,  of  the  patients 
do  not  pass  blood — that  the  pain  is  very  violent  and  is  usually  umbihcal — that 
tenderness  is  seldom  acute  unless  there  is  peritonitis — that  there  may  be  an 
abnormal  umbilical  cicatrix — that  in  a  minority  of  cases  there  is  a  palpable 
abdominal  mass — that  the  mortality  after  operation  in  an  acute  case  is  nearly 
60  per  cent. 

2.  Volvulus,  or  twisdng  of  the  bowel.  The  twist  may  be  about  the  mes- 
enteric axis  or  on  the  axis  of  the  bowel  itself,  or  two  intestinal  coils  may  be 
twisted  together.  Volvulus  is  commonest  in  the  sigmoid  flexure.  It  may 
occur  in  a  hernial  sac. 

3.  Intussusception  is  the  invagination  of  a  portion  of  bowel- wall  into  the 
lumen  of  an  adjacent  part  of  the  gut.  One-third  of  all  cases  of  obstrucdon 
are  due  to  this  cause  (Treves) .  Most  cases  of  obstruction  in  children  are  due 
to  intussusception.  Pitt  reports  that  in  St.  Thomas's  Hospital,  from  1875  to 
1900  inclusive,  there  were  115  cases  of  intussusception,  and  every  patient 
was  under  fifty  years  of  age.  Gibbon's  patient  was  fifty-eight.  Rutherford 
Morrison  had  a  case  due  to  polypus,  and  the  padent  was  sixty-two  years 
of  age.  Males  are  twice  as  hable  as  females.  During  the  performance  of 
peristalsis  a  localized  circular  constriction  forms  and  the  invagination  takes 
place  through  the  constricted  area.  The  great  reladve  frequency  of  intussus- 
cepdon  in  childhood  is  due  to  the  greater  mobihty  and  irritabihty  of  the  child's 
bowel  (Treves).  The  irregular  and  localized  spasm  is  due  to  bulky  or  irritant 
material  within  the  gut,  and  according  to  Rushmore  ("Annals  of  Surgery," 
August,  1907)  the  starting-point  of  invaginadon  is  obstrucdon.  Were  peris- 
talsis alone  the  cause  the  condition  would  be  far  more  common  than  it  is  in  the 
diarrhea  of  children.  There  are  four  chief  varieties:  the  ileocecal,  in  which  the 
ileum  and  the  ileocecal  valve  pass  into  the  cecum  and  colon;  the  colic,  in  which 
the  large  intestine  is  prolapsed  into  itself;  the  ileal,  in  which  the  small  intestine 
alone  is  involved;  and  the  ■ileocolic,  in  which  the  ileum  prolapses  through  the 
ileocecal  valve.  Other  iorms  are  diverticular  (with  a  diverticulum),  retrograde 
(due  to  reversed  peristalsis),  MeckeVs  diverticulum,  ileo-appcndiccal,  and  cecal. 
The  first  variety  is  vastly  the  most  common.  In  Rushmore's  table  ("Annals 
of  Surgery,"  August,  1907)  the  location  was  definitely  stated  in  237  cases: 
140  of  these  were  ileocecal  and  31  were  ileocoHc. 

4.  Stricture  of  the  intestine,  which  may  be  either  cicatricial  or  cancerous. 

5.  Obstruction  by  Tumors  of  the  Bowel  and  by  Foreign  Bodies. — Tumors 
may  be  innocent  or  malignant.  Foreign  bodies  include,  besides  certain  sub- 
stances that  have  been  swallowed,  gall-stones  and  enteroHths  or  intestinal 
calculi.  Foreign  bodies  are  apt  to  lodge  in  the  lower  portion  of  the  ileum 
or  in  the  cecum,  and  they  may  cause  ulceration  at  the  seat  of  lodgment.  If 
a  gall-stone  is  sufficiently  large  to  cause  obstruction,  it  cannot  have  passed 
the  duct,  but  must  have  ulcerated  into  the  bowel  from  the  gall-bladder. 
About  three-fourths  of  the  cases  of  gall-stone  intestinal  obstruction  occur  in 
women.  The  stone  is  arrested  at  some  point  because  a  local  paralysis  of 
the  bowel  has  developed.  A.  W.  Mayo  Robson  ("Brit.  Med.  Jour.,"  May  i, 
1909)  points  out  that  all  cases  of  obstruction  due  to  gall-stones  are  not  the  result 


Symptoms  of  Chronic  Obstruction  971 

of  mechanical  obstruction  by  a  large  stone  which  entered  the  intestinal  canal  by 
ulceration,  but  that  there  are  three  other  possible  conditions,  viz.:  Local 
peritonitis  in  the  gall-bladder  region  causing  paralysis  of  the  bowel;  volvulus 
of  the  small  intestine  due  to  biliary  colic  or  to  ulceration  of  a  gall-stone  into 
the  gut;  obstruction  coming  on  "after  the  original  cause  has  disappeared" 
and  due  to  adhesions  without  or  obstruction  within  the  gut. 

6.  Obstruction  by  tumors,  etc.,  outside  the  bowel,  among  the  causes  of 
which  are  retroflexion  or  retroversion  of  the  womb,  especially  in  pregnancy, 
cysts  or  tumors  of  the  kidneys,  ovaries,  uterus,  etc.,  movable  kidney,  and 
enlarged  spleen.  Obstruction  from  any  of  the  above  causes  takes  place  in 
the  rectum  or  the  sigmoid  flexure. 

7.  Obstruction  from  fecal  accumulation  is  due  to  paresis  or  paralysis  of 
the  bowel  and  the  diminution  or  abolition  of  peristalsis.  Obstruction  may 
follow  an  abdominal  operation.  Paresis  or  paralysis  arises  in  the  colon. 
Treves  mentions  among  the  rare  forms  of  obstruction  kinking  of  the  bowel, 
adhesions  matting  the  bowels  together  or  compressing  the  gut,  and  shrinking 
of  the  mesentery. 

In  addition  to  the  seven  groups  previously  mentioned,  we  should  consider  post- 
operative intestinal  obstruction  and  obstritction  from  embolism  or  thrombosis  of  the 
mesenteric  vessels.  Obstruction  of  the  mesenteric  vessels  is  liable  to  occur 
■when  the  aorta  is  atheromatous,  and  usually  causes  gangrene  of  the  intestine. 

Symptoms  of  Acute  Obstruction.— Severe  coHc  comes  on  suddenly, 
the  pain  varying  in  intensity,  but  at  no  time  entirely  ceasing.  In  a  suddenly 
arising  intraperitoneal  accident,  whether  it  be  perforation,  acute  obstruction, 
or  acute  strangulation,  there  is  at  first  shock,  from  which  the  patient  usually 
reacts  for  a  time.  In  obstruction  there  is  constipation,  which  soon  becomes 
absolute,  not  even  gas  being  passed;  vomiting  is  early— first  of  the  contents  of 
the  stomach,  next  of  bilious  matter,  and  finally  of  feces  {stercoraceous  vomiting) ; 
the  abdomen  becomes  distended  and  tender.  After  reaction  from  shock 
some  fever  may  be  noted,  but  in  any  unrelieved  case  collapse  soon  arises; 
the  temperature  becomes  subnormal;  the  face,  Hippocratic;  the  pulse,  rapid 
and  feeble.  The  amount  of  urine  passed  is  very  small.  In  obstruction  of 
the  upper  third  of  the  ileum  true  fecal  vomiting  cannot  occur.  If  obstruction 
is  high  up  in  the  small  intestine,  tympanites  does  not  occur.  The  tongue 
is  dry,  the  mind  is  clear,  and  muscular  cramp  may  occur.  Intestinal  peri- 
stalsis above  the  obstruction  may  be  detected  through  the  abdominal  wall. 
According  to  Elsberg  gangrene  occurs  in  only  13  per  cent,  of  the  cases.  Tap- 
ping is  more  apt  to  cause  pain  than  is  pressure;  in  peritonitis  pressure  is  more 
apt  to  cause  pain  than  tapping  (Battle).  In  intestinal  obstruction  (post- 
operative and  primary)  there  is  a  leukocytosis  of  from  15,000  to  30,000  (Blood- 
good,  in  "Johns  Hopkins  Hospital  Reports,"  vol.  vii). 

Symptoms  of  Chronic  Obstruction.— At  intervals  there  arise  attacks 
of  pain  which  become  gradually  more  frequent  and  severe,  and  are  linked 
with  vomiting  and  constipation,  the  vomiting  not  being  stercoraceous  and 
the  constipation  not  being  absolute.  Between  the  painful  seizures  the  patient 
complains  of  constipation  alternating  with  fluid  diarrhea,  distention  of  the 
belly,  some  abdominal  uneasiness,  anorexia,  and  dyspepsia.  The  attacks 
recur  with  increasing  frequency  and  severity,  and  acute  obstruction  may 
arise  or  the  patient  may  be  worn  out  by  pain,  vomiting,  and  want  of  food. 


972  Diseases  and  Injuries  of  the  Abdomen 

Diagnosis. — The  determination  0}  the  seat  of  lesion  requires  abdominal 
and  rectal  examination.  An  intussusception  may  sometimes  be  felt  by  a  fin- 
ger in  the  rectum.  Vaginal  examination  may  be  demanded.  Pain  is  apt  to 
arise  at  the  seat  of  obstruction  or  to  radiate  from  there.  Abdominal  palpa- 
tion may  detect  a  tumor.  Rectal  insufflation  of  hydrogen  may  locate  the  ob- 
struction by  causing  great  distention  below  it.  Entire  suppression  of  urine, 
early  vomiting,  which  is  not  truly  stercoraceous,  absence  of  abdominal  disten- 
tion, and  rapid  collapse  mean  obstruction  in  the  duodenum  or  in  the  jejunum. 
Early  vomiting,  which  is  often  stercoraceous  in  a  rapidly  progressive  case, 
with  great  distention  of  the  umbihcal  region,  means  obstruction  of  the  ileum 
or  the  cecum.  Distention  of  the  entire  abdomen  and  of  the  flanks,  linked 
with  tenesmus,  with  less  violent  symptoms,  less  rapidity  of  progress,  and  less 
diminution  of  urine  than  in  the  above-cited  forms,  means  obstruction  low 
down  in  the  colon  or  in  the  rectum.  A  test  for  obstruction  in  the  adult  large 
intestine  is  an  injection  by  a  fountain-syringe:  if  six  quarts  can  be  introduced, 
there  is  no  obstruction  in  the  large  intestine;  if  less  than  four  quarts  can  be 
introduced,  there  is  probably  obstruction  in  the  large  intestine.  The  passage 
of  a  sound  in  the  rectum  is  generally  useless  and  is  often  unsafe.  In  many 
cases  the  seat  of  the  lesion  and  the  cause  of  the  obstruction  can  be  determined 
only  by  exploratory  laparotomy. 

The  determination  of  the  causative  condition  is  always  difficult  and  is 
often  impossible.  Intussusception  is  the  common  cause  in  children,  and  in 
most  cases  the  child  was  previously  healthy.  It  begins  with  violent  seizures 
of  pain,  but  although  the  patient  is  pale,  there  is  seldom  shock  at  this  stage. 
Between  the  seizures  of  pain  the  patient  often  appears  to  be  in  good  condition, 
with  a  normal  temperature  and  an  almost  normal  pulse.  A  sausage-shaped 
mass  can  usually  soon  be  felt  somewhere  over  the  large  intestine.  It  may 
be  in  the  right  ihac  fossa  or  in  the  left  iliac  fossa,  but  usually  over  the  region  of 
the  transverse  colon.  Osier  reports  that  a  mass  was  palpable  in  66  of  93  cases, 
and  in  over  one-third  of  the  cases  it  was  noted  the  first  day.  It  has  been  felt 
as  early  as  three  hours  after  the  onset  of  pain.  It  may  shift  its  position  hour 
by  hour,  and  it  may  disappear  after  having  been  obvious.  It  may  be  detected 
only  when  an  anesthetic  is  given.  Rectal  examination  gives  no  information  in 
early  cases  or  cases  invohing  only  the  small  bowel.  In  late  cases  a  mass  may 
perhaps  be  felt  in  the  rectum.  Tenesmus  exists,  and  bloody  mucus  is  passed 
in  most  cases.  The  abdomen  is  rarely  distended  or  tender  until  late  in  the 
case  and  at  this  period  there  may  be  shock  or  sepsis.  Vomiting  occurs,  but  it  is 
seldom  stercoraceous.  In  obstruction  from  hands,  internal  hernia,  etc.,  there 
is  a  record  of  antecedent  peritonitis,  of  a  traumatism,  of  a  violent  effort,  or  of 
pehic  pain.  The  attack  is  sudden  in  onset,  is  fierce  in  character,  and  is  usu- 
ally excited  by  violent  exercise  or  the  taking  of  food.  Vomiting  is  early  and 
intractable,  and  it  soon  becomes  stercoraceous;  pain  is  violent;  peristalsis  above 
the  obstruction  is  forcible;  tympanites  and  abdominal  tenderness  appear  after 
the  attack  has  lasted  for  some  little  time;  obstruction  is  complete,  no  gas  even 
being  passed;  collapse  soon  arises;  no  tumor  can  be  detected,  and  rectal  ex- 
amination is  negative.  Volvidus,  which  is  usually  located  in  the  sigmoid 
flexure,  is  preceded  by  constipation.  The  symptoms  come  on  with  explosive 
suddenness  and  rapidly  attain  great  severity.  Constipation  is  absolute;  vomit- 
ing is  late  and  is  rarely  stercoraceous;  no  tumor  can  be  detected;  rectal  examina- 


Diagnosis  of  Intestinal  Obstruction  973 

tion  is  negative;  abdominal  distention  and  tenderness  are  early  and  pronounced; 
peristalsis  above  the  volvulus  is  vigorous;  collapse  is  not  so  rapid  nor  so  grave  as 
in  obstruction  from  bands  and  internal  hernia.  Obstruction  by  a  foreign  body 
may  sometimes  be  inferred  from  the  history  of  some  such  body  having  been 
swallowed.  The  obstructing  body  may  occasionally  be  felt  during  palpation 
or  may  be  discovered  with  the  .v-rays.  Abdominal  distress  may  exist  for  days 
or  weeks  before  obstruction  occurs.  Vomiting  is  late  and  is  rarely  severe, 
but  pain,  tenderness,  and  distention  are  marked.  In  obstruction  from  gdU 
stones  there  will  be  a  record  of  one  or  more  attacks  of  hepatic  colic.  Pain  is 
early  and  acute,  and  vomiting  is  invariable  and  usually  becomes  stercoraceous. 
In  obstruction  from  fecal  accumulation  chronic  obstruction  evolves  into  acute 
obstruction,  pain  and  vomiting  are  late  or  even  absent,  and  the  doughlike 
mass  of  feces  may  be  felt  by  rectal  examination  or  by  abdominal  palpation. 
In  some  cases  the  fluid  elements  of  the  feces  pass,  but  the  solid  elements 
agglutinate  to  the  walls  of  the  bowel  (the  diarrhea  of  constipation).  Ob- 
struction from  stricture  or  from  pressure  comes  on  acutely  after  a  pro- 
longed period  of  disturbance,  during  which  period  attack  after  attack  of 
temporary  obstruction,  complete  or  partial,  takes  place.  A  history  of  blood 
or  pus  in  the  stools  would  indicate  tumor  of  the  bowel;  a  history  of  blood  or 
pus  having  been  absent  would  indicate  pressure  from  without.  In  func- 
tional obstruction  there  is  no  local  pain,  no  tenderness,  no  tumor,  no  tendency 
to  collapse,  but  simply  distention  and  absolute  constipation,  and  possibly 
non-fecal  vomiting  occurring  in  a  neurotic  or  hysterical  subject.  A  phantom, 
tumor  due  to  a  local  distention  of  the  intestine  from  limited  muscular  spasm 
disappears  under  ether.  Obstruction  of  the  mesenteric  vessels  causes  colicky 
abdominal  pain,  but  early  in  the  case  there  is  no  tenderness,  rigidity,  or  dis- 
tention. Pain  in  the  loin  and  back  is  often  complained  of  (McArthur,  in 
"Annals  of  Surgery,"  vol.  xxxiii).  Moderate  vomiting  may  occur  and  there 
may  be  blood  in  the  vomitus.  There  is  great  restlessness,  usually  collapse, 
and  frequently  bloody  diarrhea,  or,  at  least,  bowel  washings  may  be  bloody. 
Cardiac  disease  can  usually  be  demonstrated  and  albuminuria  is  common. 
Obstruction  may  follow  an  abdominal  operation  {postoperative  obstruction); 
it  may  arise  a  day  or  so  after  operation;  it  may  arise  in  ten  or  twelve  days 
after  operation;  it  may  not  arise  for  weeks  or  months  (Legeve).  It  may 
be  due  to  some  cause  at  the  seat  of  operation  (adhesion  of  the  bowel  to  a  raw 
surface,  volvulus,  catching  of  the  intestine  under  adhesions,  etc.).  It  may 
be  due  to  some  cause  distant  from  the  seat  of  operation  (displacement  of 
intestine,  bands,  etc.).  It  may  arise  from  paralysis  of  a  portion  of  the  bowel, 
which  may  or  may  not  be  due  to  sepsis.*  It  may  be  due  to  thrombosis  of 
a  mesenteric  vessel.  The  symptoms  of  postoperative  thrombosis  of  the  mesen- 
teric vessels,  according  to  A.  E.  Maylard,f  are  as  follows:  Abdominal  pain, 
perhaps  colicky  in  character,  gradual  or  acute  in  onset,  and,  as  a  rule,  constant. 
Early  in  the  case  there  is  no  abdominal  tenderness,  no  distention,  and  no 
rigidity.  The  pulse  is  rapid,  the  patient  is  extremely  restless,  there  may  be 
vomiting,  but  it  is  never  violent,  as  in  acute  obstruction;  often  there  is  diarrhea, 
and  sometimes  bloody  diarrhea.  These  symptoms  become  particularly 
significant  if  there  is  cardiac  or  vascular  disease.  Obstruction  from  Meckel's 
diverticulum  is  usually  acute,  but  is  sometimes  chronic,  and  occurs  particu- 

*  Legeve,  Gaz.  des  Hop.,  Nov.  23, 1895.  f  Brit.  Med.  Jour.,  Nov.  16,  1901. 


974  Diseases  and  Injuries  of  the  Abdomen 

larly  in  young  adults  and  children.  It  has  been  stated  that  other  and  visible 
deformides  are  usually  present,  but  in  a  study  of  69  cases  by  A.  E.  Halstead* 
this  was  true  of  but  one  case,  in  which  harelip  existed.  In  obstruction  from 
Meckel's  diverticulum  there  is  often  a  history  of  former  mild  attacks  (Hal- 
stead).  Halstead  sums  up  the  symptoms  as  follows:  As  the  obstruction  is 
high  up,  the  abdomen  is  the  shape  of  an  inverted  cone;  early  in  the  attack 
there  is  often  local  meteorism,  especially  under  the  costal  arch  of  the  right 
side,  but  there  is  no  distention  in  the  flanks.  Early,  active  peristalsis  may  be 
visible.  The  tenderness  is  just  to  the  right  of  the  umbilicus,  on  a  level  with 
it  or  below  it.     In  most  cases  there  is  early  fecal  vomiting,  f 

Differentiation  oj  Intestinal  Obstruction  from  Other  Diseases. — Always  ex- 
amine for  a  strangulated  hernia  at  every  hernial  outlet.  If  obstruction  is 
complicated  with  an  irreducible  hernia  above  the  seat  of  lesion,  the  hernia 
will  always  enlarge  and  become  tender  because  of  accumulation  of  feces. 
Functional  obstruction  may  attend  peritonitis  or  may  follow  the  reduction 
of  a  hernia.  Appendicitis  with  peritonitis  may  cause  symptoms  similar  to 
those  of  obstruction;  but  there  are  fever,  a  history  of  pain  in  the  right  iliac 
fossa,  and  the  vomiting  is  not  stercoraceous.  Acute  pancreatitis  produces 
symptoms  so  similar  to  those  of  intestinal  obstruction  that  a  diagnosis  cannot 
always  be  made.  Poisoning  by  arsenic  or  by  corrosive  sublimate  should  not 
be  confounded  with  intestinal  obstruction. 

Prognosis. — Without  surgical  interference  most  cases  of  acute  intestinal 
obstruction  die  within  ten  days — usually  within  seven  days.  Death  may  be 
due  to  shock,  to  exhaustion,  to  perforation,  to  peritonitis,  or  to  obstruction 
of  respiration  and  circulation  by  tympanites.  Recovery  occasionally  happens 
by  the  formation  of  a  fistula  externally  or  into  another  portion  of  the  bowel. 
In  acute  obstruction  from  foreign  bodies  the  obstructing  body  occasionally 
passes.  Volvulus  and  strangulation  by  bands  are  almost  invariably  fatal 
unless  an  operation  is  performed.  In  intussusception  recovery  occasionally 
follows  the  sloughing  away  of  the  prolapsed  gut,  but  stricture  almost  inevit- 
ably results  from  this  rare  event.  Functional  obstruction  gives  a  good  prog- 
nosis. The  prognosis  of  chronic  obstruction  depends  upon  the  causative 
lesion.  It  does  not  threaten  life  immediately  to  anything  like  the  degree 
that  acute  obstruction  does. 

Treatment. — In  any  abdominal  case  in  which  the  diagnosis  is  uncertain 
and  the  patient  is  shocked  give  an  enema  of  brandy  and  hot  water,  wrap 
the  patient  in  blankets,  surround  him  with  hot-water  bottles,  and  study  the 
development  of  symptoms  and  signs.  In  half  an  hour,  as  a  rule,  reaction 
will  be  brought  about,  and  a  probable  diagnosis  may  be  made  (Greig  Smith). 
In  acute  obstruction  it  is  usually  customary  to  empty  the  stomach  by  lavage 
and  to  evacuate  the  rectum  by  means  of  copious  injections  given  while  thr 
patient  is  in  the  knee-chest  position.  The  emptying  of  the  stomach  is  imper- 
ative if  stercoraceous  vomiting  has  been  going  on,  for  vomiting  of  a  quantity 
of  such  material  while  a  patient  is  under  ether  may  cause  death  by  drowning, 
the  fluid  flowing  in  enormous  quantity  into  the  bronchi.  In  very  severe  cases 
a  general  anesthetic  cannot  be  given  and  the  belly  must  be  opened  under 
rocain.     Hutchinson's  method  of  taxis  and  massage  is  uncertain^  and  is  as 

*  Annals  of  Surgery,  April,  1902. 
t  Ibid.,  April,  1902. 


Treatment  of  Intestinal  Obstruction  975 

liable  to  inflict  harm  as  to  confer  benefit.     Some  surgeons  apply  constant 
compression  to  the  abdomen  by  means  of  straps  of  adhesive  plaster.     Punc- 
ture of   the   intestine  with   an   aseptic    hypodermic    needle   introduced    ob- 
liquely to  relieve  gaseous  distention  is  a  decidedly  dangerous  proceeding.     The 
passage  of  a  small  tube  from  the  anus  to  the  sigmoid  flexure  will  empty  the 
colon  of  gas  if  no  obstruction  intervenes.     In  intussusception  it  is  the  custom 
of  some  surgeons  to  give  no  food  by  the  stomach;  administer  opium  and  bella- 
donna to  arrest  peristalsis,  wash  out  the  rectum  with  copious  injections,  give 
an  anesthetic,  and  insufflate  hydrogen  gas  or  carbonic-acid  gas  in  order  to 
distend  the  bowel.     Other  surgeons  treat  intussusception  by  forcing  air  into 
the  rectum  by  means  of  an  ordinary  bellows,  and  others  inject  water  by  a 
fountain-syringe,  the  reservoir  being  at  a  height  of  three  feet.     D'Arcy  Power 
believes  in  the  value  of  hydrostatic  pressure  in  intussusception  in  children. 
He  states  that  the  child  should  be  anesthetized  and  the  large  intestine  filled 
gradually  with  hot  saline  fluid,  the  reservoir  not  being  raised  more  than  three 
feet  above  the  patient.     The  fluid  should  be  retained  for  ten  minutes.     My 
own  feeling  is  that  whereas  it  may  be  justifiable  to  try  to  reduce  by  gaseous 
or  hydrostatic  pressure  during  the  first  twenty-four  hours  of  the  attack,  early 
operation  except  in  newborn  infants  gives  a  better  prognosis  and  is  safer  and 
more  certain.     Without  opening  the  abdomen  it  is  impossible  to  know  the 
condition  of  the  intestine.     Gangrene  may  occur  early  (it  has  been  found  in  less 
than  four  hours  after  the  onset  of  symptoms),  and  if  gangrene  exists  air  disten- 
tion or  hydrostatic  pressure  will  cause  death.     Rushmore's  reported  case  shows 
that  there  may  be  "no  systemic  symptoms  to  indicate  the  presence  of  gangrene" 
("Annals  of  Surgery,"  August,  1907).     Another  point  against  conservative 
treatment  is  the  common  uncertainty  as  to  whether  complete  reduction  has 
been  accomplished.     Vomiting  may  continue  for  hours  after  genuine  reduc- 
tion and  the  bowels  may  not  move  for  some  time.     Waiting  to  be  sure  reduc- 
tion was  accomplished  will  probably  be  responsible  for  death  if  reduction  was 
not  obtained.     After  the  first  twenty-four  hours  it  is  never  justifiable  to  use 
gaseous  or  hydrostatic  pressure  because  of  the  great  risk  that  ulcer  or  gangrene 
may  exist.     Pressure  cannot  be  accurately  regulated,  and  if  the  bowel  is  much 
damaged,  may  lead  to  rupture.     If  the  case  is  not  seen  until  after  the  first  day, 
or  if  injections  have  been  used  and  have  failed,  all  surgeons  believe  that  lapa- 
rotomy should  be  performed. 

Frederick  Holme  Wiggin  has  made  a  study  of  the  reported  cases  of  lap- 
arotomy for  infantile  intussusception,  and  considers  that  operation  done 
wdthin  the  first  forty-eight  hours  ^^-ill  give  a  mortality  of  22.2  per  cent.*  (see 
Operation  for  Intussusception) .  In  very  young  infants  the  mortality  of  lapar- 
otomy is  very  high  and  it  is  a  fair  question  if  on  them  immediate  laparotomy 
should  be  advised  \\ithout  a  trial  of  conservative  methods  if  the  case  is  seen 
during  the  first  twelve  or  twenty-four  hours.  The  mortaUty  of  operation  is 
very  large  on  those  under  eighteen  months  of  age.  But  even  in  those  under 
six  months  of  age  Wiggin  thinks  the  mortality  after  operation  is  not  above 
22.2  per  cent,  if  operation  is  done  within  forty-eight  hours,  and  my  personal 
feeling  is  that  operation  should  be  the  method  of  treatment  even  in  the  case  of  a 
young  baby. 

I  agree  \\\\h  Rushmore  that  operation  done  during  the  first  twelve  hours 
*Med.  Record,  Jan.  i8,  1896. 


976  Diseases  and  Injuries  of  the  Abdomen 

would  greatly  reduce  the  mortality,  perhaps  to  the  figures  he  expects  would 
come  from  such  a  practice,  viz.,  12.5  per  cent. 

In  obstruction  of  the  main  mesenteric  vessels  operation  is  of  no  avail. 
In  obstruction  of  branches  it  may  be  possible  to  resect  the  involved  region 
of  bowel,  a  region  which  is  found  to  be  gangrenous  or  at  least  is  becoming  so. 

In  obstruction  from  fecal  impaction  use  large  rectal  injections  and  give 
small  repeated  doses  of  salines  or  of  castor  oil.  If  there  are  signs  of  inflam- 
mation, do  not  give  cathartics,  even  in  small  doses,  but  give  opium  and  bella- 
donna to  arrest  vomiting  and  to  relax  spasm.  Impactions  in  the  rectum  can 
be  removed  by  the  use  of  a  spoon.  In  acute  intestinal  obstruction,  if  the 
symptoms  grow  worse,  do  not  wait,  but  open  the  abdomen  before  collapse 
comes  on  and  find  the  cause  of  the  obstruction.  If  it  is  a  gall-stone  or  entero- 
lith, try  to  crush  it  without  opening  the  intestine;  if  this  fails,  push  it  up  a  little 
distance,  incise  the  bowel,  remove  the  stone,  and  close  the  incision  with  Hal- 
sted  sutures.  Pilcher*  reports  40  cases  operated  upon  for  gall-stone  obstruc- 
tion with  21  deaths.  If  there  is  fecal  obstruction,  break  up  the  masses  by 
pressure  and  push  the  fecal  plug  down  without  opening  the  bowel.  If  there 
is  intussusception,  reduce  the  prolapse  and  shorten  the  mesentery;  but  if 
reduction  is  impossible,  perform  an  anastomosis  or  a  resection  and  enter- 
orrhaphy,  or  make  an  artificial  anus.  In  volvulus  untwist  and  shorten  the 
mesentery;  but  if  this  is  impossible,  treat  as  an  irreducible  invagination.  In 
obstruction  from  adhesions  try  to  separate  them  and  straighten  out  the  bowel, 
stitching  healthy  peritoneum  over  each  raw  spot  to  prevent  recurrence.  Anas- 
tomosis may  be  necessary.  In  flexion  separate  the  intestines,  remove  the  flexion 
by  a  V-shaped  incision,  and  suture  the  wound  in  the  bowel  (Senn) .  In  chronic 
obstruction  it  is  often  advisable  to  perform  an  exploratory  laparotomy,  dis- 
cover the  condition,  and  determine  what  is  to  be  done  to  correct  it.  Some 
tumors  external  to  the  bowel  may  be  removed.  Growths  in  the  bowel-wall 
may  be  removed  by  resection  of  the  involved  portion  of  intestine,  or  an  anasto- 
mosis may  be  performed,  or  it  may  be  necessary  to  make  an  artificial  anus. 
In  obstruction  from  Meckel's  diverticulum  that  structure  may  be  found  twisted, 
the  gut  near  it  may  be  kinked  or  twisted,  or  the  diverticulum  may  act  as  a 
band,  the  bowel  being  caught  under  it  or  kinked  over  it.  Intussusception  of 
the  gut  below  it  sometimes  occurs;  so  does  invagination  of  the  mucous  mem- 
brane of  the  diverticulum;  so  does  chronic  inflammation  and  cicatricial  nar- 
rowing of  the  diverticulum  or  gut  (Halstead).  The  diverticulum  may  be 
gangrenous,  perforated,  or  cystic. 

After  opening  the  abdomen  the  surgeon  must  be  guided  by  conditions. 
The  diverticulum  should  be  removed,  just  as  the  appendix  is  removed  in 
appendicitis,  and  comphcations  relating  to  the  gut  must  be  dealt  with. 

The  mortality  after  operations  for  acute  intestinal  obstruction  is  very  high 
(from  60  to  75  per  cent.) .  If  the  diagnosis  were  made  earlier,  operations  would 
be  done  earlier  and  the  mortality  would  be  much  less.  Nine  out  of  10  of  these 
cases  that  I  see  in  hospital  work  are  gravely  shocked  and  practically  dying  on 
admission.  If  a  patient  wath  obstruction  is  very  gravely  shocked,  I  usually 
follow  MovTiihan's  plan,  of  simply  opening  the  bowel  and  draining  it  in  its 
most  distended  coil  without  any  search  being  made  for  the  lesion.  The 
object  is  to  drain  the  poisons  from  the  intestine,  poisons  which  are  the  active 
*Med.  News,  Feb.  8,  1902. 


Treatment  of  Intestinal  Obstruction  977 

agents  in  killing  the  patient.  The  abdomen  is  opened  under  cocain,  the 
incision  being  small.  A  distended  coil  of  intestine  is  sutured  to  the  peritoneum 
about  the  abdominal  incision,  every  care  being  taken  that  the  stitches  do  not 
penetrate  the  mucous  membrane  of  the  gut  (Moynihan) .  A  purse-string  suture 
is  now  inserted  so  as  to  enclose  an  area  of  the  exposed  gut;  an  incision  is  made 
into  the  gut  in  this  enclosed  area,  and  gas  and  feces  flow  out.  Paul's  glass  tube 
is  passed  into  the  gut  and  the  purse-string  suture  is  tied.  Instead  of  Paul's 
tube  we  may  use  a  rubber  tube  sutured  as  is  the  tube  in  Kader's  gastrostomy 
(Elsberg,  in  "Annals  of  Surgery,"  May,  1908).  The  obstruction  is  thus 
temporarily  relieved,  and  if  the  patient  recovers,  the  causative  lesion  may  be 
subsequently  sought  for  and  attacked.  If  a  fecal  fistula  follows  the  enteros- 
tomy and  refuses  to  close,  it  may  be  closed  by  operation.  If  Elsberg's  plan 
is  followed  a  persisting  fecal  fistula  will  be  rare.  Francis  T.  Stewart  has 
devised  a  method  by  which  the  bowel  can  be  drained  without  any  risk  of 
infection  of  the  peritoneal  cavity,  a  risk  which  always  exists  in  using  Paul's 
tube.  Stewart  places  a  clamp  at  either  extremity  of  the  loop  of  bowel  and 
surrounds  it  with  gauze.  One  half  of  a  Murphy  button  is  inserted  into  the 
empty  loop  through  a  small  incision.  The  other  half  of  the  button  is  squeezed 
into  a  rubber  tube  the  diameter  of  which  is  somewhat  smaller  than  the  flange 
of  the  button.     The  two  parts  of  the  button  are  then  clamped,  and  the  clamps 


Fig.  520. — Fecal  fistula:  a,  Di-  Fig.  521. — Artificial  anus,  show- 

rection  of  fecal  flow;  b,  b,  bell}--  ing  spur:  o,  Spur;   b,  b,  belly-wall; 

wall.  c,  direction  of  fecal  flow. 

are  removed  from  the  loop  of  bowel.  The  intestine  is  sutured  to  the  wound 
margins  and  the  feces  drain  into  a  receptacle  on  the  floor.  Fig.  522  shows 
Stewart's  operation.  In  any  cases  of  intestinal  obstruction  if  gangrene  exists 
the  temptation  to  do  immediate  resection  is  strong.  I  have  done  it  a  number 
of  times  with  a  very  large  mortality.  Of  late  I  have  been  following  the  plan 
of  Mikulicz  and  results  have  been  far  better.  The  gangrenous  loop  is  brought 
outside  of  the  abdomen,  it  is  fixed  parallel  to  the  wound  and  enterostomy  is 
performed  above  it.  If  a  fecal  fistula  forms  it  is  subsequently  closed  by  ap- 
propriate methods.  Postoperative  obstruction  coming  on  soon  after  a  surgical 
operation  is  often  not  recognized  for  a  time,  and  the  surgeon  will  be  in  doubt  as 
to  whether  he  is  dealing  with  peritonitis  or  intestinal  paresis.  When  in  doubt, 
wash  out  the  stomach  with  warm  salt  solution,  administer  salines  in  small  doses 
frequently  repeated,  employ  enemata,  and  give  two  or  three  doses  of  atropin  at 
intervals  of  two  hours.  Each  dose  should  be  gr.  otj-q.  Atropin  is  given  with  the 
idea  that  it  increases  peristalsis  and  contracts  blood-vessels.  It  is  proba- 
bly merely  sedative,  relaxes  spasm,  and  is  useless  if  strangulation  exists.  If 
these  measures  are  not  quickly  followed  by  the  passage  of  flatus  or  feces, 
open  the  abdomen;  never  wait  for  the  advent  of  stercoraceous  vomiting  (see 
Legeve) . 
62 


978 


Diseases  and  Injuries  of  the  Abdomen 


Fecal  Fistula  and  Artificial  Anus. — A  fistula  is  an  abnormal  open- 
ing in  the  intestine  through  which  gas  or  a  portion  of  the  feces  escape  (Fig. 
520).  If  all  the  intestinal  contents  escape  through  the  opening,  it  is  called 
an  artificial  anus  (Fig.  521,  Senn).  A  surgeon  may  make  a  fistula  dehberately 
{intentional  fistida).  A  fistula  may  be  the  product  of  disease  or  injury  (acci- 
dental fistula).  Senn  enumerates  the  following  causes  of  accidental  fistula: 
wounds,  injury  of  the  intestine,  intestinal  ulceration,  intestinal  strangulation, 
foreign  bodies  in  the  intestinal  canal,  malignant  tumors,  actinomycosis,  pelvic 
and  abdominal  abscess,  appendicitis,  injury  of  the  bowel  during  an  abdominal 
operation,  the  application  of  ligatures,  catching  by  sutures,  and  the  employ- 
ment of  drainage-tubes. 

Treatment. — Many  fistulas  close  spontaneously.  This  can  be  hoped  for 
only  if  the  opening  is  quite  small,  if  the  general  health  of  the  patient  is  good, 


Fig.  522 — Stewart's  method  of  enterostomy. 


if  the  cause  has  passed  away,  if  the  fistula  is  not  lined  with  mucous  mem- 
brane, and  if  there  is  no  spur  (spur  is  shown  at  a,  Fig.  521),  In  most  cases 
of  fistula  not  high  up  it  is  well  to  give  nature  a  chance  to  effect  a  cure,  and 
not  to  be  in  a  hurry  to  operate.  The  part  is  cleansed  frequently  with  peroxid 
of  hydrogen,  the  patient  is  kept  recumbent,  food  is  given  which  does  not 
leave  much  residue,  pads  of  gauze  with  pressure  are  applied,  and  the  bow^els 
are  kept  regular. 


Peptic  Ulcer  of  the  Duodenum  979 

If  the  track  is  lined  with  granu'ations,  it  may  be  touched  with  lunar 
caustic;  if  it  is  Uned  with  mucous  membrane,  the  actual  cautery  should  be 
applied;  any  collection  of  pus  which  exists  should  be  drained.  If  these 
methods  fail,  an  operation  must  be  performed.  The  fistula  may  be  sutured 
by  extraperitoneal  manipulation  (Greig  Smith);  it  may  be  covered  with  skin 
(bieffenbach);  the  spur  may  be  removed  by  means  of  a  clamp;  or  resection 
may  be  performed.  In  most  cases  it  is  best  to  incise  a  button  of  skin  around 
the' opening,  temporarily  suture  the  fistula,  open  the  peritoneal  cavity,  deliver 
the  bowel,  and  suture  carefully  (Senn's  method).  In  some  cases  partial 
exclusion  of  the  fistulous  part  is  necessar>^  the  bowel  being  divided  above 
the  fistula,  the  end  near  the  fistula  sutured,  and  the  other  end  anastomosed 
to  the  bowel  below  the  fistula.  In  other  cases  complete  exclusion  may  be 
performed  (page  1107). 

Ulcer  of  the  Bowel. — In  typhoid  fever  and  in  dysentery  ulceration 
occurs.  An  ulcer  may  be  due  to  tuberculosis  or  cancer.  An  ulcer  of  the 
duodenum  (see  below)  is  due  to  the  same  causes  as  an  ulcer  of  the  stomach. 
An  ulcer  of  the  jejunum  sometimes  develops  after  the  performance  of  gas- 
tro-jejunostomy  for  gastric  ulcer  (page  1075).  Curling's  ulcer  is  a  chronic 
ulcer  of  the  duodenum  following  a  burn  of  the  cutaneous  surface  and  due 
to  embolism.  An  ulcer  may  heal,  and,  by  causing  thickening  and  constric- 
tion, produce  chronic  intestinal  obstruction.  It  may  perforate,  causing 
collapse  and  subsequent  peritonitis. 

Peptic  Ulcer  of  the  Duodenum.— Occurs  usually  in  that  portion 
of  the  duodenum  which  is  above  the  opening  of  the  bile-duct;  in  other  words, 
only  in  the  region  acted  on  by  the  acid  fluid  from  the  stomach.  In  Perr}'  and 
Shaw's  list  of  149  cases,  the  first  portion  was  involved  in  123,  the  second  por- 
tion in  16,  and  the  third  and  fourth  portions  in  2.  Reversing  the  rule  in  gastric 
ulceration,  duodenal  ulceration  is  more  common  in  males  than  in  females  in 
the  proportion  of  3  or  4  to  i.  It  may  occur  at  any  period  of  Hfe,  from  early 
youth  to  extreme  old  age,  but  is  most  common  between  the  tenth  and  fortieth 
years.  Duodenal  ulcers  are  usually  single,  but  may  be  multiple,  and  they  are 
one-twelfth  as  common  as  gastric  ulcers.  A  gastric  ulcer  may  exist  with  a 
duodenal  ulcer.  Murphy  sums  up  the  supposed  causes  into  h}-perchlorhydria, 
local  infection,  embolism,  and  thrombosis,  and  disturbances  of  the  organs  of 
elimination  (for  instance,  a  burn  of  the  skin  which  may  cause  CurUng's  ulcer) . 
An  indurated  chronic  ulcer  may  exist,  and  this  may  heal  and  produce  cicatricial 
stenosis.  An  acute  ulcer  is  apt  to  perforate.  Just  as  chronic  gastric  ulcer 
may  be  latent,  no  symptoms  ever  being  observed,  so  may  chronic  duodenal 
ulcer  be  latent.  Usually  there  is  pain  coming  on  about  three  or  four  hours 
after  taking  food,  and  located  in  the  epigastric  or  right  h>-pochondriac  region. 
This  pain  lasts  until  the  next  meal  and  is  relieved  when  the  meal  is  taken, 
hence  we  say  that  food  reheves  it.  If  the  digestion  of  the  evening  meal  is 
delayed  the  pain  rouses  the  patient  from  sleep,  but  a  glass  of  milk  will  quiet  it. 
Patients  usually  discover  these  facts.  The  pain  is  less  severe  than  is  usual  in 
gastric  ulcer  and  in  many  cases  does  not  radiate  to  the  back,  although  in  others 
it  does  radiate  to  the  right  scapular  region.  Symptoms  of  indigestion  are  not 
nearly  so  marked  as  in  ulcer  of  the  stomach.  Vomiting  is  far  less  common  than 
in  gastric  ulcer  and  it  does  not  reUeve  pain.  In  one-third  of  the  cases  there  is 
hematemesis,  and  sometimes  there  is  blood  in  the  stools.     The  stools  may  be, 


980  Diseases  and  Injuries  of  the  Abdomen 

at  times,  dark  and  tarry  from  blood.  The  hemorrhage  from  the  bowels  may 
be  so  profuse  as  to  kill  or  almost  kill  the  padent.  It  may  be  so  frequently 
repeated  as  to  make  him  profoundly  anemic.  In  many  cases  there  is  no  vis- 
ible blood  in  the  feces,  but  the  guaiac  or  aloin  tests  show  occult  blood. 
Vomiting  of  quantities  of  blood  is  much  rarer  than  in  gastric  ulcer.  Moyni- 
han*  mentions  the  following  comphcations:  severe  hemorrhage;  perforation; 
periduodenitis;  cancer;  and  cicatricial  contraction  involving  the  bile-duct. 

Perforating  ulcer  is  more  common  than  we  once  thought.  Perforation  is 
usually  on  the  anterior  wall.  It  is  much  less  common  on  the  posterior  wall. 
It  is  extremely  rare  on  the  superior  wall  and  practically  never  occurs  on  the 
inferior  wall.  Moynihan  gathered  49  cases  from  literature  and  added  2 
of  his  own.  In  the  great  majority  of  cases  perforation  of  the  duodenum 
cannot  be  differentiated  from  perforation  of  the  stomach  by  a  study  of  the 
symptoms.  In  some  cases  the  symptoms  resemble  appendicitis.  In  most 
cases  there  is  a  sudden  onset  of  violent  abdominal  pain,  followed  by  vomit- 
ing, shock,  rapid  pulse,  and  tenderness  of  the  epigastric  or  right  hypochondriac 
region.  As  a  rule,  after  a  few  hours  the  patient  reacts  from  shock.  Sheild's 
case  got  better  in  four  hours  and  walked  some  distance  to  the  hospital. f  Lucy's 
case  got  better  a  short  time  after  the  onset,  walked  home,  and  attended  to  a 
horse,  but  then  became  rapidly  worse.  The  improvement  is  apparent,  not 
real,  and  is  only  temporary.  The  symptoms  quickly  become  worse,  and  when 
they  become  worse,  besides  the  pain  and  tenderness  and  rapid  pulse,  there 
will  be  occasional  vomiting,  rigidity  of  the  abdomen,  usually  an  elevated  or 
normal  temperature,  and  possibly  diminution  of  the  area  of  hver-dulness. 

Treatment. — In  duodenal  ulcer  the  risks  of  serious  hemorrhage  and  of 
perforation  are  much  greater  than  in  gastric  ulcer,  and  operation  should  always 
be  recommended  if  the  diagnosis  is  made.  We  used  to  say  operate  only  if 
the  symptoms  are  not  amended  by  rigid  diet  and  medication;  if  severe  hemor- 
rhage occurs  or  if  cicatricial  contraction  interferes  with  the  passage  of  food 
through  the  bowel  or  bile  into  the  duodenum.  Moynihan  refers  to  four  cases 
of  chronic  ulcer  operated  upon  and  all  recovered.  In  some  cases  excision  is 
practised,  in  others  excision  with  gastro-enterostomy  or  gastro-enterostomy 
alone. 

If  grave  hemorrhage  occurs  and  is  repeated  the  surgeon  should  open  the 
abdomen,  ligate  the  bleeding  vessels,  bring  the  outer  coats  of  the  bowel  together 
over  the  indurated  area,  and  perform  posterior  gastrojejunostomy  (Wm. 
J.  Mayo,  in  "Surg.,  Gynec,  and  Obstet.,"  May,  1908).  In  such  a  bleeding 
iilcer  the  vessels  entering  it  are  usually  varicose. 

In  perforation  operation  is  performed,  as  in  gastric  ulcer,  as  soon  as  pos- 
sible. In  these  cases,  as  in  perforated  gastric  ulcer,  I  believe  operation  should 
be  immediate  and  that  we  should  not  wait  for  a  possible  reaction  from  shock. 
The  ulcer  is  inverted  by  two  rows  of  silk  sutures.  Some  surgeons  do  not 
drain,  but  I  would  feel  it  safer  to  drain.  B.  G.  A.  MoynihanJ  gathered  49 
operations  for  perforated  ulcer  with  8  recoveries.  Mr.  T.  Crisp  Enghsh 
reports  8  operations  for  perforation  of  duodenal  ulcers,  with  2  recoveries 
("Lancet."  Nov.  28,  1903).     In  perforated  duodenal  ulcer  the  extra vasated 

*  Lancet,  Dec.  14,  1901. 
flbid.,  March  29,  1902. 
j  Ibid.,  Dec.  14,  igoi. 


Perforated  Typhoid  Ulcer  981 

fluid  is  a]:»t  to  flow  into  the  right  iliac  region.  If  an  erroneous  diagnosis  of 
appendicitis  was  made,  on  opening  in  the  right  iliac  region,  by  giving  vent 
to  this  fluid,  might  for  a  time  confirm  the  surgeon  in  error,  but  the  character 
of  the  fluid  should  make  evident  the  condition  of  affairs. 

Ulcer  of  the  Jejunum  after  Qastro=enterostomy. — (See  page  1075.) 
Perforated  Typhoid  Ulcer. — Perforation  occurs  in  2  or  possibly  3  cases 
out  of  100.  About  70  per  cent,  of  perforations  occur  in  the  second,  third, 
or  fourth  week.  Perforation  in  a  typhoid  ulcer  is  usually  effected  rapidly, 
a  large  opening  is  formed,  and  a  considerable  quantity  of  fecal  matter  is 
passed  into  the  peritoneal  cavity.  In  some  perforations  very  little  fluid  es- 
capes. Severe  pain  and  a  nervous  chill  indicate  that  perforation  is  occurring 
or  has  occurred.  Some  maintain  that  the  two  above-named  symptoms  asso- 
ciated with  marked  leukocytosis  indicate  that  perforation  is  about  to  occur, 
and  they  call  this  stage  the  preperjorative  stage.  That  distinct  symptoms 
may  in  some  cases  point  to  impending  perforation  is,  I  beheve,  true,  and 
in  one  case  I  operated  on  the  conviction  and  found  two  areas  almost  perforated. 
In  most  cases,  however,  I  do  not  believe  that  there  is  a  distinct  preperforative 
stage,  but  the  perforation  exists  when  the  symptoms  are  first  noted.  The  con- 
viction that  perforation  was  occurring  would  be  strengthened  by  a  progressive 
increase  in  the  leukocyte  count.  It  is  to  be  remembered,  however,  that  the 
leukocyte  count  is  increased  by  sweating,  cold  bathing,  vomiting,  hemorrhage, 
severe  diarrhea,  or  some  positive  complication.  When  perforation  occurs,  vio- 
lent pain  develops.  As  a  rule,  there  are  tenderness,  rapid  pulse,  costal  respira- 
tion, abdominal  rigidity,  vomiting,  and  shock.  Usually  there  is  temporary  re- 
action from  shock,  the  subnormal  temperature  giving  way  to  a  normal  or  to  an 
elevated  temperature.  The  vomiting  in  some  cases  becomes  stercoraceous. 
There  is  constipation  and  sometimes  dulness  on  percussing  the  flanks.  The 
face  is  Hippocratic.  The  patient  may  die  of  the  preliminary  shock  or  may  react 
and  die  subsequently  of  blood-poisoning.  In  a  few  hours  after  perforation 
distinct  leukocytosis  may  be  observed,  but  it  may  never  take  place  at  all. 
Even  when  leukocytosis  arises,  it  may  disappear  as  peritoneal  infection  spreads 
and  systemic  poisoning  deepens.  Le  Conte  points  out  that  rupture  of  the 
mesenteric  glands  simulates  intestinal  perforation. 

Treatment. — Leyden  suggested  operation  in  1884  and  in  the  same  year 
Mikulicz  did  the  first  successful  operation.  Before  MikuHcz's  paper  was 
published  my  colleague,  Dr.  James  C.  Wilson,  published  a  paper  in  which  he 
advocated  operation.  Death  is  practically  certain  without  operation.  Opera- 
tion should  save  at  least  one-fifth  of  the  cases.  Operation  should  be  done  at 
once,  proper  means  being  adopted  to  combat  shock.  In  many  cases  a  general 
anesthetic  should  not  be  given,  but  a  local  anesthetic  should  be  employed. 
The  incision  should  be  made  in  the  right  iliac  region  and  the  colon  should 
be  first  located  and  then  the  end  of  the  ileum.  By  locating  the  colon  we 
obtain  a  fixed  point  from  which  to  begin  our  search  for  perforations,  and 
by  opening  the  abdomen  in  the  right  iliac  region  we  come  down  at  once  onto 
the  perforated  gut  in  the  vast  majority  of  cases.  When  a  perforation  is 
found,  it  should  be  inverted  with  two  layers  of  Halsted  sutures.  It  is  not 
wise  to  excise  the  ulcer.  If  the  bowel  is  very  badly  damaged,  resection  can 
be  considered,  but  it  is  usually  wiser  to  make  a  temporary  artificial  anus. 
After  finding  a  perforation  and  closing  it,  examine  to  see  if  there  are  others. 


982*  Diseases  and  Injuries  of  the  Abdomen 

Close  every  perforation,  and  if  a  point  is  found  where  the  thinning  of  the 
bowel-wall  indicates  that  perforation  is  liable  to  occur,  protect  this  point  by 
inverting  the  area  of  ulceration  by  sutures.  Clean  the  peritoneum  by  flush- 
ing with  hot  salt  solution.  Leave  the  wound  open,  insert  strands  of  iodoform 
gauze,  and  establish  tubular  suprapubic  drainage.  Elevate  the  patient  a  little 
in  bed  and  employ  continuous  proctoclysis  of  salt  soludon.  I  have  operated 
ten  times  for  typhoid  perforation  with  three  recoveries.  Three  cases  died 
of  shock.  In  one  case  the  perforation  was  not  found,  but  was  discovered 
postmortem  in  the  hepatic  flexure  of  the  colon,  the  gall-bladder  being  respon- 
sible for  the  ulcer  of  the  bowel.  One  case  improved  greatly,  lived  for  eight 
days,  developed  another  perforation,  and  died  of  shock.  The  necropsy 
showed  that  the  sutured  perforation  was  soundly  closed.  One  case,  a  young 
man,  brought  to  me  by  Dr.  Godfrey,  was  operated  upon  twenty-four  hours 
after  perforation.  There  was  one  perforation  near  the  ileum  and  considerable 
fecal  extravasation.  The  opening  was  large  and  stitches  would  not  hold. 
The  several  inches  of  bowel  between  the  ulcer  and  the  ileocecal  valve  pre- 
sented several  ulcers  almost  perforated.  The  patient  was  too  weak  for  a 
resection.  After  cleansing  the  abdomen  an  artificial  anus  was  made  proximal 
to  the  perforation.  The  patient  recovered  and  subsequently  the  anus  was 
successfully  abolished  by  a  resection.  In  another  case,  that  of  a  young  woman, 
on  opening  the  abdomen  a  violent  appendicitis  was  found,  the  appendix  being 
swathed  in  lymph  and  gangrenous.  The  appendix  was  removed.  Search 
showed  a  perforation  in  a  loop  of  gut  two  feet  from  the  ileocecal  valve.  There 
was  considerable  extravasation.  The  perforation  was  closed.  The  periton- 
eum was  cleansed,  drainage  was  inserted,  and  the  patient  recovered.  Cul- 
tures from  the  appendix  and  from  the  peritoneal  cavity  showed  only  the  colon 
bacillus.  In  a  third  case,  that  of  a  young  woman,  impending  perforation  was 
diagnosticated  by  Dr.  Kalteyer  because  of  pain,  tenderness,  some  rigidity,  and 
definite  and  increasing  leukocytosis.  Two  ulcers  almost,  but  not  quite, 
perforated  were  found.  They  were  covered  over  by  the  use  of  inversion 
sutures,  the  wound  was  closed  without  drainage,  and  recovery  followed. 
Culture  from  the  peritoneal  cavity  was  negative.  These  three  successful 
cases  were  operated  upon  in  the  Jefferson  College  Hospital. 

Primary  Intestinal  Tuberculosis. — According  to  Kocher,  there  are 
80  cases  on  record.  He  reported  29  cases  to  the  Swiss  Medical  Congress 
in  1892.  Primary  tuberculosis  is  very  rare,  whereas  secondary  tuberculosis 
is  common.  The  exact  propriety  of  rigidly  regarding  such  cases  as  primary 
is  doubtful.  Kocher's  cases  came  from  tuberculous  stock,  and  suffered  in 
infancy  from  enlarged  glands,  pleurisy,  or  bronchitis,  and  that  surgeon  says 
that,  in  all  probability,  there  had  for  some  time  been  somewhere  in  -the  body 
a  latent  tuberculous  focus,  and  from  this  focus  came  the  bacteria  which 
attacked  the'  intestine.  Intestinal  tuberculosis,  in  the  victims  of  phthisis, 
begins  with  the  formation  of  multiple  ulcers,  due  to  swallowing  tuberculous 
sputum.  Primary  intestinal  tuberculosis  usually  begins  as  one  ulcer  or 
several,  or  even  many  ulcers  in  the  ileum  or  perhaps  in  the  cecum.  These 
ulcers  tend  to  heal  and  form  strictures.  Occasionally,  in  primary  tuberculosis 
there  is  enormous  tumor-like  thickening  of  the  cecum.  This  is  hyperplastic 
tuberculosis,  the  conglomerate  tuberculosis  of  Mayo.  The  symptoms,  as  a 
rule,  are  slight,  attacks  of  pain  occurring  now  and  then,  and  stricture  grad- 
ually developing.     The  urine  shows  the  diazo  reaction  (Kocher). 


Appendicitis  983 

Treatment, — In  the  first  stage  the  projjer  treatment  is  excision  of  ulcerated 
areas,  possibly  excision  of  the  cecum.  Later,  if  stricture  is  causing  chronic 
obstruction,  an  operation  may  be  performed  to  give  relief.  Laparotomy, 
careful  separation  of  adhesions  which  are  not  fused  with  the  gut,  and  the 
introduction  of  iodoform  may  prove  of  value. 

Malignant  Tumor  of  the  Intestine. — Sarcoma  is  very  rare,  but  does 
sometimes  arise,  particularly  in  young  persons,  and  it  enlarges  very  rapidly. 
It  is  most  prone  to  attack  the  large  intestine.  Jopson  and  White  *  report  i  case 
and  also  collect  22  others.  The  mesenteric  glands  frequently  enlarge.  Can- 
cer is  not  uncommon,  attacking  especially  the  middle  aged.  According  to 
Rolleston,  the  average  age  in  duodenal  cancer  is  fifty-two  years,  in  jejunal  and 
iliac  cancer  forty-seven,  in  cancer  of  the  cecum  nearly  forty-eight,  and  in  cancer 
of  the  rest  of  the  large  intestines  about  forty-nine  years.  It  is  most  common 
in  the  neighborhood  of  the  ileocecal  valve  and  in  the  sigmoid  flexure.  Ewald 
collected  1148  cases  of  cancer  of  the  intestine.  In  64  cases  the  cecum  was 
involved;  in  24  cases  the  ileum  was  involved.  It  produces  pain  at  the  seat 
of  growth,  and  after  a  time  constipation,  or  constipation  alternating  with 
diarrhea,  and  finally  intestinal  obstruction.  In  some  cases  the  symptoms 
appear  suddenly,  acute  obstruction  taking  place  or  intussusception  occurring. 
It  is  usually  possible  to  palpate  the  tumor,  which  is  hard  and  immovable. 
The  patient  wastes  rapidly  and  is  apt  occasionally  to  pass  blood  at  stool. 
The  growth  does  not  enlarge  very  rapidly  and  glands  are  not  involved  early. 
In  some  cases  the  supraclavicular  glands  enlarge.  In  more  than  one-half  of 
the  cases  which  die  of  intestinal  cancer  there  is  no  lymphatic  infection. f 

Treatment. — Early  in  the  case  exploratory  laparotomy  should  be  per- 
formed, followed,  if  possible,  by  excision  with  end-to-end  or  side-to-side  approxi- 
mation. This  is  done  for  either  cancer  or  sarcoma.  It  may  be  possible  to 
remove  enlarged  glands.  In  cancer  of  the  cecum  extirpate  the  cecum  and 
implant  the  end  of  the  ileum  into  the  side  of  the  colon  (Wm.  J.  Mayo).  If  ex- 
cision is  impossible,  the  growth  should  be  side-tracked  by  performing  lateral 
anastomosis.  In  advanced  cancer  of  the  large  bowel,  if  resection  is  impossible, 
make  an  artificial  anus  above  the  tumor  (cancer  of  rectum,  page  1182). 

Appendicitis. — Appendicitis,  which  is  an  inflammation  of  the  vermi- 
form appendix  of  the  cecum,  is  almost  invariably  the  primary  lesion  of  all  of 
those  various  conditions  known  as  typhlitis,  perityphlitis,  paratyphlitis,  etc. — 
terms  which  seldom  imply  pathological  entities,  and  are  in  most  instances 
well  relegated  to  obscurity.  I  say  in  most  instances,  not  in  all,  because  I 
believe  there  is  such  a  condition  as  primary  inflammation  of  the  cecum,  al- 
though it  is  extremely  rare.  This  rare  condition  may  cause  perforation, 
perityphlitic  abscess,  or  peritonitis  when  the  appendix  is  sound.  It  is  not  to  be 
distinguished  chnically  from  appendicitis  (McWilliams,  in  "Annals  of  Surgery," 
June,  1907).  Involvement  of  the  cecum  as  a  result  of  appendicitis  is  common. 
It  was  recognized  by  some  observers  many  years  ago  that  such  a  disease  as 
inflammation  of  the  appendix  existed,  but  the  majority  of  the  profession  did 
not  grasp  the  fact.  In  1750  Mestevier,  of  France,  reported  a  case  of  perfora- 
tive appendicitis  with  peritonitis,  f     In  181 2  a  perforated  appendix  was  shown 

*Ani.  Jour.  Med.  Sciences,  Dec,  igoi. 

fWm.  J.  Mayo,  Jour.  Am.  Med.  Assoc,  Oct.  19,  1901. 

j  Jour.  Med.  at  Chir.,  1760. 


984  Diseases  and  Injuries  of  the  Abdomen 

to  the  Medico-Chirurgical  Society  of  London,  and  in  1835  Southam  reported  an 
appendiceal  abscess  (Manley).     In  1848  Hancock  reported  an  appendiceal 
abscess  ("Lancet,"  1848,  p.  380).     It  is  interesting  to  note  that  this  was  a 
case  of  appendicitis  in  pregnancy.     Ten  days  after  a  premature  delivery  an 
abscess  was  opened.     About  two  weeks  after  o])eration  two  fecal  concretions 
came  out  of  the  wound.     In  1827  Dr.  L.  Mellier  described  appendicitis,  and 
named  among  its  symptoms  fixed  pain  in  the  right  iHac  fossa  and  colic.     This 
brilliant  and  original  man  was  years  ahead  of  his  contemporaries.    He  reported 
cases  of  undoubted  appendicitis  verified  by  autopsy,  described  gangrene,  per- 
foration, associated  peritonitis,  and  appendiceal  concretions.     His  original 
article,  Manley  tells  us,  is  in  the  "Journal  of  Medicine,  Surgery,  and  Pharmacy  " 
for  1827,  second  series,  no.*     MeUier  said:  "If  it  were  possible  to  establish 
with  certainty  the  diagnosis  of  this  affection,  we  could  see  the  possibility  of 
curing  the  patient  by  operation.     We  shall  perhaps  some  day  arrive  at  this 
result."  f     In  spite  of  Mellier's  writing's,  the  profession  adhered  for  half  a 
century  to  the  view  of  Dupuytren,  put  forth  in  1833,  that  abscesses  in  the  iUac 
region  take  origin  from  the  cecum  and  not  from  the  appendix.     Dr.  Reginald 
Fitz,  of  Boston,  in   1886  persuaded  the  world  that  the  appendix  is  the  real 
seat  of  most  inflammations  in  the  right  iUac  fossa.     This  structure  is  par- 
ticularly liable  to  infection  because  of  the  large   amount  of  lymphoid  tis- 
sue in  its  make-up,   because   it  is  in  a  dependent   position,   is  always  full 
of  bacteria,  has  a  poor  blood  supply,  and  is  readily  blocked  by  kinking  or 
by  sweUing  of  its  mucous  membrane.     Further,  as  a  vestigial  structure,  it 
has  a  low  resisting  power.     The  appendix  is  a  long  and  narrow  diverticulum 
(musculomembranous  in  structure),  which  comes   from   the  posterior  and 
internal  part  of  the  head  of  the  colon,  and  which  probably  has  no  physi- 
ological   function    (in    herbivora    and    rodents   it   is    a    functionally  active 
organ).    The  structure  of  the  appendix  is  similar  to   the  structure  of  the 
colon,  except  that  the  muscular  structure  is  ill  developed  and  trivial  in  amount. 
Lockwood  points  out  that  there  is  an  extensive  lymph  system  in  the  appendix, 
and  that  the  submucous  and  subperitoneal  tissues  communicate  by  numerous 
gaps  in  the  muscles.  J     This  structure  has  a  poor  blood-supply,  and  in  conse- 
quence gangrene  occurs  from  rather  trivial  causes.     It  is  supplied  by  a  branch 
from  the  superior  mesenteric  artery.     In  women  there  is  sometimes  an  addi- 
tional supply  by  a  vessel  running  in  the  appendiculo-ovarian  ligament.     The 
nerves   are   derived  from   the   superior  mesenteric   plexus.     The   appendix 
averages  about  four  and  a  half  inches  in  length,  but  varies  in  size  between  the 
limits  of  one-third  of  an  inch  and  a  little  over  9  inches.     In  641  autopsies  the 
longest  appendix  was  9J  inches  and  the  shortest  was  one-third  of  an  inch 
(Monks  and  Blake).     Its  diameter  is,  as  a  rule,  about  equal  to  that  of  a  No. 
9  English  bougie;    its  canal  is  narrow  and  is  partly  closed  by  the  valve  of 
Gerlach  (Talamon).     The  appendix  enters  the  cecum  at  its  posterior  inter- 
nal part,  which  is  usually  the  seat  of  the  most  intense  pain  in  inflammation, 
and  corresponds  to  a  point  on  the  surface  two  inches  from  the  anterior  supe- 
rior spine  of  the  ilium,  on  a  line  drawn  from  the  umbilicus  to  the  iliac  spine, 
which  is  known  as  "McBitrneys  point."     The  free  part  of  the  appendix 

*  Thomas  H.  Manley,  Med.  Record,  July  19,  1902. 

fSee  R.  J.  Lee  Morrill's  article  in  the  Amer.  Med.-Surg.  Bull.,  Dec.  19,  1896. 

j  Brit.  Med.  Jour.,  Jan.  27,  1900. 


Etiology  and  Pathology  of  Appendicitis  985 

in  one-third  of  all  persons  is  in  relation  with  the  posterior  surface  of  the 
cecum;  in  almost  one-third  of  all  persons  it  is  fixed  in  the  iliac  fossa,  so  that 
if  perforation  occurs,  the  contents  will  be  voided  in  the  retroperitoneal  tissue 
(iliac  abscess).  In  some  cases  it  is  external  to  the  cecum;  in  some  it  passes 
downward,  and  in  some  inward.  It  is  important  to  remember  that  the  appen- 
dix may  be  met  with  in  the  most  unexpected  situations.  When  the  ascend- 
ing colon  is  displaced,  the  diverticulum  may  be  upon  the  left  side.  Tt  is  not 
unusual  to  find  its  tip  in  the  middle  line,  up  toward  or  adherent  to  the  gall- 
bladder, or  in  the  pelvis.  In  about  two-thirds  of  all  cases  the  appendix  is  com- 
pletely covered  with  peritoneum;  in  one-third  of  all  cases  it  is  in  contact,  in 
some  part  of  its  length,  with  cellular  tissue  (Talamon).  Byron  Robinson  has 
called  attention  to  the  fact  that  the  appendix  is  frequently  in  contact  with  the 
psoas  muscle  in  men,  and  may  be  bruised  by  this  muscle.  In  10,000  autopsies 
the  appendix  is  said  to  have  been  absent  five  times.  In  most  cases  where  sur- 
geons have  been  unable  to  find  the  appendix  it  was  not  absent,  but  was  covered 
with  peritoneum.     Occasionally  the  appendix  is  found  in  a  hernial  sac. 

Etiology  and  Pathology.— Appendicitis  is  very  rare  in  infants.  I 
operated  unsuccessfully  on  a  male  two  years  of  age  for  gangrenous  appen- 
dicitis. Savage  operated  unsuccessfully  on  a  baby  sixty-one  days,  and  Weiss 
operated  unsuccessfully  on  a  child  twenty  months  old.*  J.  P.  Crozer  Griffith  f 
has  collected  15  cases  in  children  under  two  years  of  age.  One  of  these 
patients  was  three  months  of  age.  Nine  of  the  15  were  operated  upon,  with 
7  recoveries.  In  4  of  the  cases  the  appendix  was  in  the  scrotum.  In  2  cases 
a  diagnosis  of  intussusception  was  made.  In  children  of  nine  or  ten  years  of  age 
the  disease  is  by  no  means  infrequent.  Appendicitis  is  common  at  any  period 
beyond  childhood,  being  more  frequent  in  young  and  middle-aged  people 
than  in  the  aged.  It  is  about  four  times  as  common  in  males  as  in  females. 
It  is  more  common  in  summer  than  in  other  seasons,  and  in  warm  coun- 
tries than  in  cold  or  temperate  climes.  Appendicitis  is  a  bacterial  disease. 
It  is  produced  occasionally  by  pus  cocci,  but  most  commonly  by  the  action  of 
the  bacterium  coli  commune  of  Escherich.  The  colon  bacilli,  which  normally 
inhabit  the  appendix,  are  harmless  when  the  appendix  is  healthy,  but  become 
active  for  harm  when  the  diverticulum  is  bruised,  obstructed,  irritated  by  the 
presence  of  uric  acid,  congested  because  of  chilling  of  the  cutaneous  surface 
of  the  body,  or  distended  by  the  ingress  of  colonic  fluid  (C.  Van  Zwulenburg 
in  "Annals  of  Surgery,"  March,  1905).  It  seems  probable  that  flatulent 
distention  of  the  colon  may  be  responsible  for  forcing  fecal  matter  in  quantity 
into  the  appendix  and  may  lead  to  plugging  of  the  opening  (Rubin,  in  "  Jour. 
Am.  Med.  Assoc,"  vol.  xliii.  No.  18).  When  non-traumatic  inflammation 
occurs,  swelling  of  the  mucous  membrane  occludes  the  opening  into  the  colon, 
and  the  lumen  of  the  appendix  dilates  and  fills  up  and  becomes  distended  with 
a  thick  mucopurulent  fluid.  Ulcers  sometimes  form,  which  may  only  involve 
the  mucous  membrane,  may  pass  deeply  into  the  coats,  or  may  even  perforate. 
Dieulafoy  |  maintains  forcefully  that  appendicitis  is  due  always  to  the  conver- 
sion of  the  appendix  into  a  closed  cavity,  but  cases  are  met  with  which  disprove 
this  assertion.     Various  conditions  may  bring  about  this  transformation. 

*  Manley,  in  Med.  Record,  July  9,  1902. 

t  University  of  Penna.  Med.  Bull.,  Oct.,  1902. 

I  Progres  medicale,  No.  11,  1896. 


986  Diseases  and  Injuries  of  the  Abdomen 

Partial  obstruction  may  be  caused  by  calculi,  which  are  composed  of  stercoral 
material  and  hordes  of  bacteria  mixed  with  salts  of  lime  and  magnesia.  These 
calculi  are  not  formed  in  the  colon  but  are  formed  in  the  appendix.  The 
theory  that  concretions  form  in  the  colon  and  are  forced  into  the  appendix  by 
peristalsis  has  been  very  largely  abandoned.  Dieulafoy  speaks  of  the  con- 
dition as  appendicular  lithiasis,  and  says  it  has  a  tendency  to  run  in  family 
lines,  and  has  a  kinship  with  gout  and  rheumatism.  Obstruction  may  be 
caused  by  local  infection  of  a  catarrhal  area,  by  the  formation  of  a  fibrous 
stricture,  or  by  several  causes  acting  in  unison.  The  presence  of  a  concre- 
tion is  always  dangerous.  It  is  frequently  associated  with  ulceration,  either 
as  cause  or  effect.  It  is  a  mass  of  virulent  bacteria.  It  may  lead  to  perfor- 
ation or  gangrene.  Talamon  taught  that  the  appendix  resents  the  presence 
of  the  concretion,  reflex  contraction  of  the  muscular  coat  taking  place,  which 
is  accompanied  by  violent  pain  {appendicular  colic).  The  muscular  struc- 
ture is  so  rudimentary  that  it  does  not  seem  probable  that  attempts  at  con- 
traction, even  should  they  arise,  would  produce  violent  pain  and  distant 
symptoms.  Pozzi  believes  that  appendicular  colic  may  be  caused  by  torsion 
or  bending  of  the  appendix  or  malposition  of  the  diverticulum,  and  holds 
that  pain  may  arise  when  there  is  no  lesion  in  the  appendix  and  no  inflam- 
mation of  the  peritoneum  or  pericecal  structures.*  What  is  called  appen- 
dicular colic  is  really  inflammation  of  the  appendix  without  involvement  of 
the  peritoneum.  The  term  appendicular  colic  has  led  to  much  injudicious 
conservatism,  and,  as  Lockwood  shows,  if  an  appendix  is  removed  from  an 
individual  who  suffers  from  attacks  of  appendicular  colic,  it  will  usually  be 
found  that  the  diverticulum  is  inflamed  or  the  lumen  contains  a  concretion. 
Foreign  bodies,  such  as  pins,  fish-bones,  nails,  buttons,  date-stones,  cherry- 
stones, and  grape-seeds  may  enter  the  appendix,  but  they  do  so  far  less  often 
than  is  generally  supposed,  most  alleged  grape-seeds  from  the  appendix  being 
fecal  concretions.  Fitz  found  concretions  in  15  cases  out  of  300.  Ranvier 
collected  the  records  of  459  postmortems,  and  found  reported  179  fecal  con- 
cretions and  16  foreign  bodies.  Appendicitis  due  to  a  foreign  body,  such  as  a 
grape-seed  or  a  pin,  is  known  as  traumatic;  appendicitis  in  which  a  concretion 
is  the  assumed  cause  is  known  as  stercoral.  A  foreign  body  may  produce 
instant  perforation.  If  impaction  of  a  foreign  body  or  concretion  occurs,  the 
orifice  of  the  appendix  is  closed,  the  circulation  is  soon  cut  off,  the  secretions 
are  retained,  the  coats  become  congested,  the  diverticulum  enlarges  enor- 
mously, microbes  multiply  with  great  rapidity,  and  the  wall  of  the  congested 
appendix  inflames  and  may  become  gangrenous  or  ulcerated,  and  is  finally  per- 
forated. Interference  with  the  blood-supply  of  the  appendix  will  predispose 
to  appendicitis.  This  may  be  brought  about  by  twists,  bruises,  adhesions, 
concretions,  pressure,  or  bands;  and  the  psoas  muscle  may  play  a  part  in  the 
production  of  these  conditions.  In  women  appendicitis  is  occasionally  secon- 
dary to  tubo-ovarian  disease.  Appendicitis  is  rarer  in  women  than  in  men, 
probably  because  in  many  females  the  appendix  has  a  better  blood-supply  than 
in  males,  the  additional  supply  coming  through  the  folds  of  the  appendiculo- 
ovarian  hgament.  In  women  disease  of  the  uterus  or  adnexa  frequently  pre- 
cedes or  actually  causes  appendicitis.  Catarrhal  conditions  of  the  intestine, 
habitual  constipation,  and  indigestion  with  flatulence  predispose  to  appen 
*  Progres  medicale,  No.  19,  1896. 


Forms  of  Appendicitis  987 

dicitis.  In  fact,  in  a  great  many  cases  there  has  been  a  more  or  less  pro- 
lonj^cd  history  of  diarrhea  or  constipation  and  (latulent  indigestion  before  the 
development  of  acute  appendicitis.  An  acute  attack  of  appendicitis  may 
arise  after  the  eating  of  a  large  and  indigestible  meal,  especially  if  such  a  meal 
was  taken  late  at  night.  Bolting  the  food  and  eating  large  meals  at  irregular 
hours  predis])ose  to  an  attack.  It  seems  probable  that  catarrhal  appendicitis 
may  result  from  e.xtension  of  a  catarrh  of  the  colon,  and  may  also  in  rare  cases 
arise  from  external  traumadsm.  In  most  cases,  however,  in  which  appendicitis 
seems  to  be  produced  by  a  blow,  the  injury  simply  "awakened  a  sleeping  dog" 
and  stirred  into  acute  inflammation  an  appendix  already  diseased.  If  before 
perforation  the  appendix  adheres  to  the  cellular  tissue  behind  the  cecum,  celluH- 
tis  or  abscess  without  peritonitis  may  result.  When  appendicitis  goes  on  to  per- 
foration, there  is  always  some  peritonitis;  but  if  the  steps  to  perforation  are  grad- 
ual, and  if  the  causative  organism  is  the  colon  bacillus,  the  peritonitis  may  be 
local,  and  will  sometimes,  by  formation  of  adhesions,  make  a  barrier  between 
the  appendix  and  the  peritoneal  cavity  before  operation  occurs.  When  perfora- 
tion takes  place  suddenly,  diffused  septic  peritonitis  is  inevitable.  When  the 
causative  organism  is  the  streptococcus,  general  peritonitis  is  very  apt  to  arise. 
Peritonitis  may  arise  without  perforation  by  contiguity  of  structure  or  by  migra- 
tion of  bacteria  through  the  congested  walls  of  an  obstructed  appendix.  In 
some  cases  perforation  takes  place  into  the  peritoneal  cavity,  but  pus  is  circum- 
scribed by  matting  together  of  the  intestines  with  plastic  exudate.  The  appen- 
dix may  become  gangrenous  very  rapidly  or  after  some  time.  A  case  of  ap- 
pendicitis in  which  gangrene  and  perforation  come  on  very  quickly  is  spoken 
of  as  fulminating  appendicitis.  In  some  cases,  if  the  perforation  is  very  small 
and  the  appendix  is  swathed  in  lymph,  or  if  perforation  does  not  occur,  the  in- 
flammation may  subside.  Perforation  rarely  occurs  from  liquid  pressure  or 
from  the  pressure  of  a  concretion;  it  is  generally  due  to  ulceration  produced  by 
the  action  of  micro-organisms.  Appendicitis  which  subsides  may  at  any  time 
recur,  and  the  life  of  such  a  patient  is  under  constant  menace.  An  enormous 
number  of  people  have  had  appendicitis.  Toft  recorded  500  autopsies,  and 
in  36  per  cent,  of  them  there  were  positive  signs  of  past  attacks.  The  disease 
is  occasionally  unsuspected  during  life.  These  facts  prove  that  the  disease 
may  subside  without  the  aid  of  surgery. 

Forms  of  Appendicitis. — In  what  is  known  as  appendicular  colic  the 
appendix  is  temporarily  obstructed  because  of  transitory  inflammatory  swelling 
of  the  mucous  membrane  of  the  outlet,  and  the  stercoral  contents  are  retained 
in  the  diverticulum.  The  peritoneal  covering  is  not  involved  in  the  inflamma- 
tion. This  condition  is  called  by  Fergusson  "constipation  of  the  appendix." 
If  not  relieved,  it  will  eventuate  in  appendicitis  with  involvement  of  the  perito- 
neum. It  is  an  unfortunate  term,  sometimes  used  as  an  excuse  for  avoiding 
operation.     In  such  cases  a  concretion  is  frequently  or  usually  present. 

Simple  parietal  or  catarrhal  appendicitis  is  not  limited  to  the  mucous  mem- 
brane; hence  the  term  catarrhal  is  not  strictly  correct.  The  vessels  of  the 
appendix  are  distended  with  blood,  the  lumen  at  the  intestinal  end  becomes 
partially  or  completely  obstructed,  the  epithelium  desquamates  from  numerous 
glands,  the  mucosa  ulcerates,  and  the  lumen  of  the  appendix  becomes  filled 
with  a  mixture  of  mucus,  bacteria,  and  portions  of  organic  matter.  Bacteria 
enter  the  lymph-spaces  of  the  wall  of  the  appendix,  and  pass  rapidly  from  th^ 


988  Diseases  and  Injuries  of  the  Abdomen 

submucous  to  the  subperitoneal  tissues.  Within  forty-eight  hours  after  the 
mucous  coat  begins  to  inflame  the  peritoneal  coat  will  probably  be  involved. 
This  inflammation  may  undergo  resolution  and  the  patient  get  well  or  a  wait  for 
cure  may  result  disastrously.  The  appendix  may  thicken  and  ulceration  take 
place.  Suppuration  or  gangrene  may  occur,  perforation  may  take  place,  or 
pyemia,  with  abscess  of  the  Hver,  may  arise.  The  acute  condition  may  pass  into 
chronic  appendicitis,  or  ulcerations  of  the  mucosa  may  remain;  the  mucous 
crypts  may  be  filled  with  bacteria;  a  concretion  may  exist;  cicatricial  con- 
tractions may  occur;  in  any  of  these  conditions  the  patient  is  in  danger  of  a 
fresh  attack  at  any  time.  In  a  catarrhal  inflammation  secondary  to  catarrh  of 
the  colon  the  case  may  be  chronic  from  the  beginning.  If  the  lumen  of  the 
appendix  is  gradually  and  completely  obliterated,  the  condition  is  denominated 
obliterative  appendicitis  (Senn).  This  progressive  obliteration  may  result 
from  repeated  attacks  of  inflammation,  or  may  be  simply  a  degenerative  change. 
Recurrent  appendicitis,  it  was  once  said,  may  be  due  to  inordinate  size  of  the 
mouth  of  the  appendix,  making  of  this  diverticulum  a  drag-net  for  foreign 
bodies;  but  we  now  know  that  it  is  more  probably  due  to  smallness  of  the 
opening,  so  that  it  quickly  closes  from  slight  swelling  and  converts  the  appen- 
dix into  a  closed  vase  filled  with  septic  material.  Suppurative  appendicitis 
is  due  to  purulent  infiltration  of  the  walls.  Pus  in  the  lumen  is  not  purulent 
appendicitis.  Pus  may  form  about  the  appendix,  a  condition  known  as  appen- 
diceal or  appendicidar  abscess.  Gangrenous  appendicitis  is  a  moist  or  septic 
gangrene,  due  to  interference  with  the  circulation  and  to  tissue-destruction  by 
the  action  of  micro-organisms.  Perforations  occur,  and  they  are  often  multi- 
ple. The  entire  appendix  may  slough  off.  Interference  with  circulation  may 
be  caused  by  an  obstruction,  by  a  bend  or  twist  or  bruise  of  the  appendix,  or  by 
the  action  of  virulent  organisms  on  an  appendix  whose  tissue-resistance  is  low- 
ered by  injury  or  disease.  In  gangrenous  cases  the  vessels  of  the  meso-appen- 
dix  are  usually  obstructed  by  thrombi  or  the  changes  of  arteritis  (Van  Cott). 
In  rare  instances  appendicitis  is  due  to  tuberculous  ulceration,  in  other  cases  to 
typhoid  ulceration,  and  genuine  appendicitis  may  arise  during  typhoid  fever. 

Fowler  suggests  the  following  classification  of  cases  of  appendicitis:  (i) 
endo-appendicitis;  (2)  parietal  appendicitis;  (3)  peri-appendicitis;  (4)  para- 
appendicitis. 

As  a  matter  of  fact,  appendicitis  is  always  one  disease,  which  varies  in  inten- 
sity, and  it  is  useless  to  divide  it  into  a  great  number  of  symptomatic  groups. 

Symptoms  and  Signs. — In  what  is  known  as  appendicular  colic  the  pa- 
tient suffers  from  disorder  of  digestion  and  occasionally  has  a  brief  attack  of 
abdominal  pain  associated  with  trivial  and  temporary  tenderness  in  the  right 
iliac  fossa.  The  colicky  pain  is  about  the  umbilicus  and  right  iliac  fossa;  there 
is  often  nausea  and  usually  constipation.  This  condition,  if  not  soon  reheved, 
is  followed  by  the  evidences  of  peritoneal  inflammation.  The  symptoms  of 
genuine  appendicitis  are  as  follows:  In  some  cases  the  disease  seems  to  begin 
suddenly,  but  in  most  of  the  cases  there  are  noted  for  a  few  hours  or  even  for 
a  day  or  two  distinct  premonitory  symptoms,  among  which  are  constipation 
and  diarrhea,  flatulence,  nausea,  anorexia,  dyspepsia,  coated  tongue,  weak- 
ness, general  gastro-intestinal  uneasiness,  colicky  pain  about  the  umbilicus, 
and  the  development  of  tenderness,  a  sense  of  weight,  soreness,  or  actual  pain 
in  the  right  iliac  fossa.     The  acute  symptoms  suddenly  appear  after  the  pre- 


appi;ni)icitis. 


Plate  9. 


:<fS^ 


Various  forms  of  appendicitis  (from  drawings  by  Dr.  M.  H.  Richardson):  i.  Obstruction  from 
stenosis  of  appendix.  2.  Dilatation  of  distal  end  of  appendix  ;  perforation  by  a  fecal  concretion. 
3.  Gangrene  of  nearly  the  whole  of  the  appendix  ;  fecal  concretion  in  lumen. 


Symptoms  and  Signs  of  Appendicitis  989 

monitory  symptoms  have  lasted  a  variable  time,  and  the  acute  symptoms  very 
frequently  appear  in  the  early  hours  of  the  morning.  The  first  definite  symp- 
tom is  severe  colicky  pain.  The  tongue  is  coated  and  usually  dry.  Great 
thirst  is  often  complained  of.  The  face  is  expressive  of  pain,  or  later,  in  a 
severe  case,  becomes  Hippocratic.  The  posture  assumed  for  greater  ease  is 
one  of  recumbency  with  the  right  thigh  and  knee  or  both  thighs  and  knees 
partly  flexed.  Respirations  in  acute  appendicitis  are  shallow  and  thoracic. 
The  development  of  acute  pain  is  usually  the  most  prominent  symptom. 
The  pain  is  at  first  colicky  and  located  about  the  umbilicus  or  through  the 
abdomen  in  general,  this  distant,  primary,  or  generalized  pain,  according  to 
Treves,  corresponding  to  the  distribution  of  the  superior  mesenteric  plexus. 
This  primary  pain  may  subside  if  the  appendix  succeeds  in  emptying  its  con- 
tents into  the  colon,  but  it  may  also  subside  if  the  appendix  becomes  gan- 
grenous or  ruptures  (Murphy).  Usually,  in  from  twelve  to  thirty-six  hours 
the  pain  becomes  localized  in  the  right  iliac  fossa,  and  associated  with  tender- 
ness and  hyperesthesia  of  the  skin — in  other  words,  true  inflammatory  pain 
develops.  It  is  due  to  peritoneal  inflammation.  The  usual  location  of  the 
pain  in  the  right  iliac  fossa  depends  on  the  fact  that  the  appendix  is  usually 
placed  in  that  region.  Occasionally,  when  the  appendix  crosses  the  belly, 
the  pain  is  located  on  the  left  side,  and  occasionally,  for  like  reasons,  in  the 
gall-bladder  region,  the  right  loin,  or  the  pelvis.  If  the  pain  of  appendicitis 
is  violent,  the  patient  presents  some  evidences  of  shock.  Nausea  is  the  rule 
in  appendicitis;  vomiting  usually  occurs  early — about  three  or  four  hours 
after  the  beginning  of  pain.  In  children  vomiting  is  often  violent  and  per- 
sistent, but  in  adults,  after  the  early  hours  of  the  attack,  vomiting  occiirs,  as 
a  rule,  occasionally  or  not  at  all,  although  nausea  is  complained  of.  Early 
vomiting  is  a  reflex  symptom  due  to  distention  of  the  appendix  (■Murphy). 
If  vomiting  persists,  it  points  to  peritonitis,  to  pus- formation,  or  to  intestinal 
obstruction  unless  it  results  from  the  administration  of  morphin.  There  is 
usually  constipation  in  acute  appendicitis,  although  diarrhea  occasionally 
occurs.  In  appendicitis  there  is  always  some  elevation  of  temperature, 
although  it  may  be  very  slight  and  of  brief  duration.  The  fever  is  not  ushered 
in  by  a  chill,  but  the  temperature  mounts  in  the  course  of  a  few  hours  to  102° 
or  103°  F.  or  even  higher.  The  fever  does  not  begin  until  several  hours  or 
a  number  of  hours  after  the  onset  of  pain.  In  a  very  mild  case  the  temperature 
remains  elevated  for  a  day  or  two  and  then  falls  to  normal.  In  severe  cases 
it  is  apt  to  remain  elevated  for  a  longer  period,  but  it  is  always  to  be  borne  in 
mind  that  in  very  grave  appendicitis  the  surgeon  may  find  very  little  eleva- 
tion of  temperature,  no  elevation,  or  actually  a  subnormal  temperature.  In 
gangrenous  cases,  and  in  cases  in  which  a  large  perforation  suddenly  forms, 
and  when  general  peritonitis  develops,  there  is  usually,  for  a  time  at  least, 
a  subnormal  temperature.  A  sudden  drop  of  temperature  indicates,  as  a 
rule,  a  calamity,  particularly  gangrene  of  the  mucosa  of  the  appendix,  which 
prevents  absorption  (Murphy)  or  perforation  of  the  appendix.  Leuko- 
cytosis is  usually  present  (see  Diagnosis).  The  pulse  in  appendicitis  is  in 
most  cases  rapid.  A  very  rapid  pulse  (over  no)  is  significant,  usually,  of 
a  severe  case,  and  the  auguries  are  especially  ominous  if  the  pulse  is  rapid 
but  the  temperature  is  normal  or  subnormal.  Occasionally,  however,  a  slow 
pulse  exists,  even  in  the  ^\'orst  cases. 


99°  Diseases  and  Injuries  of  the  Abdomen 

Examination  of  the  abdomen  discovers,  early  in  the  case,  general  abdom- 
inal rigidity;  but  usually  in  the  course  of  twenty-four  hours  or  more  the 
general  rigidity  passes  away,  the  abdomen  distends  more  or  less,  and  rigidity  of 
the  lower  half  of  the  right  belly  becomes  evident  and  persists.  If  general 
peritonitis  begins  early,  general  abdominal  rigidity  does  not  abate  or  pass  away. 
If  general  peritonitis  begins  later,  general  abdominal  rigidity,  which  was  pres- 
ent at  first  but  which  passed  away,  returns.  Rigidity  may  not  exist  in  the 
very  beginning  of  appendicitis,  in  a  case  in  which  the  appendix  is  retrocecal 
or  pelvic,  in  some  abscess  cases,  or  in  a  case  with  relaxed  belly  walls. 

A  symptom  almost  invariably  present  in  appendicitis  is  tenderness.  In 
some  cases  the  tenderness  is  diffuse;  in  most  it  is  localized,  or  at  least  most 
acute,  in  the  right  iliac  fossa.  The  point  where  tenderness  is  usually  most 
acute  is  a  spot  about  2  inches  internal  to  the  anterior  superior  spine  of  the  ilium, 
on  a  line  drawn  from  that  bony  point  to  the  umbilicus.  This  is  known  as 
"  McBurney^s  point, "  and  overlies  the  usual  point  of  origin  of  the  appendix. 
In  some  cases,  however,  the  greatest  point  of  tenderness  is  nearer  the  gall- 
bladder; in  others  in  the  loin;  in  others  toward  the  umbilicus,  in  the  mid-line, 
or  on  the  opposite  side;  in  others  in  the  rectum.  The  seat  of  greatest  ten- 
derness depends  on  the  situation  of  the  appendix,  and  it  is  usually  at  McBur- 
ney's  point,  because  this  usually  overHes  the  origin  of  the  appendix.  The 
lesson  is  that  in  appendicitis  there  is  a  point  of  tenderness  or  of  greatest  ten- 
derness in  a  region  which  the  appendix  could  occupy.  If  tenderness  exists 
on  the  right  side  and  then  develops  in  the  left  side,  severe  spreading  perito- 
nitis usually  exists  (W.  Meyer).  When  the  appendix  becomes  gangrenous, 
local  tenderness  may  for  a  time  disappear,  because  the  peritoneum  of  the 
involved  region  has  become  anesthetic;  later,  however,  it  returns,  spreads, 
and  may  become  general.  In  view  of  the  fact  that  tenderness  in  the  right 
iUac  fossa  is  often  demonstrable  in  tubal  and  ovarian  disease,  the  sign  in  males 
"is  of  greater  significance  than  in  females"  (A.  H.  Tubby,  on  "Appendici- 
tis," Medical  Monograph  Series).  Pressure  upon  the  left  side  will,  in  some 
cases,  cause  pain  in  the  right  iliac  region.  When  rigidity  abates  or  disap- 
pears, the  case  may  go  on  to  cure,  but  sometimes  a  mass  becomes  evident  in 
the  right  iliac  fossa.  The  mass,  of  variable  shape,  is  at  first  hard,  and  if  of 
any  considerable  size,  is  dull  on  percussion.  In  some  cases,  when  no  mass  is 
palpable  through  the  abdominal  wall,  rectal  examination  detects  one.  This  mass 
may  be  agglutinated  bowel  and  omentum  or  a  collection  of  coagulated  inflamma- 
tory exudate.  It  may  gradually  disappear  or  an  abscess  may  form.  The  evi- 
dences of  general  peritonitis  are:  great  distention  because  of  intestinal  paresis, 
general  abdominal  tenderness,  rectal  tenderness,  very  rapid  pulse,  hiccough, 
persistent  vomiting  which  may  become  regurgitation,  and,  as  Meyer  points  out, 
percussion  dulness  over  the  right  iliac  region  or  entire  lower  abdomen. 

In  some  cases  the  symptoms,  at  first  trivial,  become  grave.  In  some 
all  the  symptoms  are  violent  from  the  beginning,  the  attack  tends  to  linger, 
and  is  followed  by  persistent  soreness  of  the  appendix  and  harassing  digestive 
disturbances.  Any  case  of  appendicitis  may  become  suddenly  desperately 
grave  because  of  perforation  or  gangrene,  and  in  any  case  general  peritonitis 
may  develop.  After  sudden  perforation  or  rapid  gangrene  the  temperature 
falls,  hiccough  begins,  abdominal  distention,  pain,  and  tenderness  become 
marked  and  general,  and    the    pulse  becomes  very  rapid.     In    some    cases 


Terminations  and  Prognosis  of  Appendicitis  991 

these  grave  symptoms  are  present  almost  from  the  start  (fulminating  cases). 
A  sudden  perforation  produces  collapse,  and,  if  reaction  takes  place,  general 
peritonitis  arises.  Peritonitis,  be  it  remembered,  may  arise  without  either 
perforation  or  gangrene.  If  pus  forms,  it  may  be  unlimited  by  adhesion. 
In  such  cases  there  is  the  rapid  onset  of  fatal  peritonitis  and  septicemia. 
Pus  may  be  limited  by  adhesions  and  be  practically  extraperitoneal.  In 
such  a  case  a  lump  is  felt  in  the  right  iliac  region,  but  dusky  discoloration 
and  edema  of  skin  very  seldom  exist.  The  surgeon  does  not  wait  for  fluctua- 
tion before  he  makes  a  diagnosis.  In  an  abscess  case  there  are  usually 
irregular  fever  and  sweating,  but  rigors  do  not  occur.  Hawkins  says  we 
should  always  suspect  pus  if  the  symptoms  continue  after  the  sixth  day, 
and  particularly  when  the  symptoms  abate  and  suddenly  increase  between 
the  seventh  and  tenth  days.  A  limited  collection  of  pus  may  be  liberated 
into  the  peritoneal  cavity  by  rupture  of  the  abscess-wall.  Such  a  rupture 
may  be  caused  by  pressure  or  muscular  effort;  rupture  is  followed  at  once 
by  shock  and  later  by  diffused  peritonitis.  An  abscess  may  rupture  exter- 
nally or  into  the  vagina,  intestinal  tract,  or  bladder.  It  is  desirable,  if  pos- 
sible, to  locate  the  situation  of  the  appendix,  and  this  is  usually  determined 
by  locating  the  seat  of  swelling  and  of  greatest  tenderness.  The  surgeon 
should  not  lose  sight  of  the  fact  that  the  appendix  may  be  found  in  the  most 
unexpected  situations.  In  every  case  a  rectal  or  vaginal  examination  should 
be  made,  in  order  to  detect  swelling  and  tenderness,  and  thus  determine 
if  the  inflammation  took  origin  in  or  has  come  to  involve  the  pelvic  region. 
Pain  at  the  end  of  micturition  points  to  involvement  of  the  vesical  perito- 
neum.* In  cases  where  there  is  not  localized  swelling  and  is  not  local  tender- 
ness,— for  instance,  in  gangrenous  or  perforative  appendicitis  with  general 
peritonitis, — "diagnostic  localization"  is  impossible  (Van  Hook). 

Terminations  and  Prognosis. — Acute  appendicitis  may  terminate  in 
death,  in  complete  recovery,  or  in  a  condition  of  lowered  vitality  during 
the  existence  of  which  acute  attacks  are  almost  certain  to  occur.  Sometimes 
after  and  sometimes  without  an  antecedent  acute  attack  the  patient  develops 
persistent  soreness  and  tenderness  in  the  right  iliac  region.  Between  the 
attacks  of  recurrent  appendicitis  there  may  be  soreness,  tenderness,  and 
gastro-intestinal  disturbance,  or  there  may  be  no  evident  trouble  whatever; 
yet,  even  in  the  latter  case,  there  may  be  an  ulcer  or  ulcers  of  the  mucous 
lining.  If  a  patient  has  once  had  appendicitis,  he  will  always  be  hable  to 
suffer  from  another  attack  if  the  appendix  has  not  been  removed.  The 
liability  becomes  almost  a  certainty  if  the  intestinal  end  of  the  appendix 
is  narrowed  or  if  the  lumen  is  obstructed  at  any  point,  if  a  concretion  exists, 
or  if  there  is  an  area  of  ulceration  or  of  desquamating  epithelium.  After 
an  attack  the  appendix  may  remain  enlarged  and  tender;  exercise  or  indis- 
cretion in  diet  may  cause  it  to  become  tender  or  the  patient  may  have  occa- 
sional attacks  of  colicky  pain.  If  any  of  the  above  conditions  exist,  another 
attack  may  be  confidently  anticipated  if  operation  is  not  performed.  In 
such  cases  the  appendix  can  usually  be  palpated.  The  method  of  palpation 
proposed  by  Robert  T.  Morris  is  very  useful.f     It  is  applied  as  follows: 

*Van  Hook,  in  Jour.  Am.  Med.  Assoc,  Feb.  20,  1897. 
fSee  Medical  Record,  Sept.  17,  1898. 


992  Diseases  and  Injuries  of  the  Abdomen 

The  surgeon  stands  to  the  right  of  the  patient  and  uses  three  fingers 
of  the  right  hand  to  feel  with  and  three  fingers  of  the  left  hand  to  press  with. 
Morris  insists  that  no  muscular  effort  should  be  used  by  the  hand  which 
feels.  The  feeling  fingers  are  pressed  by  the  other  fingers  beneath  the  margin 
of  the  right  rectus  muscle  on  a  level  with  the  umbilicus,  and  are  dra\\Ti  toward 
the  patient's  right  side,  and  the  colon  will  be  felt  to  roll  under  the  fingers. 
The  process  is  repeated  several  times  until  the  end  of  the  cecum  is  reached. 
The  appendix  is  sought  for  by  rolling  the  cecum  from  side  to  side  with  the 
finger-tips,  and  working  toward  the  proximal  end  of  the  appendix.* 

Adhesions  may  form  as  a  result  of  appendicitis,  general  peritonitis  may 
arise,  the  appendix  may  slough  or  become  perforated,  or  abscess  may  ensue 
upon  local  peritonitis.  Lymphangitis  of  the  appendix  may  accompany, 
and  septic  lymphangitis  or  phlebitis  and  secondary  hepatic  and  lymphatic 
infections  may  follow,  appendicitis.  They  are  thought  to  be  most  common 
after  mild  attacks  of  appendicitis.  The  secondary  lymphatic  and  hepatic 
injections  are  of  the  greatest  importance.  There  may  be  abscess  of  the  liver, 
subphrenic  abscess,  or  retroperitoneal  lymphangitis. 

A  subphrenic  abscess  may  result  from  infection  carried  from  the  appendix 
by  the  hinphatics,  from  pus  ascending  along  the  posterior  cellular  spaces, 
or  by  direct  invasion  from  the  peritoneal  ca^-ity  (John  C.  Munro,  in  "Annals 
of  Surg.,"  Nov.,  1905);  such  an  abscess  is  usually  on  the  right  side  but  may 
be  upon  the  left. 

Lymphangitis  is  the  rule  in  appendicitis,  and  when  we  open  the  abdomen, 
there  is  usually  evidence  of  it  in  the  lymph-glands  of  the  mesentery,  and  in 
children  particularly  these  glands  are  apt  to  be  enlarged.  One  lymph  path 
from  the  appendix  is  through  the  ileocecal  glands,  another  is  posterior 
to  the  cecum  and  retroperitoneal,  and  the  latter  reaches  the  liver  and  dia- 
phragm (Munro).  In  lymphatic  infection  an  abscess  may  form  anpvhere 
in  the  course  of  the  l}Tnphatics.  Abscess  of  the  liver  usually  results  from 
portal  invasion  but  may  result  from  lymphatic  infection. 

Among  other  possible  consequences  of  appendicitis  may  be  mentioned 
pyemia,  empyema,  inflammation  of  the  parotid  gland,  and  thrombosis  of 
the  right  iliac  vein.  A  positive  prognosis  of  any  case  of  appendicitis  is  an 
absolute  impossibility.  The  future  of  every  case  is  cloudy  with  uncertainty, 
and  the  most  that  can  be  attained  in  the  field  of  prediction  is  a  scientific 
guess  of  more  or  less  probability.  All  surgeons  have  seen  apparently  hopeless 
cases  recover,  and  have  observed  cases  with  the  most  trivial  symptoms  grow 
progressively  worse  or  suddenly  develop  a  fatal  complication.  Further, 
after  one  attack  other  attacks  are  very  apt  to  arise.  The  medical  man  who 
estimates  that  80  or  90  per  cent,  of  cases  get  well  without  operation  has  prob- 
ably dealt  with  many  catarrhal  cases,  and  he  certainly  is  optimistic  as  to 
freedom  from  future  attacks,  because,  as  stated  before,  recovery  from  an 
attack  does  not  of  necessity  mean  freedom  from  the  disease.  In  appendici- 
tis there  may  be  delusive  evidences  of  improvement ;  for  instance,  the  abate- 
ment of  pain  and  the  lessening  of  fever,  being  regarded  by  the  patient  him- 
self as  indubitable  signs  of  improvement,  may  in  reality  be  indicative  of  gan- 
grene. In  spite  of  the  previously  mentioned  difficulties  and  obscurities  we 
can  in  the  majority  of  cases  decide  with  a  reasonable  probabiHty  of  accuracy 
*  Robert  T.  Morris,  in  Medical  Record,  Sept.  17,  1898. 


Diagnosis  of  Appendicitis  993 

whether  or  not  the  patient  is  becoming  worse.  In  a  delusive  improvement 
some  signs  and  symptoms  improve,  but  all  do  not;  and  in  endeavoring  to 
form  a  prognosis,  all  the  signs  and  symptoms  must  be  noted  and  weighed-, 
pain,  tenderness,  rigidity,  distention,  nausea  and  vomiting,  delirium,  intesti- 
nal obstruction,  shock,  the  temperature,  the  rapidity  of  the  pulse,  the  blood 
examination,  etc.  If  all  these  elements,  not  only  some  of  them,  point  to  im- 
provement, we  may  be  reasonably  confident  that  improvement  is  really  taking 
place.  If  only  some  of  them  point  to  improvement,  we  will  in  many  cases 
be  altogether  uncertain  as  to  the  significance  of  the  change. 

Diagnosis. — The  diagnosis  is  not  invariably  certain,  as  many  light- 
hearted  operators  seem  to  believe.  It  is  frequently  far  from  easy  and  is 
sometimes  altogether  impossible  without  exploratory  operation.  Sonnenburg 
maintains  that  we  can  diagnosticate  the  pathological  condition  of  the  inflamed 
appendix.  Personally,  I  am  unable  to  do  this  with  any  certainty,  although 
I  always  try,  and  am  often  right  and  just  as  often  wrong. 

In  attempting  to  make  a  diagnosis,  besides  the  ordinary  examination 
of  the  abdomen  a  rectal  or  vaginal  examination  should  be  made,  associated 
in  many  cases  with  bimanual  palpation.  If  an  appendix  is  enlarged  and 
an  individual  has  a  thin  abdomen  which  is  not  rigid,  it  is  often  possible  to 
palpate  the  appendix.  Sometimes  it  can  be  felt  after  the  administration 
of  ether  when  it  could  not  be  detected  before.  In  an  acute  case  forcible 
or  prolonged  palpation  is  always  unjustifiable,  as  it  may  force  an  ulcer  to 
perforate,  or  may  rupture  an  abscess,  and  the  information  gained  is  not 
of  sufficient  importance  to  justify  the  risk.  In  a  chronic  case  information 
of  great  value  may  be  obtained  and  there  is  no  real  risk  in  the  maneuver. 
I  am  persuaded  John  B.  Murphy  is  correct  in  attaching  the  greatest  possible 
importance  to  the  order  in  which  symptoms  appear.  Pain  precedes  nausea  and 
vomiting,  elevated" temperature,  and  abdominal  tenderness.  If  fever  precedes 
pain,  the  condition  is  not  appendicitis.  If  vomiting  precedes  pain,  the  con- 
dition is  probably  not  appendicitis. 

The  disease  may  be  confused  with  a  nuhiber  of  different  conditions. 
It  sometimes  is  confused  with  typhoid  fever;  in  fact,  an  early  typhoid  fever 
associated  with  marked  abdominal  pain  gives  a  picture  very  similar  to  that 
furnished  by  appendicitis. 

In  typhoid  fever  the  temperature  is  usually  distinctly  higher  than  that 
commonly  encountered  in  appendicitis.  Maurice  H.  Richardson*  tells  us 
that  in  every  case  in  which  typhoid  is  suspected,  operation  is  not  justifiable 
on  the  hypothesis  of  existing  appendicitis,  unless  there  are  local  pain  and 
locahzed  tenderness  in  the  appendix  region,  associated  with  definite  mus- 
cular resistance  or  distinct  rigidity;  and  that  operation  should  be  postponed 
in  a  case  in  which  the  constitutional  signs  are  severe  and  the  local  signs  are 
difficult  to  detect;  but  when  there  are  pain,  tenderness,  and  rigidity  with 
or  without  distention,  operation  must  be  performed,  even  when  one  recog- 
nizes the  possibility  of  the  existence  of  typhoid  fever.  Richardson  lays 
down  the  following  rule:  Soft  abdomen  plus  high  temperature  suggests 
typhoid,  even  if  there  are  pain  and  tenderness.  In  appendicitis  there  is  usually 
leukocytosis;  in  typhoid  leukocytosis  is  absent,  except  when  perforation  is 
imminent  or  has  occurred,  or  when  some  other  compHcation  exists.  I  have 
*  Boston  Med.  and  Surg.  Jour.,  Jan.  9,  1902. 
63 


994  Diseases  and  Injuries  of  the  Abdomen 

seen  the  operation  performed  twice  for  supposed  appendicitis  when  the  con- 
dition in  each  case  was  found  to  be  early  typhoid  fever. 

Acute  intestinal  obstruction  is  sometimes  confused  with  acute  appendi- 
citis, and  the  mistake  is  particularly  likely  to  occur  if  the  obstruction  is  due 
to  intussusception.  In  acute  obstruction,  as  in  appendicitis,  the  pain  is 
first  appreciated  about  the  umbilicus;  but  in  acute  obstruction  it  remains 
in  that  region,  does  not  pass  to  and  localize  itself  in  the  right  iliac  fossa, 
and  is  not  associated  with  tenderness  of  the  right  iliac  fossa.  In  obstruction 
the  vomiting  is  persistent;  in  appendicitis,  except  in  the  beginning,  it  is 
usually  trivial  and  often  absent,  although  in  children  it  may  be  violent  and 
persistent.  In  acute  obstruction  shock  is  much  more  pronounced  than  in 
appendicitis,  and  early  and  great  distention  of  the  abdomen  is  noted.  The 
temperature  in  obstruction  is  usually  subnormal;  while  in  appendicitis,  at 
least  in  the  majority  of  cases,  the  temperature  is  distinctly  elevated.  Fur- 
ther, in  acute  intestinal  obstruction  the  constipation  is  absolute,  e.xcept  in 
cases  of  intussusception.  In  children,  intussusception  is  capable  of  par- 
ticularly confusing  the  diagnosis,  because,  after  the  first  day,  it  is  by  no  means 
unusual  to  have  distinct  fever  in  this  condition,  and  occasionally  a  tumor- 
hke  mass  is  found  in  the  right  iliac  fossa;  but  in  intussusception  the  tumor 
does  not  remain  fixed,  but  alters  its  position;  it  is  movable;  and  the  patient 
usually  suffers  from  tenesmus  and  the  passage  of  bloody  mucus.  One  should 
bear  in  mind  that  in  acute  appendicitis  associated  with  septic  peritonitis 
acute  obstruction  may  exist;  and  that  the  diagnosis  of  obstruction  may  be 
made  without  recognizing  the  appendicitis. 

Lesions  of  the  kidney  are  sometimes  mistaken  for  appendicitis,  but  in 
renal  colic  the  pain  runs  into  the  groin  and  testicle  of  that  side,  and  occasion- 
ally passes  down  the  front  of  the  thigh  or  into  the  rectum;  and  if  any  tender- 
ness exists,  it  is  found  in  the  loin  or  in  the  groin,  rather  than  in  the  right 
iliac  fossa.  Besides  this,  there  are  other  s}-mptoms  of  kidney  trouble.  The 
urine  may  contain  blood  or  pus,  and  there  may  be  a  history  of  difficult  or 
of  frequent  urination,  though  one  should  bear  in  mind  that  in  appendicitis 
with  intlammation  of  the  vesical  peritoneum  there  may  also  be  a  record  of 
urinary  difficulties.  An  x-ray  picture  may  exhibit  a  calculus  in  the  ureter 
or  kidney,  and  a  movable  kidney  is  distinctly  palpable.  In  ordinary  renal 
colic  there  is  vomiting  in  the  beginning,  just  as  in  the  beginning  of  appen- 
dicitis. In  movable  kidney  the  vomiting  is  often  more  violent  and  pro- 
longed than  is  common  in  appendicitis.  Movable  kidney  and  appendicitis 
may  exist  coincidentally.  Very  confusing  cases  are  those  in  which  hematuria 
accompanies  appendicitis.  I  have  seen  it  twice  and  in  neither  case  was  there 
any  apparent  connection  between  the  appendix  and  the  kidney,  ureter,  or 
bladder.  They  must  have  been  due  to  acute  nephritis  which  is  known  to 
occur  in  some  cases  of  appendicids,  the  nephrids  resulting  from  the  toxins 
of  a  bacterial  disease.  This  form  of  nephritis  Dieulafoy  calls  "Nephrite 
toxique  Appendiculaire."  As  pointed  out  by  M.  G.  Seehg  ("Annals  of  Sur- 
gery," Sept.,  1908),  hematuria  may  also  be  due  to  direct  involvement  of  the 
kidney,  ureter,  Or  bladder. 

Gall-bladder  difficuldes,  too,  may  be  confounded  with  appendicitis.  I 
have  operated  upon  a  case  of  cholecystitis  under  the  supposition  that  it 
was  one  of  appendicids;  and  upon  a  case  of  appendicitis  with  the  appendix 


Diagnosis  of  Appendicitis  995 

adherent  to  the  gall-bladder,  in  the  belief  that  the  condition  was  cholecystitis. 
In  an  inflammation  of  the  gall-bladder,  with  a  distended  gall-bladder  hanging 
low  down,  and  with  muscular  rigidity,  the  distinction  is  always  difl&cult  and 
sometimes  impossible.  In  ordinary  gall-stone  colic  the  condition  is  usually 
sudden  in  onset;  it  is  characterized  by  pain  in  the  epigastric  region,  pass- 
ing toward  the  shoulder-blade  and  the  shoulder,  the  pain  being  most  acute 
and  becoming  more  or  less  localized  in  the  region  of  the  gall-bladder;  and 
there  is  always  tenderness  over  the  gall-bladder  region.  In  gall-bladder 
colic  the  vomiting  is  violent  and  continuous. 

The  perforation  of  a  gastric  ulcer  or  of  a  duodenal  ulcer  may  be  diag- 
nosticated as  appendicitis.  In  perforation  of  a  gastric  ulcer  there  is  usually 
a  history  of  previous  difficulty  with  the  stomach,  though  this  is  not  always 
the  case.  The  onset  of  perforation  is  sudden,  with  much  greater  shock 
than  is  characteristic  of  the  onset  of  appendicitis.  The  pain  is  violent  and 
the  pain  and  rigidity  and  tenderness  are  in  the  epigastric  region. 

Among  other  conditions  that  may  be  confused  with  appendicitis  may 
be  mentioned  malignant  disease  of  the  cecum,  tuberculosis  of  the  cecum, 
acute  tuberculous  peritonitis,  twisting  of  the  pedicle  of  an  ovarian  tumor, 
tubal  disease,  extra-uterine  pregnancy,  membranous  colitis,  perinephric 
abscess,  tuberculous  abscess  of  the  loin  or  of  the  groin,  and  abscess  from  hip- 
joint  disease. 

Pneumonia  of  the  right  base  and  pleurisy  may  cause  abdominal  pain 
and  be  mistaken  for  appendicitis.  There  may  even  be  siiperficial  tenderness 
in  the  abdomen,  but  deep  pressure  is  well  tolerated  (Donald  W.  Hood,  "  Brit. 
Med.  Jour.,"  Dec.  30,  1905).  There  may  be  abdominal  rigidity.  The 
abdominal  pain  seldom  persists  for  more  than  a  few  hours.  It  is  intensified  by 
deep  respiration  and  is  accompanied  by  high  fever.  As  Hood  says,  whenever 
a  patient  suffers  from  vomiting,  abdominal  pain,  and  high  fevqr  examine 
the  chest.  In  young  children  pneumonia  is  particularly  apt  to  cause  abdominal 
pain  and  rigidity.  Beyond  a  doubt  more  than  one  abdomen  has  been  opened 
for  supposed  appendicitis  when  the  real  condition  was  pneumonia. 

In  reaching  a  diagnosis  in  doubtful  cases  of  appendicitis  I  believe  that 
the  blood-count  is  often  of  service.  It  is,  of  course,  not  to  be  maintained 
that  the  diagnosis  of  appendicitis  may  be  made  by  counting  the  blood;  but 
the  blood-count  may  furnish  evidence  that,  when  added  to  the  other  signs 
and  symptoms,  may  be  of  great  importance.  In  nearly  every  case  of  appen- 
dicitis the  hemoglobin  is  diminished  by  at  least  30  per  cent.  In  a  catarrhal 
appendicitis  or  in  an  interstitial  appendicitis  the  leukocytosis  is  trivial;  but 
in  cases  of  abscess  or  of  gangrene  of  the  appendix  the  leukocytes,  as  a  rule, 
rise  from  15,000  to  20,000,  It  is  to  be  remembered,  however,  that 
when  the  patient  is  profoundly  septic,  the  systemic  condition  is  so  de- 
pressed that  leukocytosis  is  impossible;  hence  leukocytosis  may  be  absent  in 
trivial  catarrhal  cases  or  in  grave  cases  with  overwhelming  general  sepsis. 
This  latter  condition,  however,  is  extremely  rare.  The  blood-count  will  not 
help  one  in  making  the  differentiation  between  appendicitis  and  an  inflam- 
matory disorder  of  the  pelvis  or  abdomen,  but  will  aid  one  in  making  a  diag- 
nosis from  typhoid  fever,  intra-abdominal  or  pelvic  neuralgia,  and  mova- 
ble kidney  (see  J.  C.  DaCosta,  Jr.,  study  of  118  cases:  "Am.  Jour.  Med. 
Sciences,"  Nov.,  1901). 


996  Diseases  and  Injuries  of  the  Abdomen 

Appendicitis  in  Children. — The  disease  is  much  more  common  than  was 
once  thought  (page  985).  There  is  usually  a  history  of  antecedent  attacks  of 
gastro-intestinal  disorder.  The  onset  is  apt  to  be  sudden,  but  may  be  insidi- 
ous, the  symptoms  as  a  general  thing  are  violent,  and  the  progress  of  the  dis- 
ease is  rapid.  Vomiting  is  usually  more  violent  and  prolonged  than  in  adults. 
There  is  a  great  Hkelihood  of  pus  formation,  and  general  peritonids  is  more 
common  than  in  adults.  Occasionally  in  young  children  pneumonia  begins 
with  so  much  pain  and  rigidity  in  the  lower  abdomen  that  the  signs  seem 
to  point  to  appendicitis,  and  an  attack  of  appendicitis  may  begin  coincidently 
with  or  soon  after  a  pulmonary  inflammation.  I  have  seen  three  cases  in 
children  in  which  pneumonia  was  ushered  in  by  abdominal  pain  and  rigidity. 
In  children  the  appendix  occupies  a  lower  position  than  in  adults,  the  point  of 
abdominal  tenderness  is  usually  lower  than  in  adults,  the  inflammation  usually 
reaches  the  right  side  of  the  pelvis,  a  painful  point  can  generally  be  discovered 
by  a  finger  in  the  rectum,  hence  a  digital  rectal  examinadon  must  always  be 
made.  This  usual  involvement  of  the  pehis  is  responsible  for  the  frequent 
and  painful  micturition  which  is  very  common  (Karewski).  Sometimes  when 
the  bladder  symptoms  are  very  prominent  they  dominate  the  clinical  picture 
and  the  bladder  is  thought  to  be  the  real  seat  of  disease.  An  attack  of  peritonitis 
in  a  child  is  more  apt  to  result  in  general  peritonitis  than  is  the  same  disease  in 
an  adult  (Selter).  I  agree  with  Springer  ("Prag.  med.  Wochenschr.,"  1909, 
xxxiv,  Nos.  7  and  8)  that  operation  in  children  should  invariably  be  prompt 
and  that  purgatives  should  not  be  given. 

Appendicitis  in  Pregnant  Women. — Appendicitis  is  a  very  dangerous  but, 
fortunately,  a  very  rare  complication  of  pregnancy.  In  731  women  operated  on 
for  appendicitis  in  the  Mount  Sinai  Hospital  of  New  York,  from  1898  to  ^907, 
only  7  were  pregnant  (Cooke,  in  "N.  Y.  Med.  Jour.,"  May  i,  1909).  Lobenstine 
states  that  in  30,000  cases  under  the  care  of  the  New  York  Lying-in  Hospital 
there  were  but  5  cases  of  acute  appendicitis  (Cooke,  Ibid.).  Most  of  the  cases 
which  occur  in  pregnancy  have  had  previous  attacks. 

The  condition  may  arise  at  any  stage  of  pregnancy.  It  is  usually  violent, 
rapid  in  progress,  and  accompanied  by  vomiting.  Early  in  pregnancy  the 
pain  and  tenderness  are  significant  and  are  located  regionally,  as  when  preg- 
nancy is  absent.  Cooke  points  out  that  later  in  pregnancy  the  pains  may 
be  so  spasmodic  as  to  cause  them  to  be  attributed  to  beginning  labor,  and  they 
are  often  located  in  the  region  of  the  hver  or  even  on  the  left  side  of  the  belly 
(Ibid.) .  Two  hundred  and  fifty  cases  have  been  reported  and  over  100  have 
been  operated  on  (Renvall). 

Appendicitis  in  the  pregnant  is  far  more  dangerous  than  in  the  non-pregnant. 
In  about  40  per  cent,  of  cases  abortion  occurs,  and  usually  the  child  dies 
from  infection.  In  some  cases  of  successful  operation  pregnancy  continues 
to  term.  The  diagnosis  is  often  very  difficult  because  of  the  enlarged  uterus. 
Tuberculous  Appendicitis  (Fig.  523). — Acute  symptoms  may  develop  re- 
sembUng  acute  appendicitis.  There  is  usually  a  history  pointing  to  stenosis, 
the  stenosis  existing  at  the  ileocecal  valve.*  There  is  always  great  thicken- 
ing, and  an  abscess  of  large  size  is  apt  to  form.  The  cecum  usually,  but 
not  always,  is  involved  in  the  tuberculous  process.  Chronic  cases,  with  pal- 
pable enlargement,  are  sometimes  mistaken  for  cancer  of  the  cecum. 
*  Andrews,  Annals  of  Surgery,  Dec,  1901. 


Treatment  of  Appendicitis 


997 


Malignant  Disease  of  the  Appendix. — This  is  a  very  rare  condition  (less  than 
^  of  I  per  cent,  of  appendices  removed  for  supposed  inflammation).  It  is 
impossible  of  recognition  clinically,  but  is  sometimes  discovered  postmortem 
or  during  operation  for  supposed  acute  or  chronic  appendicitis  or  pelvic  dis- 
ease. Inflammation  does  not  cause  the  malignant  disease,  but  the  malignant 
disease  is  apt  to  block  the  appendix  and  so  cause  inflammation.  The  condition 
may  be  carcinoma,  sarcoma,  or  endothelioma,  and  usually  there  are  distinct 
inflammatory  changes.  It  is  more  common  in  women  than  in  men.  RoUes- 
ton  and  Jones  collected  42  cases.  McWilliams  reported  3  cases  and  collected 
45  not  in  Rolleston's  table.  This  makes  90  reported  cases  ("Am.  Jour. 
Med.  Sciences,"  June,  1908).  Since  writing  his  article  McWilliams  has  found 
15  more  cases  reported.  No  case  is  counted  in  which  the  colon  is  diseased. 
The  combined  statistics  show  the  average  age  of  the  patients  to  be  only  twenty- 


Fig.  523. — Tuberculous  appendix  with  perforation  and  abscess. 

nine  years.  Two  patients  were  only  eight.  In  most  cases  the  appendix 
alone  is  diseased;  in  some  the  colon  or  glands  of  the  mesentery  are  involved. 
In  three-fourths  of  the  cases  the  growth  is  distal  to  the  middle.  Glands  are 
involved  late.  Out  of  90  cases  in  McWilUams'  table  only  8  had  enlarged 
glands,  and  in  4  of  these  it  was  proved  that  the  glands  were  not  cancerous. 
In  about  5  per  cent,  of  cases  concretions  were  found.  The  chance  for  per- 
manent cure  after  removal  of  an  appendix  the  seat  of  malignant  disease  is 
very  good  if  the  disease  is  limited  to  the  appendix,  and  is  particularly  good  if 
the  growth  is  spheroidal-celled  carcinoma  (RoUeston  and  Jones) .  Metastasis 
is  rarely  noted.     The  growth  is  seldom  larger  than  an  almond. 

Treatment. — If  the  diagnosis  were  always  certain  from  the  beginning, 
and  if  the  case  were  seen  at  the  very  start  by  a  surgeon,  immediate  operation 
in  every  case  would  be  eminently  proper.     If  this  plan  could  be  followed, 


998  Diseases  and  Injuries  of  the  Abdomen 

the  mortality  from  appendicitis  would  be  extremely  small.  At  this  early 
stage  the  peritoneum  is  free  from  infection,  and  the  appendix  can  be  rapidly 
and  easily  removed  without  risk  of  infecting  the  peritoneum.  Whenever  I  see 
a  case  early,  that  is,  during  the  first  twenty-four  hours  of  the  attack,  I  practi- 
cally always  advise  operation..  Unfortunately  this  plan  cannot  be  habitually 
followed.  As  a  rule,  when  the  physician  first  sees  the  case,  the  appendicular 
peritoneum  is  inflamed,  and  the  surgeon  usually  sees  the  case  at  even  a 
later  period  than  the  physician.  At  this  time  the  barriers  of  leukocytes  are 
being  heaped  up  to  limit  the  spread  of  infection,  and  delicate  encompassing 
adhesions  are  usually  being  formed.  Even  in  these  later  cases  I  often,  in 
fact  usually,  advise  operation.  Operation  at  this  stage  may  be  imperatively 
necessary,  because  of  the  rapid  spread  and  dangerous  nature  of  the  process; 
but  when  operation  is  not  done,  in  some  cases  at  least,  a  temporary  limita- 
tion will  be  secured  and  the  case  will  go  on  to  an  interval.  Operation  in 
this  period  is  always  dangerous;  operation  in  an  inter\'al  is  safe.  In  some 
instances,  when  the  case  is  not  seen  early,  it  is  wiser  to  avoid  operating  at  the 
time,  and  it  is  proper  to  wait  for  an  interval.  The  period  in  which  the  sur- 
geon usually  sees  the  case  for  the  first  time  is  said  by  Maurice  Richardson  to  be 
'"too  late  for  an  early  operation  and  too  early  for  a  late  operation."  Those  who 
say  "  operate  as  soon  as  the  diagnosis  is  made, "  operate,  as  a  rule,  in  this 
dangerous  period,  and  in  this  period  I  do  not  believe  that  every  case  should  be 
promptly  cut.  Many  cases,  it  is  true,  must  be  operated  on  as  soon  as  seen, 
irrespective  of  the  duration  of  the  disease.  We  must  operate  promptly  if  the 
pulse  is  small  and  well  above  100;  if  there  is  persistent  vomiting;  if  there  is 
delirium;  if  intestinal  obstruction  exists;  if  a  chill  has  occurred;  if  the  pain 
and  rigidity  are  very  marked;  if  a  mass  can  be  felt  in  the  right  iliac  fossa  or 
by  rectal  examination;  if  there  is  marked  abdominal  distention;  if  there  are 
evidences  of  pus-formation;  if  the  patient  is  growing  worse;  if  there  is  or  has 
been  shock;  or  if  the  pain  suddenly  passes  away  without  the  use  of  opiates. 

In  an  ordinary  mild  case,  not  seen  early,  in  which  none  of  the  above- 
named  conditions  or  symptoms  exist,  it  is  best  to  defer  operation.  Those  who 
advocate  operating  upon  every  case  consider  such  delay  reprehensible  and 
dangerous,  point  out  that  even  in  apparently  rnild  cases  gangrene  or  perfor- 
ation may  quickly  occur,  and  cite  striking  cases  to  emphasize  their  belief. 
There  is  much  force  in  this  view,  and  it  must  not  be  hastily  rejected.  The 
choice,  however,  is  not  between  a  dangerous  delay  and  a  safe  operation,  but 
is  rather  between  a  dangerous  delay  and  a  dangerous  operation.  It  is  a 
question  of  two  dangers,  and  each  side  chooses  the  danger  which  seems  to  it 
the  least.  Richardson's  elaborate  study  of  750  cases,  showing  a  mortality  of 
18  per  cent,  in  operations  for  acute  appendicitis,  determines  us  in  the  prac- 
tice of  the  more  conservative  plan. 

In  an  ordinary  mild  case  of  appendicitis  in  which  operation  is  refused, 
it  is  a  common  custom  to  purge  by  means  of  Epsom  or  Rochelle  salt.  This 
practice  was  begun  because  of  the  behef  that  inflammation  of  the  appendix 
is  associated  with  fecal  impaction  in  the  head  of  the  colon.  This  belief 
has  been  exploded,  but  the  treatment  is  still  used,  and  many  regard  it  as 
beneficial.  If  the  condition  of  the  stomach  prevents  the  administration  of 
saHnes,  high  enemata  are  usually  given.  My  own  belief  is  that  if  operation 
is  refused,  or  if  the  surgeon  determines  to  wait  for  an  inten-al,  he  should  fol- 


Treatment  of  Appendicitis  999 

low  the  plan  of  treatment  suggested  by  Ochsner  to  control  peristalsis  and  favor 
limitation  of  infection.  The  patient  is  kept  perfectly  quiet,  no  cathartics  are 
given,  no  food  or  drink  is  administered  by  the  mouth,  and  thirst  is  allayed 
by  enemata  of  salt  solution.  Nutritive  enemata  may  be  given.  It  is  also  my 
custom  to  place  a  hot-water  bag  instead  of  an  ice-bag  over  the  appendix  region. 
To  permit  peristalsis  favors  diffusion  of  the  infection:  to  prevent  peri- 
stalsis is  to  favor  the  formation  of  encompassing  and  defensive  adhesions. 

Manv  surgeons  use  the  ice-bag,  but  I  do  not  believe  in  it  in  these  cases. 
We  have  already  shown  (page  99)  that  cold  as  a  remedy  for  inflammation 
is  useful  only  in  the  brief  stage  of  hyperemia,  and  when  a  surgeon  sees  a 
case  of  appendicitis,  there  is  certainly  more  or  less  stasis.  Cold  adds  to  stasis 
and  does  harm,  and  I  am  persuaded  that  the  routine  use  of  the  ice-bag  is 
responsible  for  some  cases  of  gangrene.  Again  cold  actually  antagonizes 
the  migration  of  leukocytes  and  the  formation  of  adhesions. 

Heat  is  a  remedy  which  favors  limitation  of  the  process.  It  relieves 
stasis,  stimulates  the  activity  of  the  leukocytes,  favors  the  formation  of  an 
encompassing  barrier  of  phagocytic  cells,  and  aids  the  cellular  proliferation 
which  leads  to  the  formation  of  adhesions.  Hence  I  prefer  the  hot-water  bag. 
The  ice-bag,  when  apphed  before  the  diagnosis  has  been  made,  that  is, 
in  the  earliest  hours  of  the  attack,  when  it  might  be  thought  to  be  most  ser- 
viceable, alla>'s  pain  and  lessens  rigidity  in  some  cases,  almost  Hke  a  full  dose 
of  opium,  and  hence  masks  the  s}Tnptoms  as  does  that  drug. 

Opium  should  never  be  given  until  the  diagnosis  is  made.  In  the  first 
place,  it  is  not  needed,  for  if  the  pam  is  so  violent  as  absolutely  to  demand  opium, 
operation  should  be  performed.  In  the  second  place,  opium  masks  the 
symptoms,  makes  the  patient  feel  comfortable,  and  gives  the  physician  an 
unfortunate  and  ill-founded  sense  of  security.  The  pain  about  the  umbil- 
icus, if  severe,  can  be  distinctly  and  safely  relieved  by  the  administration 
of  thirty  minims  of  spirits  of  chloroform  every  half-hour  until  three  doses  are 
taken.  '  Opium  should  not  be  given  if  the  surgeon,  having  decided  not  to 
operate  at  once,  is  awaiting  an  inter\-al,  because  it  may  prevent  or  delay  the 
recognition  of  some  disastrous  change.  If  a  patient  refuses  operation,  it 
can  be  given. 

\Mien  we  decide  to  wait  for  an  interval,  the  case  should  be  seen  again 
within  six  hours.  We  are  accustomed  to  follow  McBurney's  rule,  which  is  as 
follows :  If  on  seeing  the  patient  again,  six  hours  after  the  first  visit,  the  patient 
is  worse,  operate  at  once.     If  he  is  no  worse,  there  is  no  pressing  danger. 

If  in  twelve  hours  after  the  beginning  of  the  attack  the  S3Tnptoms  are 
not  intensified,  they  will  soon  begin  to  abate;  if  the  smptoms  have  become 
worse  during  this  time,  operate.  If  in  twenty-four  hours  after  the  beginning 
of  the  attack  the  severity  of  the  s}Tnptoms  lessens,  it  is  usually  possible  to 
wait  for  an  interval;  but  if  during  the  second  twenty-four  hours  the  abate- 
ment in  the  severity  of  symptoms  has  not  gone  on  and  there  is  doubt  as  to 
the  condition,  operate  at  once.*  When  the  attack  has  subsided,  and  about 
three  weeks  or  more  have  passed,  the  appendix  can  be  removed  with  remark- 
able safety.  After  a  patient  has  had  two  or  more  attacks  of  appendicitis 
all  surgeons  agree  that  the  appendLx  should  be  removed. 

If  pus  is  present  some  surgeons  delay  operation  in  the  hope  that  firm 
*For  McBurney's  views,  see  X.  Y.  Polyclinic,  Jan.  15,  1897. 


looo  Diseases  and  Injuries  of  the  Abdomen 

adhesions  will  form  around  the  pus,  and  that  the  necessary  operation  will 
simply  be  the  opening  of  an  abscess.  I  do  not  believe  it  is  safe  to  delay 
operation  in  a  pus  case.  The  pus  may  become  limited,  but  it  may  instead 
pass  up  toward  the  liver  or  down  into  the  pelvis.  Delay  is  fraught  with 
peril. 

If  only  one  attack  has  occurred,  there  may  never  be  another,  and  the 
question  arises,  Should  the  appendix  be  removed  after  one  attack?  We 
do  not  know  that  a  man  has  really  recovered  after  purely  medical  treatment. 
Many  cases  reported  as  cured  by  medical  means  have  subsequently  required 
operation.  As  Lockwood  puts  it,*  "To  say  that  a  man  with  appendicitis 
has  been  cured  by  medical  means  is  in  many  cases  equivalent  to  saying  that 
a  man  with  a  stone  in  his  bladder  has  recovered  from  calculus  after  the  cure 
of  a  cystitis  by  rest  in  bed. " 

Even  after  a  first  attack,  if  the  appendix  remains  tender  or  becomes 
tender  after  exercise,  or  if  attacks  of  colicky  pain  occur,  operate. 

In  some  cases  a  single  attack  of  appendicitis  is  followed  by  persistent 
dyspepsia  and  ill  health,  and  in  such  cases  operation  should  be  performed. 
In  the  majority  of  cases,  after  even  one  well-marked  attack,  operation  is 
necessary.  It  is  always  necessary  after  two  attacks  (see  Operation  for  Appen- 
dicitis). 

Appendicitis  cases  which  are  far  advanced  in  general  peritonitis  when  seen 
by  the  surgeon  some  operators  decline  to  touch.  If  we  make  a  custom  of 
operating  on  such  cases  we  will  lose  very  many  but  will  save  some  few,  and 
these  few  would  have  died  if  we  had  not  operated.  To  operate  spoils  statis- 
tics, but  occasionally  saves  lives.  The  operation  should  consist  of  a  simple 
incision  to  relieve  tension  and  afford  exit  to  infected  fluids — rapid  removal 
of  the  appendix  if  it  is  easily  accessible,  otherwise  leaving  it  alone — and 
drainage  of  the  pelvis.  After  such  an  operation  the  patient  is  placed  in 
Fowler's  position  and  a  continuous  stream  of  salt  solution  at  low  pressure  is 
caused  to  trickle  into  the  rectum  (see  Murphy's  Treatment  for  Peritonitis, 
page  1006). 

Appendicitis  in  a  child  is  treated  exactly  as  in  an  adult.  Appendicitis 
in  a  pregnant  woman  is  treated  as  in  the  non-pregnant.  Early  operation  is 
particularly  indicated,  and  it  is  not  proper  to  induce  premature  labor  unless 
there  is  general  peritonitis  in  a  patient  far  advanced  in  pregnancy.  Then  it  is 
proper  to  empty  the  uterus,  primarily  to  obtain  drainage  and  to  give  the  patient 
a  chance  for  hfe  and  secondarily  to  obtain  a  hving  child. 

When  operating  upon  a  woman,  bear  in  mind  that  ovarian,  tubal,  or 
uterine  disease  may  have  preceded,  actually  caused,  or  resulted  from  the 
appendicitis;  examine  the  adnexa  and  remove  them  if  necessary. 

An  operation  for  tuberculous  appendicitis  is  rather  apt  to  be  followed 
by  a  fecal  fistula.  An  ordinary  laparotomy  is  sometimes  followed  by  cure, 
but  the  rule  of  operating  should  be,  when  possible,  to  remove  the  appendix 
and  resect  the  diseased  bowel.  Andrewsf  mentions  as  expedients  suited 
to  special  cases  of  tuberculous  disease:  total  exclusion;  partial  exclusion; 
lateral  anastomosis,  and  the  formation  of  an  artificial  anus. 

Congenital  Idiopathic  Dilatation  of  the  Colon  (Hirschsprung's 
Disease). — This  condition  is  of  prenatal  origin.     It  may  be  obvious  in  early 

*Brit.  Med.  Jour.,  Jan.  27,  1900.  f  Annals  of  Surgery,  Dec,  1901. 


Enteroptosis,  or  Glenard's  Disease  looi 

life  or  it  may  not  become  so  until  adult  years,  being  aggravated  and  developed 
but  not  caused  by  habitual  atony  of  the  bowel.  The  supposed  cause  is  an 
anatomical  anomaly  (perhaps  elongation)  leading  to  looping  of  the  colon,  a 
muscular  aplasia  leading  to  dilatation  and  valve  formation.     Various  causes 

have  been  suggested.  _  ,•  .      i    i 

The  victim  of  this  condition  is  obstinately  constipated  and  has  a  distended 
abdomen,  usually  from  early  infancy,  although,  as  previously  stated,  the 
condition  may  not  manifest  itself  until  childhood,  youth,  or  even  adult  life. 
It  is  most  difficult  to  get  the  bowels  to  move  at  all.  Gay  reported  a  case  m 
which  there  was  no  bowel  movement  for  three  months  and  periods  of  several 
weeks  are  by  no  means  uncommon.  Now  and  then  an  attack  of  diarrhea  may 
cause  the  emptying  out  of  great  quantities  of  feces.  The  abdomen  is  enor- 
mously distended  and  the  patient  is  emaciated. 

The  abdominal  veins  are  distended  and  the  rectus  muscles  may  be  separated. 
In  Finney's  cases  (as  in  some  other  reported  cases)  the  cords  of  distended  gut 
could  be  seen  or  felt  to  be  more  prominent  on  one  side  than  on  the  other. 
There  is  no  abdominal  tenderness  and  pain  is  absent  unless  there  is  diarrhea. 
Borborygmus  is  often  very  loud.     Vomiting  is  rare. 
The  urine  shows  marked  increase  of  indican.  _ 

The  disease  does  not  directly  cause  death,  but  the  ill-nourished  condition 
lessens  the  chance  for  recovery  from  any  attack  of  illness. 

Treatment.— Medical  treatment  consists  of  the  ordinary  plans  for  com- 
bating constipation.  Some  surgeons  have  removed  almost  the  entire  large 
intestine,  others  have  performed  entero-anastomosis,  others  colopexy,  others 
have  established  a  permanent  artificial  anus,  others  have  made  an  artificial 
anus  preliminary  to  entero-anastomosis.  Finney  bdieves  that  the  operation 
of  choice  is  resection  of  the  affected  gut  followed  by  entero-anastomosis.     _ 

Splanchnoptosis.— This  condition  is  due  to  relaxation  of  the  abdominal 
walls  and  decrease  of  intra-abdominal  tension,  which  leads  to  gradual  stretch- 
ing of  suspensorv  ligaments  and  finally  to  movement  of  the  viscera  downward. 
The  prolapse  may  involve  all  the  abdominal  viscera,  one  viscus,  or  several  vis- 
cera Prolapse  of  the  stomach  is  known  as  gastroptosis  (page  968) ;  prolapse 
of  the  Uver,  as  hepatoptosis  (page  102 1);  prolapse  of  the  spleen,  as  splenop- 
tosis (page  1048);  prolapse  of  the  kidney,  as  nephroptosis  (page  1273);  and 
prolapse  of  the  intestines,  as  enteroptosis  or  Glenard's  disease  (page  iooi)._ 

The  causative  relaxation  of  the  abdominal  walls  is  most  common  in 
women,  but  Is  by  no  means  confined  to  that  sex.  It  may  be  produced  by 
ascites,  pregnancy,  muscular  effort,  febrile  maladies,  or  wasting  diseases.  In 
some  cases  no  cause  can  be  assigned.  Such  a  relaxed  abdomen  may  be 
thin,  but  is  not  unusually  thick,  the  fascial  strands  and  muscular  fibers 
are  stretched,  attenuated,  and  separated,  the  belly  bulges  downward  and  for- 
ward  and  a  viscus  or  the  viscera  follow  because  of  lack  of  support. 

Enteroptosis,  or  Glenard's  Disease.— This  disease  is  a  prolapse  of 
the  intestine.  It  may  be  but  a  part  of  ptosis  or  prolapse  of  all  the  abdom- 
inal viscera;  it  may  exist  alone;  it  may  be  associated  with  movable  kid- 
ney, prolapse  of  the  stomach  (gastroptosis),  of  the  liver  (hepatoptosis),  or  of 
the  spleen  (splenoptosis).  .        r  .1       1  j 

In  Glenard's  disease  the  intestines  occupy  the  lower  portion  of  the  abdo- 
men, and  the  belly  below  the  costal  margins  is  fiat,  is  dull  on  percussion. 


I002  Diseases  and  Injuries  of  the  Abdomen 

and  the  pulsations  of  the  aorta  are  very  evident.  The  right  portion  of  the 
transverse  colon  begins  to  descend  first,  and  other  portions  of  the  intes- 
tine follow.  The  splenic  and  hepatic  flexures  are  elongated  and  sometimes 
there  is  venous  engorgement  of  dependent  parts  of  the  mesentery  (Lam- 
botte,  in  "Presse  Med.  Beige,"  1901,  Nov.  24).  The  victims  of  this  disease 
are  dyspeptic,  anemic,  and  neurasthenic.  The  condition  may  arise  without 
apparent  cause,  may  be  caused  by  wearing  corsets,  by  falls,  by  blows,  by 
hfting  hea\y  weights,  and  by  prolonged  vomiting.  The  dyspepsia  is  due 
to  dragging  on  the  duodenum,  the  tube  becoming  flattened  out  (A.  K.  Stone). 
The  flattening  of  the  duodenum  may  be  followed  by  kinking  of  the  pylorus, 
and  in  such  a  case  the  stomach  dilates,  otherwise  it  does  not  dilate.  Normally 
the  tenth  rib  is  firmly  attached  by  fibrous  tissue  to  the  ninth  costal  cartilage. 
In  enteroptosis  the  tip  of  the  tenth  rib  is  freely  movable  and  obviously  sepa- 
rated from  the  ninth  costal  cartilage  {S tiller's  sign). 

Treatment. — In  many  cases  medical  treatment  is  of  benefit.  The  fol- 
lowing is  the  usual  plan:  Employ  lavage,  massage,  and  electricity;  order  a 
proper  abdominal  support;  insist  on  regular  exercise,  and  treat  the  anemia 
and  dyspepsia.  There  are  two  possible  surgical  plans  and  each  has  its  ad- 
vocates: (i)  The  suture  of  the  prolapsed  \iscus  to  some  adjacent  structure  or 
the  shortening  by  sutures  of  its  supporting  hgament.  (2)  Plastic  operation  to 
lessen  the  area  of  the  abdominal  wall  and  thus  increase  intra-abdominal 
tension.  Depage  makes  the  abdominal  wall  less  in  both  directions.  Webster, 
in  cases  with  separation  of  the  recti,  resects  and  sutures  the  fascia  of  the  muscles. 
I  believe  that  Depage's  method  of  shortening  the  diameters  of  the  abdominal 
wall  cannot  permanently  succeed,  because  the  \dscera,  hanging  to  relaxed  Hga- 
ments,  will  eventually  stretch  the  wall;  it  wiW  be  stretched  easily  because  of 
damage  done  to  its  nerve  supply  by  operation,  and  hernia  will  be  apt  to  occur, 
and  if  it  should,  the  patient  will  be  worse  off  than  before  operation.  Of 
course,  whatever  operation  is  done,  diastased  rectus  muscles  should  be  approx- 
imated and  sutured.  For  ptosis  of  the  small  intestine  the  mesentery  may  be 
shortened,  as  suggested  and  performed  by  Da\-is  of  Omaha,  in  1897. 

In  prolapse  of  the  transverse  colon  good  results  are  said  to  have  been 
obtained  by  attaching  the  splenic  and  hepatic  flexures  to  the  abdominal  wall 
(Lamhotte's  operation).  The  surgical  treatment  of  ptosis  of  the  stomach  is 
considered  on  page  968;  of  the  liver,  on  page  1022;  of  the  spleen,  on  page 
1048;  of  the  kidney,  on  page  1276. 

The  Peritoneum. 

Acute  Peritonitis.— Peritonids,  or  inflammation  of  the  peritoneum, 
is  a  common  and  usually  a  very  dangerous  disease. 

Aseptic  irritation  by  a  traumatism  or  a  chemical  irritant  produces  aseptic 
peritonitis,  a  condition  which  is  strictly  limited;  which  may  produce  local 
pain  and  tenderness;  which  may  cause  aseptic  fever  from  the  absorption  of 
fibrin-ferment  and  the  products  of  tissue  change;  which  leads  to  the  formation 
of  temporary  or  permanent  adhesions,  and  which  is,  in  reality,  a  process  of 

repair. 

Peritonitis,  as  the  term  is  used  by  the  surgeon,  is  always  due  to  bacteria. 
Bacteria  may  reach  the  peritoneal  cavity  by  means  of  an  abdominal  wound 
or  the  entrance  of  foreign  bodies;  by  extravasations  from  the  stomach,  bowel, 


Acute  Peritonitis  1003 

vermiform  appendix,  gall-bladder,  urinary  bladder,  kidney,  Fallopian  tube, 
or  uterus,  or  by  the  passage  of  micro-organisms  through  the  damaged  walls 
of  any  of  these  viscera  or  structures;  by  way  of  an  open  Fallopian  tube; 
from  the  breaking  of  an  abscess  into  the  peritoneal  cavity;  from  areas  of 
necrosis  due  to  volvulus,  strangulation,  or  intussusception  of  the  intestine; 
twisting  of  the  pedicle  of  an  ovarian  tumor,  a  floating  kidney,  or  a  floating 
spleen;  blocking  of  a  mesenteric  vessel  by  a  thrombus  or  an  embolism; 
gangrene  of  the  pancreas  or  spleen,  and  fat-necrosis.*  In  some  cases  the 
peritoneum  may  contain  a  point  of  least  resistance,  and  bacteria  contained 
in  the  blood  reach  this  point  and  produce  infection.  It  was  once  taught 
that  cold  could  produce  peritonitis,  but  it  seems  probable  that  it  can  only 
act  by  producing  an  area  of  least  resistance.  The  capacity  of  the  rheumatic 
poison  to  produce  peritonitis  is  doubtful. 

The  peritoneum,  as  Byron  Robinson  pointed  out  and  Fowler  confirmed, 
is  in  reality  a  great  lymph-sac,  and  peritonitis  is  lymphangitis.  "When 
the  peritoneum  is  infected  the  lymphatics  furnish  an  exudate  which  clots 
in  the  lymph-channels,  blocks  them,  and  limits  or  prevents  absorption:  This 
blocking  of  the  lymph-channels  serves  to  preserve  the  life  of  the  subject, 
on  the  one  hand,  while  a  failure  in  this  respect,  either  because  of  the  enor- 
mous and  overwhelmingly  rapid  increase  of  septic  material  and  the  large 
size  and  number  of  channels  necessary  to  destroy  and  obstruct,  on  the  other 
hand,  permits  the  destruction  of  the  organism."!  Absorption  takes  place 
most  actively  from  the  region  of  the  diaphragm,  hence  peritonitis  in  this 
region  is  peculiarly  fatal.  Absorption  takes  place  very  rapidly  from  the 
intestinal  region,  although  not  quite  so  quickly  as  from  the  diaphragmatic 
area.  Absorption  takes  place  slowly  from  the  pelvic  region,  hence  perito- 
nitis of  this  region  is  much  less  dangerous  than  is  the  disease  in  the  intes- 
tinal region,  and  vastly  less  dangerous  than  is  the  disease  in  the  diaphrag- 
matic region  (Fowler). 

When  severe  bacterial  infection  of  the  peritoneum  occurs,  exudation 
of  blood-liquor  takes  place,  leukocytes  migrate  from  the  blood-vessels 
beneath  the  endothelial  layer,  particularly  into  the  peritoneal  cavity,  and 
the  causative  bacteria  rapidly  spread  about  the  cavity.  The  fibrinous  exu- 
date, in  many  infections,  coagulates  in  masses  on  the  free  surface  of  the 
peritoneum  and  thus  serves  a  useful  purpose  by  blocking  the  lymph-channels 
and  hindering  absorption  of  toxins  and  bacteria.  This  fibrinous  exudate 
may  break  down  in  a  wide-spread  suppuration  or  may  be  organized  into  an 
adhesion.  In  very  virulent  streptococcic  infections  a  patient  may  die  and 
there  may  be  scarcely  any  coagulated  exudation  or  may  be  none  at  all.  Exu- 
dation and  migration  take  place  also  into  the  subserous  tissues  and  into  the 
muscular  coat  of  the  bowel,  and  the  segment  of  bowel  which  is  attacked  becomes 
paralyzed  and  distended  with  gas,  the  gas  within  causes  it  to  rise  up,  and, 
as  peristalsis  is  absent,  obstruction  occurs  (James  P.  Warbasse,  in  "Am. 
Jour.  Med.  Sciences,"  July,  1905).  Absorption  of  poison  in  peritonitis 
takes  place  in  part  from  the  peritoneal  cavity  and  in  part  from  the  subserous 
tissues.  Warbasse  believes  that  the  inflamed  peritoneum  is  scarcely  an 
absorbing  surface,  but  in  cases  in  which  coagulated  exudate  has  not  formed 

*  See  Park's  "  Surgery  by  American  Authors." 

tGeorgeR.  Fowler,  "  Diffuse  Septic  Peritonitis,"  in  Medical  Record,  April  14,  1900. 


I004  Diseases  and  Injuries  of  the  Abdomen 

or  has  been  destroyed,  it  seems  probable  that  it  is  an  active  absorbing  sur- 
face, and  absorption  may  occur  from  some  regions,  but  not  from  others. 

Various  bacteria  may  be  responsible  for  peritonitis,  especially  staphy- 
lococci, streptococci,  pneumococci,  and  colon  bacilli.  The  infections  which 
spread  most  rapidly  and  widely  are  due  to  streptococci.  In  streptococcus 
infection  the  protective  exudate  does  not  coagulate,  barriers  of  leukocytes 
are  not  heaped  up,  encompassing  adhesions  do  not  form,  there  is  rapid  ab- 
sorption of  toxins,  and  overwhelming  systemic  poisoning.  Colon  bacilli 
cause  a  very  grave  form  of  peritonitis,  but  less  rapid  and  diffuse  than  that 
caused  by  streptococci— in  fact,  the  process  is  often  encompassed  for  a  time 
by  coagulated  lymph,  leukocytes,  and  adhesions.  The  omentum  particularly 
is  thickened,  and  is  apt  to  apply  itself  about  the  area  of  infection.  Staphylo- 
cocci and  pneumococci  produce  peritonitis  which  is  more  apt  to  be  hmited 
than  that  produced  by  colon  bacilli.  In  most  cases  of  peritonitis  a  mixed 
infection  exists;  for  instance,  colon  bacilli  and  staphylococci  or  colon  bacilli 
and  streptococci.  In  some  apparently  severe  cases  of  acute  peritonitis  cul- 
tures have  remained  sterile. 

Forms  of  Peritonitis. — An  accurate  bacteriological  classification  is  not 
as  yet  possible. 

Peritonitis  can  be  named,  according  to  regions,  pelvic,  subdiaphragmatic, 
etc. ;  it  can  be  divided  pathologically  into  difjuse  septic,  putrid,  hemorrhagic, 
suppurative,  serous,  and  fibrinoplastic  (Senn);  it  can  be  classified,  etiologi- 
cally,  into  traumatic,  puerperal,  perforative,  metastatic,  scarlatinal,  etc.;  and 
it  can  be  divided,  clinically,  into  circumscribed  suppurative,  difjuse  suppurative, 
and  difjuse  septic. 

Circumscribed  Suppurative  Peritonitis.— In  this  condition,  which  is 
frequently  met  with  in  appendicitis,  the  area  of  infection  is  circumscribed 
by  coagulated  exudate,  leukocytes,  and  adhesions,  and  an  abscess  forms. 
After  a  time  distinct  locahzation  becomes  evident. 

The  symptoms  of  circumscribed  peritonitis  are  pain,  at  first  general  and 
then  local,  tenderness  in  a  particular  region,  muscular  rigidity,  distention, 
vomiting,  rapid  and  often  wiry  pulse,  constipation,  fever,  great  weakness, 
and  dorsal  decubitus  with  the  thighs  flexed.  After  a  time  a  distinct  mass 
can  usually  be  detected  by  palpation,  and  there  may  be  dulness  on  percussion, 
local  rigidity,  irregular  temperature,  sweats,  and  possibly  edema  of  the  belly- 
wall.  An  abscess,  though  limited  for  a  time,  is  always  liable  to  break  through 
its  walls  and  produce  general  peritonitis.  Such  an  accident  may  be  pro- 
duced by  muscular  effort  on  the  part  of  the  patient  or  by  injudicious  pal- 
pation on  the  part  of  the  surgeon;  its  occurrence  is  announced  by  shock, 
and  the  symptoms  of  general  peritonitis  quickly  arise. 

Diffuse  or  general  septic  peritonitis  is  apt  to  destroy  life  even  before  the 
peritoneum  presents  any  marked  change.  Death  ensues  from  the  absorption 
of  toxic  alkaloids.  Septic  peritonitis  may  arise  during  puerperality,  through 
lymphatic  infection ;  it  may  be  due  to  infection  from  without  by  an  operation 
or  an  accident;  to  perforation  of  an  ulcer;  to  gangrene  of  a  portion  of  the 
intestine;  to  rupture  of  an  abscess  into  the  peritoneal  cavity;  or  to  migration 
of  micro-organisms  through  a  damaged  wall  of  the  bowel.  Peritonitis  due 
to  perforation  is  called  perjorative  peritonitis.  Perforation  is  made  manifest 
by  a  chill,  shock,  or  rapid  collapse.     Gas  may  pass  into  the  peritoneal  cavity, 


Treatment  of  Peritonitis  1005 

and  if  it  does  so,  the  area  of  liver-dulness  may  be  lessened  or  abolished. 
Symptoms  and  signs  of  hemorrhage  may  arise.  Diffuse  septic  peritonitis  is 
announced  by  a  very  rapid  pulse,  which  is  at  first  wiry  and  later  gaseous; 
a  temperature  which  may  be  at  times  febrile,  but  which  is  apt  to  be  sub- 
normal or  which  soon  becomes  so;  diffused  abdominal  pain,  general  tender- 
ness, dry  tongue,  delirium,  persistent  vomiting,  constipation,  and  collapse. 
Rigidity  may  exist,  and  also  intestinal  obstruction;  often,  but  not  invaria- 
bly, there  is  distention.  In  puerperal  peritonitis  or  septic  peritonitis  from 
operation  there  is  often  no  severe  pain;  in  perforative  peritonitis  there  is 
acute  pain.     Patients  usually  die  within  five  or  six  days. 

Diffuse  or  general  suppurative  peritonitis  differs  clinically  from  diffuse 
septic  peritonitis  in  the  fact  that  it  is  less  apt  to  be  fatal  and  wide-spread.  In 
fact,  adhesions  may  form  about  an  area  representing  a  considerable  portion  of 
the  peritoneal  cavity.  The  causes  of  both  are  identical.  In  septic  peritonitis 
death  occurs  from  absorption  of  toxins  before  obvious  pathological  changes 
occur  in  the  peritoneum;  in  suppurative  peritonitis  the  microbes  are  fewer, 
are  less  virulent,  or  vital  resistance  is  more  decided,  and  suppuration  follows 
marked  changes  in  the  peritoneum.  In  suppurative  peritonitis  the  pyogenic 
bacteria  are  always  present,  and  there  exists  in  the  peritoneum  a  wound 
or  damaged  area  to  constitute  a  point  of  least  resistance. 

Symptoms. — Chilliness  or  a  rigor  is  common,  followed  by  fever,  the 
temperature  rising  to  102°  or  104°  F.;  pain  is  intense,  and  is  accentuated  by 
motion  and  pressure;  the  attitude  of  the  patient  is  assumed  to  relieve  pain 
(he  lies  upon  his  back,  with  the  shoulders  raised  and  the  thighs  drawn  up); 
there  are  vomiting,  obstinate  constipation,  and  rigidity  of  the  abdominal 
walls,  followed  by  distention  when  the  intestine  becomes  paretic  from  septic 
poisoning.  The  pulse  is  rapid;  is  at  first  wiry,  but  may  become  gaseous. 
The  constipation  may  be  due  either  to  tympanitic  distention  or  to  the  shock 
and  toxemia  inhibiting  intestinal  peristalsis.  Vomiting  is  frequent.  In  per- 
foration gas  often  passes  into  the  peritoneal  cavity,  and  it  may  obscure  the 
liver-dulness;  in  tympanites  without  perforation  the  liver  is  apt  to  be  pushed 
up  and  its  dulness  often  remains,  but  on  a  higher  level.  Pus  unconfined  by  ad- 
hesions will  gravitate  to  the  most  dependent  part  of  the  peritoneal  cavity.  In 
some  cases  of  suppurative  peritonitis  there  is  no  tympanitic  distention  or 
rigidity;  in  some  cases  there  is  no  fever,  and  a  subnormal  temperature  may 
even  exist. 

Treatment  of  Peritonitis. — After  an  abdominal  operation  the  patient 
may  have  pain,  slight  rigidity,  constipation,  nausea,  etc.,  and  the  surgeon  is  in 
doubt  if  peritonitis  is  beginning.  Our  custom  is  in  such  cases  to  give  a  saline 
cathartic,  which  will  empty  the  peritoneal  cavity  of  fluid,  will  favor  the  elimina- 
tion of  microbes,  and  will  combat  inflammation.  The  old-time  remedy  was 
opium,  but  Tait  denounced  it  as  inefficient,  and  showed  that  it  masked  the 
symptoms  and  often  created  a  false  sense  of  security  in  the  very  midst  of  im- 
minent dangers.  The  usual  method  of  administering  salines  is  to  give  5j  of 
Rochelle  salt  and  3j  of  Epsom  salt  every  hour  until  a  free  movement  occurs. 
Administer  an  enema  of  turpentine  at  the  time  the  first  dose  of  the  saline  is 
given.  This  treatment  will  often  abolish  pain  and  distention  and  will  perhaps 
prevent  peritonitis  after  an  abdominal  operation.  If,  however,  genuine  peri- 
tonitis actually  exists,  operation  is  required.    When  diffuse  septic  or  suppura- 


ioo6 


Diseases  and  Injuries  of  the  Abdomen 


tive  peritonitis  exists,  the  al)domen  should  be  opened.  If  a  perforation  exists, 
it  should  be  closed.  If  there  is  an  inflamed  appendix,  it  should  be  removed. 
Until  recently  it  was  surgical  custom  to  break  up  adhesions,  eviscerate,  wash 
the  belly  with  gallons  of  very  warm  salt  solution,  wipe  out  the  space  between 
the  liver  and  diaphragm,  wipe  out  the  pelvis,  wipe  off  the  intestines,  and 
remove  masses  of  adherent  coagulated  exudate.  We  thus  produced  dread- 
ful shock,  tried  to  cleanse  the  peritoneal  cavity  when  it  is  impossible  thoroughly 
to  cleanse  it,  carefully  removed  the  exudate  which  was  doing  good  by  plugging 
the  lymph-spaces,  and  yet  did  not  reach  the  infection  inside  of  the  lymphatics, 
which  is,  after  all,  the  greatest  source  of  danger.  Then  we  drained  through 
two  or  more  incisions  and  put  the  patient  recumbent  in  bed,  and  thus  per- 
mitted infected  material  to  flow  up  to  the  diaphragm,  where  it  is  quickly 
absorbed.  The  mortality  from  this  procedure  was  dreadful.  John  B. 
Murphy  has  taught  us  wisdom  and  has  combined  some  of  the  conservative 
views  of  Ochsner  with  the  use  of  the  semi-erect  position  of  Fowler,  and  with 


Fig.  524. — Murphy  treatment  for  suppurative  peritonitis. 

che  continuous  rectal  irrigations    that  several  advocated.     Murphy's   plan 
is  founded  upon  the  following  principles: 

First,  that  the  initial  lesion  of  the  peritonitis  should  be  got  rid  of  as  quickly 
as  possible  and  with  the  slightest  possible  amount  of  handhng.  For  instance, 
we  should  remove  a  gangrenous  appendix;  we  should  close  a  perforation  in 
the  bowel,  etc.  Flushing  of  the  peritoneal  cavity  with  gallons  of  salt  solu- 
tion is  inadvisable.  It  cannot  thoroughly  cleanse  the  peritoneum;  it  may 
diffuse  the  infection  to  regions  that  it  had  not  previously  reached,  and  it  may 
tear  up  adhesions.  Inflammatory  exudate  should  not  be  removed  from  the 
intraperitoneal  structures.  It  is  nature's  method  of  sealing  the  lymph- 
spaces;  and  if  we  remove  it,  we  open  thousands  of  channels,  previously 
sealed,  to  the  dissemination  of  the  infection.  A  drainage-tube  should  be 
introduced  through  the  operation  wound,  and  a  suprapubic  incision  should 
also  be  made,  and  a  drainage-tube  be  carried  through  this  into  the  pelvis. 
When  the  operation  is  completed,  the  patient  should  be  placed  in  the  semi- 
erect  position,  which  is  commonly  called  Foivler's  position.  This  is  done 
in  order  that  the  intraperitoneal  fluids  may  gravitate  away  from  the  dia- 


Treatment  of  Peritonitis 


ICO'; 


phragm,   where  absori)ti()n  is  extremely   rapid,  and  into   the  i^elvis,   where 
absorption  is  much  slower. 

When  the  patient  is  placed  in  the  bed,  quantities  of  warm  salt  solution  are 
passed  slowly  into  the  rectum.  The  mucous  membrane  of  the  large  intestme 
absorbs  fluid  with  great  rapidity  when  that  portion  of  the  gut  is  in  its  normal 
condition  of  moderate  distention.  Overdistention  leads  to  spasm,  which 
expels  the  fluid.  Hence  the  fluid  must  be  given  at  low  pressure  and  admin- 
istration should  be  continuous.  The  simplest  sort  of  apparatus  is  shown  in 
Fig  526.  It  consists  of  a  fountain  syringe,  a  large  rubber  tube,  and  a  rectal 
tip  of  hard  rubber.  The  nozzle  that  is  used  is  angled,  has  one  opening  on  the 
end  and  several  on  the  side,  and  this  nozzle  is  passed  so  that  the  angle  fits  to 
the  sphincter.     The  tube  is  strapped  to  the  thighs  by  adhesive  plaster.     The 


Fig.  52 5. —.Alcohol  or  gas  heater  in  operation,  showing  it  properly  connected.     A  short  glass 
tube  connects  catheter  to  rubber  tubing  (Murphy). 

hose  that  comes  from  the  nozzle  is  attached  to  a  reservoir,  the  base  of  which  is 
hun^  from  4  to  6  inches  above  the  level  of  the  patient's  buttocks;  and  the  fluid, 
therefore  enters  the  rectum  only  about  as  fast  as  the  rectum  ^vlll  absorb  it. 
The  reservoir  is  kept  hot  by  bags  of  hot  water.  The  fluid  is  allowed  to  enter 
continuously,  unless  it  should  run  out  from  the  side  of  the  tube;  if  this  happens, 
the  flow  mav  be  cut  off  for  a  short  time  and  then  allowed  to  begin  again.  Gas 
from  the  bowel  passes  into  the  openings  of  the  tube,  and  every  now  and  then 
bubbles  up  through  the  resen^oir.  By  this  continuous,  low-pressure  instilla- 
tion {proctoclysis)  an  enormous  quantity  of  fluid  is  absorbed  by  the  rectum. 
In  some  cases  a  number  of  quarts  are  taken  up  in  twenty-four  hours.  Ihe 
absorption  of  this  fluid  greatlv  increases  the  amount  of  urine  eliminated  and 
stimulates  the  heart.  The  reservoir  must  not  be  high.  Increase  of  pressure 
will  cause  expulsion  of  fluid  and  defeat  the  possibiUty  of  continuous  admin- 
istration.    The  plan  so  often  followed  of  keeping  the  reservoir  high  and  hmit- 


ioo8 


Diseases  and  Injuries  of  the  Abdomen 


ing  the  flow  by  a  clip  on  the  tube  is  a  mistake.  Murpjhy  says:  "It  should 
never  have  a  headway  of  more  than  15  inches  hydrostatic  pressure,  and  it 
gives  the  best  and  most  uniform  results  at  4  to  7  inches"  ("Jour.  Am.  Med. 
Assoc,"  April  17,  1909).  A  straight  tube  is  somedmes  responsible  for  ex- 
pulsion of  the  fluid,  because  it  touches  the  posterior  rectal  wall  of  a  patient 
in  Fowler's  position.     Fig.  525  shows  a  more  elaborate  apparatus. 

After  the  water  has  been  entering  the  rectum  for  some  dme,  a  profuse 
discharge  of  sour-smelling  material  comes  from  the  drainage-tube.  This 
discharge  may  be  profuse  for  one  day,  two  days,  or  longer,  when  its  sour 

smell  disappears  and  it  greatly  lessens  in  quan- 
tity. The  outflow  of  this  fluid  from  the  wound 
means  that  saline  fluid  from  the  rectum  has 
entered  the  lymph-spaces  and  flowed  into  the 
peritoneal  cavity.  Murphy  thinks  the  lymph- 
current  has  been  reversed.  Whether  this  is 
true  or  not  the  peritoneum  certainly  seems  to 
become  a  secreting  instead  of  an  absorbing  sur- 
face, and  the  lymphatics  are  washed  out.  Dur- 
ing the  time  that  this  treatment  is  pursued  the 
patient  has  no  food  or  water  given  him  by  the 
mouth.  Stomach  feeding  is  rigidly  forbidden 
in  order  to  prevent  peristaltic  movements. 
Small  amounts  of  opium  may  be  given  to  pre- 
vent peristalsis.  If  the  patient  is  in  a  weak 
condition,  stirriulants  or  food  can  be  given  by 
the  rectum,  the  solution  in  the  reservior  being 
allowed  to  reach  a  low  level,  and  then  the 
material  that  it  is  desired  to  give  is  poured  in. 
Besides  the  above  method  of  treatment  anti- 
streptococcic serum  is  given. 

I  am  convinced  that  this  method  of  treat- 
ment is  of  the  greatest  value,  and  that  the  prin- 
ciples upon  which  it  rests  are  entirely  sound, 
and  I  have  had  a  number  of  striking  successes 
from  its  employment. 
A  circumscribed  suppuration  is  treated  as  follows:  Open  the  abscess.  It 
will  be  possible,  if  the  abscess  is  adherent  to  the  abdominal  wall,  to  open 
the  abscess  directly  without  opening  the  peritoneal  cavity.  If  this  is  not 
possible,  after  opening  the  abdominal  cavity  pack  gauze  pads  in  such  a 
manner  about  the  abscess  as  to  prevent  the  diffusion  of  pus  when  the  abscess 
is  evacuated.  After  opening  the  abscess  the  primary  lesion  is  sought  for 
and,  if  possible,  removed.  The  surgeon  should  not,  in  most  cases,  tear  away 
the  abscess  walls  in  an  attempt  to  find  the  primary  lesion,  but  should  rather 
let  it  go  undiscovered.  Pack  iodoform  gauze  against  the  intestines  to  rein- 
force the  barrier  of  lymph  and  insert  a  tube.  It  is  frequently  advisable  to 
leave  the  wound  open  and  drain  with  iodoform  gauze. 

Every  patient  with  peritonitis  requires  stimulants  and  frequent  feeding  with 
liquid  food. 

Tuberculous  Peritonitis. — Tuberculosis  of  the  peritoneum  is  not  very 


Fig.  526.. — Proctoclysis  appa- 
ratus consisting  of  fountain 
syringe,  large  rubber  tube,  and 
vaginal  hard-rubber  or  glass  tip 
(Murphy). 


Tuberculous  Peritonitis  1009 

common.  In  11 70  autopsies  in  the  Boston  City  Hospitol  tubercle  existed 
in  some  region  in  197,  and  in  14  of  these  the  peritoneum  was  involved.* 
Primary  local  peritoneal  tuberculosis  is  occasionally,  though  very  rarely,  seen 
by  the  surgeon.  In  a  great  majority  of  cases  of  peritoneal  tuberculosis  other 
distant  structures  are  involved.  In  about  half  of  the  cases  the  lungs  are  in- 
volved. In  28  cases  reported  by  Bottomly  f  not  one  was  primary.  In  every 
one  of  these  cases  the  diagnosis  was  confirmed  by  the  microscope,  by  the  tuber- 
culin test,  or  by  autopsy.  In  most  supposed  cases  of  primary  peritoneal 
tuberculosis  another  focus  of  disease  exists,  but  is  not  demonstrable  by  clini- 
cal methods  or  has  been  overlooked.  The  disease  sometimes  exists  as  a  part 
of  a  general  tuberculosis.  Tuberculous  peritonitis  may  be  only  a  part  of 
acute  miliary  tuberculosis.  Bacteria  may  be  swallowed  with  tuberculous  food 
or  a  tuberculous  patient  may  swallow  tuberculous  sputum  and  intestinal  tuber- 
culosis may  result,  the  peritoneum  being  involved  later.  Peritoneal  infection 
may  follow  a  tuberculous  lesion  of  the  intestine,  the  bacteria  may  enter  by 
way  of  the  Fallopian  tube,  the  initial  lesion  may  be  tuberculous  appendicitis 
or  tuberculosis  of  the  mesenteric  glands.     The  germ  may  lodge  from  the  blood 


Fig.  527. — Tube  with  orifices  filled  with  chalk  in  order  to  show  openings  better. 

or  lymph.  The  lymphatic  form  most  commonly  attacks  the  cecum.  Tubercu- 
lous peritonitis  is  four  times  as  common  among  women  as  among  men,  and  most 
frequently  attacks  those  between  twenty  and  forty  years  of  age,  but  I  have 
seen  it  in  a  child  of  five  and  in  a  colored  man  of  sixty.  There  are  two  groups 
of  cases — the  common  chronic  form  and  the  rarer  acute  condition.  The 
acute  form  begins  suddenly,  and  such  cases,  as  pointed  out  by  Lejars,  resemble 
acute  appendicitis.  In  either  the  acute  or  chronic  condition  it  is  frequently 
the  case  that  pulmonary  phthisis  exists.  Cirrhosis  of  the  liver  is  sometimes 
found  with  tuberculous  peritonitis.  There  are  three  forms  of  chronic  tuber- 
culous peritonitis:  the  ascitic,  the  fibrinoplastic,  and  the  caseo2is,X  although, 
as  a  matter  of  fact,  these  so-called  forms  are  only  stages  of  the  same  disease. 
Tuberculous  infection  may  exist  for  some  time  without  causing  symptoms, 
acute  symptoms  may  suddenly  arise,  or  intestinal  obstruction  may  take  place. 
S\Tnptoms  sometimes  develop  quickly  after  pregnancy.  In  other  cases  the 
symptoms  appear  gradually  and  progressively  grow  more  positive. 

Symptoms  of  the  Chronic  Form. — Usually  the  disease  begins  insidiously. 
The  digestion  is  found  to  be  disturbed,  there  is  nausea,  the  bowels  are  out  of 

*  Bottomly,  in  Amer.  Med.,  Feb.,  15,  1902.  t  Amer.  Med.,  Feb.  15,  1902. 

X  Parker  Syms,  in  Medical  Record,  April  2,  1898. 
64 


loio  Diseases  and  Injuries  of  the  Abdomen 

order,  the  abdomen  is  distended  and  tender,  there  is  occasional  colicky  pain, 
and  the  patient  is  weak,  loses  flesh  rapidly,  and  becomes  very  anemic.  Fre- 
quently pain  is  the  symptom  which  leads  the  patient  to  seek  advice.  The 
pain  may  be  present  from  the  very  beginning,  it  may  arise  after  malaise  and 
gastro-intestinal  disorder  have  existed  for  some  time,  but  sooner  or  later  it 
will  develop. 

In  many  cases  there  is  ascites,  but  the  amount  of  fluid  is  rarely  very  great. 
In  some  cases  the  fluid  is  serous,  in  some  seropurulent,  in  some  purulent,  and 
in  some  bloody.  Chylous  fluid  occasionally  exists  because  of  fatty  degenera- 
tion of  tuberculous  masses.  Ascites  may  be  either  unconfined  or  sacculated  by 
adhesions.  In  some  cases,  and  especially  in  early  youth,  there  is  little  or  no 
ascites,  and  the  condition  is  characterized  by  the  production  of  a  quantity  of 
adhesions  which  bind  coils  of  intestine  to  each  other,  to  the  omentum,  to  the 
stomach,  Hver,  and  other  viscera.  In  this  condition,  which  develops  very 
slowly,  small  cavities  are  formed  between  adhesions  and  the  spaces  contain 
fluid  and  bacteria.  This  is  the  most  chronic  form  of  the  disease.  In  any  case 
of  tuberculous  peritonitis  the  mesenteric  glands  may  enlarge.  There  is  usually 
moderate  fever,  but  there  may  be  episodes  of  high  fever  and  protracted  periods 
of  subnormal  temperature,  or  the  temperature  may  be  shghtly  elevated  in  the 
evening  and  subnormal  in  the  morning.  When  the  temperature  becomes 
markedly  elevated,  pain,  tenderness,  and  distention  notably  increase.  In 
some  cases  there  is  a  continued  fever  resembling  typhoid.  Tumor-like  forma- 
tions may  be  detected.  These  formations  may  consist  of  indurated  omentum; 
encysted  exudate,  or  enlarged  mesenteric  glands.  If  diarrhea  exists  for  a  long 
period,  there  is  probably  tuberculous  ulceration  of  the  gut. 

In  every  suspected  case  a  bimanual  examination  should  be  made  under 
ether,  in  order  to  discover  if  there  are  any  matted  masses  of  intestine  (Thom- 
son). 

In  many  cases  a  careful  examination  will  detect  tuberculous  disease  of  other 
regions  of  the  body,  particularly  of  the  lungs.  If  tuberculous  disease  of  the 
lungs  or  pleura  is  detected,  if  tuberculous  glands  exist  or  have  been  present, 
if  a  nodule  not  due  to  gonorrheal  inflammation  is  palpable  in  the  epididymis, 
or  if  there  are  indurations  in  the  prostate,  the  probability  of  the  presence  of 
tuberculous  peritonitis  is  much  enhanced.  In  many  cases  there  is  dilatation 
of  the  superficial  abdominal  veins.  In  some  cases  tuberculous  peritonitis 
undergoes  spontaneous  cure.  In  the  majority  of  instances  death  ensues  from 
the  tuberculous  peritonitis  directly  or  from  associated  or  secondary  disease  in 
other  organs. 

If  an  intraperitoneal  tuberculous  area  caseates,  a  large  cold  abscess  may 
form,  and  such  an  abscess  may  break  into  the  intestine  or  may  be  opened  ex- 
ternally, and  may  be  responsible  for  the  formation  of  a  fecal  fistula. 

In  a  case  of  tuberculous  peritonitis  intestinal  obstruction  may  occur,  the 
gut  getting  caught  by  bands  or  adhesions,  or  becoming  a  rigid  tube  because  of 
the  formation  of  tubercles. 

Symptoms  of  the  Acute  Form. — This  is  sometimes  mistaken  for  appen- 
dicitis. It  comes  on  rather  suddenly,  but  a  carefully  elicited  history  will 
usually  show  the  previous  existence  of  malaise,  gastro-intestinal  disturbance, 
loss  of  flesh,  and  anemia.  The  symptoms  are  not  so  strictly  localized  to  the 
right  iliac  fossa  as  in  appendicitis.     There  are  abdominal  distention,  a  cer- 


Tuberculous  Peritonitis  loii 

tain  amount  of  rigidity,  nausea  and  vomiting,  colicky  pain  which  may  be 
very  severe,  general  abdominal  tenderness,  fever,  and  exhaustion.  It  may 
be  possible  to  palpate  masses  like  tumors,  or  to  feel  nodules  in  the  prostate 
or  epididymis,  or  to  detect  tuberculosis  in  some  other  part. 

Treatment. — In  some  cases  there  is  a  tendency  to  spontaneous  cure,  and  in 
them  medical  treatment  is  of  great  service.  The  patient  should  be  placed 
under  antituberculous  conditions  (page  245),  nutritious  food  and  tonics  should 
be  administered,  the  abdomen  should  be  counterirritated  and  massaged,  and 
purgatives  should  be  given  frequently.  Guaiacol  applied  daily  to  the  abdomen 
is  thought  by  some  to  be  of  service,  but  I  doubt  it.  A  mixture  is  made  of  i  part 
of  guaiacol  and  5  parts  of  olive  oil;  one  dram  of  this  mixture  is  rubbed  into  the 
abdomen,  and  the  part  is  covered  with  a  piece  of  flannel  held  in  place  by  means 
of  a  binder.  If  medical  treatment  is  not  soon  productive  of  benefit,  the  advisa- 
bility of  operating  must  be  considered.  It  is  a  curious  fact,  but  one  confirmed 
by  ample  evidence,  that  after  simple  abdominal  section,  without  the  intro- 
duction of  germicides  and  without  drainage,  at  least  30  per  cent,  of  the  cases 
recover  from  the  disease  in  from  six  months  to  one  year.  Some  surgeons 
doubt  the  curative  effect  of  operation.  For  instance,  the  late  Professor 
Fenger  was  strongly  of  the  opinion  that  many  patients  recover  after  operation, 
but  not  as  a  result  of  operation.  In  his  opinion  they  recover  because  they 
were  strong,  free  from  fever,  and  well  nourished,  and  because  the  disease 
tended  to  spontaneous  cure.  He  further  believed  that  some  died  from  opera- 
tion because  the  traumatism  lessens  the  already  lowered  tissue  resistance. 
The  majority  of  surgeons,  however,  believe  that  operation  in  many  cases  tends 
to  cure,  Ochsner,  in  a  paper  before  the  American  Surgical  Association  in  1902, 
proved  that  simple  incision  and  evacuation  of  fluid  tends  to  cure.  It  is 
uncertain  how  an  operation  tends  to  cure.  It  has  been  thought  that  the 
ascitic  fluid  is  a  culture-medium  for  bacilli,  and  when  it  is  withdrawn  the 
bacilli  die,  but  opposed  to  this  view  is  the  fact  that  aspiration  is  rarely  curative. 
It  has  been  suggested  that  the  operation  brings  numerous  phagocytes  to  the 
peritoneum;  that  it  stimulates  vital  resistance;  that  it  leads  to  the  exudation 
of  antitoxic  serum.  The  entrance  of  air  seems  to  play  a  definite  and  important 
part  in  effecting  a  cure. 

The  ascitic  cases  are  most  frequently  benefited  by  operation.  In  en- 
cysted fluid  operation  often  cures. 

In  cases  in  which  there  are  numerous  adhesions  operation  is  not  so  likely  to 
produce  a  cure.  Great  care  should  be  exercised  in  separating  adhesions, 
because  the  bowel  is  apt  to  be  torn  and  a  fecal  fistula  may  result.  It  may  be 
necessary  to  separate  adhesions  or  short-circuit  a  portion  of  gut  to  relieve 
obstruction.  Drainage  should  not  be  used  unless  a  cold  abscess  exists.  Not 
only  is  drainage  of  no  service,  but  it  is  dangerous;  death  is  more  apt  to  ensue 
in  a  drained  case  and  a  fecal  fistula  will  arise  in  nearly  one- fourth  of  the  cases. 
If  operation  is  performed  for  cold  abscess,  tube-drainage  must  be  used  for  some 
days.  In  a  woman  with  tuberculous  peritonitis  the  abdomen  should  be 
opened  in  the  mid-line,  and  if  the  Fallopian  tubes  are  tuberculous,  they  should 
be  removed.  In  a  man  the  incision  should  be  made  over  the  appendix,  and  if 
this  is  tuberculous,  it  should  be  removed.  In  either  sex  it  may  be  necessary  to 
resect  tuberculous  intestine  or  perform  anastomosis  because  of  stricture. 
(In  confirmation  of  these  views  see    W.   J.   Mayo,  in    "Jour.   Am.   Med. 


IOI2  Diseases  and  Injuries  of  the  Abdomen 

Assoc,"  April  15,  1905.)  The  Mayos  have  performed  26  radical  tubal  opera- 
tions on  cases  of  tuberculous  peritonitis  and  25  recovered.  Of  these,  7  had 
previously  been  operated  on  from  one  to  four  times  by  simple  laparotomy 
("Jour.  Am.  Med.  Assoc,"  April  15,  1905).  In  a  very  advanced  case,  in  a 
case  v^rith  notably  high  temperature,  or  in  a  case  with  marked  and  advanc- 
ing tuberculosis  in  another  region,  an  operation  should  not  be  performed  ex- 
cept to  relieve  obstruction  or  drain  an  abscess.  If  a  patient  does  not  die 
within  a  few  months  after  the  operation,  he  will  probably  recover,  and  in 
most  cases  operation  secures  at  least  temporary  improvement  (Bottomly). 
The  mortality  from  operation  is  i  or  2  per  cent.  (Fenger). 

Pneumococcus  Peritonitis. — This  condition  is  an  unusual  one.  It  is 
most  apt  to  arise  during  the  progress  or  after  the  termination  of  pneumonia, 
but  is  sometimes  primary — is  far  commoner  in  females  than  in  males  and  in 
children  than  in  adults.  Out  of  74  reported  cases,  57  were  children  under 
five  years  of  age  (Dr.  Max  von  Brunn,  in  "Beitrage  zur  klinischen 
Chirurgie,"  Bd.  xxxix.  Heft  i).  The  condition  may  appear  in  a  sufferer 
from  otitis  media.  The  symptoms  in  children  are  sudden  in  onset.  The  first 
symptoms  are  general  abdominal  pain,  usually  a  continuous  pain  with  colicky 
exacerbations,  tenderness,  rigidity,  vomiting,  elevated  temperature,  disten- 
tion, and  diarrhea.  In  a  few  days  the  symptoms  abate  and  some  of  them 
disappear,  although  pain,  tenderness,  and  rigidity  are  apt  to  localize  at  some 
point,  particularly  about  the  umbilicus,  and  perhaps  remain  for  a  number  of 
weeks.  In  such  a  chronic  case  physical  signs  of  a  fluid  collection  are  usually 
demonstrable.  In  the  chronic  stage,  as  Brunn  points  out,  there  is  seldom  severe 
tenderness  and  there  may  be  no  fever  at  all,  and  a  septic  temperature  is  very 
rarely  observed.  Pus  may  form,  and  if  it  does,  it  contains  pneumococci. 
Adhesions  practically  always  form.  These  adhesions  glue  the  intestines  to- 
gether and  often  encompass  pus.  Rapid  emaciation  and  progressive  weak- 
ness are  always  noted.  In  adults  the  symptoms  are  irregular  and  less  char- 
acteristic than  in  children  (Brunn).     The  prognosis  is  excellent. 

Treatment. — Is  incision  and  drainage. 

Subphrenic  Abscess. — A  subphrenic  abscess  is  a  collection  of  pus  beneath 
the  diaphragm.  The  pus,  as  a  rule,  occupies  a  part  of  the  lesser  peritoneal 
cavity;  in  rare  instances  it  is  extraperitoneal  (when  it  is  of  renal  origin); 
in  some  cases  it  is  contained  in  the  area  between  the  diaphragm,  cardiac  end 
of  the  stomach,  and  liver  or  spleen.  It  is  an  unusual  thing  for  such  an  abscess 
to  break  into  the  general  cavity  of  the  peritoneum,  but  it  may  break  into  the 
pleural  sac  (Maydl). 

Causes. — Perforation  of  a  gastric  ulcer,  perforation  of  the  gall-bladder  or 
gall-ducts,  ulceration  of  the  duodenum,  disease  of  the  liver,  spleen,  pancreas, 
intestine,  appendix,  or  kidney,  hydatid  disease,  internal  injury,  metastasis, 
external  injury,  caries  of  rib,  or  disease  of  the  pleura  may  be  responsible  for  a 
subphrenic  abscess  (Maydl).  Charles  A.  Elsberg*  has  collected  73  cases  of 
subphrenic  abscess  after  appendicitis.  He  points  out  that  the  condition  may 
arise  from,  direct  extension  or  by  way  of  the  lymph-channels,  and  may  be 
either  intraperitoneal  or  extraperitoneal,  although  in  the  majority  of  cases  it  is 
intraperitoneal.  In  all  but  seven  of  these  cases  there  was  suppuration  about 
the  appendix.  The  pus  was  thick  and  foul  in  all  the  cases.  In  15  per  cent,  of 
*  Annals  of  Surgery,  Dec,  1901. 


Treatment  of  Subphrenic  Abscess  1013 

them  gas  was  also  present,  and  in  25  per  cent,  of  these  cases  the  diaphragm 
was  perforated.  In  one  case  on  which  I  operated  the  abscess  developed 
after  cholecystitis. 

Symptoms. — A  patient  with  subphrenic  abscess  usually  complains  of  pain 
in  the  lower  part  of  the  chest  on  the  right  side.  The  area  of  liver-dulness  is 
distinctly  enlarged,  and  there  is  tenderness  in  the  lower  part  of  the  right  chest 
when  pressure  is  made  through  one  or  through  several  intercostal  spaces. 
Frequently  friction-sounds  may  be  heard  about  the  region  of  the  dome  of  the 
liver.  Sometimes  the  symptoms  are  obscure  or  indefinite,  and  not  accom- 
panied with  particular  pain.  If  the  abscess  happens  to  contain  a  considerable 
amount  of  gas, — and  about  one-half  of  such  abscesses  do  contain  gas, — not 
only  will  there  be  no  increase  in  the  area  of  liver-duhiess,  but  the  normal 
area  of  dulness  may  be  diminished  or  obhteratcd.  The  presence  of  gas  is 
due  to  some  connection  with  an  organ  which  contains  gas.  It  is  very  common 
for  a  pleural  effusion  to  be  associated  with  a  subphrenic  abscess.  A  pleural 
effusion  will  be  preceded  by  or  accompanied  with  s}'mptoms  pointing  to 
the  lung  or  pleura;  and  it  is  to  be  remembered  that  the  area  of  percussion- 
dulness  found  in  the  pleural  efltusion  shifts  its  position  whenever  the  posi- 
tion of  the  patient  is  changed,  which  is  not  true  of  the  area  of  dulness  foimd 
in  subphrenic  abscess.  \\Tien  the  abscess  breaks  through  the  diaphragm,  the 
patient  develops  collapse,  cough,  and  other  thoracic  symptoms;  and  if  the 
abscess  breaks  into  a  bronchus,  the  patient  will  expectorate  pus.  In  sub- 
phrenic abscess  the  diaphragm  of  the  diseased  side  is  paralyzed — a  con- 
dition rarely  met  with  in  liver-abscess.  There  are  general  s}-mptoms  of 
suppuration  and  a  swelUng  in  the  subdiaphragmatic  region  following  some 
recognized  causative  condition.  The  history  of  chills  with  recurrent  fever  and 
sweats  is  rather  indicative  of  abscess  of  the  Uver;  but  in  abscess  of  the  hver  there 
is  usually  pain  in  the  shoulder-blade  of  the  right  side,  and  this  is  rarely  en- 
countered in  subphrenic  abscess.  The  proof  of  the  diagnosis  is  not,  however, 
obtained  until  an  exploratory  incision  has  been  made  and  the  purulent  matter 
has  been  examined.  In  many  cases  the  abscess-cavity  will  be  found  to  contain 
gas  as  well  as  iluid.  Empyema  and  subphrenic  abscess  resemble  each  other. 
In  empyema  the  upper  limit  of  the  fluid  is  concave;  in  subphrenic  abscess  it  is 
convex.  In  empyema  the  flow  of  pus  through  an  aspirating-needle  will  be  most 
marked  during  expiration;  in  abscess,  during  inspiration.  The  same  is  true  of 
the  rush  of  gas.  In  empyema  the  needle  does  not  oscillate;  in  abscess  it  does.* 
If  an  abscess  contains  gas,  percussion  elicits  a  tympanitic  note  over  a  part  of 
the  cavity  and  there  is  an  alteration  in  the  area  of  tympany  with  an  alteration 
in  the  position  of  the  patient.  An  abscess  of  the  liver  almost  never  contains  gas 
and  decidedly  changes  the  outlines  of  the  organ. -f 

Treatment. — Incision  and  drainage.  The  incision  in  some  cases  may  be 
made  in  the  limibar  region,  in  some  cases  through  the  abdominal  wall  (epi- 
gastric region,  iUac  region,  h}'pochondrium).  In  other  cases  the  chest- wall 
is  incised,  the  ninth  or  tenth  rib  is  resected,  and  the  abscess  is  opened  below  the 
pleura  or  the  pleura  is  opened  and  the  diaphragm  is  incised.  If  appendicitis 
is  the  cause,  be  sure  the  appendicitis  is  weU;  and  if  not,  open  and  drain  freely 

♦"WTiarton  and  Curtis,  "Practice  of  Surgen-." 

t  In  a  case  of  abscess  of  the  liver  secondary  to  appendicitis  operated  upon  in  the 
Jefferson  Hospital  the  abscess  did  contain  gas  produced  by  gas-forming  bacteria. 


IOI4  Diseases  and  Injuries  of  the  Abdomen 

(Elsberg).  If  it  is  necessary  to  open  the  pleural  sac,  first  try  to  stitch  the 
parietal  to  the  diaphragmatic  layer  of  the  pleura,  or,  if  this  is  impossible,  protect 
the  cavity  with  iodoform  gauze  to  prevent  infection. 

The  Liver,  Gall-bladder,  and  Bile-ducts. 

Rupture  and  Wounds  of  the  Liver. — Rupture  of  the  liver  is  due  to 
very  great  force,  and  is  usually  accompanied  by  injury  of  other  viscera.     It 
may  be  produced  by  a  blow,  by  a  fall,  or  by  the  end  of  a  broken  rib.     The 
superior  surface  or  margin  most  often  suffers.  •  It  is  a  very  fatal  accident.     Out 
of  543  reported  cases,  over  one-half  died  of  hemorrhage  within  twenty-four 
hours  of  the  accident.*     At  least  80  per  cent,  will  die  if  not  operated  upon. 
Wilms  t  collected  19  cases,  and  only  3  recovered  after  operation.     Eisen- 
drath  J  has  collected  37  cases  of  suture  of  the  Hver  for  rupture  and  22  of  them 
recovered  (59.5  per  cent.).     The  first  operation  was  performed  by  Willette 
in  i888.     An  attempt  should  be  made  to  save  the  patient  by  opening  the 
abdomen  and  arresting  hemorrhage,  and  in  a  suspected  case  an  explora- 
tory operation  should  be  performed.     A  wound  of  the  liver  causes  violent 
hemorrhage  which  is  usually  rapidly  fatal.     Such  a  wound  is  apt  to  divide 
bile-ducts  and  allow  bile  to  escape  into  the  peritoneal  cavity.     Bile,  if  sterile, 
will  do  httle  harm,  but  if  it  contains  bacteria,  it  will  produce  diffuse  peri- 
tonitis.    Even  sterile  bile  is  corrosive  and  may  cause  fibrous  peritonitis. 
The  symptoms  of  a  rupture  or  wound  of  the  hver  are  those  of  severe  intra- 
abdominal hemorrhage,  with  collapse,  hepatic   tenderness,  and  respiratory 
embarrassment.     Soon  after  the  injury  the  abdomen  is  soft  and  fiat,  but  it 
quickly  becomes  rigid  and  ultimately  distended.     The  diagnosis  becomes 
more  probable  when  it  is  known  that  violence  was  applied  in  the  hepatic 
region.     Usually  there  is  abdominal  pain  and  often  pain  in  the  back.     Sugar 
may  appear  in  the  urine.     In  a  few  cases  after  several  days  jaundice  and  skin 
itching  have  been  noted.     The  area  of  liver-dulness  is  usually  increased. 
Patients  do  not  always  die  from  a  serious  traumatism  of  the  liver.     Some 
recover  because  operation  has  been  performed.     Some  few  recover   with- 
out operation.     This  last  fact  is  proved  by  reports  of  autopsies  in  which  scars 
were  found  in  the  liver-parenchyma  (Nussbaum).     The  fatality  which  usually 
ensues  on  a  liver  injury-  may  be  due  to  hemorrhage  or  peritonitis.     If  a  surgeon 
is  called  to  a  patient  suft"ering  from  wound  of  the  liver,  he  must  open  the  abdo- 
men to  arrest  hemorrhage.     If  a  penetrating  wound  is  suspected,  it  may  be 
desirable  to  enlarge  the  wound  in  the  abdominal  wall  layer  by  layer,  in  order 
to  determine  that  the  liver  is  wounded.     If  the  left  lobe  of  the  liver  is  wounded, 
or  if  it  is  uncertain  which  lobe  is  wounded,  the  incision  should  be  median. 
If  the  right  lobe  is  wounded,  a  curved  incision  is  made  along  the  hne  of  the 
costal   cartilages.     In   some   cases   these   two   incisions   are   joined. §     The 
convex  surface  of  the  liver  can  be  reached  by  Lannelongue's  plan.     Lan- 
nelongue   resects   the   eighth,   ninth,   tenth,   and  eleventh  costal  cartilages 
and  draws  the  ends  of  the  ribs  well  out.     It  can  also  be  reached  by  Lan- 
genbuch's  plan,  that  is,  by  cutting  the  coronary  ligament  and  the  right  lateral 
ligament.     This  allows  the  liver  to  be  pulled  weU  up  into  the  wound  in  the  belly 

*Mercade,  in  Rev.  de  Chir.,  Jan.  10,  1902. 

tDeut.  med.  Woch.,  Nos.  34  and  35,  1901. 

jjour.  Am.  Med.  Assoc,  Nov.  i,  1902. 

I  See  Schlatter,  Beitrage  zur  klinischen  Chirurgie,  Bd.  xv,  Heft  11,  1896. 


Tumors  and  Cysts  of  the  Liver  1015 

wall.  The  site  of  the  wound  can  be  discovered  if  the  hepatic  vessels  are 
grasped  between  the  thumb  and  a  finger  (the  finger  in  the  foramen  of  Winslow 
and  the  thumb  in  front  on  the  gastrohepatic  omentum).  This  completely 
arrests  hemorrhage,  and  the  blood  that  has  gathered  may  be  sponged  out  and 
the  wound  sought  for  in  a  clear  field  (see  Pringle,  of  Glascow,  in  "Annals  of 
Surgery,"  Oct.,  1908).  When  the  wound  in  the  Hver  is  discovered  and  well 
exposed,  deep  sutures  of  catgut  should  be  inserted  in  the  liver  and  the  cap- 
sule should  be  stitched  with  fine  silk  (Schlatter).  If  sutures  fail  to  arrest  hem- 
orrhage, the  Hver  should  be  sutured  to  the  belly-wall  and  the  wound  in  the 
liver  packed  with  iodoform  gauze.  It  is  useless  to  try  packing  without  first 
attaching  the  liver  to  the  abdominal  wall,  because  pressure  will  simply  push 
the  liver  away  and  will  not  arrest  the  bleeding.  The  cautery  is  a  very  useful 
means  of  arresting  bleeding.  It  should  be  avoided  if  possible  in  a  large  wound, 
because,  even  if  it  arrests  primary  hemorrhage,  secondary  hemorrhage  may 
occur.  After  arresting  hemorrhage,  wash  out  the  abdomen  with  hot  sahne 
fluid,  insert  drainage,  and  close  the  abdominal  wound.  In  a  case  of  the 
author's  in  the  Philadelphia  Hospital  the  Hver  was  wounded  by  the  sharp  ends 
of  fractured  ribs.  The  abdomen  was  opened,  a  wound  was  found,  and  bleed- 
ing was  arrested  by  suturing  the  liver  to  the  belly-wall  and  packing  the  wound. 
The  patient  died,  and  necropsy  showed  another  wound  on  the  posterior  portion 
of  the  organ.    The  possibility  of  such  an  occurrence  should  not  be  lost  sight  of. 

Tumors  and  Cysts  of  the  Liver.— The  liver  may  be  the  seat  of 
primary  carcinoma,  sarcoma,  or  endothelioma,  of  angioma,  lymphangioma, 
adenoma,  fibroma,  myxoma,  or  Hpoma.  Many  tumors  called  adenomata 
are  really  adenocarcinoma ta.  Secondary  malignant  growths  are  far  more 
common  than  primary  neoplasms — in  fact,  96  per  cent,  of  liver  tumors  are  sec- 
ondary. Primary  cancer  of  the  liver  is  found  once  in  every  2000  autopsies 
(Eggel).  The  commonest  variety  is  the  nodular,  but  the  diffuse  form,  known 
as  cancerous  cirrhosis,  may  occur.  The  nodular  form  is  most  often  encoun- 
tered in  the  right  lobe,  and  it  has  been  found  in  persons  under  the  age  of  twenty, 
^letastases  occur  early.  "There  is  always  more  or  less  coexisting  cirrhosis  of 
the  Hver"  (Leonard  Freeman,  in  "Trans,  of  Am.  Surg.  Assoc,"  1904). 
It  takes  origin  from  the  hepatic  cells.  The  frequency  of  cancer  of  the  Hver 
secondary  to  cancer  of  the  stomach  has  already  been  alluded  to.  The  com- 
monest primary  tumor  of  the  Hver  is  cavernous  hemangioma.  It  is  especially 
apt  to  take  origin  in  the  atrophying  liver  of  an  elderly  individual.  Primary 
sarcoma  may  arise  at  any  age  and  may  even  be  congenital.  The  growth  is 
rapid  and  emaciation  is  soon  noted.  The  liver  enlarges,  often  greatly.  Jaun- 
dice and  ascites  are  rather  rare.  The  patient  soon  becomes  very  weak.  There 
is  always  pain.  As  Knott  points  out  ("Surgery,  Gynecology,  and  Obstetrics," 
Sept.,  1908)  the  condition  may  simulate  abscess,  and  if  it  arises  in  a  middle- 
aged  or  elderly  person  can  scarcely  be  differentiated  from  carcinoma. 

Knott  (Ibid.)  has  collected  59  cases  of  primary  sarcoma  from  Hterature, 
and  adds  14  reported  by  personal  communications,  and  i  of  his  own,  74  in  all. 

He  shows  that  28  cases  have  been  operated  upon.  In  9  the  operation  was 
exploratory  and  no  attempt  was  made  to  remove  the  growth.  In  19  the 
growth  was  extirpated,  with  10  recoveries  and  9  deaths.  One  of  these  patients 
was  well  after  nineteen  months,  i  after  two  years,  i  after  seven  months. 
Operation  is  indicated  for  a  circumscribed  growth. 


ioi6  Diseases  and  Injuries  of  the  Abdomen 

Among  the  cysts  occurring  in  the  liver  are  blood  cysts,  congenital  cysts, 
bile  cysts,  and  hydatid  cysts.  Terrier  and  Auvray  in  1901  collected  52  opera- 
tions for  hepatic  tumors. 

Angiomata  have  been  removed  successfully  by  hepatectomy,  a  cautery- 
knife  at  a  red  heat  being  used  to  cut  through  the  normal  liver  tissue  around  the 
base  of  the  tumor,  the  large  vessels  being  tied  with  catgut.  Enucleation 
is  not  feasible  because  of  excessive  hemorrhage.  If  a  tumor  is  pedunculated, 
the  base  may  be  encircled  by  an  elastic  Hgature  held  in  place  by  a  steel  needle, 
and  five  or  six  days  later  the  tumor  may  be  cut  across  vdth  the  cauter}-.*  I 
assisted  Prof.  Keen  in  such  an  operation. 

Carcinoma  of  the  Uver  has  been  extirpated,  but  it  is  seldom  that  a  growth 
is  recognized  early  enough  and  is  found  to  be  sufficiently  Hmited  to  justify 
such  a  procedure.  Operation  is  proper  only  when  there  is  a  limited  nodule  of 
primary  cancer.  In  1901  Terrier  and  Auvray  collected  9  operadons  for  pri- 
mary cancer.  In  most  cases  there  has  been  rapid  recurrence  or  secondary 
growth,  but  Schrader's  case  was  well  at  the  end  of  seven  years  and  Leonard 
Freeman's  at  the  end  of  sixteen  months.  (For  operative  methods,  see  Leonard 
Freeman,  in  "Trans.  Am.  Surg.  Assoc,"  1904.)  Hunbald  has  collected 
96  cases  of  resection  of  the  Uver  with  a  mortality  rate  of  26  per  cent.  Probably 
the  best  method  of  arresdng  hemorrhage  is  the  use  of  suture  Hgatures  of  doubled 
catgut  passed  by  blunt  needles,  as  advised  by  Mikulicz. 

Hydatid  cysts  of  the  liver  may  be  of  small  size  and  productive  of 
no  signs  or  symptoms;  or  may  be  of  large  size  and  productive  of  the  signs  of 
tumor.  In  the  epigastrium  the  mass  may  be  prominent  and  may  fluctuate. 
In  cyst  of  the  right  lobe  the  dulness  is  found  in  the  axillary  line  and  the  growth 
encroaches  on  the  pleura.  In  a  large  cyst  fluctuation  and  hydatid  fremitus 
may  exist.  Hydatid  fremitus  is  a  vibration  imparted  to  the  palpating  fingers 
of  one  hand  when  the  fingers  of  the  other  hand  knock  upon  the  cyst.  There 
may  be  no  discomfort  produced  by  even  a  large  cyst,  but,  as  a  rule,  the  patient 
suffers  from  a  dragging  sensation  in  the  epigastrium  and  pressure-symptoms. 
Suppuration  in  the  cyst  produces  the  symptoms  of  abscess  of  the  liver  and 
septicemia.  Rupture  of  the  cyst  produces  shock  and  even  death.  Rupture 
may  take  place  into  the  pleural  sac,  the  lung,  or  the  peritoneal  cavity.  If  the 
shock  is  recovered  from,  inflammation  arises,  the  area  of  which  depends  upon 
the  structures  damaged.  The  escape  of  even  a  small  quantity  of  hydatid  fluid 
into  the  peritoneal  cavity  produces  urticaria  {hydatid  toxemia).  Aspiration 
for  diagnostic  purposes  is  not  advisable. 

Treatment. — Exploratory  incision  may  be  necessary  to  confirm  the  diag- 
nosis, and  the  operation  is  completed  at  this  time.  After  exposing  the  cyst 
it  is  packed  around  with  gauze  and  a  trocar  is  introduced.  If  there  is  a  con- 
siderable thickness  of  liver  tissue  over  the  cyst,  incise  the  liver  with  the  cautery 
knife.  When  the  fluid  is  evacuated,  the  sac  is  incised  and  is  drawn  partly 
through  the  wound  in  the  abdominal  wall,  and  is  attached  to  the  wound-mar- 
gins {marsupialization) .  The  endocyst  can  then  be  removed  by  the  hand  or 
by  irrigation.     A  large  drainage-tube  is  introduced. 

Syphilis  of  the  Liver. — This  is  a  tertiary  lesion.  It  may  appear  as 
irregular  patches  of  inflammation  in  Ghsson's  capsule  (a  condition  apt  to 
eventuate  in  hepatic  sclerosis) — as  a  large  solitary  gumma  (only  one-eighth 

*  Russell  S.  Fowler  on  "  Tumors  of  the  Liver,"  Brooklyn  Medical  Journal,  Dec,  1900. 


Pyemic  Abscess  1017 

of  cases  of  gumma  ])rcsent  a  solitary  lesion) — or  as  multiple,  and  usually  small 
gummata.  Gummata  are  most  usual  upon  the  anteri(jr  surface  of  the  right 
lobe.  The  large  gumma  is  often  mistaken  for  cancer  of  the  liver  and  it  is  a 
curious  fact  that  in  hepatic  gummata  we  are  often  unable  to  obtain  any  history 
of  syphilis.  Syphilis  may  be  mistaken  for  ordinary  cirrhosis,  but  in  the  latter 
disease  the  general  nutrition  is  more  impaired  than  in  the  former,  and  vomiting 
of  blood,  dilated  cutaneous  veins,  ascites  and  indigestion  are  far  more  apt  to  be 
present  (Archibald  MacLaren,  in  "Annals  of  Surgery,"  August,  1908).  These 
patients  are  apt  sooner  or  later  to  develop  jaundice,  colicky  pain,  moderate 
fever,  and  palpable  enlargement  of  the  liver. 

Treatment. — Mercury  and  iodid  will  cure  most  cases.  If  these  drugs  fail, 
it  is  proper  to  remove  the  tumor,  if  solitary,  by  resecting  the  involved  area  of  the 
liver.  MacLaren  (Ibid.)  collected  9  cases  of  resection  for  solitary  gumma 
and  added  i  of  his  own.     There  were  2  deaths  in  this  series. 

If  an  area  is  opened  for  exploration  and  a  solitary  gumma  is  discovered, 
the  abdomen  should  be  closed  and  specific  treatment  be  tried  before  resorting 
to  resection,  that  is,  if  specific  treatment  has  not  been  tried  before. 

Abscess  of  the  Liver. — An  abscess  of  the  liver  may  be  produced  by 
bacteria,  especially  staphylococci  and  streptococci.  These  organisms  reach 
the  liver  by  the  general  circulation,  or,  what  is  more  frequent,  are  taken  up 
from  the  intestinal  tract  and  reach  the  liver  by  the  portal  circulation,  or  pass 
to  the  liver  by  the  lymphatics.  Appendicitis  with  lymphatic  infection  may 
result  in  hepatic  abscess.  A  subphrenic  abscess  may  break  into  the  liver  and 
thus  induce  a  liver  abscess.  Liver  abscess  may  directly  result  from  peritoneal 
infection.  The  fact  that  abscess  of  the  liver  is  in  hot  countries  frequently 
preceded  by  amebic  dysentery  led  to  the  presumption  that  amoeba  coli  produces 
the  abscess,  and  in  a  large  majority  of  cases  of  tropical  abscess  amebae  exist 
in  the  pus  or  at  least  on  the  abscess  walls.  Habitual  intemperance  and  con- 
stant overeating  predispose  to  abscess  of  the  liver.  The  disease  may  follow 
traumatism,  dysentery,  diarrhea,  cholangitis,  suppuration  of  a  hydatid  cyst, 
gall-stones,  typhoid  fever,  appendicitis,  and  a  chill  to  the  surface  of  the  body.* 
Abscess  of  the  liver  may  be  metastatic,  and  such  abscesses  are  multiple. 
It  may  be  caused  by  foreign  bodies  and  parasites.  A  tropical  abscess  is  an 
abscess  of  the  liver  in  an  inhabitant  of  a  hot  country. 

There  are  three  forms  of  abscess  of  the  liver:  traumatic,  pyemic,  and 
tropical. 

Traumatic  abscess  may  result  from  a  wound  of  the  liver  or  may  follow 
a  contusion  without  a  break  of  the  skin.  In  the  latter  case  bacteria  from  the 
blood  are  arrested  in  the  injured  Uver  tissue.  Such  an  abscess  is  usually 
solitary.     Streptococci,  staphylococci,  or  colon  bacilli  may  be  found. 

Pyemic  Abscess. — Multiple  abscesses  exist,  but  they  may  fuse  into  one. 
It  is  frequently  due  to  suppurative  inflammation  of  radicles  of  the  portal  vein, 
infected  emboli  forming  and  reaching  the  liver;  it  may  follow  ulceration  of  the 
intestine,  hemorrhoids,  or  appendicitis. 

Occasionally  abscess  may  arise  from  the  extension  of  an  infective  pro- 
cess, such  as  pylephlebitis,  or  in  cholelithiasis  with  obstruction.  In  these 
latter  cases  both  the  bacillus  typhosis  and  the  pneumobacillus  of  Friedlander 
have  been  found  as  the  direct  bacterial  agent.  Colon  bacilli  are  a  common 
*  G.  B.  Johnston,  Annals  of  Surgery,  October,  1897. 


ioi8  Diseases  and  Injuries  of  the  Abdomen 

cause.  Abscess  of  the  liver  following  appendicitis  may  be  due  to  portal  in- 
fection {portal  pyemia)  or  to  lymphatic  infection.  It  is  usually  multiple, 
but  in  a  case  of  mine  in  the  Jefferson  Hospital  it  was  solitary,  several  cavities 
having  probably  joined  to  form  one.  Echinococcus  cyst  of  the  liver  may 
suppurate  and  form  abscess.  I  operated  unsuccessfully  on  one  such  case 
which  was  brought  to  me  by  Dr.  Hultsizer.  The  round-worm,  the  liver  fluke, 
and  the  balantidium  coli  sometimes  cause  abscess,  and,  finally,  it  has  been  ob- 
served in  measles,  epidemic  influenza,  and  perforating  ulcer  of  the  stomach.* 

Tropical  Abscess  of  the  Liver. — Tropical  abscess  of  the  liver  is  rare 
in  temperate  climates,  but  is  extremely  common  in  the  tropics.  Its  usual 
antecedent  in  either  climate  is  dysentery.  The  reason  for  the  great  frequency 
of  the  disease  in  tropical  regions  is  that  the  chief  causative  agent,  the  amoeba 
coli,  is  found  widely  distributed  in  hot  countries;  and  that  passive  congestion 
of  the  liver  is  a  common  condition  among  the  white  inhabitants  of  tropical 
regions.  It  has  been  pointed  out  that  tropical  abscess  is  particularly  common 
among  white  persons  that  abuse  alcohol,  the  condition  of  passive  congestion 
of  the  liver  making  that  organ  a  nutritious  soil  for  a  fruitful  infection.  Pre- 
disposing factors  are  protracted  malaria  and  chilUng  of  the  surface  of  the 
body. 

Major  Charles  F.  Kieffer,  U.  S.  A.,f  in  a  lecture  on  tropical  abscess 
of  the  liver,  states  that  in  his  own  experience  he  found,  in  a  series  of  2,3  ab- 
scess cases  in  soldiers,  that  dysentery  was  present  in  every  case;  and  that 
in  a  second  series  of  25  cases  in  natives  and  civilians  he  elicited  a  history 
of  dysentery  in  22  cases.  Some  observers — notably  McLeod — state  that 
dysentery  is  the  antecedent  factor  in  97.5  per  cent,  of  cases.  Kieffer  points 
out  that  in  all  the  figures  allowance  must  be  made  for  a  number  of  latent 
dysenteries,  as  well  as  for  cases  in  which  no  effort  was  made  to  ehcit  a  history 
of  dysentery  one  or  two  years  previously.  It  is  also  to  be  remembered  that 
a  case  of  amebic  infection  of  the  colon  may  have  been  so  mild  in  the  beginning 
as  to  have  caused  but  a  transient  diarrhea,  which  the  patient  may  have  for- 
gotten. Again,  as  Kieffer  observes,  amebae  occasionally  exist  in  the  colon 
without  producing  any  dysenteric  evidences.  His  conclusions  are  that  from 
20  to  25  per  cent,  of  severe  amebic  dysenteries  lead  to  the  formation  of  abscess 
of  the  liver,  and  that  at  least  85  per  cent,  of  all  tropical  abscesses  are  due  to 
infection  with  the  amoeba  coh.  Occasionally,  an  abscess  begins  very  soon 
after  the  dysentery;  but,  as  a  rule,  it  does  not  form  for  some  time  after- 
ward— weeks,  months,  a  year,  or  even  two  years. 

When  an  abscess  of  this  sort  forms  in  the  Hver,  that  organ  becomes  en- 
larged and  congested,  and  an  area  or  areas  of  necrosis  exist  in  it.  But  one 
abscess  may  be  present;  there  may  be  an  abscess  with  satellite  abscesses  about 
it;  several  abscesses  may  coalesce,  making  a  very  large  cavity;  or  genuine 
multiple  abscesses  may  exist.  In  about  70  per  cent,  of  cases,  however,  the 
tropical  abscess  is  solitary  (Kieffer). 

The  right  lobe  of  the  Hver  is  the  region  most  frequently  involved.  The 
abscess  is  found  in  the  right  lobe  in  from  70  to  80  per  cent,  of  cases;  and 
it  is  more  often  toward  the  convexity  of  the  liver  than  toward  the  base. 

An  abscess  of  the  liver  contains  characteristic    and    peculiar   material; 

*  Major  Chas.  F.  Kieffer,  U.  S.  A.,  in  Phila.  Med.  Jour.,  Feb.  21,  1903. 
t  Phila.  Med.  Jour.,  Feb.  21,  1903. 


Tropical  Abscess  of  the  Liver  1019 

it  is  dififerent  from  the  pus  found  in  other  abscesses,  and,  in  fact,  is  not  pus, 
but  is  necrotic  liver-substance.  Liver  abscesses  due  to  pyogenic  organisms 
contain  true  pus;  a  tropical  abscess,  free  from  pyogenic  infection,  does  not. 
Ordinary  pus  contains  hordes  of  leukocytes;  but  the  pus  of  a  tropical  abscess 
contains  very  few.  Riesman  is  of  the  opinion  that  the  reason  there  are  so 
few  leukocytes  is  that  the  abscess  contains  a  substance  that,  by  chemotaxis, 
repels  leukocytes.  The  pus  is  of  a  reddish-brown  color,  is  thick,  and  fre- 
quently contains  some  blood.  Occasionally  it  is  offensive  in  odor.  Micro- 
scopic examination  shows  it  to  contain  portions  of  necrotic  hver  tissue, 
some  hver-cells  that  are  not  destroyed,  elastic  tissue,  blood,  pus-cells, 
and  amebae  (Kieffer).  On  bacterial  examination  it  may  be  found  that 
the  pus  is  infected,  containing  staphylococci,  streptococci,  or  pyogenic 
bacteria.  In  about  20  per  cent,  of  the  cases  the  pus  contains  neither 
bacteria  nor  the  amoeba  coU.  In  over  60  per  cent,  of  the  cases  the  pus  of 
a  recently  opened  abscess  is  free  from  bacteria.  In  cases  in  which  the  fluid 
is  sterile  it  is  possible  that  bacteria  were  originally  present,  but  have  died.  The 
reason  for  the  death  of  micro-organisms  in  this  pus  is  in  great  doubt;  because, 
as  Riesman  points  out,  bile  cannot  kill  them,  and  organisms  may  be  grown  in 
the  pus.  Kieffer  says  that  in  the  large  majority  of  cases  amebae  are  readily 
demonstrable  in  the  pus;  but  that  in  some  few  cases  it  is  necessary  to  rub  a 
piece  of  gauze  on  an  abscess-wall  in  order  to  obtain  amebae,  and  that  in  others 
they  can  be  demonstrated  only  after  the  abscess  has  been  discharging  for  some 
days.  The  causative  role  of  the  amoeba  has  been  doubted  by  some  observers, 
but  most  surgeons  who  have  had  experience  in  the  tropics  believe  it  to  be  a 
fact. 

Symptoms. — The  symptoms  may  be  very  definite  and  positive;  they  are 
frequently  misleading  and  obscure;  and  in  some  cases  nothing  whatever 
directs  the  surgeon's  attention  to  the  liver  until  the  patient  passes  a  huge 
quantity  of  pus  at  stool  or  coughs  up  an  enormous  amount  of  the  charac- 
teristic material.  If  rupture  takes  place,  death  usually  ensues.  As  a  rule, 
the  s)Tnptoms  of  a  tropical  abscess  are  positive  and  marked. 

Kieffer  sums  up  the  chief  symptoms  under  four  heads:  fever,  sepsis,  en- 
largement 0}  the  liver,  and  pain.  In  about  three-fourths  of  the  patients 
fever  and  sweats  are  definitely  present;  in  about  one-fourth  they  are  absent  or 
are  very  trivial.  The  type  of  fever  met  with  is  what  has  been  previously 
spoken  of  as  hectic.  Usually  there  is  an  evening  rise,  preceded  by  a  chilly 
sensation  or  by  a  chill;  and  as  the  temperature  begins  to  fall,  toward  morning, 
there  is  a  profuse  sweat.  It  is  seldom  that  there  is  any  violent  chill,  though 
there  is  frequently  a  shght  one.  The  sweats  are  extremely  exhausting.  They 
may  occur  either  during  the  night  or  in  the  daytime,  according  to  the  time 
in  which  the  patient  sleeps.  Kieffer  says  that  they  should  not  be  called 
night-sweats,  but  rather  sleeping-sweats.  In  very  chronic  cases  there  may 
be  no  pyrexia.  As  a  rule,  the  temperature  resembles  that  of  malaria,  but 
it  is  not  controlled  by  quinin  and  the  blood  is  free  from  malarial  parasites. 
Sometimes  the  temperature  suggests  typhoid,  with  the  exception  that  from 
time  to  time  there  are  episodes  of  subnormal  temperature.  The  patient 
loses  flesh  and  strength,  the  appetite  fails  completely,  and  the  skin  becomes 
pasty  or  dirty  yellow. 

The  entire  liver  is  usually  enlarged,  and  the  enlargement  may  be  detected 


T020  Diseases  and  Injuries  of  the  Abdomen 

by  percussion,  and  in  some  cases  a  hard,  smooth  area  can  be  palpated.  Some- 
times the  liver  reaches  as  high  as  the  third  rib  anteriorly,  or  to  the  spine 
of  the  scapula  behind,  and  it  may  extend  downward  to  the  anterior-superior 
spine  of  the  ilium.  It  is  rarely,  however,  that  the  enlargement  takes 
place  in  a  downward  direction;  it  is  usually  upward.  In  many  cases  the 
right  side  of  the  chest  appears  to  be  rather  full,  and  sometimes  there  is 
actual  obliteration  of  several  intercostal  spaces.  If  an  abscess  becomes  ad- 
herent to  the  surface,  there  may  be  skin  edema  and  dusky  discoloration. 
In  very  rare  instances,  if  a  very  large  abscess  comes  near  the  surface,  fluctua- 
tion may  be  obtained.  By  auscultation  it  is  frequently  possible  to  obtain 
friction-sounds  in  the  region  of  the  diaphragm  and  the  superior  surface  of 
the  hver. 

The  liver  becomes  tender.  This  tenderness  may  be  developed  par- 
ticularly by  pressure  upon  the  lower  edge  of  the  organ,  and  sometimes  by 
pressure  through  the  intercostal  spaces.  There  is  not  always  pain,  but, 
as  a  rule,  there  is.  The  pain  may  be  dull  and  heavy;  but  as  the  abscess 
nears  the  surface  of  the  organ,  the  pain  becomes  sharp  and  lancinating. 
The  pain  is  persistent  and  is  not  strictly  localized,  but  radiates  to  the  back, 
the  right  shoulder-blade,  and  the  point  of  the  shoulder.  Pain  is  increased  by 
pressure,  coughing,  sudden  or  violent  movement,  and  is  sometimes  felt  in 
the  esophagus  when  food  is  swallowed.  When  the  upper  surface  of  the  liver 
is  involved,  the  patient  breathes  as  if  he  had  pleurisy;  and  pleurisy  frequently 
does  develop,  with  marked  effusion. 

Paralysis  of  the  diaphragm  rarely  occurs  in  abscess  of  the  liver;  and  the 
respiration  is  not  much  affected,  unless  the  diaphragm  of  that  side  and  the 
pleura  become  involved,  though  the  patient  frequently  has  a  dry  cough. 
A  severe  cough  suggests  that  the  abscess  is  on  the  convex  surface  of  the 
organ.  Such  a  cough  is  aggravated  by  recumbency.  Kieffer  points  out  that 
the  patient  hes  on  his  right  side,  and  almost  on  the  right  front  aspect,  the 
shoulder  being  drawn  down  and  the  right  knee  drawn  up,  to  relieve  the 
tension  of  the  abdominal  muscles.  In  about  one-fourth  of  the  cases  of  tropical 
abscess  of  the  liver  jaundice  occurs;  usually,  however,  it  occurs  only  when 
the  abscess  is  on  the  inferior  surface.  Jaundice  does  not  occur  unless  the 
common  or  hepatic  ducts  are  compressed  or  cholangitis  exists.  The  leukocyte- 
count  is  of  no  particular  help  in  the  diagnosis,  as  there  may  or  may  not  be 
leukocytosis.  The  urine  is  usually  scanty.  Diarrhea  is  a  common  accom- 
paniment, but  constipation  may  exist,  and  nausea  and  vomiting  are  by  no 
means  unusual. 

Diagnosis. — With  an  antecedent  history  of  dysentery  the  diagnosis  is 
easy.  Without  such  a  history,  it  is  always  difficult  and  may  be  impossible. 
In  the  tropics  exploratory  aspiration  is  freely  used,  but  exploratory  incision, 
with  subsequent  exploratory  aspiration,  if  necessary,  would  seem  to  be  safer 
and  more  certain. 

Symptoms  of  Traumatic  Abscess. — Are  similar  to  those  of  tropical  abscess. 

Symptoms  of  Pyemic  Abscess. — The  Hver  is  enlarged  and  tender,  there 
is  shght  jaundice,  and  the  general  symptoms  of  pyemia  are  present. 

Treatment  of  Tropical  Abscess. — Make  an  exploratory  incision.  If  the 
abscess  is  adherent  to  the  parietal  peritoneum  and  is  not  covered  by  liver- 
substance,  at  once  proceed  to  operation.     If  it  is  not  adherent,  or  is  covered 


Hepatoptosis  102 1 

by  a  considerable  layer  of  liver  substance,  stitch  the  visceral  peritoneum 
to  the  parietal  peritoneum  and  postpone  further  interference  for  forty-eight 
hours.  The  operation  consists  in  evacuating  the  pus  with  a  trocar  and 
cannula,  incising  the  abscess,  stitching  its  edges  to  the  edges  of  the  abdominal 
wound,  irrigating,  and  inserting  a  drainage-tube.  If  the  abscess  is  covered 
by  a  layer  of  liver  tissue,  after  locating  it  with  an  aspirating  cannula  open  into  it 
with  a  cautery  knife  and  arrest  hemorrhage  by  packing.  When  the  parietal 
and  visceral  layers  of  peritoneum  are  adherent,  packing  will  arrest  bleeding; 
if  they  are  not  adherent,  packing  will  only  push  away  the  movable  liver  (John 
O'Connor).  If  pyothorax  exists,  resect  a  rib,  open  the  pleural  sac,  and  reach 
the  abscess  in  the  liver  by  an  incision  through  the  diaphragmatic  pleura  and  the 
diaphragm  (transthoracic  hepatotomy). 

Rogers  and  Wilson("Brit.Med.  Jour.,"  June  16, 1906)  advocate  aspiration 
and  examination  of  the  pus.  If  amebas  only  are  present,  they  inject  a  solution 
of  quinin,  a  material  quickly  fatal  to  amebae.  The  dose  is  30  grains  of 
bihydrochlorate  of  quinin  in  a  sterile  solution.  If  the  abscess  holds  less  than 
10  ounces  of  pus,  the  quinin  is  given  in  2  ounces  of  fluid;  if  it  holds  more, 
in  4  ounces  of  fluid.     The  authors  report  2  cases  cured  by  this  method. 

Treatment  of  Traumatic  Abscess.— Is  the  same  as  for  tropical  abscess. 

Treatment  of  Pyemic  Abscess.— ^nrgtry  is  usually  futile,  because  multiple 
abscesses  exist,  but  an  operation  should  be  performed  in  the  hope  that  it  may 
do  good.  In  a  case  in  the  Jefferson  Hospital  in  which  abscess  of  the 
liver  followed  appendicitis  the  patient  recovered  after  operation. 

Hepatoptosis  (Floating  or  Movable  Liver).— Hepatoptosis  may  be 

congenital,  but  is  usually  acquired.  In  a  congenital  case  certain  ligamen- 
tous supports  of  the  Hver  are  absent.  In  the  following  discussion  the  acquired 
form  is  the  variety  referred  to.  This  condition  is  rare.  Ninety-eight  cases 
have  been  reported.*  It  is  a  form  of  splanchnoptosis  and  is  due  to  relaxation 
of  the  abdominal  wall  and  stretching  of  the  supports  of  the  liver.  It  may 
occur  alone,  but  it  is  more  often  a  part  of  a  general  abdominal  relaxation  or 
of  Glenard's  disease,  and  often  a  kidney  is  movable,  or  uterine  displacement 
or  hernia  may  exist.  The  Uver  may  descend  into  the  lower  abdomen,  may 
be  upside  down  (Demarquay),  may  rotate  on  its  transverse  axis  (Griffiths), 
the  anterior  surface  may  become  posterior,  or  the  organ  may  he  with  the 
superior  surface  in  the  right  flank  and  the  inferior  surface  looking  to  the  left,t 
may  be  movable,  or  may  be  anchored  by  adhesions.  It  is  most  common  in 
women.  The  liver  is  supported  by  ligaments  and  also  by  the  inferior  vena 
cava,  which  vessel  is  firmly  adherent  to  the  central  tendon  of  the  diaphragm 
(Faure),  by  the  abdominal  wall,  and  by  the  intestines  (Glenard).  The  cause 
of  the  condition  is  in  dispute.  It  can  result  from  relaxation  of  the  belly-wall, 
relaxation  of  the  Hgaments,  enteroptosis,  great  enlargement  of  the  gall-bladder, 
increase  in  weight  of  the  liver,  atrophy  of  the  connective  tissue  between  the 
liver  and  diaphragm,  pregnancy,  the  growth  of  a  liver  tumor,  and  tight  lacing. 
Either  a  strain,  cough,  or  the  dragging  of  an  adherent  tumor  may  be  the 

exciting  cause. 

Signs  and  Symptoms.— An  abdominal  mass  may  appear  suddenly  alter 
a  blow  or  a  strain,  and  if  it  does  appear  suddenly  there  is  always  pain  in 

*  J  H.  Carstens,  Jour.  Am.  Med.  Assoc,  May  17,  1902. 
t  Terrier  and  Auvray,  Rev.  de  Chir.,  Aug.  and  Sept.,  1897 


I02  2  Diseases  and  Injuries  of  the  Abdomen 

the  hepatic  region,  nausea,  and  weakness.  When  the  condition  comes  on 
gradually,  there  may  be  no  symptoms  for  a  long  time,  but,  as  a  rule,  there 
is  some  pain  in  the  loin  which  becomes  worse  after  exercise  or  effort.  In 
rare  cases  jaundice  appears,  and  occasionally  there  is  ascites.  The  abdominal 
walls  are  relaxed  and  the  signs  of  splanchnoptosis  are  manifest.  When 
the  patient  stands,  a  transverse  furrow  of  skin  covers  the  lower  part  of  the 
umbilicus  {GlenanVs  sign).  In  most  cases  the  shape,  the  movability,  and 
the  absence  of  the  liver  from  its  proper  position  are  diagnostic.  Even  when 
the  organ  is  dislocated  and  attached  in  its  new  situation,  it  is  missed  from 
its  proper  abode,  and  palpation  outhnes  the  characteristic  shape.  When  the 
patient  lies  down,  the  liver  usually  returns  to  place,  and  in  most  cases  it  can 
be  restored  by  manipulation.  In  some  cases,  however,  it  will  not  return 
to  place  and  cannot  be  restored  by  manipulation.  A  floating  liver  causes  a  recog- 
nizable enlargement  in  the  right  loin,  and  the  mass  usually  moves  on  respiration. 

Treatment. — In  many  cases  the  patient  can  be  kept  comfortable  by 
wearing  an  abdominal  support,  and  can  be  distinctly  improved  by  the  use 
of  massage  and  electricity  to  the  abdominal  wall,  the  administration  of  tonics, 
and  a  course  of  forced  feeding.  If  these  means  fail  and  the  patient  suffers, 
an  operation  should  be  performed.  The  operation  of  hepatopexy  was  de- 
vised by  Marchant.  He  opens  the  abdomen  and  tries  to  restore  the  liver 
to  its  proper  position.  This  can  usually  be  accomplished.  In  some  cases 
it  can  be  done  after  adhesions  have  been  separated.  In  other  cases  it  can 
be  only  partially  accomplished.  After  the  liver  has  been  restored,  he  sutures 
it  by  means  of  catgut  or  silk  to  the  abdominal  wall  or  costal  cartilages,  the 
stitches  passing  through  the  hepatic  parenchyma  and  being  carried  through 
the  liver  by  means  of  a  round  and  blunt  needle.  The  sutures  attaching  the 
liver  to  the  belly-wall  are  tied  beneath  the  skin.  Marchant  scarifies  the 
dome  of  the  liver  in  order  to  favor  adhesions.  Ramsay  rubs  the  upper 
surface  of  the  Uver  with  gauze  to  promote  adhesion  and  transfixes  the  round 
ligament  with  a  suture  which  is  carried  around  the  cartilage  of  the  seventh 
rib.  In  a  severe  case  Depage  advises  us  to  associate  hepatopexy  with 
an  excision  of  a  portion  of  the  abdominal  wall  to  amend  relaxation  {laparec- 
tomy).  If,  in  operating  on  a  floating  liver,  it  is  found  impossible  to  get  the 
liver  back  into  its  normal  position,  fix  it  with  sutures  as  near  its  proper  abode 
as  is  possible.  Terrier  and  Auvray  report  ii  cases  of  hepatopexy.  One 
case  died  and  eight   completely  recovered. 

Floating  Hepatic  Lobe  (Partial  Hepatoptosis).— This  condition 
is  not  uncommon  in  cases  of  chronic  disease  of  the  gall-bladder  and  is 
most  often  met  in  cholelithiasis.  It  is  beUeved  that  it  can  be  caused  by 
tight  lacing.  A  tongue-like  projection  forms  upon  the  right  lobe  of  the 
liver  {linguiforni  lobe).  It  can  be  palpated  below  the  costal  margin  and 
the  dulness  of  the  mass  on  percussion  is  continuous  with  liver-dulness.  A 
linguiform  lobe  can  usually  be  moved  laterally  and  forward  and  backward; 
it  is  always  tender  and  is  sometimes  the  seat  of  pain. 

Treatment. — When  this  condition  is  associated  with  gall-bladder  trouble, 
it  may  disappear,  or  at  least  cease  to  cause  pain,  when  the  gall-bladder  is 
drained  by  cholecystostomy.  Langenbuch  has  successfully  removed  a  lin- 
guiform lobe. 

Cholecystitis  (Inflammation  of  the  Qall=bladder).— Inflammation 


Bacteriology  of  Cholecystitis  1023 

of  the  gall-bladder  is  produced  by  infection.  Healthy  bile  is  sterile;  and 
when  bacteria  are  found  in  the  bile,  the  condition  is  one  of  disease,  Micro- 
organisms may  find  entrance  into  the  gall-bladder  by  way  of  the  blood,  the 
bile  becoming  infected  secondarily  to  the  infection  of  the  gall-bladder;  or 
they  may  enter  by  way  of  the  ducts,  from  the  intestine.  The  conditions  that 
follow  infection  depend  upon  the  characteristic  tendency  and  the  virulence 
of  the  infecting  germs.  A  trivial  infection  produces  mucous  catarrh;  a  more 
active  infection  causes  suppuration,  and  possibly  ulceration;  a  very  violent 
infection  leads  to  gangrene. 

In  most  cases  of  cholecystitis  an  inflammatory  swelling  blocks  the  cystic 
duct,  and  obstructs  it  so  that  the  bile  stagnates  in  the  gall-bladder.  In 
many  cases  this  condition  lasts  but  a  short  time;  and  when  the  obstruction 
is  relieved,  bile  flows  down  the  duct.  Occasionally,  as  a  secondary  conse- 
quence, cholangitis,  or  infection  of  the  hepatic  ducts,  follows.*  Occasionally, 
also,  the  obstruction  of  the  duct  is  not  relieved,  and  a  quantity  of  clear, 
thin  mucus  gathers  in  the  gall-bladder  and  overdistends  it — the  condition 
known  as  hydrops.  The  gall-bladder  may  likewise  become  distended  with 
pus,  constituting  an  empyema  of  the  gall-bladder;  and  any  overdistended 
gall-bladder  may  rupture.  A  gall-bladder  may  distend  to  a  most  enormous 
size.  Terrier  reported  a  case  of  distended  gall-bladder  in  which  the  viscus 
contained  42  pints  of  fluid.  F.  W.  ColUnson  ("Brit.  Med.  Jour.,"  May  29, 
1909)  reports  the  case  of  a  woman  of  thirty-one  years  of  age  who  was  tapped 
twice  before  operation  and  at  each  tapping  25  pints  of  fluid  were  withdrawn. 
At  the  operation  22  pints  were  obtained.  Colhnson's  case  arose  from  blocking 
of  the  common  duct  as  a  result  of  traumatism,  followed  by  kinking  of  the  cystic 
duct  and  subsequent  opening  of  the  common  duct.  In  cases  of  very  chronic 
inflammation  of  the  gall-bladder  this  structure  becomes  fibrous  and  contracts, 
until  it  may  become  no  larger  than  the  thumb,  in  which  condition  it  may 
contain  a  very  small  amount  of  thickened  bile.  In  some  inflammatory  con- 
ditions due  to  infection  the  bile  mixes  vdth  thickened  mucus,  and  micro- 
organisrhs  form  the  nucleus  upon  which  bile  salts  are  deposited  to  form 
gall-stones.  As  the  same  author  points  out,  cholehthiasis  may  result  from 
cholecystitis,  and  may  cause  chronic  cholecystitis,  because  the  stones  existing 
in  a  gall-bladder  are  sources  of  irritation. 

Bacteriology  of  Cholecystitis. — It  has  been  proved  by  abundant  ob- 
servation that  the  fact  that  bile  contains  micro-organisms  is  no  evidence 
that  the  gall-bladder  is  inflamed;  but  that  when  the  gall-bladder  is  inflamed, 
micro-organisms  are  demonstrable  in  the  bile.  We  know  that  the  bile  is 
infected  during  the  course  of  typhoid  fever,  and  that  it  is  frequently  so  in 
pneumonia.  The  colon  bacillus  is  not  unusually  demonstrable  in  chole- 
cystitis; and  pus-cocci,  either  in  pure  culture  or  mixed  with  other  germs, 
constitute  the  most  common  cause  of  the  inflammation.  It  is  probable  that 
bacteria  entering  the  gall-bladder  and  not  being  particularly  virulent  produce 
no  immediate  harm  when  the  flow  of  bile  is  unobstructed,  though  even  then 
they  may  become  the  nuclei  of  gall-stones;  but  if  the  bacteria  are  very  viru- 
lent, they  may  actually  lead  to  obstruction.  Stagnation  of  the  bile  favors 
infection,  and  infection  may  be  the  cause  of  stagnation.  Each  influence 
reacts  upon  the  other  and  aggravates  the  other,  and  it  seems  more  than 
*  Joseph  McFarland,  Proceedings  of  the  Phila.  Co.  Med.  Soc,  Sept.,  1902. 


I024  Diseases  and  Injuries  of  the  Abdomen 

possible  that  infection  of  the  gall-bladder  is  to  be  regarded  as  serious  only 
when  there  is  obstruction  to  the  outflow  of  bile.  The  same  variety  of  germ 
may,  under  some  circumstances,  cause  catarrhal,  and  under  others  suppu- 
rative, inflammation;  that  is,  when  bacteria  are  virulent  and  tissue  resist- 
ance is  sHght,  suppurative  cholecystitis  results;  but  when  the  bacteria  are  not 
virulent  and  the  tissue  resistance  is  powerful,  the  gall-bladder  is  not  infected 
at  all,  or  only  catarrhal  inflammation  is  produced.  I  operated  upon  a  case 
of  acute  suppurative  inflammation  of  the  gall-bladder  three  weeks  after  the 
termination  of  an  attack  of  t}-phoid  fever.  The  culture  taken  from  the 
gall-bladder  showed  an  unidentified  bacillus,  which  was  not  the  colon  bacillus 
or  the  paracolon  bacillus,  and  which  was  not  identical  with  the  typhoid 
bacillus  or  the  paratyphoid  bacillus.  It  strongly  resembled  the  t}-phoid 
bacillus,  but  possessed  no  agglutinative  power  (the  author,  in  "New  York 
Med.  Jour.,"  April  8,  1905). 

A  patient  in  the  medical  ward  of  the  Jefferson  Hospital  was  supposed 
to  be  developing  a  typhoid  relapse,  but  no  fresh  spots  appeared,  and  there 
were  pain,  tenderness,  and  rigidity  in  the  region  of  the  gall-bladder.  I  oper- 
ated and  found  the  gall-bladder  full,  dark-colored,  and  surrounded  by  numer- 
ous recent  adhesions.  It  could  be  emptied  slowly  by  pressure.  There 
was  no  pus.  It  was  drained  and  the  symptoms  promptly  passed  away  and 
the  man  recovered.  The  culture  was  reported  sterile.  I  cannot  under- 
stand this  finding,  as  inflammation  undoubtedly  existed.  It  may  have  been 
peritonitis  rather  than  cholecystitis,  but  from  what  cause  is  unknown.  No 
culture  was  taken  from  the  peritoneal  cavity.  The  finding  of  sterile  bile 
at  the  end  of  an  attack  of  undoubted  typhoid  is  of  interest. 

Catarrhal  Inflammation  of  the  Qall=bladder  and  Bile=ducts. 
— This  condition  is  known  as  catarrhal  jaundice,  acute  or  chronic,  and 
is  usually  treated  by  the  physician;  but,  as  A.  W.  ^Mayo  Robson  points  out, 
chronic  catarrhal  jaundice  sometimes  resembles  the  jaundice  of  organic 
disease,  and  is  occasionally  associated  with  gall-stones,  maUgnant  disease, 
or  hydatid  cyst.  The  same  authority  asserts  his  beUef  that  chronic  catarrhal 
jaundice  usually  results  from  interstitial  pancreatitis  and  duct  obstruction. 
This  condition  usually  comes  on  without  pain.  If  there  is  pain  it  means  some 
comphcation.  Robson  ("Surg.,  Gynecol.,  and  Obstet.,"  Jan.,  1908)  names 
among  such  compUcations  catarrhal  cholecystitis,  cholangitis,  gall-stone,  and 
duodenal  ulcer.  The  jaundice  is  striking.  There  is  loss  of  flesh  and  anemia, 
and  the  hver  is  enlarged  and  smooth.  Robson  tells  us  that  if  the  gall- 
bladder is  not  shrunken  from  stone,  and  if  there  is  great  duct  obstruction,  the 
bladder  will  be  distended.  Chills  and  fever  mean  infective  cholangitis.  In  a 
case  of  chronic  catarrhal  jaundice  in  which  medical  treatment  fails,  surgical 
treatment  must  be  considered  (cholecystostomy  or  cholecystenterostomy) . 

Catarrhal  Cholecystitis. — This  is  a  catarrhal  inflammation  of  the 
gall-bladder  usually  without  jaundice.  The  gall-bladder  becomes  thick  and  its 
mucous  membrane  is  frequently  pHcated.  Very  thick  mucus  is  secreted, 
which  gathers  in  masses,  and  the  descent  of  these  plugs  causes  pain  that 
is  sometimes  indistinguishable  from  that  produced  by  the  passage  of  a  gall- 
stone. Such  a  plug  may  temporarily  block  the  cystic  duct.  In  catarrhal 
cholecystitis  the  gall-bladder  is  frequently  distended,  but  rarely  admits  of 
palpation;  and  there  are  no  adhesions   to  surrounjding  structures,   unless 


Suppurative  Inflammation  of  the  Gall-bladder,  etc.  1025 

gall-stones  have  been  present  (Robson).  Catarrhal  cholecystitis  may  lead 
to  the  formation  of  gall-stones;  may  result  from  the  presence  of  gall-stones; 
or  may  be  found  in  cases  in  which  gall-stones  have  been  present,  but  have 
passed.  In  one  case  upon  which  I  operated  the  gall-bladder  was  enlarged, 
thick,  and  without  adhesions;  the  mucous  membrane  was  convoluted;  and 
the  viscus  was  filled  with  thick,  tenacious  mucus,  and  the  mucous  membrane 
of  the  gall-bladder  contained  many  minute  concretions.  In  this  case  stone- 
formation  was  probably  beginning  to  follow  upon  catarrhal  cholecystitis. 
In  another  case  a  woman  had  presented  violent  symptoms  of  gall-stone 
colic,  and  stones  had  been  recovered  from  the  feces;  but  on  opening  the  gall- 
bladder no  stones  were  found — only  a  condition  of  catarrhal  cholecystitis. 
Jaundice  is  rare  in  catarrhal  cholecystitis  unless  gall-stones  are  present; 
it  is,  however,  occasionally  noted.  Even  if  jaundice  does  occur,  it  is  slight 
and  lasts  but  a  short  time.  The  painful  attacks  that  occur  during  catarrhal 
cholecystitis  are  similar  to  gall-stone  attacks;  but  the  pain  is  less  violent  and 
of  briefer  duration,  and  jaundice  is  not  apt  to  follow  the  passage  of  a  plug  of 
mucus  and  is  apt  to  follow  the  passage  of  a  gall-stone.  Further,  as  Robson 
has  shown,  in  cholecystitis  with  gall-stones  there  is  usually  tenderness  on 
pressure  over  the  gall-bladder;  and  there  is  rarely  tenderness  in  uncompli- 
cated catarrhal  cholecystitis. 

Treatment. — The  majority  of  the  cases  recover  under  medical  treatment. 
If  a  case  fails  to  recover  under  medical  treatment,  one  cannot  be  sure  whether 
there  are  gall-stones  or  not;  but  an  operation  is  indicated  in  either  case. 
Cholecystostomy  should  be  performed,  and  the  gall-bladder  should  be  drained 
for  a  week  or  two.     This  treatment  will  almost  always  produce  cure. 

Croupous  Inflammation  of  the  Qall=bladder  and  the  Bile= 
ducts. — This  is  an  extremely  rare  condition,  due  to  the  formation  of  a 
thick  membrane  in  the  bile-passages,  which  causes  obstruction  to  the  flow 
of  bile  and  spasmodic  contraction  of  the  gall-bladder.  The  symptoms  are 
identical  with  those  of  gall-stones.  Robson  points  out  that  a  study  of  the 
evacuations  may  discover  membranous  intestinal  casts;  and  that,  as  mem- 
branous enteritis  is  usually  associated  with  croupous  inflammation  of  the 
gall-bladder  and  bile-ducts,  a  diagnosis  may  thus  be  reached.  The  same 
author  says  that  one  may,  in  some  cases,  even  find  a  cast  of  the  gall-bladder 
in  the  evacuations. 

Treatment. — If  medical  treatment  fails,  cholecystostomy  should  be  per- 
formed  and  drainage  should  be  employed  for  a  considerable  time. 

Suppurative  Inflammation  of  the  Qall=bladder  and  Bile=ducts.— 
Adopting  the  classification  of  Mr.  Robson,  we  divide  these  suppurative 
inflammations  into  simple  suppurative  cholecystitis,  suppurative  and  in- 
fective cholangitis,  phlegmonous  cholecystitis  and  gangrene  of  the  gall- 
bladder, ulceration  of  the  gall-bladder  and  bile-ducts,  pericystic  abscess 
with  adhesions,  and  certain  consequences  of  these  conditions,  such  as  stric- 
ture of  the  gall-bladder  and  bile-ducts,  perforation  of  the  gall-bladder  and 
bile-ducts,  and  fistula  of  the  gall-bladder  and  bile-ducts.  Suppurative  in- 
flammations of  the  gall-bladder  and  the  bile-passages  are  due  to  infection 
with  virulent  organisms  or  to  infection  when  the  tissue  resistance  is  at  a 
low  ebb. 

One  fact  must  strike  the  physician  in  regard  to  these  cases;  that  is,  that 
65 


I026  Diseases  and  Injuries  of  the  Abdomen 

there  is  a  strong  similarity  between  the  possible  changes  of  acute  cholecystitis 
and  the  possible  changes  of  acute  appendicitis.  In  the  gall-bladder,  as  in 
the  appendix,  there  may  be  a  catarrhal  inflammation,  which  may  not  advance 
beyond  this  stage,  or  which  may  advance  into  a  more  dangerous  form;  in 
each  structure,  blocking  and  stagnation  favor  infection  and  aggravate  ex- 
isting infection;  in  each  there  may  be  suppuration,  ulceration,  gangrene,  and 
perforation;  in  each  there  may  be  grave  complications  and  disastrous  and 
fatal  consequences;    and  in  each  prompt  surgical  operation  is  usually  Hfe- 


savmg. 


* 


Simple  Suppurative  Cholecystitis. — This  condition  is  also  spoken 
of  as  suppurative  catarrh  of  the  gall-bladder  or  simple  empyema  of  the 
gall-bladder.  It  is  a  rare  condition,  unless  gall-stones  exist,  or  unless  some 
infectious  disease — especially  typhoid  fever — has  antedated  the  condition. 
I  operated  for  this  condition  upon  a  boy  of  eleven  years  of  age  three  weeks 
after  the  termination  of  an  attack  of  t}'phoid  fever.  It  is  not  only  typhoid 
fever  that  may  be  causative,  but  also  other  continued  fevers.  No  matter, 
however,  what  organism  is  primarily  responsible, — be  it  colon  bacillus,  typhoid 
bacillus,  or  what  not, — a  mixed  infection  with  pyogenic  cocci  usually  takes 
place.  Pyogenic  cocci  may  alone  be  causative.  In  simple  suppurative 
catarrh  of  the  gall-bladder  when  the  duct  becomes  blocked,  the  condition 
known  as  simple  empyema  exists;  and  w^hen  hydrops  of  the  gall-bladder 
undergoes  suppuration,  simple  empyema  is  produced. 

In  an  ordinary  case  of  suppurative  catarrh  following  gall-stones  one 
usually  obtains  the  history  of  a  number  of  attacks  of  biliary  colic,  the  pain 
finally  having  become  persistent,  instead  of  intermittent;  and  a  definite  swell- 
ing being  palpable  in  the  gall-bladder  region.  This  swelling  is  tender  on 
pressure.  There  are  usually  constitutional  symptoms,  sometimes  trivial, 
often  severe.  The  trivial  symptoms  are  a  somewhat  rapid  pulse,  sweating 
at  night,  and  some  elevation  of  temperature.  The  more  severe  symptoms 
are  chills,  a  remittent  fever,  and  profuse  sweats.  The  development  of  severe 
symptoms  indicates  that  a  dangerous  change  is  taking  place — usually  ulcera- 
tion of  the  gall-bladder,  occasionally  phlegmonous  cholecystitis.  Distinct 
jaundice  is  rare  in  simple  empyema,  though  the  patient  usually  shows  loss 
of  flesh,  has  a  very  poor  appetite,  and  sufi'ers  considerably  from  thirst. 

To  distinguish  an  enlarged  gall-bladder  from  any  other  intra-abdominal 
mass  is  sometimes  difficult.  Very  large  gall-bladders,  such  as  have  been  placed 
on  record  by  Collinson,  Terrier,  Lawson  Tait,  Gersuny,  and  others,  may  be 
mistaken  for  ovarian  cysts.  Alban  Doran  discusses  such  cases  in  the  "Brit. 
Med.  Jour.,"  June  17,  1905.  An  enlarged  gall-bladder  moves  on  respiration, 
unless  the  mass  becomes  adherent  to  the  abdominal  walls,  when  it  will  cease 
to  do  so.  /\n  enlarged  gall-bladder  is  sometimes  mistaken  for  a  movable 
kidney,  and  the  diagnosis  between  these  conditions  is  discussed  in  the  section 
on  Movable  Kidney  (page  1275). 

Treatment. — The  gall-bladder  should  be  opened  and  drained  by  the 
operation  of  cholecystostomy.  After  it  has  been  exposed,  it  is  packed  about 
with  gauze  pads,  a  considerable  amount  of  the  contents  is  removed  through 
an  aspirator,  the  gall-bladder  is  opened  and  irrigated  with  salt  solution, 
and  a  search  is  made  for  any  cause  of  obstruction  in  the  cysdc  duct.  This 
*  The  author,  Proceedings  of  the  Phila.  Co.  Med.  Soc,  Sept.,  1902. 


Acute  Phlegmonous  Cholecystitis  1027 

cause  should  be  removed,  and  any  gall-stones  that  are  present  should,  of 
course,  be  taken  away.  The  walls  of  the  gall-bladder  will  frequently  be 
found  diseased  and  softened,  so  that  it  is  impossible  to  apply  stitches.  In 
some  cases,  if  the  gall-bladder  is  badly  diseased,  it  should  be  removed;  but 
in  others,  incision  with  drainage  is"  sufficient. 

Recurrent  Simple  Empyema  of  the  Qall=bladder.— In  this  con- 
dition a  person  develops,  at  intervals,  pain,  fever,  tenderness,  and  enlarge- 
ment of  the  gall-bladder.  Then  the  symptoms  clear  up  and  he  is  well  for  a 
time,  but  they  again  become  manifest;  and  at  last  they  may  become  persis- 


Fig.  528. — Gall-bladder  removed   by   chokL\>in  tomy  for  calculus,  empyema,  and  gangrene. 

tent  or  violent,  because  of  the  development  of  some  comphcation.  In  these 
cases  it  is  impossible,  after  a  number  of  attacks,  to  palpate  any  enlargement 
of  the  gall-bladder;  and  when  an  operation  is  performed,  the  gall-bladder  is 
found  shrunken,  thickened,  and  deeply  placed,  containing  some  purulent 
matter,  and  strongly  fixed  to  the  surrounding  structures  by  adhesions. 

Treatment. — Cholecystectomy  is  usually  the  proper  operation. 

Acute  Phlegmonous  Cholecystitis.— Some  call  this  condition  acute 
empyema.  It  is  extremely  dangerous,  and  is  apt  to  cause  gangrene  of  the 
gall-bladder.  It  is  due  to  infection  with  extremely  virulent  organisms. 
It  may  produce  rapid  peritonitis  and  death  without  perforation,  but  oftener 
perforation  takes  place.  It  is  generally  associated  with  the  presence  of  calculi, 
but  sometimes  none  are  found;  and  the  condition  sometimes  develops  during 
typhoid  fever  or  septicemia. 

This  disease  begins  with  sudden  and  violent  pain  in  the  gall-bladder 
region.  This  pain  usually  radiates  toward  the  right  shoulder-blade,  and 
soon  becomes  general  throughout  the  abdomen.  There  are  tenderness  in  and 
great  rigidity  over  the  gall-bladder  region,  thoracic  respiration,  exhausting 
vomiting,  septic  fever,  and  in  some  cases  jaundice.  If  an  operation  is  not 
promptly  performed,  general  peritonitis  quickly  takes  the  patient's  life.  In 
one  case  upon  which  I  operated  there  were  intense  jaundice,  tenderness, 
violent  pain,  abdominal  rigidity  and  distention,  chills,  and  septic  fever;  and 
when  the  abdomen  was  opened,  it  was  found  that  a  portion  of  the  gall-bladder 
was  gangrenous  and  that  a  calculus  projected  through  the  gangrenous  opening. 


I028  Diseases  and  Injuries  of  the  Abdomen 

It  is  this  form  of  cholecystitis  that  is  especially  likely  to  be  mistaken 
for  appendicitis.  In  making  a  diagnosis  the  situation  of  the  primary  pain 
is  of  importance,  and  likewise  the  situation  of  the  tenderness;  but  a  dis- 
placed gall-bladder  or  an  abnormally  situated  appendix  will  lead  to  error. 
Acute  phlegmonous  cholecystitis  is  usually  accompanied  by  absolute  con- 
stipation, and  the  sudden  onset  and  the  abdominal  distention  may  lead  to 
the  disease  being  mistaken  for  intestinal  obstruction.  It  may  also  be  con- 
fused with  ])erforating  ulcer  of  the  stomach  or  of  the  duodenum. 

Treatment. — In  any  case  of  doubt  an  exploratory  incision  should  be 
made.  If  phlegmonous  cholecystitis  is  found  to  exist,  the  gall-bladder  should, 
whenever  possible,  be  extirpated;  but  if  the  desperate  condition  of  the  patient 
forbids  this  operation,  it  should  be  surrounded  with  iodoform  gauze  and  a 
drainage-tube  should  be  carried  well  up  toward. the  cystic  duct. 

Pericystic  Abscess. — Pericystic  abscess  may  follow  infection  of  the 
gall-bladder.  It  is  especially  common  in  the  condition  known  as  recurrent 
simple  empyema.  When  a  pericystic  abscess  exists,  there  are  great  localized 
abdominal  tenderness  and  rigidity  and  the  temperature  is  usually  indicative 
of  suppuration.  The  causative  micro-organisms  may  have  passed  through  a 
diseased  gall-bladder  wall,  rupture  not  existing;  or  the  abscess  may  follow 
ulceration  or  perforation  of  the  gall-bladder  wall. 

Treatment. — Operation  should  invariably  be  performed,  though  it  is 
frequently  difficult.  After  a  pericystic  abscess  has  been  drained,  it  will 
be  found  necessary  in  some  cases  to  extirpate  the  gall-bladder;  whereas  in 
others,  cholecystostomy  and  drainage  will  prove  sufficient. 

Suppurative  and  Infective  Cholangitis.— The  usual  cause  of 
infective  cholangitis  is  gall-stones  lodged  in  the  common  duct,  particularly 
those  cases  in  which  a  gall-stone  acts  as  a  ball-valve.  A.  W.  Mayo  Robson, 
though  he  believes  that  infective  cholangitis  does  occur  when  the  gall-stones 
are  freelv  movable  in  the  common  duct,  sets  it  forth  as  his  experience  that 
it  is  much  more  common  in  such  cases  to  find  gall-stones  impacted  in  the 
common  duct. 

In  such  cases  the  patient  gives  a  history  of  attacks  of  gall-stone  colic 
without  jaundice  for  several  years,  and  then  of  attacks  followed  by  tempo- 
rary jaundice  (page  1033).  Finally  comes  an  attack  that  is  followed  by  a  chill 
and  fever;  and  jaundice,  varying  in  intensity,  ensues  upon  this,  and  now  though 
it  may  fade,  it  seldom  completely  disappears  between  the  attacks  of  pain. 
Robson  points  out  that  the  interval  between  the  attacks  may  be  short  or  long, 
and  that  the  rigors  may  be  repeated  daily  or  at  uncertain  intervals;  that  the 
gall-bladder  is  usually,  but  not  always,  contracted;  and  that  after  the  condi- 
tion has  persisted  for  some  time,  the  liver  becomes  distinctly  enlarged.  There 
are  tenderness  over  the  gall-bladder  or  in  the  epigastric  region,  loss  of  flesh, 
and  persistent  jaundice  which  may  vary  in  hue. 

Infective  cholangitis,  even  after  it  has  lasted  for  a  considerable  length 
of  time,  may  be  recovered  from;  but  it  may  pass  on  into  an  acute  condition 
in  which  poisoning  takes  place  from  the  biliary  elements,  suppurative  cho- 
langitis may  arise,  an  empyema  of  the  gall-bladder  may  develop,  and  there 
may  be  an  abscess  of  the  Uver  or  some  other  dangerous  or  fatal  complication. 
The  ague-like  attacks  of  infective  cholangitis  have  been  called  by  Charcot 
intermittent  hepatic  fever  (page  1034)- 


Typhoid  Cholecystitis  1029 

Treatment. — After  an  incision  has  been  made,  the  duct  is  opened  and 
the  cause  removed;  but,  as  Mr.  Robson  points  out,  the  compHcation  should  be 
anticipated.  When  one  finds  that  carefully  applied  medical  treatment  has 
failed  to  free  the  patient  from  gall-stones,  they  should  be  removed  surgically. 

Suppurative  Cholangitis.— Suppurative  cholangitis  is  usually  a  de- 
velopment of  the  ordinary  infective  cholangitis,  which  has  just  been  discussed. 
Among  the  other  causes  that  Robson  sums  up  are  acute  infectious  diseases, 
particularly  typhoid  fever  and  influenza;  cancer  of  the  bile-ducts;  and 
hydatid  disease. 

In  this  condition  the  hver  enlarges  notably  and  becomes  tender.  In 
some  cases  there  is  an  empyema  of  the  gall-bladder,  but  this  is  rare;  in  fact, 
the  gall-bladder  is  usually  very  much  shrunken.  When,  in  a  chronic  case, 
there  are  enlargement  of  the  liver,  blocking  of  the  common  duct,  and  enlarge- 
ment of  the  gall-bladder,  the  inference  is  in  favor  of  cancerous  obstruction 
of  the  common  duct.  If  the  obstruction  is  due  to  cancer,  there  will  usually 
be  httle  pain;  but  when  it  is  due  to  gall-stones,  there  will  be  violent  attacks 
of  pain,  accompanied  by  rigors  and  fever,  with  deepening  of  the  jaundice. 
In  this  disease  there  is  always  jaundice,  usually  unfading;  but  in  cases  of 
ball-valve  gall-stone  in  the  duct  it  will  be  mitigated  from  time  to  time  (page 
1034).   The  patient  suffers  with  septic  fever  and  very  rapid  loss  of  flesh. 

The  condition  is  generally  fatal,  unless  operation  is  performed  early. 
There  is  a  strong  tendency  for  abscess  of  the  liver  to  form,  and  in  one  case 
upon  which  I  operated  a  subphrenic  abscess  had  developed. 

Treatment. — Cholecystostomy  with  free  and  prolonged  drainage.  If  an 
abscess  of  the  hver  exists,  it  should  also  be  drained.  If  gall-stones  are  gath- 
ered in  the  common  duct,  they  should,  be  removed. 

Typhoid  Cholecystitis.— As  previously  stated,  typhoid  bacilh  are 
usually  present  in  the  bile  during,  and  perhaps  are  present  months  or  years 
after,  an  attack  of  typhoid  fever.  They  are  not  always  present,  however, 
for  in  a  case  of  cholecystitis  following  typhoid  on  which  I  operated  an  uniden- 
tified bacillus  was  found  ("New  York  Med.  Jour.,"  April  8,  1905);  in  a 
case  on  which  I  had  made  an  artificial  anus  for  typhoid  perforation  and  sub- 
sequently performed  intestinal  resection  I  drained  a  greatly  distended  gall- 
bladder at  the  second  operation  and  cultures  of  the  bile  remained  sterile; 
and  in  a  case  of  t)^hoid  with  distended  and  apparently  inflamed  gall-bladder 
on  which  I  operated  the  bile  was  reported  to  be  sterile.  Because  typhoid 
bacilli  are  usually  present  in  the  bile  during  typhoid  does  not  mean  that 
most  cases  of  typhoid  have  cholecystitis;  cholecystitis  is  not  very  common, 
and  arises  when  bacilli  are  very  numerous  or  very  virulent,  when  vital  resis- 
tance is  lowered,  when  there  is  antecedent  inflammation  of  the  gall-bladder, 
when  there  are  gall-stones,  and  particularly  if  there  is  a  block  of  the  duct 
causing  stagnation  of  bile.  Bacilli  then  may  do  no  harm  at  ail,  but  they  may 
cause  a  catarrh,  a  purulent  catarrh,  suppuration  of  the  gall-bladder  walls, 
suppuration  outside  of  the  gall-bladder,  or  perforation.  When  bile  or  inflam- 
matory exudate  contains  typhoid  bacilli,  agglutinins  are  present  and  may 
precipitate  masses  which  become  nuclei  for  gall-stones. 

The  most  usual  period  for  cholecystitis  to  arise  is  during  the  third  week 
of  the  fever,  but  it  is  not  uncommonly  met  with  during  convalescence  and  is 
perhaps  mistaken  for  a  relapse. 


1030  Diseases  and  Injuries  of  the  Abdomen 

The  condition  may  arise  months  or  a  year  after  the  attack  of  typhoid,  and 
yet  a  pure  culture  of  typhoid  bacilli  may  be  obtained  from  the  gall-bladder. 
Strange  to  say,  cases  of  cholecystitis  have  been  operated  on  in  persons  giving 
no  history  of  having  had  typhoid,  and  typhoid  bacilli  have  been  obtained 
from  the  gall-bladder.  Such  a  person  may  have  had  a  very  mild  attack  of 
typhoid,  or  he  may  be  immune  to  typhoid  fever  and  yet  the  bacillus  may  be 
capable  of  causing  inflammation.  Many  cases  of  typhoid  cholecystitis  are 
probably  unrecognized  because  of  the  trivial  symptoms,  or  because  a  high 
position  of  the  liver  renders  the  real  seat  of  pain  obscure,  because  the  general 
symptoms  are  uncertain,  because  toxemia  blurs  perception  of  pain,  or  because 
the  condition  is  confused  with  appendicitis.  It  is  rare  in  children,  more 
common  in  adults.  Most  infections  result  from  the  bacilli  ascending  the 
common  duct,  some  are  by  way  of  the  lymphatics  (Charles  H.  Mayo),  some 
by  an  adhesion  of  the  gall-bladder  to  the  bowel,  some  by  way  of  the  portal 
circulation  and  the  bile-ducts.  Mixed  infection  may  occur,  and  a  secondary 
staphylococcus  infection  may  be  followed  by  disappearance  of  the  typhoid 
bacilli.  The  symptoms  of  typhoid  cholecystitis  are  pain  and  tenderness  in 
the  gall-bladder  region,  rigidity  of  the  upper  half  of  the  right  rectus  muscle, 
perhaps  a  palpable  mass,  an  elevated  and  remittent  temperature,  sweats, 
perhaps  jaundice,  and  sometimes  leukocytosis.  In  some  cases  perforation 
occurs.  Erdmann  reported  i  case  and  collected  34  from  literature  (''  Annals 
of  Surg.,"  June,  1903). 

In  an  ordinary  case  without  perforation  incise  and  drain  the  gall-bladder. 

If  perforation  exists,  do  cholecystectomy  if  possible;  if  not,  drain.  No 
attempt  should  be  made  to  suture  the  perforation.  If  perforation  exists  and 
operation  is  not  done,  death  is  practically  certain.  Of  27  cases  not  operated 
upon,  all  died;  of  7  cases  operated  upon,  4  recovered  (Erdmann). 

Qall=stones. — Gall-stones  are  formed  during  life  in  the  gall-bladder 
or  bile-ducts  by  the  agglutination  of  materials  which  have  precipitated  from 
bile.  The  nucleus  of  a  gall-stone  may  be  a  mass  of  bacteria,  a  blood-clot, 
epithelium,  crystals  of  cholesterin  or  carbonate  of  lime,  or  a  cast  of  a  small 
duct.*  A  condition  of  the  body  thought  to  lead  to  the  formation  of  gall- 
stones is  designated  by  the  term  cholelithiasis  (Brockbank).  But  one  stone 
may  be  present  or  great  numbers  may  exist.  Solitary  stones  may  be  nearly 
round  or  cylindrical.  When  several  stones  or  many  stones  exist,  the  mutual 
pressure  often  leads  to  the  formation  of  facets  (Naunyn).  In  color,  calculi 
may  be  pale  yellow,  green,  black,  or  brown.  Some  are  heavier  than  bile 
and  some  are  lighter.  Brockbank  gives  the  following  varieties  of  gall-stones : 
pure  cholesterin  stones,  stratified  cholesterin  stones,  common  or  gall-bladder 
calculi,  mixed  bilirubin-calcium  calculi,  pure  bilirubin-calcium  calculi,  and 
certain  rare  forms. f  Gall-stones  usually  take  origin  in  the  gall-bladder,  but 
may  arise  in  the  common  duct,  the  cystic  duct,  the  hepatic  duct,  or  the  smaller 
ducts  of  the  liver.  As  a  rule,  however,  calculi  in  the  common  or  cystic  duct  were 
not  formed  there,  but  were  transported  from  the  gall-bladder  or  hepatic  ducts. 

Causes. — Gall-stones  are  very  commonly  found  postmortem.  In 
Germany  it  is  estimated  that  they  are  found  in  12  per  cent,  of  all  cases.  In 
1655  autopsies  in  the  Johns  Hopkins  Hospital  gall-stones  were  present  in 

*  Bevan,  in  Chicago  Med.  Recorder,  April,  1898. 
t  Brockbank's  treatise  on  "Gall-stones." 


Gall-stones  1031 


6  04  per  cent,  of  all  cases  *     The  usual  estimate  is  5  per  cent,  o    autopsies. 
The  cause  is  a  catarrhal  condition  of   the  bile-ducts    due  particularly  to  the 
entrance  of  bacteria  from  the  intestine  (colon  bacilli,  typhoid  bacilli,  pus- 
c,r.^anisms,  pneumococci) .     This  catarrhal   condition    causes    stagnation  of 
bii;      Healthy  bile  is  sterile,  but  not  germicidal,  and  bacteria  will  grow  in  it^ 
Bacteria  have  been  found  in  bile  years  after  the  termination  of  an  attack  of 
fyphoid  fever.     Experimental  infection  of  the  gall-bladder  producing  mild 
holecystitis   is  almost   always   followed   by   gall-stone   formation.f     V\  elch 
pointed  out  that  recent  gall-stones  have  bacteria  in  their  center.     Cushmg  ells 
usThat  30  per  cent,  of  gall-stone  cases  operated  upon  m  the  Johns  Hopkins 
Ho  pital  had  previously  suffered  from  typhoid  fever,  but  Mayo  s  expenence 
is Z  in  accord  with  this  view.     In  view  of  the  fact  that  bile  contaimng  typhoid 
bacilli  must  contain  agglutinins  we  can  understand  how  masses  could  be  pre- 
cipitated to  form  nuclei     Thirty  per  cent,  of  Ochsner's  cases  had  had  appendi- 


citis 


The  chief  predisposing  causes  are  advancing  years,  insufficien    exercise, 
the  daily  consumption  of  unnecessarily  large  quantities  of  food  gouty  tenden- 
d^s  conditions  which  interfere  with  the  emptying  of  the  gal  -bladder,  cardiac 
di^e'ase   and  cancer  of  the  liver.     Gall-stones  rarely  form  before  the  age  o 
thirty-five.     The  youngest  patient  I  ever  removed  stones  from  was  a  giri 
of  twenty      The  disease  is  more  common  in  the  insane  than  m  the  mentally 
sound  in  the  white  race  than  in  the  black,  and  in  women  than  m  men.     In 
2,  pe^  cent,  of  all  females  beyond  sixty  years  of  age  gall-stones  are  presen 
(Naunyn)      The  special  liability  of  woman  may  be  brought  about  by  tight 
acing  pregnancy,  inactivity,  or  movable  right  kidney.     Stout  and  lazy  women 
are  particularly  liable  to  gall-stone  formation  and  women  who  have  born 
ch Xn  are  far  more  liable  than  those  who  have  not.     Total  abstainers  seem 
o  possess  a  greater  predisposition  than  users  of  alcohol,  probably  because  they 
are  more  apt  to  be  large  eaters  (Herbert  F.  Waterhouse,  in  ''I--^^     ^^^  ^' 
inoQ)      There  are  two  forms  of  the  condition  to  be  considered:  the  acute  type, 
due  to  efforts  made  by  the  gall-bladder  or  duct  to  expel  the  concretion;  and  the 
chronic  condition,  in  which  a  calculus  is  lodged  for  a  long  time,  or  m  which, 
as  soon  as  one  calculus  is  passed  into  the  intestine,  ''another  begins  its  journey 
(Brockbank)      The  fact  that  bacteria  cause  the  condition  must  not  lead  us  to 
infer  that  pus  is  of  necessity  formed.     The  bacteria  are  present  in  small  num- 
bers or  else  their  virulence  is  greatly  mitigated;  they  produce  only  catarrhal 
inflammation,  the  bile  stagnates,  and  a  stone  forms.     There  may  be  one 
stone,  two  stones,  several,  or  many  stones.     I  have  removed  200  from  a 
patient      Multiple  stones  are  facetted.     SoUtary  stones  are  not  facetted. 

Many  observers  believe  that  inflammation  of  the  mucous  membrane  causes 
the  secretion  of  quantities  of  cholesterin,  which  material  forms  a  large  par 
of  most  gall-stones.     Others  maintain  that  cholestenn  is  a  normal  constituent 
of  bile  and  is  not  obtained  from  the  mucous  membrane. 

Bachmeister  ("Miinch.  Med.  Woch.,"  Feb.  x8,  ^9o8)  demonstrates  that 
if  pure  sterile  bile  is  permitted  to  stand  for  a  considerable  time  cho  estenn 
will  be  precipitated,  an'd  that  if  epitheUal  cells  are  added  to  this  the  choles  enn 
is  precipitated  much  more  rapidly.     The  catarrhal  mflamm.ation  furmshes 

*C   D.  Mosher,  in  Johns  Hopkins  Hosp.  Bull.,  Aug.,  iQOi^ 
t  Gilbert,  in  Archives  generates  de  med.,  Aug.  and  Sept.,  i89»- 


1032  Diseases  and  Injuries  of  the  Abdomen 

quantities  of  epithelial  cells  and  the  cells  precipitate  cholesterin,  and  in  this 
way  inflammation  causes  gall-stones.  It  is  probable  that  when  gall-stones 
exist  they  are  all  due  to  a  common  cause  and  all  began  to  form  at  the  same 
time.  It  is  not  likely  that  one  begins  and  then  another,  and  so  on.  After 
a  stone  once  begins  it  may  progressively  increase  in  size.  In  many  cases  the 
stone  or  stones  never  cause  trouble.  A  gall-stone  may  begin  to  descend 
because  of  violent  muscular  exertion,  external  joressure,  or  at  the  onset  of  a 
fresh  inflammation  which  leads  to  loosening  of  the  stone.  A  very  small  stone 
usually  passes  freely.  A  larger  stone  in  passing  causes  colic.  A  still  larger 
stone  remains  in  the  gall-bladder,  or  becomes  fixed  in  the  cystic  duct  or  the 
intestinal  outlet  of  the  common  duct.  In  most  cases  gall-stones  form  in  the 
gall-bladder.  In  some  they  form  in  the  common  duct  if  stones  have  previously 
existed  in  the  gall-bladder.  When  the  common  duct  retains  a  stone  and  is 
suffering  from  some  degree  of  obstruction  and  from  infection,  stones  may 
form  in  the  hepatic  ducts  (Wm.  J.  and  Chas.  H.  Mayo,  in  "Am.  Jour.  Med. 
Sciences,"  March,  1905).  Stones  are  occasionally  found  at  necropsy  in  the 
radicles  of  the  hepatic  duct. 

Symptoms. — The  formation  of  a  stone  requires  several  months,  and 
during  the  antecedent  period  of  gastro-intestinal  catarrh,  "the  prodromal 
state"  of  Kraus,  certain  symptoms  may  exist,  viz.:  consdpation,  flatulence, 
loss  of  appetite,  migraine,  uneasy  sensations  in  the  epigastrium  or  right 
hypochondrium,  sallowness  of  the  skin,  shght  yellowness  of  the  conjunctiva", 
scantiness  of  urine,  which  excretion  is  saturated  with  uric  acid,  and  may  after 
a  time  contain  a  Httle  bile.  If  this  condition  is  not  arrested  by  treatment,  it 
grows  worse.  The  abdomen  becomes  decidedly  distended;  pressure  over  the 
stomach  or  Hver  may  cause  distinct  uneasiness  or  even  pain;  acid  indigestion 
is  very  troublesome;  violent  attacks  of  migraine  occur;  constipation  becomes 
more  decided,  the  feces  become  clay  colored,  gastralgia  may  occur,  the  skin 
is  apt  to  be  sHghtly  jaundiced,  itching  is  complained  of,  the  patient  is  irritable 
and  sleeps  poorly.  The  hver  is  found  to  be  enlarged,  and  the  urine  contains 
distinct  amounts  of  bile.  When  the  patient  reaches  this  stage,  gall-stones  are 
very  liable  to  form.  These  symptoms  may  pass  away  even  if  a  concredon 
forms.  It  is  c^uite  true  that  in  some  cases  a  stone  exists  for  years  without 
causing  trouble.  This  is  pardcularly  true  in  elderly  people.  Often  it  causes 
unrecognized  symptoms  and  seldom  does  it  fail  to  cause  some  symptoms. 
In  many  cases  the  symptoms  which  stones  cause  are  thought  to  be  due  to  dis- 
ease of  the  stomach  (indigestion,  flatulence,  pain  after  eating,  pyloric  spasm, 
etc.). 

As  Waterhouse  says  (Ibid.),  the  symptoms  do  not  bear  any  relation  to  the 
size  or  the  number  of  the  stones.  In  fact,  gall-stones  give  rise  to  active  symp- 
toms only  when  infection  occurs  or  when  the  ducts  become  occluded  and  cease 
to  drain,  or  when  a  stone  starts  to  pass.  If  infection  occurs,  it  may  pass  away 
spontaneously,  but  seldom  does  so.  When  a  stone  forms,  pain  is  apt  to  become 
a  marked  feature  of  the  case.  John  B.  Murphy  ("Med.  News,"  Nov.  2, 
1903)  points  out  that  in  a  person  with  stones  in  the  gall-bladder  there  may  be: 

1.  The  pain  of  acute  inflammation,  the  result  of  a  severe  infection.  In 
this  condition  there  are  abdominal  rigidity  and  contracted  gall-bladder. 

2.  The  pain  of  tension.  In  this  there  is  not  persistent  abdominal  rigidity, 
but  pressure  always  causes  sudden  and  transient  tension  of  the  belly  muscles. 


Symptoms  of  Gall-stones  1033 

Murphy's  method  of  demonstrating  tenderness  of  the  gall-bladder  is  most 
valuable,  and  I  always  use  it.  It  is  as  follows:  Hook  the  fingers  well  up  under 
the  liver  and  tell  the  patient  to  take  a  deep  inspiration.  On  inspiration  pain 
becomes  acute  and  respiration  suddenly  ceases. 

3.  Referred  pain,  which  may  exist  with  either  of  the  above  conditions. 
Colic  is  spasmodic  pain,  and  means  that  a  stone  has  left  or  is  trying  to  leave 
the  gall-bladder,  and  is  in  or  is  trying  to  enter  a  duct.  Many  persons  with  a 
stone  or  with  stones  in  the  gall-bladder  never  have  colic.  A  sense  of  pressure 
or  of  soreness  in  the  hepatic  region,  the  result  of  cholecystitis,  has  added  to  it 
sudden  and  transient  paroxysms  of  pain,  due  to  the  passage  of  thick  bile  from 
the  gall-bladder  and  small  ducts,  or  of  gravel  from  the  small  ducts,  urged  on  by 
bile  pressure.  When  a  stone  begins  to  pass  from  the  gall-bladder,  violent  colic 
is  experienced.  Such  a  coHc  usually  comes  on  very  suddenly,  and  often  about 
three  hours  after  a  meal.  It  may,  however,  come  on  gradually,  the  patient 
complaining  greatly  of  flatulence.  In  some  cases  it  is  so  sudden  and  violent 
as  to  simulate  perforation  of  the  stomach  or  duodenum.  The  reason  colic 
is  particularly  apt  to  come  several  hours  after  a  heavy  meal  is  that  at  that  time 
bile  is  passing  down  into  the  intestine.  A  bladder  containing  calcuH  often 
tolerates  the  presence  of  the  foreign  bodies  for  an  indefinite  length  of  time,  and 
then  suddenly  resents  their  presence  and  ejects  them  forcibly  or  tries  to  eject 
them.  The  pains  are  violent,  spasmodic,  and  paroxysmal,  and  over  the  hepatic 
and  epigastric  regions,  "radiating  upward  over  the  right  half  of  the  thorax" 
(Kraus),  and  passing  particularly  from  the  epigastrium  to  the  right  shoulder- 
blade.  The  patient  is  profoundly  nauseated  and  usually  vomits,  the  abdomen 
is  distended,  and  a  condition  almost  of  collapse  is  soon  reached.  The  tempera- 
ture is  usually  normal,  or  subnormal,  but  is  occasionally  somewhat  elevated. 
The  patient  may  shiver  and  sweating  may  follow,  but  rigors  are  rare.  The 
respirations  are  shallow,  the  patient  groans,  cries  out,  flings  himself  about  in 
bed,  and  often,  in  seeking  for  relief,  assumes  some  strange  or  contorted  posi- 
tion. He  frequently  holds  one  hand  over  the  liver  region.  His  expression  is 
indicative  of  intense  suffering  and  apprehension  and  sometimes  of  abject  terror. 
The  pain  is  one  of  the  most  awful  a  human  being  can  feel  and  women  who  have 
felt  it  assert  that  the  pains  of  parturition  are  trivial  in  comparison.  The  attack 
lasts  a  variable  time,  and  terminates  by  the  stone  passing  into  the  intestine  or 
falling  back  into  the  bladder.  The  usual  duration  of  an  attack  is  from  four 
to  twenty  hours.  I  have  seen  attacks  that  lasted  three  days,  four  days,  or  even 
five  days,  almost  without  intermission.  It  terminates  suddenly  if  the  stone 
passes  or  falls  back  in  the  gall-bladder.  In  many  cases  at  the  termination  of 
the  attack  an  enormous  amount  of  clear  pale  urine  is  passed.  During  and  for  a 
time  after  the  attack  the  gall-bladder  may  be  very  tender.  After  the  cessation  of 
colic,  if  the  feces  are  examined  carefully  during  several  days,  the  stone  may  be 
discovered.  The  fact  that  no  stone  is  discovered  does  not  prove  that  no  stone 
was  passed,  because  a  cholesterin  stone  may  be  destroyed  in  the  intestinal  canal. 
If  the  stone  is  passed,  jaundice  almost  invariably  follows  the  colic  in  from 
twenty  to  thirty-six  hours  and  lasts  several  days.  The  jaundice  results  from 
the  stone  being  in  the  common  duct.  If  stones  do  not  pass  from  the  cystic 
duct  so  as  to  enter  or  protrude  into  the  common  duct,  jaundice  does  not  occur. 
In  80  per  cent,  of  my  cases  (excluding  common  duct  cases)  there  was  no  history 
of  jaundice.     Even  when  a  stone  is  lodged  in  the  common  duct  jaundice  may 


I034  Diseases  and  Injuries  of  the  Abdomen 

be  slight  or  absent.  When  jaundice  arises  after  a  colic,  it  comes  on  gradually, 
bile  appears  in  the  urine,  and  often,  but  not  always,  the  stools  become  clay 
colored  from  absence  of  bile.  Jaundice  may  be  first  noticeable  in  the  urine  or 
in  the  conjunctiva.  The  skin  is  apt  to  itch  annoyingly,  even  atrociously.  The 
patient  is  constipated  and  very  thirsty.  The  Hver  is  enlarged  and  tender  and 
the  spleen  is  enlarged.  Some  writers  state  that  the  pulse  is  slow  in  jaundice. 
My  experience  is  in  agreement  with  the  much  larger  experience  of  Moynihan, 
who  says:  "I  have  not  found  any  reduction  in  the  pulse-rate  in  jaundice 
unless  a  degree  of  chronic  pancreatitis  is  present"  ("Gall-stones  and  Their 
Surgical  Treatment").  If  the  stone  is  impacted,  after  a  time  the  pains  be- 
come less  violent,  and  may  entirely  cease.  If  it  ceases  and  the  stone  does  not 
move,  pain  does  not  recur;  if  the  stone  moves  pains  recur,  and,  usually,  again 
and  again  the  patient  suffers  from  aggravation  of  them.  An  individual  may  get 
about  with  impacted  stone,  but  again  and  again  fierce  attacks  of  coUc  occur, 
and  if  the  stone  is  wedged  immovably  in  the  common  duct,  producing  absolute 
obstruction,  the  patient  becomes  and  remains  deeply  jaundiced.  Continued 
deep  jaundice  is  seldom  seen  when  stones  are  lodged  in  the  common  duct,  be- 
cause they  are  seldom  absolutely  fixed  and  hence  seldom  produce  complete 
obstruction.  Usually  the  stone  moves  from  time  to  time  or  is  at  least  Ufted, 
so  that  bile  gets  by  it  at  intervals.  This  condidon  constitutes  the  ''ball-valve'' 
stone,  and  in  it  jaundice,  though  present  more  or  less,  is  at  times  much  more 
intense  than  at  other  times.  It  is  a  jaundice  in  which  the  hue  is  yellow,  not 
deep  brown,  and  it  is  a  jaundice  that  wanes  and  deepens.  It  deepens  after 
each  coHc  and  later  wanes,  but  seldom  entirely  disappears  while  the  stone 
remains  in  the  duct. 

In  persistent  jaundice  due  to  gall-stones  the  gall-bladder  is  seldom  en- 
larged. Courvoisier  showed  that  when  persistent  jaundice  is  associated  with 
enlargement  of  the  gall-bladder  the  cause  is  usually  pressure  on  the  duct  from 
without  (maUgnant  disease  of  the  pancreas) . 

Slight  jaundice  is  not  always  easy  of  recognidon.  Recognition  is  par- 
ticularly difficult  in  sallow  indi\aduals  and  by  arUficial  light.  Moynihan  praises 
Hamel's  test  for  slight  jaundice.  It  is  made  by  drawing  a  little  blood  from 
a  puncture  of  the  lobe  of  the  ear  into  a  capillary  tube  and  permitting  the  tube 
to  stand  for  a  few  hours.  If  any  jaundice  is  present  the  serum,  which  collects 
in  the  upper  part  of  the  tube,  mil  be  yellow  ("Gall-stones  and  Their  Surgical 
Treatment"). 

In  certain  cases  when  a  stone  is  in  the  common  duct  an  attack  of  cohc  is 
followed  by  or  accompanied  by  a  chill  or  chills,  which  may  be  very  violent, 
moderate,  or  sUght,  and  by  a  febrile  seizure  resembUng  malaria  and  called 
hepatic  fever,  or  Charcot's  fever.  The  temperature  rises  rapidly,  and  in  an  hour 
becomes  104°  F.  or  more,  remains  high  for  several  hours,  and  then  drops  sud- 
denly to  normal.  It  may  remain  normal  for  a  few  hours,  a  day,  two  days,  sev- 
eral days,  or  weeks.  In  this  condidon  there  are  jaundice  and  tenderness  of 
the  Hver.  Charcot's  fever  is  brief  in  duration.  It  usually  means  stone  in  the 
common  duct.  If  stones  are  in  the  bladder,  we  are  more  apt  to  get  a  persist- 
ent slightly  elevated  temperature.  These  intermissions  disdnguish  Charcot's 
fever  from  the  remittent  fever  of  sepsis,  and  the  absence  of  the  plasmodium 
in  the  blood  and  the  history  of  coHc  disdnguish  it  from  malaria.  The  fever 
is  due  to  intoxication  with  ptomains  from  infected  bile  retained  in  the  ducts 


Symptoms  of  Gall-stones  1035 

by  obstruction.     The  condition  is  ominous  because  it  is  clue  to  infection, 
and  means  inllammation  of  the  duct  {cholangitis). 

The  chart  of  Charcot's  fever  shows  sudden  elevations,  precipitate  descents, 
and  complete  intermissions.  Moynihan  calls  it  the  "steeple  chart"  ("  Gall- 
stones and  Their  Surgical  Treatment ") .  When  infection  spreads  w^idely  in  the 
smaller  intrahepatic  ducts,  the  temperature  is  high  and  does  not  remit. 
Continuous  fever  of  this  type  has  usually  been  preceded  by  Charcot's  fever. 

If  a  stone  lodges  in  the  cystic  duct,  it  does  not  cause  jaundice  unless  an 
end  of  the  stone  projects  into  the  common  duct.  It  grows  in  size  from  incrus- 
tation, prevents  the  entrance  of  bile  into  the  gall-bladder,  and  the  bladder 
may  shrivel  and  thicken  or  become  filled  with  mucus,  the  bile  being  absorbed 
{hydrops  of  the  gall-bladder) .  If  a  bladder  so  blocked  becomes  infected,  pus 
forms,  and  the  condition  known  as  empyema  of  the  gall-bladder  exists.  An 
empyema  of  the  gall-bladder  may  rupture  into  the  bowel,  the  peritoneal  cavity, 
or  even  through  the  skin. 

The  common  duct  is  involved  in  i  out  of  5  or  6  cases  of  gall-stone  dis- 
ease.* Brewer  points  out  that  in  67  per  cent,  of  cases  the  stone  is  in  the  duod- 
enal extremity,  in  15  per  cent,  in  the  hepatic  extremity,  and  in  18  per  cent,  in 
the  middle.  If  a  stone  blocks  the  common  duct,  jaundice  always  exists  and 
persists.  Blocking  may  be  complete  and  the  stone  may  ulcerate  into  the  bowel 
or  the  peritoneal  cavity.  Blocking  may  be  incomplete,  the  stone  acting  as  a 
ball-valve  and  producing  intermittent  colic  and  jaundice,  which  waves  and 
deepens  (page  1034).  Fenger  points  out  that  if  a  stone  remains  fixed  in  the 
common  duct,  the  fiver  becomes  tender  and  enlarged;  but  if  a  stone  floats 
about  in  the  common  duct,  the  gall-bladder  undergoes  atrophy.  In  complete 
obstruction  the  stools  become  clay  colored  and  bifirubin  is  found  in  the  urine. 
Fluctuating  jaundice,  with  attacks  of  pain  and  fever,  and  a  shrunken  gall- 
bladder are  strongly  suggestive  of  a  "ball-valve"  stone  in  the  common  duct. 
Persistent  deepening,  painless  jaundice,  the  color  of  the  skin  becoming  brown 
or  even  mahogany,  associated  with  a  distended  gall-bladder,  is  strongly  sug- 
gestive of  malignant  disease  compressing  the  common  duct.  The  above  state- 
ments constitute  Courvoisier's  law.  It  is  found  true  in  90  per  cent,  of  cases. 
We  may  add  that  a  persistent  jaundice  of  yellow  hue,  varying  somewhat,  and 
associated  with  pain  or  with  actual  cofic,  suggests  blocking  of  the  duct  by  an 
immovable  stone. 

^Gall-stones  may  lead  to  suppurative  inflammation  of  the  gall-bladder 
or  bile-passages,  ulceration,  occlusion  of  the  neck  of  the  gall-bladder,  dilata- 
tion of  the  stomach  from  the  formation  of  adhesions  which  kink  the  pylorus, 
abscess,  peritonitis,  empyema  of  the  gall-bladder,  and  cancer  of  the  gall- 
bladder. In  cancer  of  the  ducts  gall-stones  are  seldom  found,  at  least  are 
seldom  found  in  the  ducts.  Eddes  collected  22  cases  of  cancer  of  the  papilla. 
In  3  of  these  cases  there  were  stones  in  the  gall-bladder,  in  i  there  was  a  stone 
in  the  common  duct  ("Boston  Med.  and  Surg.  Jour.,"  March  7, 1901).  If  the 
patient  develops  distinct  infection  of  the  gall-bladder  or  bile-ducts,  he  will  suffer 
from  chills,  fever,  and  sweats. 

Gall-stones  may  lead  to  cirrhosis  of    the  liver.     A   stone  may  ulcerate 
into  the  bowel  and  cause  intestinal  obstruction.     It  may  be  difficult  to  make 
a  diagnosis  between  gall-stones  with  icterus  and  cirrhosis  of  the  fiver  with 
*Robson,  in  Lancet,  April  12,  1902. 


1036  Diseases  and  Injuries  of  the  Abdomen 

icterus.  In  the  former  case  the  urine  contains  bihrubin  and  in  the  latter 
case  urobilin. 

Treatment. — In  the  prodromal  stage  and  after  recovery  from  an  attack 
insist  on  the  patient  taking  considerable  outdoor  exercise.  Direct  him  to 
take  a  cold  sponge-bath  every  morning,  to  move  the  bowels  freely  every 
day,  and  to  employ  a  simple  diet.  He  should  avoid  all  highly  seasoned 
foods,  pastry,  rich  soups,  fatty  food,  cheese,  alcohol,  and  sweets.  Alkalies 
internally  are  of  value. 

During  a  colic  give  an  enema,  apply  hot  turpentine  stupes  over  the 
hepatic  region,  and  administer  hypodermatic  injections  of  morphin  and 
atropin.  If  vomiting  does  not  occur,  let  the  patient  drink  a  large  amount 
of  warm  water  to  favor  it.     After  the  attack  administer  a  purgative. 

When  the  attack  has  terminated,  examine  carefully  for  any  evidence  of 
inflammatory  trouble  in  the  hepatic  region. 

In  certain  cases  operation  becomes  necessary.  Mr.  A.  W.  Mayo  Robson 
advises  operation  in  the  following  cases:  *  in  frequently  recurring  biliary  colic 
without  jaundice,  whether  the  gall-bladder  is  enlarged  or  not;  in  cases  of 
enlargement  of  the  gall-bladder  without  jaundice,  even  if  there  is  no  pain; 
in  persistent  jaundice  which  was  ushered  in  by  pain,  painful  seizures  occur- 
ring, whether  or  not  febrile  attacks  occur;  in  empyema  of  the  gall-bladder; 
in  peritonitis  beginning  in  the  gall-bladder  region;  in  intrahepatic  abscess  and 
in  abscess  about  the  liver,  gall-bladder,  or  bile-ducts;  in  some  cases  where 
the  stones  have  been  passed,  but  adhesions  remain  and  produce  pain;  in 
fistula  cases;  in  some  cases  of  persistent  jaundice  due  to  obstruction  of  the 
common  duct,  although  there  may  be  a  possibility  of  cancer  existing;  in 
phlegmonous  cholecystitis  and  gangrene  of  the  gall-bladder.  Besides  these 
conditions,  which  may  be  produced  by  gall-stones,  Robson  operates  for  wounds 
of  the  gall-bladder,  infective  and  suppurative  cholangitis,  and  for  some  con- 
ditions of  chronic  catarrh  of  the  bile-ducts  and  gall-bladder.f  The  tendency 
to  operate  early  for  gall-stones  is  growing.  It  is  true  that  stones  juay  cause 
no  trouble,  but  sooner  or  later  they  are  apt  to,  there  is  no  tendency  whatever 
to  spontaneous  cure,  and  medicine  cannot  dissolve  them  in  the  bladder. 
Early  operations  are  easy  and  comparatively  safe;  late  operations  are  difficult 
and  dangerous,  and  by  early  operation  dangerous  complications  (infection, 
adhesions,  obstructive  jaundice)  are  avoided.  As  Maurice  H.  Richardson  % 
says:  An  early  operation  is  less  dangerous  than  the  passage  of  a  stone;  com- 
plications are  avoided  or  lessened;  even  if  the  diagnosis  is  wrong,  the  real 
condition  may  be  found  and  removed.  If  obstructive  jaundice  exists,  opera- 
tion is  dangerous  because  of  the  possibility  of  fatal  oozing  of  blood. 

The  common  operation  is  cholecystostomy,  which  consists  in  opening  the 
gall-bladder,  removing  the  stones,  and  making  a  temporary  fistula  in  the  gall- 
bladder. The  fistula  is  permitted  to  heal,  after  a  time,  hence  many  call 
it  cholecystotomy  rather  than  cholecystostomy.  Operation  should  .be  done 
promptly  and  should  not  be  delayed.  To  delay  permits  the  gall-bladder  to 
thicken  and  shrink,  and  allows  the  stone  to  enter  the  duct.  After  drainage  gall- 
stones rarely  reform.    Wm.  J.  Mayo  collected  2000  operations  done  by  six  sur- 

*Mayo  Robson  on  the  "Gall-bladder  and  Bile-ducts." 

tRobson's  treatise,  from  which  the  above  is  taken,  is  a  valuable  exposition  of  the 
surgery  of  the  gall-bladder  and  bile-ducts. 

:|:  Boston  Med.  and  Surg.  Jour.,  Sept.  5,  1901. 


Carcinoma  of  the  Gall-bladder  1037 

geons,  and  in  not  i  case  did  stones  reform.     Kocher  has  seen  stones  recur  in 
3  cases  out  of  31  cases  of  cholelithiasis  after  ideal  cholecystotf)my  (suturing 
gall-bladder  after  removing  stones),  in  i  case  out  of  19  cholecystostomies,  and 
in  I  case  out  of  30  cholecystectomies.     The  operation  of  incision,  removal  of 
the  stone,  and  suture  of  the  gall-bladder  is  known  as  ideal  cholecystotomy  or 
cholecyslendysis.     If  calculi  exist  in  the  common  duct,  it  may  be  possible,  after 
celiotomy,  to  manipulate  them  back  into  the  bladder  and  extract  them  from 
that  viscus  with  a  scoop,  but  this  maneuver  is  impossible  unless  the  cystic  duct 
is  dilated.     In  some  cases  the  gall-bladder  is  incised,  a  fistula  is  made,  and  the 
duct  and  bladder  are  frequently  irrigated.     In  other  cases  the  stone  may  be 
crushed  by  the  fingers  manipulating  the  duct  and  the  concretion  within  it 
{choledocholithotrity).     Robson  points  out  that  crushing  of  the  stone  is  apt 
to  leave  fragments  which  may  cause  trouble,  and  it  should  be  done  only  when 
the  stones  are  soft.     It  is  wrong  to  endeavor  to  force  a  stone  from  the  common 
duct  into  the  duodenum.     The  attempt  will  fail,  and  in  some  cases  the  patient 
will  be  placed  in  a  worse  condition  by  the  stone  lodging  in  Vater's  diverticu- 
lum.*   The  duct  may  be  opened,  and  after  the  removal  of  the  stone  closed 
by  sutures  (choledochotomy)  or  drained  for  a  time  (choledochostomy) ,  strands 
of  gauze  being  carried  down  to  the  opening  and  in  some  cases  a  tube  being 
carried  up  a  dilated  duct  toward  the  liver.     If  the  stone  is  impacted  near  the 
outlet  of  the  duct,  it  may  be  necessary  to  incise  the  duodenum  in  order  to  re- 
move the  stone  (duodenocholedochotomy).     A  dilated  bile-duct  may  be  anasto- 
mosed to  the  bowel  (choledocho-enterostomy)  or  to  the  surface  (choledochostomy). 
The  obstruction  may  be  side-tracked  by  anastomosing  the  gall-bladder  to  the 
bowel  (cholecystenterostomy)  (p.  1 1 16) .    Cholecystenterostomy  affords  drainage, 
but  does  not  remove  the  cause  of  trouble,  and  infection  is  apt  to  be  received  from 
the  bowel.     In  some  rare  cases  of  common  duct  obstruction,  in  which  the  gall- 
bladder is  distended  and  the  condition  of  the  patient  is  desperate,  anastomose 
the  gall-bladder  to  the  colon  (Robson).    In  some  cases  of  diseased  gall-bladder 
the  viscus  is  removed  {cholecystectomy).     Cysticotomy  is  incision  of  the  cystic 
duct.    Wm.  J.  Mayo  and  others  have  pointed  out  that  a  danger  in  operations  on 
the  common  duct  is  a  sudden  fall  in  blood-pressure  when  the  duct  is  being 
manipulated.     All  operators  have  observed  it.     Ransohoff  maintains  that  it 
arises  only  when  the  portal  vein  is  compressed. 

Carcinoma  of    the  Qall=bladder.— In  405   operations  on  the  gall- 
bladder and  biliary  passages  the  Mayo  brothers  found  malignant  disease 
20  times  (5  per  cent,  of  cases).     (See  Wm.  J.  Mayo,  in  "Med.  News,"  Dec. 
13,  1902.)     Malignant  disease  may  be  primary  or  secondary.     In  primary  car- 
cinoma calculi  are  always  present,  and  are  apparently  causative  by  maintaining 
chronic  irritation.     Stones  are  seldom  present  in  secondary  malignant  disease. 
Carcinoma  of  the  gall-bladder  can  usually  be  palpated.     It  is  hard  and 
nodular,  and  seldom  accompanied  by  much  abdominal  rigidity.     There  will 
be  a  long  history  of  attacks  of  gall-stone  colic  and  of  recent  or  comparatively 
recent  grave  loss  of  flesh.    Sooner  or  later  jaundice  arises,  deepens,  and  persists. 
Cholecystectomy   has  been  employed  for  this  condition,  but  offers  but 
little  hope.     In  2  cases  in  which  I  opened  the  abdomen  without  suspecting 
malignant  disease  of  the  gall-bladder  the  liver  was  hopelessly  involved.     In 
I  case  in  which  I  operated  for  a  supposed  impacted  stone  in  the  common  duct  an 
inoperable  cancer  of  the  common  duct  was  found. 

♦  See  A.  W.  Mayo  Robson,  in  Lancet,  April  12,  1902. 


1038  Diseases  and  Injuries  of  the  Abdomen 


Diseases  and  Injuries  of  the  Pancreas. 

Wounds  and  Injuries. — The  pancreas  is  very  rarely  ruptured  alone, 
although  this  sometimes  occurs  as  the  result  of  blows  or  crushes.  In  the 
majority  of  cases  in  which  the  pancreas  is  damaged  other  organs  are  in- 
volved; for  instance,  the  stomach,  the  spleen,  and  the  liver.  A  gunshot- 
wound  of  the  pancreas  is  almost  certain  to  injure  the  left  kidney,  the  stomach, 
or  the  vertebral  column.  It  will  be  remembered  that  in  the  case  of  President 
McKinley  the  bullet  passed  through  the  stomach,  damaged  the  left  kidney, 
and  injured  the  pancreas.  Garre  ("Beitrage  zur  Klinische  Chirurgie,"  xlvi, 
No.  i)  collected  30  cases  of  subcutaneous  rupture  of  the  pancreas  and  in  only 
8  of  these  cases  was  the  pancreas  alone  damaged. 

Symptoms. — When  the  pancreas  is  injured  alone,  hemorrhage  is  not 
usually  severe;  but  if  adjacent  organs  are  also  damaged,  it  is  sure  to  be  pro- 
fuse. Hence  when  adjacent  organs  are  damaged  there  are  apt  to  be  imme- 
diate symptoms  of  severe  intra-abdominal  hemorrhage;  but  profound  col- 
lapse is  not  often  present  when  the  pancreas  alone  is  injured.  In  fact,  symp- 
toms may  not  arise  for  a  considerable  length  of  time  after  injury  of  the  pan- 
creas. A  diagnosis  at  this  stage  is  impossible  without  exploratory  operation. 
Severe  injury  of  the  pancreas  is  usually,  but  not  invariably,  fatal.  After  slight 
damage  of  the  gland  the  patient  may  completely  recover;  but,  as  a  rule, 
he  partly  recovers,  and,  after  a  number  of  weeks,  a  smooth  tumor,  palpable 
in  the  epigastric  region,  is  formed.  When  operation  is  performed,  this 
tumor  is  found  to  be  back  of  the  stomach.  It  contains  a  quantity  of  blood, 
clot,  and  pancreatic  fluid.  Such  a  fluid  collection  is  in  the  lesser  peritoneal 
cavity  and  is  called  a  cyst,  though  it  is  not  a  true  cyst  of  the  pancreas.  Rob- 
son  and  Moynihan,  in  their  valuable  treatise  on  "  Diseases  of  the  Pancreas, " 
explain  the  formation  of  this  collection  of  fluid  as  follows: 

The  injury  lacerates  the  posterior  layer  of  the  lesser  sac  of  the  peritoneum 
and  the  pancreas,  to  which  it  is  adherent.  Blood  and  pancreatic  fluid  enter 
the  lesser  peritoneal  sac.  Peritonitis  follows.  The  foramen  of  Winslow  is 
blocked  by  adhesions;  and  the  lesser  peritoneal  cavity,  being  now  a  closed 
sac,  is  distended  with  a  serous  exudate  mixed  with  blood  and  pancreatic 
fluid.  CoUecdons  of  this  character  form  very  rapidly,  and  several  pints 
may  gather  in  a  few  days.  Other  results  of  injury  to  the  pancreas  are  abscess, 
pancreatids,  and  true  cyst  formation.  A  fistula  may  follow  operation  for 
rupture  of  the  pancreas.  Such  a  fistula  is  very  troublesome,  often  refuses 
obstinately  to  heal,  and  the  pancreatic  fluid  macerates  the  skin  severely.  The 
usual  treatment  has  been  to  keep  the  fluid  drained  off.  A  treatment  suggested 
by  Wohlgemuth  has  proved  successful  in  5  cases  ("Berliner  KHn.  Wochen- 
schrift,"  1908,  No.  8) .  The  fistulae  heal  in  from  three  days  to  six  weeks.  The 
treatment  consists  of  strict  antidiabetic  diet  and  large  doses  of  bicarbonate  of 
sodium  before  and  after  meals. 

By  cutting  out  carbohydrates  a  powerful  stimulus  to  the  flow  of  pancreatic 
juice  is  removed.  The  bicarbonate  of  sodium  lessens  the  activity  of  the  stom- 
ach contents  before  they  outer  the  intestine  and  it  is  known  that  hydrochloric 
acid  strongly  stimulates  the  flow  of  pancreatic  juice. 

Treatment. — Operation  is  imperatively  demanded,  although  the  pros- 


Pancreatitis  1039 

pects  are  bad.  Garre  collected  8  cases,  3  were  operated  upon,  and  all  died 
(Ibid.),  (iarre  reported  a  successful  case  of  his  own  (Ibid.).  The  pancreas 
was  torn  in  two  and  the  pieces  were  separated.  The  splenic  vessels  were 
uninjured.  The  two  portions  of  gland  were  sutured  together.  This  stopped 
the  bleeding.  Gauze-packing  was  introduced.  In  a  gunshot-wound  of  the 
abdomen,  when  exploration  leads  the  surgeon  to  surmise  that  the  pancreas  has 
been  injured,  this  organ  should  be  approached  by  dividing  either  the  gastrocolic 
omentum  or  the  transverse  mesocolon.  The  pancreas  may  also  be  exposed  by 
dividing  the  gastrohepatic  omentum.  Accessory  injuries  must  be  carefully 
noted,  and  if  a  bullet  has  penetrated  the  posterior  wall  of  the  stomach,  the 
pancreas  is  almost  certain  to  be  damaged.  One  should  remember  that,  as 
Park  says,  even  after  opening  the  abdomen  it  is  difficult  to  explore  the  pancreas, 
especially  in  a  stout  person.  If  there  is  no  evidence  of  posterior  perforation  of 
the  stomach  by  a  foreign  body,  one  may  assume  that  the  pancreas  has  escaped. 
When  the  pancreas  is  exposed,  if  it  is  found  to  be  bleeding,  the  bleeding  vessels 
should  be  ligated  and  the  tear  in  the  gland  should  be  sutured,  care  being  taken 
not  to  puncture  the  main  duct  of  the  gland.  If  this  duct  has  been  cut,  it  must 
be  carefully  sutured.  In  some  cases  of  gunshot-wound  it  is  necessary  to  resect 
a  portion  of  the  gland.  At  the  termination  of  an  operation  upon  the  pancreas 
posterior  drainage  at  the  costovertebral  angle  should  always  be  obtained.  It 
is  necessary  to  carefully  drain  away  all  escaping  pancreatic  fluid,  as  it  tends 
to  cause  necrosis  of  tissue  with  which  it  comes  in  contact. 

In  cases  of  crush  with  pancreatic  injury  the  associated  injury  to  other 
structures  usually  proves  rapidly  fatal,  but  in  a  less  severe  case  the  abdomen 
may  be  opened  for  exploration,  and  if  this  is  done,  the  surgeon  should  pro- 
ceed as  previously  directed. 

The  question  of  excising  a  lacerated  portion  of  the  pancreas  is  one  of  great 
interest.  It  is  known  that  dogs  have  lived  for  some  time  after  complete  ex- 
cision of  the  pancreas.  Four-fifths  of  the  pancreas  can  be  removed  from  a 
dog  without  producing  permanent  glycosuria,  but  if  more  than  this  is  removed 
the  dog  develops  saccharine  diabetes  and  eventually  dies  of  it.  In  man,  quite 
large-sized  pieces  of  the  gland  have  been  removed  and  recovery  has  followed. 
Hence  it  is  justifiable  to  excise  a  hopelessly  damaged  portion,  bearing  in  mind 
Park's  caution  that  the  chief  danger  in  excising  a  portion  of  the  pancreas  is 
injury  to  the  splenic  artery. 

Movable  Pancreas. — In  cases  of  splanchnoptosis  the  pancreas  may 
become  considerably  displaced,  though  this  condition  cannot  be  recognized 
without  opening  the  abdomen.  So  far,  I  know  of  no  case  in  which  fixation 
has  been  attempted,  though,  of  course,  theoretically  it  could  be  done. 

Pancreatitis. — Pancreatitis  often  leads  to  the  production  of  jaundice; 
always  to  very  rapid  loss  of  weight;  occasionally  to  the  presence  of  fat  and 
sugar  in  the  urine;  sometimes  to  the  presence  of  fat  in  the  stools;  and  fre- 
quently to  the  condition  known  as  fat-necrosis.  Robson  and  Moynihan  point 
out  that  when  there  is  no  diarrhea  and  the  stools  contain  undigested  muscle- 
fiber,  one  may  assume  that  there  is  a  deficiency  in  pancreatic  juice.  When 
there  is  a  blockage  to  the  secretion  from  the  pancreas,  if  salol  is  given  by 
mouth,  salicyluric  acid  does  not  appear  in  the  urine.  The  test  is  made  by 
putting  gr.  XV  of  salol  into  gelatin  capsules  hardened  with  formalin  (Sahli) 
and  giving  them  with  a  roll  and  a  cup  of  water.     If  pancreatic  ferment  is  in 


1040  Diseases  and  Injuries  of  the  Abdomen 

the  intestine,  sahcyluric  acid  appears  in  the  urine  in  one  hour  or  one  hour  and 
a  half;  if  the  ferment  is  absent  from  the  intestine,  sahcyluric  acid  is  not  found 
in  the  urine  because  the  salol  is  not  split  up  and  absorbed.  The  test 
for  the  acid  is  ferric  chlorid,  which,  in  the  presence  of  the  acid,  turns 
the  urine  violet.  The  general  cause  of  pancreatitis  is  infection.  Often 
obstruction  of  the  common  bile-duct  is  followed  by  infection  and  sup- 
puration of  the  pancreatic  ducts  and  pancreatitis.  Besides  the  general 
cause,  which  is  infection,  various  exciting  causes  may  be  named,  among 
which  are  gall-stones  in  the  common  duct  and  calculi  in  the  pancreatic 
ducts,  traumatism,  cancer  of  the  stomach  or  duodenum,  catarrh  of  the  stom- 
ach or  duodenum,  and  many  infectious  diseases.  It  thus  becomes  evident 
that  the  infection  may  be  by  way  of  the  blood;  but,  undoubtedly,  in  the  vast 
majority  of  cases,  the  infection  comes  by  way  of  the  duct.  One  manner  in 
which  the  disease  may  be  produced  was  suggested  by  Halsted  and  Opie,  of 
Baltimore:  A  stone  becomes  impacted  in  the  outlet  of  the  common  duct; 
the  pancreatic  duct,  where  it  emerges  above  the  common  duct,  not  being 
blocked.  The  bile  and  pancreatic  juice  are  thus  prevented  from  entering  the 
duodenum,  and  the  bile  flows  back  into  the  pancreatic  ducts. 

That  strange  condition  known  as  jat-necrosis  is  often  present  in  pan- 
creatitis. In  fat-necrosis  the  fat  is  decomposed  into  fatty  acids  and  glycerin. 
The  glycerin  is  absorbed,  but  the  fatty  acids  unite  with  calcium  salts  and 
remain  in  the  tissues,  forming  patches  of  yellowish- white  color  and  varying 
size.  These  patches  are  found  in  the  fat  beneath  the  peritoneum,  in  the 
omentum,  and  in  the  mesentery,  and  even  in  distant  parts  (for  instance, 
the  pericardium).*  It  is  an  undoubted  fact  that  fat-necrosis  is  not  uncom- 
monly found  after  diseases  and  injuries  of  the  pancreas;  and  many  assume 
that  it  is  produced  by  the  entering  of  the  ferment  of  the  pancreas  into  the 
fatty  tissue.  How  the  ferment  gets  there  is  a  matter  of  some  doubt.  In 
the  case  of  a  wound  of  the  pancreas  one  can  understand  the  flow  of  the 
secretion  and  its  imbibition  by  adjacent  parts;  but  in  other  cases  one  must 
assume  that  it  has  been  absorbed  by  the  lymphatics  and  distributed  to  more 
distant  parts.  When  one  reflects  that  in  some  conditions  of  the  pancreas 
there  is  no  fat-necrosis,  while  in  others  this  condition  arises,  it  is  presum- 
able that  the  pancreatic  conditions  associated  with  it  are  such  as  to  permit 
the  fat-splitting  ferment  to  diffuse  into  neighboring  tissues. 

In  pancreatic  disease  hemorrhage  into  that  organ  is  common.  The 
hemorrhage  is  not,  of  necessity,  fatal,  but  frequently  is  so.  Occasionally 
death  takes  place  as  the  result  of  sudden  pancreatic  hemorrhage  in  a  person 
apparently  in  excellent  health.  It  is  thought  by  Robson  and  Moynihan  that 
during  the  existence  of  cancer  of  the  pancreas  there  is  a  strong  tendency 
to  excessive  hemorrhage  after  operation.  In  one  case  of  my  own  the  patient 
bled  to  death  after  the  performance  of  cholecystostomy  for  obstructive  jaundice. 
The  oozing  of  blood  in  this  case  was  from  the  margins  of  the  gall-bladder 
and  the  adjacent  peritoneal  surfaces.  We  therefore  conclude  that  in  certain 
conditions  of  the  pancreas  there  is  a  tendency  to  local  hemorrhage  in  that 
organ;  and  that  there  may  also  be  a  tendency  to  the  development  of  a  general 
hemorrhagic  diathesis,  the  general  hemorrhagic  tendency  being  much  in- 
creased if  jaundice  exists.  During  acute  inflammation  of  the  pancreas 
*  Robson  and  Moynihan,  on  "  Diseases  of  the  Pancreas." 


Acute  Pancreatitis  1041 

hemorrhage  is  almost  certain  to  occur  into  that  gland;  in  other  varieties  of 
inflammation  hemorrhage  may  occur  or  may  be  absent.  In  degenerative 
lesions  of  the  pancreas  a  material  hke  unfermented  pentose  is  frequently 
present  in  the  urine.  When  the  reaction  for  this  material  is  obtained  we  speak 
of  it  as  the  Cammidge  reaction,  after  its  discoverer.  (For  Cammidge's  im- 
proved method,  see  "Brit.  Med.  Jour.,"  May  ig,  1906). 

Forms  of  Pancreatitis. — This  disease  is  divided  by  Robson  and  Moyni- 
han  into  the  acute,  the  subacute,  and  the  chronic  form;  and  they  say  that 
recorded  cases  demonstrate  the  fact  that  three  distinct  classes  of  inflammation 
may  arise:  (i)  Cases  that  die  vi^ithin  forty-eight  hours  of  the  beginning  of 
the  trouble.  In  this  group  hemorrhage  is  usually  fourid;  and  if  fat-necrosis 
is  present,  it  is  limited  in  area.  (2)  Those  that  live  for  some  weeks  after 
the  beginning  of  the  trouble.  In  these  cases  the  pancreas  may  become 
necrotic  or  suppuration  may  occur.  Fat-necrosis  is  usually  wide-spread.  (3) 
In  the  third  class  of  cases  long-continued  inflammation  or  repeated  attacks 
produce  sclerosis  of  the  pancreas. 

Acute  Pancreatitis. — The  symptoms  of  this  condition  come  on  suddenly 
and  consist  of  violent  pain  in  the  epigastric  region,  vomiting,  constipation, 
rapidity  and  weakness  of  the  circulation,  cold  extremities,  and  collapse,  with 
a  great  fall  in  blood-pressure.  Some  maintain  that  collapse  is  due  to  trypsin, 
others  that  it  results  from  the  absor}:)tion  of  toxic  products  from  the  gland.  The 
pain  is  extremely  violent  and  is  intensified  in  paroxysms,  and  there  are  distinct 
tenderness  and  rigidity  of  the  epigastrium.  The  patient  vomits  the  contents 
of  the  stomach  and  then  bilious  matter.  Distention  soon  becomes  distinct 
in  the  upper  portion  of  the  abdomen.  The  patient  presents  the  appearance 
of  one  suffering  from  peritonitis.  This  condition  is  not  unusually  mistaken  for 
intestinal  obstruction,  but  in  acute  pancreatitis  the  constipation  is  not  abso- 
lute; the  patient  passes  gas,  and  may  even  have  a  bowel  movement  as  the 
result  of  the  administration  of  an  enema.  The  condition  is  usually  fatal 
vdthin  a  few  days,  but  in  very  rare  instances  recovery  takes  place.  In  acute 
pancreatitis  from  stone  in  the  common  duct  there  is  no  leukocytosis  (Murphy) . 

The  diagnosis  cannot  be  made  with  certainty  and  is  merely  an  inference. 
Reginald  Fitz  tells  us  that  the  existence  of  this  disease  should  be  suspected 
when  a  person  previously  in  good  health,  or  who  has  complained  only  of 
occasional  attacks  of  digestive  disorder,  is  suddenly  seized  with  severe  pain 
in  the  epigastric  region,  followed  by  vomiting  and  collapse;  and  when,  within 
twenty-four  hours  or  more,  there  appears  a  circumscribed  sweUing  in  the 
epigastrium  which  is  resistant  or  tympanitic.  When  an  exploratory  incision 
is  made  in  the  abdomen,  if  fat  necrosis  is  detected,  the  diagnosis  becomes 
certain. 

In  acute  pancreatitis  the  pancreas  undergoes  rapid  necrosis,  due,  according 
to  some  experimenters,  to  the  entrance  into  the  pancreatic  duct  of  bacteria  from 
the  intestine,  and  according  to  others  to  digestion  of  the  pancreas  by  its  own 
fluids.  The  fluids  when  normal  certainly  will  not  digest  the  pancreas.  It  seems 
probable  that  trypsin  is  "activated"  by  the  entrance  into  the  duct  of  material 
from  the  duodenum  and  bacteria  may  be  responsible  for  activating  trypsin 
(Polya,  in  "Pfluger's  Archiv.,"  cxxi.  Heft  9  and  10). 

Treatment.— Opera.t\on  was  suggested  by  Nahn,  in  1903.  The  exploratory 
operation  is  carried  out  in  front,  and  the  earher  it  is  made  the  better.  Robson 
66 


I042  Diseases  and  Injuries  of  the  Abdomen 

operates  at  once,  even  in  shock.  It  is  quite  true  that  the  patient  might,  if  let 
alone,  pass  through  the  acute  stage,  and  that  a  local  abscess  might  then  form, 
the  treatment  of  which  would  be  obvious.  But  the  danger  of  wairing  is  too 
great  to  justify  delay,  and  if  suppuration  should  occur  it  might  not  remain  local, 
but  might  spread  widely  in  the  retroperitoneal  tissues.  When  observation  after 
exploratory  incision  into  the  greater  cavity  of  the  peritoneum  suggests  the  ex- 
istence of  acute  pancreatis,  the  infected  area  should  be  exposed  either  above 
the  stomach  through  the  gastrohepatic  Hgament,  or  below  the  stomach  through 
the  gastrocolic  omentum.  The  pancreas  should  be  incised,  hemorrhage 
should  be  arrested  by  ligation  or  packing,  an  incision  should  be  made  at  the 
costovertebral  angle,  and  posterior  drainage  should  be  made  from  the  lesser 
peritoneal  cavity.  One  should  follow  the  rule  laid  down  by  Rosswell  Park, 
and  explore  in  every  case  in  which  the  disease  is  suspected  to  exist. 

Subacute  Pancreatitis. — Subacute  pancreatitis  comes  on  suddenly,  with 
violent  pain,  vomiting,  and  constipation,  but  there  is  far  less  exhaustion  and 
weakness  than  in  the  acute  form.  The  vomiting  is  less  marked  and  the 
sweUing  in  the  epigastric  region  is  not  so  rapid.  The  symptoms  are  similar 
to  those  of  the  acute  form,  but  not  so  violent  nor  so  rapidly  progressive. 
The  temperature  frequently  rises  higher  than  in  the  acute  form,  and  it  may 
become  irregular  or  chills  may  occur.  In  many  cases  the  patient  seems  to 
grow  better  after  a  time,  the  violent  pain  abating,  though  some  pain  and 
tenderness  remain;  but  he  does  not  gather  strength  and  continues  to  lo.se 
flesh,  and  there  is  usually  albumin  and  there  may  be  sugar  in  the  urine.  In 
rare  instances  fat  is  found  in  the  urine.  In  subacute  pancreatitis  abscess 
is  prone  to  form.  This  abscess  may  make  a  distinct  swelling  in  front,  and 
may  lead  to  the  development  of  a  subphrenic  or  of  a  perirenal  abscess.  In 
rare  cases  an  abscess  of  the  pancreas  tracks  its  way  for  a  long  distance  in 
the  subperitoneal  tissue,  occasionally  it  opens  into  the  stomach  or  bowel. 
Cases  of  subacute  pancreatitis  occasionally  recover  after  a  long  illness,  but 
usually  they  die. 

Treatment. — Exploratory  incision.  Expose  the  pancreas,  either  above  or 
below  the  stomach;  determine  the  condition;  remove  purulent  matter  and 
necrotic  areas;  arrest  hemorrhage  with  packing;  and  insert  posterior  drainage 
at  the  costovertebral  angle.  In  some  cases  close  the  anterior  wound,  and 
in  others  leave  it  open.* 

\Vm.  J.  Mayof  reports  a  successful  operation  for  subacute  pancreatitis. 
The  patient  was  a  man  of  fifty-two  years,  who,  seven  days  before  Mayo  saw 
him,  had  developed  violent  pain  in  the  epigastrium,  collapse,  distention,  and 
other  signs  of  intestinal  obstruction;  but  some  slight  movements  had  taken 
place  from  the  bowels,  as  the  result  of  medication.  On  admission,  the  abdo- 
men was  tympanitic.  An  ill-defined  mass  the  size  of  a  fist  could  be  palpated 
to  the  right  of  and  above  the  umbilicus.  The  pulse  was  120  and  very  weak; 
the  temperature,  between  101°  and  102°;  and  there  were  sHght  jaundice,  rest- 
lessness, and  hiccough.  A  diagnosis  of  gangrenous  cholecystitis  was  made. 
The  abdomen  was  opened,  and  the  omentum  was  found  to  be  studded  with 
thick,  adherent,  infiltrated  round  spots,  the  size  of  a  pea  or  larger.  There 
were  some  similar  spots  in  the  mesentery,  and  the  peritoneal  cavity  con- 

*  Roswell  Park,  Annals  of  Surgery,  December  15,  1901. 
I  Jour.  Am.  Med.  Assoc,  Jan.  11,  1902. 


Chronic  Pancreatitis  1043 

tained  bloody  fluid.  On  palpation,  the  pancreas  felt  like  a  pudding  in  a 
tight  sac;  and  on  aspiration  a  little  blood  was  obtained.  The  gall-bladder 
was  opened,  a  stone  was  removed,  and  some  pus  was  evacuated.  Drainage 
was  inserted  into  the  gall-bladder,  and  eighteen  days  later  there  was  an 
enormous  flow  of  bloody  fluid,  containing  bile  and  pancreatic  juice,  from 
the  drainage-tube.  The  patient  recovered.  This  plan  of  treatment — free 
drainage  of  the  pancreas  by  the  performing  of  cholecystostomy — is  to  be 
taken  into  consideration. 

Chronic  Pancreatitis. — There  are  many  causes  of  chronic  pancreatitis, 
viz.,  syphilis,  alcohol,  bacteremia,  block  of  the  common  duct  (stenosis,  stone, 
etc.),  extension  of  inflammation  from  the  bile-ducts,  and  ascending  infection 
from  the  duodenum.  It  usually  results  from  disease  of  the  bile-passages 
and  is  often  associated  with  gall-stones.  In  2200  operations  performed  by  the 
Mayo  brothers  on  the  gall-bladder  and  bile-ducts,  the  pancreas  was  found 
diseased  141  times  (6.4  per  cent.). 

In  168  cases  of  pancreatic  disease  on  which  they  operated,  81  per  cent,  were 
caused  by  or,  at  least,  associated  with  gall-stones.  In  operations  upon  the  com- 
mon or  hepatic  ducts  the  pancreas  was  diseased  in  18.6  per  cent,  of  cases. 
It  was  diseased  in  4.45  per  cent,  of  cases  of  operation  upon  the  gall-bladder. 
Chronic  pancreatitis  produces  enlargement  of  the  organ,  and  the  enlarged  area 
is  hard  and  feels  like  a  malignant  growth.  This  condition  is  more  common 
than  is  the  acute  or  subacute  form.  Robson  and  Moynihan  have  operated  upon 
30  cases.  The  disease  is  frequently  associated  with  gall-stones  or  with  stones 
in  the  pancreatic  duct,  and  occasionally  with  ulcer  of  the  stomach  or  of  the 
duodenum.  In  some  cases  symptoms  of  the  condition  come  on  acutely.  Pain, 
nausea,  and  vomiting  occur,  and  jaundice  develops  rapidly,  as  it  does  after  the 
passage  of  a  gall-stone.  It  is  noted,  however,  that  the  pain  is  not  in  the  region 
of  the  gall-bladder,  but  is  in  the  middle  of  the  epigastrium,  and  it  passes  to 
the  left  rather  than  to  the  right.  The  tenderness,  too,  is  in  the  middle  of  the 
epigastrium  and  not  in  the  gall-bladder  region.  There  is  either  constipation 
or  diarrhea.  A  series  of  these  attacks  may  occur,  the  jaundice  growing  worse 
after  each  attack.  In  some  cases,  however,  the  condition  comes  on  gradually 
and  insidiously,  the  pain  slowly  developing,  but  no  \'iolent  seizures  taking 
place.  There  are  rigidity  of  the  rectus  muscles,  rapid  loss  of  flesh,  anemia, 
sometimes  bronzed  skin,  usually  vomiting,  and  considerable  flatulence.  The 
gall-bladder  is  enlarged  and  commonly  palpable. 

In  some  cases  it  is  possible  to  palpate  the  inflammatory  mass.  There  may 
be  irregular  fever  and  chiUs  %Aith  episodes  of  subnormal  temperature.  None 
of  the  above  indications  are  conclusive  signs  of  disturbed  pancreatic  function. 
Signs  of  disturbed  function  of  the  gland  are  of  great  importance  in  making  the 
diagnosis,  and  these  signs  are  glycosuria  and  impaired  power  of  digesting  fats 
and  proteids  (Walko,  in  "Arch.  f.  Verdanungskrankheiten,"  1907,  xiii).  Fatty 
stools  containing  bile  and  unsaponified  neutral  fat  are  ver>'  significant. 

The  jaundice  in  chronic  pancreatitis  results  from  compression  of  the  duct  by 
the  hyperplastic  mass,  or  blocking  of  the  duct  by  a  stone.  Stenosis  of  the 
duodenum  may  occur.  In  jaundice  from  chronic  pancreatitis  capillary  hem- 
orrhage is  particularly  common  (Robson).  Mayo  Robson  attaches  much  im- 
portance to  the  Cammidge  reaction.  In  the  Jefferson  hospital  we  regard  it  as 
often  of  decided  use,  but  we  do  not  as  yet  attach  as  much  importance  to  it  as 


I044  Diseases  and  Injuries  of  the  Abdomen 

do  some  other  clinicians.  This  reaction,  when  present,  indicates  degenerative 
disease  of  the  pancreas.  It  is  obtained  when  the  urine  contains  a  substance 
having  the  characteristics  of  unfermented  pentose. 

Treatment. — Exploratory  incision,  opening  and  draining  the  gall- 
bladder; or  the  performing  of  cholecystenterostomy. 

Pancreatic  Calculi. — When  the  pancreatic  secretion  is  blocked,  stones 
tend  to  form;  and  the  blocking  may  be  due  to  inflammation  of  the  duct  of 
Wirsung,  or  may  result  from  chronic  pancreatitis.  The  stones  may  be 
single  or  multiple. 

Symptoms. — There  is  pain  in  the  epigastric  region,  which  usually  comes 
on  in  paroxysms  that  resemble  those  due  to  gall-stones,  though  they  are  not 
so  violent.  Pain  is  accompanied  by  vomiting,  exhaustion,  and  sometimes 
actual  collapse,  and  may  be  followed  by  rigors.  Portions  of  stone  are  some- 
times recovered  from  the  feces,  and  sugar  is  occasionally  found  in  the  urine. 
Fat  has  also  been  noted  in  the  stools  in  some  cases.  Sometimes  jaundice 
develops  because  the  calculus  presses  upon  the  common  duct.  Pancreatic 
calculi  are  composed  of  lime  salts  and  can  be  skiagraphed. 

Treatment. — Pancreatic  calculi  have,  in  rare  instances,  been  removed 
by  operation;  and  this  is  the  proper  procedure  when  the  diagnosis  can  be 
made.  The  diagnosis  is,  however,  possible  only  after  exploratory  incision. 
As  a  rule,  no  operation  is  performed  until  a  cyst  results  or  an  abscess  forms; 
and  when  the  cyst  or  abscess  is  opened,  fragments  of  stone  may  be  found 
in  the  fluid,  and  stones  may  subsequently  come  away  in  the  resulting  fistula. 
Pancreatic  Cysts. — Many  forms  of  cyst  may  develop  in  the  pancreas; 
the  following  are  set  forth  by  Robson  and  Moynihan:  (i)  Retention  cysts; 
(2)  proliferation  cysts,  including  cystic  adenoma  and  cystic  epithelioma;  (3) 
hydatid  cysts;  (4)  congenital  cysts;  (5)  hemorrhagic  cysts;  and  (6)  pseudo- 
cysts. What  we  speak  of  as  pseudocysts  have  aheady  been  considered  in 
discussing  effusions  into  the  lesser  peritoneal  cavity.  They  result  from 
lacerations  of  the  pancreas.  Retention  cysts  are  due  to  blocking  of  the 
pancreatic  duct.  Congenital  cystic  disease  is  extremely  rare.  Hemorrhagic 
cysts  result  from  hemorrhage  into  the  substance  of  the  pancreas  itself. 

Symptoms. — Cysts  are  somewhat  more  common  in  men  than  in  women. 
A  cyst  of  the  pancreas  proper  is  more  often  met  v.dth  in  the  head  of  the  organ 
than  in  its  body  or  tail.  The  cyst  may  be  single  or  multiple.  In  its  growth 
it  either  destroys  the  substance  of  the  pancreas  or  it  grows  away  from  the 
pancreas  and  damages  it  but  little.  In  some  cases  the  cysts  grow  to  a  very 
large  size;  and  Robson  and  Moynihan  refer  to  a  case  in  which  the  cyst 
attained  the  size  of  a  man's  head,  and  to  another  in  which  it  was  the  size 
of  a  full-term  pregnancy.  A  pancreatic  cyst  is  smooth,  round,  elastic,  and 
rather  tense  (Robson  and  Moynihan).  The  contained  fluid  varies  greatly. 
As  a  rule,  it  is  brownish-red  in  color;  in  one  case  upon  which  I  operated 
it  was  clear  yellow;  in  some  cases  it  is  milky,  and  in  others  it  is  nearly  black. 
The  fluid  is  always  albuminous.  Urea  may  be  present,  and  in  many  cases 
pancreatic  ferments  are  found.  In  most  cases  the  cyst  adheres  so  closely 
to  the  svnrounding  structures  as  to  render  extirpation  practically  impossible. 
A  pancreatic  cyst  of  considerable  size  causes  epigastric  discomfort,  pain 
during  digestion,  and  frequently  vomiting.  In  some  cases  the  pain  is  tri- 
vial;   in  others,  it  is  very  violent.     As  a  general  rule,  the  patient  is  consti- 


Tumors  and  Other  Growths  of  the  Pancreas  1045 

pated;  but  sometimes  diarrhea  occurs,  and  the  movements  may  even  con- 
tain blood.  If  the  tumor  presses  upon  the  common  bile-duct,  jaundice  will 
develop.  The  patient  loses  flesh  markedly  and  with  considerable  rapidity, 
and  he  becomes  very  weak.  In  rare  instances  fat  is  present  in  the  stools, 
and  in  other  unusual  cases  sugar  is  found  in  the  urine.  A  test  should  always 
be  made  with  salol,  to  see  whether  pancreatic  ferment  is  present  in  the  intes- 
tine (page  1039).  In  the  beginning  the  pancreatic  cyst  is  behind  the  stomach; 
but  it  enlarges  and,  as  a  rule,  pushes  the  stomach  upward  and  to  the  right 
side,  and  the  transverse  colon  downward.  The  cyst  approaches  the  surface 
of  the  abdomen  below  the  greater  curvature  of  the  stomach  (Robson  and 
Moynihan).  The  same  authors  tell  us  that  in  rare  cases  the  cyst  appears 
at  the  upper  border  of  the  stomach,  and  that  in  others  it  inserts  itself  between 
the  layers  of  the  transverse  mesocolon.  In  the  case  upon  which  I  operated 
it  had  worked  its  way  through  the  subperitoneal  tissue  into  the  right  loin, 
and  had  been  looked  upon  by  Professor  Montgomery  and  myself  as  a  hydro- 
nephrosis. As  a  rule,  the  pancreatic  cyst  is  immovable;  but  in  rare  instances 
it  is  movable.  When  a  hand  is  placed  in  the  loin  and  another  on  the  abdo- 
men, ballottement  may  be  appreciated.  If  the  distended  stomach  or  colon 
overhes  the  tumor,  there  will  be  a  tympanitic  percussion-note;  but  when 
the  tumor  reaches  the  abdominal  wall,  there  will  be  a  dull  percussion-note. 
On  inquiring  into  the  history  of  these  cases,  it  will  frequently  be  found  that 
there  has  been  a  severe  injury  to  the  upper  abdomen. 

Treatment. — Exploratory  incision  makes  the  condition  clear.  In  the 
majority  of  cases  the  cyst  is  incised,  emptied,  and  stitched  to  the  wall  of 
the  abdomen.  This  operation  may  be  done  in  two  stages — first,  exposing 
the  cyst  and  fi.xing  it  to  the  abdominal  wall;  and,  second,  when  adhesions  have 
formed,  opening  it.  As  a  rule,  however,  it  is  performed  in  one  stage,  the 
abdominal  cavity  being  carefully  protected  with  gauze.  Some  authors  advo- 
cate exposing  the  cyst,  opening  and  evacuating  it  through  the  abdominal 
wound,  and  draining  through  the  loin.  Complete  extirpation  is  usually  im- 
possible because  of  the  adherence  of  the  cyst.  If  the  cyst  is  movable,  extirpation 
may  be  carried  out;  but  the  safest  operation  consists  of  incision  and  drainage. 

Tumors  and  Other  Growths  of  the  Pancreas.— The  pancreas  may 
be  affected  with  sarcoma,  carcinoma,  adenoma,  tuberculous  disease,  or  syphilis. 

Treatment. — Attempts  have  been  made  to  remove  tumors  of  the  pan- 
creas. After  an  e.xploratory  incision  has  determined  the  condition,  the 
pancreas  is  e.xposed  at  the  point  at  which  the  tumor  projects.  This  is  usually 
done  by  an  opening  in  the  gastrocoHc  omentum.  If  the  tumor  is  in  the  tail 
of  the  pancreas,  however,  the  exposure  may  be  effected  in  the  flank.  When 
the  tumor  has  been  exposed,  an  attempt  may  be  made  to  enucleate  it.  Tumors 
of  the  splenic  porUon  of  the  pancreas  have  been  removed.  Total  pancreatec- 
tomy or  complete  resection  of  the  head  of  the  gland  should  not  be  attempted. 

In  a  large  tumor  of  the  head  of  the  pancreas  palliate  the  condition  by 
cholecystenterostomy.  Villar  reports  13  cases  of  partial  resection  of  the  pan- 
creas for  tumors  with  5  recoveries  from  operation  ("French  Surgical  Congress 
of  1905"). 


1046  Diseases  and  Injuries  of  the  Abdomen 


Injuries  and  Diseases  of  the  Spleen. 

Wounds  of  the  Spleen. — A  wound  of  the  spleen  causes  great  hemor- 
rhage, and  if  surgical  aid  is  not  soon  at  hand,  will  inevitably  produce 
death.  It  is  caused  by  a  bullet  or  a  stab  and,  as  a  rule,  other  viscera  are  also 
damaged.     Immediate  operation  is  indicated. 

Rupture  of  the  spleen  is  unusual  if  the  organ  be  healthy,  but  does  occa- 
sionally occur  from  crushes.  It  is  rarely  found  unassociated  with  other  injuries. 
The  spleen  may  be  dislocated  as  well  as  ruptured.  An  enlarged  spleen  is  par- 
ticularly Hable  to  rupture  not  only  from  a  crush,  but  from  a  kick,  a  blow,  or  a 
fall.  Rupture  of  the  spleen  produces  pain  and  rigidity  in  the  left  hypochon- 
driac region  and  the  signs  and  symptoms  of  intra-abdominal  hemorrhage. 
There  is  tenderness  over  the  spleen,  pain  over  the  heart,  and  great  shortness 
of  breath.  The  bleeding  is  profuse,  but  sometimes  slov/.  The  splenic  blood  con- 
tains numerous  leukocytes  and  clots  rapidly,  hence  the  bleeding  maybe  arrested 
for  a  time,  and  if  it  should  be  the  padent  will  not  bleed  to  death  rapidly  andre- 
acdon  will  generally  occur  (Ballance) .  The  blood  in  some  cases  clots  so  rapidly 
that  it  gathers  in  the  left  loin,  and  is  not  commonly  diffused  throughout  the 
abdomen.  It  gives  rise  to  an  increasing  area  of  dulness  on  percussion  in  the 
left  flank,  which,  Ballance  points  out,  ddes  not  shift  when  the  position  of  the 
patient  is  shifted,  as  it  does  in  bleeding  from  other  intra-abdominal  structures. 
In  some  cases,  however,  the  blood  remains  fluid  and  spreads  throughout 
the  belly,  and  then  there  is  rising  dulness  in  each  flank.  The  case  reported 
by  Le  Dentu  and  Mouchet  shows  that  the  blood  may  remain  fluid  ("Bull, 
de  I'Academie  de  Med.,"  June  16,  1903).  In  some  cases  the  signs  of  hem- 
orrhage are  late  and  they  may  even  be  deferred  until  the  fourth  day  (Eisen- 
drath,  "Annals  of  Surgery,"  Dec,  1902).  Exploratory  incision  will  be  re- 
quired to  certainly  recognize  the  condition.  In  Elder's  table  there  are  52 
uncomplicated  cases,  not  a.  case  was  operated  upon  (operation  was  not 
the  rule  until  1890),  and  84.6  per  cent.  died.  Eisendrath  has  collected  50 
cases  operated  upon:  56  per  cent,  recovered  and  44  per  cent,  died.*  Fevrierf 
has  collected  56  ruptures  of  the  spleen.  In  46  cases  operation  was  performed 
and  the  mortality  was  50  per  cent.  E.  Berger  ("Archiv.  fiir  klinische  Chir- 
urgie,"  Bd.  28,  Heft  3)  collected  168  fatal  cases  of  rupture  of  the  spleen: 
145  died  during  the  first  day  and  every  one  died  from  hemorrhage.  After  the 
first  day  23  died.  In  90  per  cent,  of  the  entire  series  hemorrhage  caused 
death;  in  10  per  cent,  infection  was  responsible  for  death.  The  same  author 
collected  67  cases  treated  by  splenectomy  and  38  of  them  recovered.  Hemor- 
rhage is  the  great  danger  in  ruptured  spleen — hemorrhage  of  the  parenchyma 
rather  than  from  the  great  vessels.  The  parenchyma  is  friable  and  contains 
multitudes  of  capillaries  and  veins,  there  is  no  muscular  tissue,  divided  vessels 
do  not  tend  to  contract,  and  the  capsule  is  thin.  (The  elder  Senn,  in  "Jour. 
Am.  Med.  Assoc,"  Nov.  21,  1903.) 

Treatment  of  Wounds  and  Rupture. — The  treatment  is  evident  from 
the  previous  remarks.  It  is  as  follows:  Open  the  abdomen  immediately, 
the  patient  being  surrounded  with  hot  bottles  and  hot  salt  solution  flowing 

*  Daniel  N.  Eisendrath,  Jour.  Am.  Med.  Assoc,  Oct.  25,  1902. 
fRev.  de  Chir.,  Nov.,  igoi. 


Enlargement  and  Tumors  of  the  Spleen  1047 

into  a  vein.  Explore  the  s])leen  and  other  viscera.  If  the  spleen  is  damaged, 
we  may  do  splenectomy  (total  or  jjartial),  may  use  the  suture,  the  cautery, 
or  the  tampon,  and  any  other  visceral  injuries  are,  of  course,  attended  to. 

The  usual  operation  has  been  total  splenectomy.  In  partial  splenectomy 
only  the  injured  part  is  excised  and  the  wound  margins  are  sutured. 

The  arrest  of  hemorrhage  by  suture  is  known  as  splenorrhaphy.  Lamar- 
chia,  in  1896,  was  the  first  to  perform  this  operation.  The  tear  or  wound 
is  sutured  with  catgut  and  the  suture  line  is  covered  with  omentum.  Berger 
collected  14  cases  of  suturing  with  2  deaths,  but  these  were  injuries  of  less 
severity  than  those  requiring  splenectomy.  In  some  cases  the  tampon  can 
be  used.  Berger  collected  10  cases  with  i  death.  Another  method  is  to 
crush  the  splenic  structure  slowly  with  broad  forcipressure  forceps  and  suture 
the  crushed  margins  with  catgut.  Senn  followed  this  plan.  George  Ben 
Johnston  (paper  read  before  "Johns  Hopkins  Med.  Soc,"  March  2,  1908)  has 
collected  150  cases  of  splenectomy  for  wounds  or  ruptures,  with  99  recoveries 
and  51  deaths,  a  mortality  of  34  per  cent. 

Abscess  of  the  spleen  is  a  rare  condition  which  is  usually  metastatic 
in  origin.  It  may  follow  typhoid,  may  develop  during  pyemia,  or  may  result 
from  injury.  Chronic  suppuration  may  be  due  to  tuberculosis  or  actinomy- 
cosis. Pain  is  felt,  and  enlargement  is  noted  in  the  splenic  region,  and  the 
symptoms  of  pyemia  exist.  The  abscess  may  become  adherent  to  the  belly-wall, 
may  become  encapsuled,  or  may  rupture  into  a  viscus  or  the  peritoneal  ca\'ity. 
Fluctuation  can  seldom  be  obtained.  What  is  known  as  a  tropical  abscess 
(Fontoynant  and  Jourdrau,  in  "Archiv.  Prov.  de  Chir.,"  No.  11,  1902)  may 
develop  during  a  malarial  attack  as  a  result  of  severe  exertion.  There  are  severe 
pain  in  the  left  h\-pochondrium,  dyspnea,  and  dry  tongue.  There  may  or  may 
not  be  fever.     The  pus  may  be  sterile. 

The  treatment  of  abscess  of  the  spleen  consists  in  incising  the  abdomen 
at  the  outer  edge  of  the  left  rectus  muscle,  suturing  the  spleen  to  the  abdominal 
wall,  opening  the  abscess,  and  providing  for  drainage  (Tedenat*).  If  the 
abscess  is  adherent  to  the  abdominal  wall,"  incise  it  directly.  There  are  9 
recorded  cases  of  splenectomy  with  i  death  (George  Ben  Johnston,  Ibid.). 

Enlargement  and  Tumors  of  the  Spleen. — The  spleen  undergoes 
hj^ertrophy  in  the  course  of  infectious  disease,  from  amyloid  disease,  from 
malaria,  from  splenic  anemia,  from  tuberculosis,  from  leukemia,  and  from 
Hodgkin's  disease.  Secondary  cancer  is  seen  after  cancer  of  the  stomach. 
Genuine  primary  tumors  are  extremely  rare.  Fibroma,  enchondroma,  lymphan- 
gioma, angioma,  and  sarcoma  occasionally  develop.  Jepson  and  Albert  re- 
ported a  case  of  primary  sarcoma  of  the  spleen  and  collected  31  others  from 
hterature  ("Annals  of  Surgery,"  July,  1904).  Primary  carcinoma  is  usually 
medullary  and  is  sometimes  melanotic.  Secondary  carcinoma  and  secondary 
sarcoma  are  more  common.  Secondary  cancer,  as  stated  above,  is  seen  after 
cancer  of  the  stomach.  Hydatid  cysts,  dermoid  cysts,  lymph  cysts,  serous 
cysts,  and  blood  cysts  occasionally  develop.  There  are  on  record  12  cases 
of  splenectomy  for  sarcoma:  9  recovered  and  3  died  (George  Ben  Johnston, 
Ibid.). 

Treatment. — The  condition  may  become   clear    only  after  exploratory 
laparotomy.     For  some  tumors  splenectomy  is  indicated.     A  hydatid  cyst  is 
*  Rev.  de  Gynec.  et  de  Chir.  Abd.,  July,  August,  1901. 


1048  Diseases  and  Injuries  of  the  Abdomen 

treated  as  is  a  cyst  of  the  liver  (page  1016).  A  blood  cyst  is  sutured  to  the  inci- 
sion in  the  abdomen  and  is  drained. 

Splenoptosis,  or  Wandering  Spleen.— The  spleen  may  wander  into 
any  part  of  the  general  peritoneal  cavity.  This  condition  is  seldom  met  with 
except  in  v^omen.  It  is  most  common  in  vi^omen  who  have  borne  children. 
A  wandering  spleen  may  undergo  atrophy,  engorgement,  or  axial  ro- 
tation (J.  Bland  Sutton).  The  spleen  may  be  healthy  or  enlarged 
from  malaria  or  leukemia.  As  a  matter  of  fact,  it  is  usually  diseased.  The 
organ  when  displaced  drags  upon  the  stomach,  producing  dilated  stomach; 
it  may  interfere  with  the  bile-duct,  causing  jaundice;  it  may  cause  intestinal 
obstruction  by  forming  adhesions,  or  may  cause  uterine  retroflexion  or  pro- 
lapse by  passing  into  the  pelvis. 

J.  Bland  Sutton  says  this  condition  may  endanger  life,  as  it  may  lead 
to  rupture  of  the  stomach,  intestinal  obstruction,  splenic  abscess,  or  splenic 
rupture.*  A  wandering  spleen  can  be  identified  by  the  fact  that  it  has  a 
notch  upon  its  edge,  and  can  be  pushed  about  the  abdomen.  When  this 
condition  exists,  the  spleen  may  be  missed  from  its  normal  situation.  Always 
examine  the  blood  in  order  to  determine  if  leukemia  or  malaria  exists. 

Treatment. — Greiffenhagen  advocates  suturing  the  organ  in  place  {spleno- 
pexy). Most  surgeons  prefer  to  perform  splenectomy.  In  a  case  without 
leukemia  the  operation  is  very  successful.  Splenectomy  for  wandering  spleen 
is  rarely  followed  by  serious  blood-changes  or  other  trouble.  The  reason 
is  that  a  wandering  spleen  is  usually  a  diseased  organ,  having  undergone 
hypertrophy  or  fibroid  change,  and  other  structures  have  taken  on  splenic 
function.  Splenectomy  should  not  be  undertaken  if  leukemia  exists.  In 
such  a  case  surgeons  usually  apply  a  support  and  employ  medical  treatment 
for  the  existing  disease  or  endeavor  to  suture  the  organ  in  place.  If  the 
spleen  were  enlarged  by  malaria,  I  would  perform  splenectomy  (as  I  did 
in  one  case).  If  the  spleen  were  healthy,  I  would  surround  it  with  gauze 
exactly  as  is  done  with  the  kidney  in  a  case  of  movable  kidney.  If  the  spleen 
were  enlarged  by  leukemia,  I  would  not  operate. 


Operations  upon  the  Abdomen. 

Abdominal  Section  {Celiotomy;  Laparotomy) . — There  are  many  dif- 
ferent methods  of  opening  the  abdomen.  The  plan  selected  depends  upon 
the  nature  and  the  situation  of  the  disease,  and  upon  the  inclinations  and 
the  custom  of  the  operator.  The  abdomen  may  be  opened  to  attack  a  recog- 
nized seat  of  disease  or  to  determine  what  the  disease  is  and  where  it  is  situated. 
Abdominal  section  performed  for  the  latter  purpose  is  spoken  of  as  exploratory 
section  or  exploratory  incision. 

Of  recent  years,  exploratory  operations  have  become  extremely  common, 
and  many  abdominal  conditions  would  be  unrecognized  without  such  explora- 
tion, or  would  be  recognized  at  so  late  a  period  as  to  be  beyond  the  reach 
of  surgery  by  the  time  the  diagnosis  had  been  made.  This  is  notably  true 
of  the  surgical  diseases  of  the  stomach.  The  surgeon  should,  however,  not 
be  too  radical  in  employing  exploratory  operations.     The  fact  that  he  can 

*Brit.  Med.  Jour.,  Jan.  16,  1897. 


Abdominal  Section  1049 

explore  with  such  comparative  impunity  does  not  release  him  from  the  obli- 
gation to  endeavor  by  every  proper  method  to  make  a  diagnosis  before  re- 
sorting to  operation.  I  fancy  that  of  recent  years  the  belief  that  it  is  almost 
waste  of  time  to  make  prolonged  efforts  to  diagnosticate  many  intra-abdom- 
inal troubles  because  the  solution  is  so  much  easier  by  section,  has  become 
so  common  as  to  have  led  young  and  unskilled  operators  to  perform  sec- 
tion in  cases  in  which  the  diagnosis  might  have  been  made  without  this 
procedure. 

Before  opening  the  abdominal  cavity  for  exploratory  purposes  or  to  gain 
access  to  some  area  of  abdominal  or  pelvic  disease  the  patient  is  carefully 
prepared  as  for  any  other  operation.  In  an  appendicitis  case  the  patient 
is  moved  with  the  utmost  care  and  is  prepared  for  operation  most  gently, 
because  of  the  possible  danger  of  rupturing  an  abscess.  In  an  emergency 
case  no  prolonged  or  complicated  method  of  cleansing  can  be  employed. 
The  abdomen  and  loins  are  scrubbed  carefully  with  soap  and  water,  special 
attention  being  given  to  the  umbilicus;  the  pubic  region  is  shaved,  the  soap- 
suds are  washed  away  with  sterile  water,  the  surface  is  gently  scrubbed  with 
alcohol  and  then  with  a  hot  solution  of  corrosive  sublimate  (i  :  1000),  and 
is  covered  \\ith  gauze  wet  \vith  the  sublimate  solution.  As  previously  stated 
(page  59)  we  no  longer  regard  it  as  necessary  to  '"prepare"  the  abdomen  the 
day  before.  The  patient  can  be  prepared  antiseptically  the  morning  of 
the  operation,  or  can  be  shaved  just  before  etherization,  and  be  cleaned 
when  under  ether.  The  instruments  required  depend  upon  the  nature 
of  the  case.  As  a  rule,  there  are  required  scalpels,  scissors,  a  dry  dissector, 
tu'o  pairs  of  dissecting  forceps,  hemostatic  forceps,  pedicle  forceps,  Hagedorn 
needles,  calyx-eyed  intestinal  needles,  a  needle-holder,  drainage-tubes,  gauze 
pads,  gauze  for  sponging,  silk,  catgut,  silkworm-gut,  the  Paquehn  cautery, 
an  electric  light,  also  an  instrument  and  a  saline  solution  for  hypodermoclysis 
or  intravenous  infusion.  Always  count  the  instruments,  sponges,  and  pads, 
and  write  down  the  number,  and  count  them  again  after  operation.  This  rule 
is  adopted  so  that  no  instrument,  sponge,  or  pad  will  be  left  in  the  abdomen. 
The  abdominal  pads  and  sponges  are  not  used  when  dry.  Dry  sponges  injure 
the  peritoneum  and  favor  the  subsequent  development  of  adhesions  (Sanger) . 
The  pads  and  sponges  should  be  wrung  out  in  hot  normal  salt  solution  before 
being  used. 

Operation. — An  anesthetic  is  given.  In  some  cases  the  patient  is  placed 
recumbent;  in  others,  is  put  in  the  position  of  Trendelenburg  (Fig.  529).  In 
the  Trendelenburg  position  the  pelvis  is  elevated,  the  intestines  fall  toward 
the  epigastrium,  are  removed  from  the  necessity  of  being  handled  and  from 
the  danger  of  being  bruised,  the  pelvis  is  thoroughly  exposed,  and  work 
becomes  easier  and  safer.  This  position  should  not  be  used  if  there 
is  myocardial  disease,  as  the  increased  pressure  in  and  flow  of  blood 
from  the  inferior  cava  may  cause  fatal  acute  dilatation  of  the  heart 
(Kraske,  of  Freiburg,  in  Proceed,  of  German  Surg.  Congress,  1903).  The 
position  is  of  Httle  use  in  very  fat  people  (Trendelenburg),  and  in  such 
a  subject  may  cause  intestinal  obstruction  (Kraske).  When  this  position 
is  employed,  the  table  should  be  lowered  as  soon  as  possible,  because 
gastric    hemorrhage    may    occur    (von   Eiselberg).     The    normal   position 


1050  Diseases  and  Injuries  of  the  Abdomen 

should  not  be  suddenly  assumed,  as  this  may  cause  intestinal  obstruction, 
the  omentum  being  mixed  with  coils  of  intestine,  pulling  the  colon  down 
(Pasteau,  in  "Bulletins  and  Mem.  de  la  Soc.  Anat.  de  Paris,"  July,  1905). 
The  position  should  not  be  used  in  a  pelvic  abscess  (Konig),  as  it  may  lead 
to  a  flow  of  pus  from  the  pelvis  into  the  far  more  dangerous  regions  above. 
Volvulus  of  the  ileum  and  also  volvulus  of  the  large  intestine  have  followed 

the  use  of  the  position.  If  the  Trendelen- 
burg position  was  employed,  before  closing  the 
belly  return  the  omentum  to  its  proper  posi- 
tion and  spread  it  out  (Lauenstein).  In 
every  abdominal  operation  the  patient  is  to  be 
carefully  protected  from  cold,  the  extremities 
and  the  chest  are  covered  with  blankets,  and 
Fig.  S29.-The  Trendelenburg  posi-  Sterilized  sheets  are  placed  well  around  the 
t'on.  field  of  operation.     The  skin  is  sterilized  anew 

immediately  before  operating.  The  surgeon 
steadies  the  skin  of  the  belly  with  the  fingers  of  his  left  hand,  and,  holding  the 
knife  free  in  the  right  hand,  makes  an  incision.  For  purposes  of  exploration  the 
incision  is  made  about  two  inches  in  length,  and  it  is  lengthened  if  it  is  found 
necessary.  The  abdomen  may  be  opened  in  the  median  line  above  or  below 
the  umbiHcus.  This  incision  is  advantageous  for  operations  on  the  pelvis, 
for  general  exploration,  and  for  certain  procedures  upon  the  stomach,  the 
intestines,  and  the  left  lobe  of  the  liver.  The  closure  of  such  an  incision,  how- 
ever, lacks  strength,  as  compared  with  the  closure  of  an  incision  where  strong 
muscles  will  overlie  the  scar  through  the  peritoneum  and  the  transversalis 
fascia.  Incision  through  the  semilunar  line  is  practised  by  a  number  of  oper- 
ators. A  favorite  incision  is  through  the  rectus  muscle.  The  fibers  of  this 
muscle  are  separated,  the  structures  beneath  it  are  divided,  and,  after  the  com- 
pletion of  the  operation,  the  deeper  structures  are  sutured  and  the  parts  of  the 
separated  muscle  are  allowed  to  fall  together.  The  scar  resulting  from  such 
an  incision  is  well  supported  and  solid,  hence  the  hkehhood  of  hernia  develop- 
ing is  diminished.  A  favorite  method  with  some  is  to  open  the  sheath  of  the 
rectus  muscle,  retract  the  entire  muscle  aside,  incise  the  posterior  portion 
of  the  sheath  and  the  structures  back  of  it,  and,  when  the  operation  has  been 
completed,  allow  the  entire  muscle  to  come  back  into  place,  and  thus  streng- 
then the  deep-seated  scar.  When  the  abdominal  trouble  is  in  a  region  that 
admits  of  it,  I  almost  invariably  go  through  the  rectus  muscle  or  retract  the 
entire  muscle.  Besides  these  methods,  there  are  special  incisions,  suitable 
for  particular  cases:  An  incision  along  the  costal  margin,  for  reaching  the 
gall-bladder;  an  incision  shaped  like  the  italic  letter  "/,"  for  the  same  pur- 
pose; special  incisions  for  certain  operations  upon  the  stomach,  for  abdomi- 
nal nephrectomy,  etc.  Some  operators  have  even  used  a  transverse  incision 
in  certain  pelvic  operations. 

In  an  operation  through  the  median  line  the  first  cut  goes  to  the  aponeu- 
rosis of  the  external  oblique  muscle.  Clamp  the  vessels.  Do  not  hunt  for 
the  linea  alba  below  the  umbilicus,  but  go  right  through  or  between  the 
recti  muscles.  Above  the  umbilicus  the  linea  alba  is  very  distinct  and  the 
surgeon  often  cuts  through  it.     Divide  the  transversalis  fascia,  beneath  which 


Abdominal  Section  105 1 

is  a  little  fat,  and  expose  the  peritoneum.  The  latter  structure  is  recognized 
by  its  glistening  appearance,  by  the  ease  with  which  it  can  be  pinched  up 
between  the  finger  and  thumb,  and  by  the  readiness  with  which  its  opposed 
surfaces  may  be  made  to  glide  over  each  other.  On  identifying  the  perito- 
neum, catch  it  at  each  side  of  the  incision  with  forceps,  raise  a  fold,  nick 
it  with  a  knife,  and  open  it  with  scissors  to  the  length  of  the  external  wound. 
To  prevent  stripping  of  the  peritoneum  a  good  plan  is  to  anchor  it  to  the 
belly-wall  with  a  stitch  on  each  side  of  the  incision.  Throughvthe  wound 
thus  made  the  abdomen  and  its  contents  are  explored,  the  trouble  located, 
and  determination  made  as  to  whether  or  not  further  operation  is  advisable, 
and,  if  it  is  advisable,  what  form  it  shall  take.  It  may  be  necessary  to  enlarge 
the  wound.  This  is  done  by  placing  the  index  and  middle  fingers  of  the 
left  hand  in  the  belly,  with  their  pulps  against  the  peritoneum,  in  the  line 
where  the  surgeon  will  cut,  to  serve  as  supports  to  the  scissors  and  as  guards 
to  intraperitoneal  structures.  The  scissors  are  introduced  and  the  wound 
is  enlarged  upward,  around  the  umbilicus  if  necessary.  As  soon  as  the 
incision  is  complete  it  is  a  good  plan  to  push  a  large  pad  into  Douglas's 
pouch  and  leave  it  there  until  the  operation  is  finished,  when  it  must  be 
removed.  Slender  adhesions  are  stripped  off  with  the  finger  or  are  pushed  off 
with  gauze;  firm  adhesions  are  tied  in  two  places  and  cut  between  the 
ligatures. 

The  toilet  of  the  peritoneum  is  important  after  the  operation  is  com- 
pleted. Following  a  clean  laparotomy,  when  but  little  blood  has  flowed  into 
the  cavity,  flushing  is  not  required;  if  much  blood  has  flowed  or  if  septic 
matter  has  passed  into  the  peritoneal  cavity,  after  removing  the  sponge  from 
Douglas's  pouch  flush  the  belly  thoroughly  with  hot  normal  salt  solution, 
empty  out  most  of  the  fluid,  but  let  a  pint  or  more  remain  in  the  abdomen.  In 
flushing  the  abdomen  bear  in  mind  Monks's  observations  as  to  the  mesentery. 
It  is  a  sort  of  shelf.  If  we  follow  down  the  left  side  of  it  with  the  finger  the 
finger  must  enter  the  left  iliac  fossa;  if  we  follow  down  the  right  side  of  it 
the  finger  must  enter  the  right  iliac  fossa.  Hence  in  order  to  flush  the  right 
cavity  carry  the  nozzle  down  the  right  side  of  the  mesentery  to  its  root,  and 
in  order  to  flush  the  left  fossa  carry  it  down  the  left  side  of  the  mesentery  to 
the  root  (Monks,  "Annals  of  Surgery,"  Oct.,  1903).  The  retention  of  the 
saline  fluid  in  the  belly  minimizes  shock.  It  is  absorbed  with  great  rapidity 
after  the  operation  if  the  patient  is  placed  with  his  head  lower  than  his  feet, 
because  in  this  position  the  saline  fluid  gravitates  to  the  diaphragmatic  region, 
where  absorption  is  very  active;  in  fact,  in  one  hour  the  peritoneal  cavity 
can  absorb  from  3  to  8  per  cent,  of  the  body  weight.  If  there  is  wide-spread 
infection  with  stomach-contents  or  feces,  eviscerate,  wipe  out  the  peritoneum 
with  pads  soaked  in  hot  normal  salt  solution,  and  wipe  the  intestines  care- 
fully, slowly  returning  them  as  they  are  wiped.  Extravasated  septic  mat- 
ter is  apt  to  collect  in  the  peritoneal  fossas  and  between  the  liver  and  dia- 
phragm, and  these  regions  must  be  carefully  wiped  or  irrigated.  In  cases 
of  septic  and  purulent  peritonitis  flushing,  evisceration,  and  wiping  with 
gauze  are  not  advisable  (page  1006).  In  some  cases  it  is  desirable  to  drain 
through  a  lumbar  incision.  Rutherford  Morison  has  pointed  out  that  a 
lumbar  opening  into  the  right  kidney  pouch  will  drain  a  fossa  which  holds 


1052  Diseases  and  Injuries  of  the  Abdomen 

over  a  pint  of  fluid,  and  which,  when  the  patient  is  recumbent,  is  the  most 
dependent  portion  of  the  peritoneal  cavity.  In  some  cases  a  drainage- 
opening  is  made  on  each  side  of  the  belly  or  above  the  pubis  or  through 
the  vagina.  In  septic  cases  it  may  be  advisable  to  drain  with  several  pieces 
of  iodoform  gauze  instead  of  inserting  tubes.  After  most  laparotomies  drainage 
is  not  needed,  but  it  should  be  used  when  stomach-contents  were  extrava- 
sated,  and  it  must  be  used  if  feces  or  urine  were  extravasated,  in  certain  recent 
septic  cases,  and  when  hemorrhage  has  been  severe.  We  may  drain  by  a 
rubber  tube,  strands  of  gauze,  or  a  glass  tube.  If  a  glass  tube  is  used,  it  is 
introduced  at  a  lower  angle  of  the  wound  and  reaches  the  bottom  of  the 
pouch  of  Douglas.  This  tube  is  repeatedly  emptied  during  the  progress 
of  the  case  by  means  of  a  syringe.  Before  closing  the  wound  arrest  hem- 
orrhage and  count  the  instruments  and  sponges  to  know  that  no  instrument 
or  sponge  has  been  left  in  the  belly. 

It  is  highly  important  that  an  abdominal  incision  shall  be  accurately 
closed,  for  any  failure  of  neat  approximation  will,  in  all  probability,  result 
in  the  formation  of  a  hernia  through  the  cicatrix.  Various  methods  have 
been  employed.  Probably  the  majority  of  operators  use  layer  sutures, 
sewing  up  the  peritoneum  with  a  continuous  suture  of  catgut,  and  the  apo- 
neurotic layers  with  the  same  material  or  with  chromicized  catgut,  and  closing 
the  skin  with  either  interrupted  sutures  of  silkworm-gut  or  a  subcuticular 
stitch  of  catgut,  silkworm-gut,  or  silver  wire.  Other  operators  close  the 
peritoneum  with  a  continuous  suture  of  catgut,  then  pass  silkworm-gut 
sutures  through  all  the  other  structures,  leaving  them  for  the  time  untied; 
put  in  layer  sutures  of  catgut  or  of  chromicized  catgut,  and  then  tie  the 
silkworm-gut  sutures.  A  layer  suture  makes  a  beautifully  neat  approxima- 
tion, and  is  frequently  quite  satisfactory;  but  I  have  become  persuaded  that 
the  dead  space,  so  often  left  unobliterated  when  this  method  of  suturing 
is  employed, — a  space  in  which  blood  and  inflammatory  exudate  may  gather, — 
is  a  danger  to  the  future  integrity  of  the  wound.  The  combination  of  a 
dead  space  with  catgut,  a  material  that  is  always  somewhat  uncertain,  is 
an  unfortunate  one  from  the  surgical  point  of  view.  Recently  I  have  re- 
turned to  the  use  of  the  through-and-through  suture  in  many  cases,  applied  ac- 
cording to  the  method  of  Dr.  Joseph  Price.  This  suture  is  inserted  \\ath  the 
straight  needle,  is  composed  of  silk  or  of  silkworm-gut,  is  put  in  close  to  the  mar- 
gin of  the  skin,  gathers  up  a  great  deal  more  muscle  than  skin,  and  then  passes 
close  to  the  margin  of  the  cut  peritoneum  and  transversalis  fascia.  When 
these  sutures  are  adjusted,  the  peritoneal  edges  are  brought  into  accurate  and 
firm  apposition,  the  peritoneal  surface  is  overlaid  with  abundant  muscle,  the 
skin  edges  are  brought  into  neat  approximation,  and  the  formation  of  a  dead 
space  is  rendered  impossible.  When  passing  the  sutures  have  a  gauze  pad 
under  the  wound  and  be  ver}'  careful  not  to  include  bowel  or  omentum. 
It  is  necessary  to  tighten  and  tie  most  carefully  to  prevent  omentum  being 
caught  in  the  loop  of  the  stitch.  After  closing  a  laparotomy  wound,  dress 
with  aseptic  gauze  and  wood-wool  and  apply  a  flannel  binder.  In  badly 
infected  cases  the  wound  is  often  kept  open. 

If  a  two-inch  incision  has  been  closed  without  drainage  and  primary  union 
has  taken  place,  the  patient  can  usually  get  out  of  bed  in  seven  or  eight  days. 


After-treatment  of  Abdominal  Section  1053 

A  large  incision  offers  greater  danger  of  subsequent  hernia,  and  the  y)atient 
should  be  kept  in  bed  for  two  or  three  weeks.  If  the  wound  has  been  kept  open 
for  drainage,  a  prolonged  retention  in  bed  may  be  necessary.  I  get  patients  up 
at  an  earlier  period  than  used  to  be  my  custom,  but  I  do  not  get  them  up  as  do 
Kiimmell  and  others  in  from  one  to  three  days  (see  Kiimmell,  in  "  Zentralblatt 
f.  Chirurgie,"  1908).  To  get  them  up  reasonably  early  lessens  constipation, 
favors  an  early  return  of  appedte  and  strength,  and  diminishes  the  risk  of 
postoperative  thrombosis  and  embolism  and  of  bronchitis.  We  must  bear 
in  mind  that  if  there  is  myocardial  degeneration  very  early  getting  up  may 
prove  disastrous,  or  even  fatal,  and  that  in  septic  diseases  there  is  often  myo- 
cardial degeneration  (see  E.  W.  Foote,  in  "Progressive  Medicine,"  June,  1909) . 
In  a  case  in  which  an  incision  of  considerable  length  has  been  made,  an  ab- 
dominal support  should  be  worn  for  a  variable  time.  It  limits  the  movements 
of  cough,  laughter,  etc.,  and  reminds  the  patient  of  the  necessity  of  caution  in 
lifting,  hurrying,  etc. 

After-treatment. — The  after-treatment  depends  somewhat  on  the  case, 
but  certain  general  rules  can  be  laid  down.  The  late  J.  Greig  Smith  said 
many  wise  things,  and  among  them  this:  "A  golden  rule  in  the  treatment 
of  cases  of  celiotomy  is  to  let  the  patient  alone.  Everything  approaching 
to  meddlesomeness  is  to  be  condemned.  The  patient  must  not  be  upset 
by  fussy  applications  of  tentative  therapeutics;  when  an  emergency  arises, 
it  is  to  be  met,  promptly  and  decisively,  by  a  method  which  has  been  approved 
trustworthy"  ("Abdominal  Surgery").  In  many  cases,  immediately  after 
the  operation  the  patient  must  be  treated  for  shock  by  methods  previously 
set  forth.  The  treatment  of  vomiting  resulting  from  the  administration  of 
an  anesthetic  is  discussed  on  page  1197,  If  vomiting  persists  during  the 
third  or  fourth  day,  it  is  probably  due  to  the  development  of  inflamma- 
tion which  has  caused  intestinal  paresis;  and  if  it  is  so  produced,  medicine 
is  practically  useless.  In  this  condition  there  is  usually  marked  tympan- 
itic distention,  and  vomiting  is,  in  a  sense,  a  relief.  Nothing  should  be 
given  by  the  mouth,  and  the  patient  should  be  fed  entirely  by  enemata. 
The  insertion  of  a  rectal  tube  and  its  retention  for  a  considerable  time  may 
afford  relief.  Lying  on  the  side  is  more  comfortable  than  recumbency. 
Washing  out  the  stomach  from  time  to  time  gives  great  comfort  and  is  often 
of  real  service. 

In  the  average  case  of  celiotomy,  in  which  persistent  vomiting  does  not 
occur,  the  question  of  feeding  is  of  much  importance.  Usually,  for  the 
first  twelve  or  twenty-four  hours,  nothing  is  given  by  the  mouth  but  small 
quantities  of  hot  water.  The  day  after  the  operation,  if  everything  is  satis- 
factory, food  is  given  to  the  patient.  In  many  cases,  however,  food  is  not 
given  by  the  stomach  for  forty-eight  hours  and  the  patient  is  fed  by  the  rec- 
tum during  the  wait.  He  should  not  be  given  milk,  because  it  will  not  be 
easily  digested,  may  lead  to  nausea,  and  causes  flatulence.  Peptonized 
milk,  if  the  patient  will  take  it,  does  not  possess  these  hurtful  qualities.  At 
first  albumin-water  or  liquid  beef  peptonoids  should  be  given  and  later 
Valentine's  meat-juice,  beef-jelly,  broth,  etc.  Food  is  given  every  third  or 
fourth  hour,  and  stimulants  are  administered  if  required.  After  the  first 
twenty-four  or  forty-eight  hours  considerable   quantities  of  plain  water  or 


I054  Diseases  and  Injuries  of  the  Abdomen 

Poland  water  should  be  taken,  when  possible,  to  favor  elimination  by  the 
kidneys.  Hot  coffee  is  not  only  a  stimulant,  but  is  an  excellent  diuretic. 
The  vurine  is  always  scanty  after  an  abdominal  operation,  and  a  normal 
daily  amount  is  not  voided  for  ten  days  or  more.  Solid  food  is  not  given 
for  seven  or  eight  days.  The  patient  is  apt  to  suffer  greatly  from  thirst, 
in  spite  of  the  hot  water  given  during  the  first  twelve  to  twenty-four  hours 
It  does  not  do  to  give  any  considerable  amount  of  hot  water,  and  cold  water 
and  ice  are  inadmissible  and  tend  to  induce  nausea  and  vomiting.  Thirst 
can  be  much  mitigated  by  enemata  of  water.  J.  Greig  Smith  recommended 
an  enema  composed  of  from  4  to  20  ounces  of  tepid  water  and  some  brandy. 
Usually,  after  the  first  twenty-four  hours,  a  sufficient  amount  of  liquid  can 
be  given  to  keep  the  patient  free  from  actual  distress. 

The  bladder  must  be  watched  to  see  that  retention  does  not  occur.  If 
retention  occurs,  a  clean  catheter  must  be  used  at  regular  intervals.  If 
tympanitic  distention  occurs  after  forty-eight  hours,  a  saline  purgative  should 
be  given  and  it  should  be  followed  by  an  enema  of  turpentine  (page  1005). 
The  rectal  tube  is  frequently  of  signal  service  in  such  cases.  If  obstruction 
develops,  it  is  treated  as  directed  on  page  976. 

In  any  ordinary  case  after  operation  the  bowels  should  be  moved  after 
forty-eight  hours  as  a  prophylactic  measure  against  distention,  peritonitis, 
and  obstruction.  From  four  to  eight  one-dram  doses  of  Epsom  salts  are  given, 
in  hot  water,  the  solution  having  been  filtered  through  gauze.  The  saline 
is  followed  by  the  administration  of  an  enema  consisting  of  soap,  water,  and 
half  an  ounce  of  castor-oil.  Should  opium  be  given?  Never  as  a  rou- 
tine, and  not  to  secure  sleep;  but  if  the  patient  is  in  pain  which  not  only 
harasses  him  but  causes  him  to  turn  and  shift  in  torturing  restlessness,  one 
or  possibly  two  hypodermatic  injections  each  containing  ^  gr.  of  morphin 
can  be  given  with  confidence  that  the  good  will  overbalance  the  harm. 

Operation  for  Appendicitis.— Before  operating  try  to  locate  the 
situation  of  the  appendix,  and  the  relation  the  area  of  infection  bears  to 
the  ascending  colon.  The  incision  should  be  over  the  seat  of  disease.  In 
the  rare  left-sided  cases  and  in  median  cases  the  incision  is  median.  In  some 
cases  where  the  appendix  is  posterior  the  cut  may  be  in  the  loin.  In  one 
case  I  opened  a  purulent  collection  through  the  rectum.  In  the  vast  majority 
of  cases  the  incision  is  made  in  the  right  iliac  region. 

In  acute  appendicitis  when  there  is  not  thought  to  be  a  distinct  abscess, 
the  incision  usually  made  is  two  inches  internal  to  the  anterior  superior 
ihac  spine  and  perpendicular  to  a  line  drawn  from  the  spine  to  the  umbilicus 
(Fig.  530).  The  skin  incision  is  usually  three  inches  in  length,  the  upper 
third  of  the  incision  being  above  the  omphalospinous  line;  the  incision  in 
the  peritoneum  is  about  two  inches  in  length,  but  if  there  are  many 
adhesions,  it  may  be  necessary  to  make  it  much  longer.  The  oblique 
incision  may  be  carried  out  as  advised  by  McBurney,  the  muscles  being 
separated  by  blunt  dissection.  By  this  method  very  few  nerve-fibers  are 
divided,  and  hence  the  operation  is  not  followed  by  marked  muscular 
wasting,  a  condition  which  strongly  predisposes  to  hernia.  Further,  as 
Van  Hook  points  out,*  the  oblique  incision  enables  the  surgeon  to  reach 
*  Jour.  Amer.   Med.  Assoc,  Feb.  20,  1897. 


Operation  for  Appendicitis 


1055 


freely  all  the  ordinary  areas  of  appendix  trouble,  the  wound  is  par- 
allel with  the  lines  of  trac- 
tion of  the  abdominal  muscles 
and  does  not  tend  to  gape 
widely.  In  an  acute  case  I 
make  an  oblique  incision,  but 
cut  the  muscles.  In  an  inter- 
val case  I  separate  the  mus- 
cular fibers.  Battle's  incision 
at  the  outer  edge  of  the  rectus 
muscle  is  preferred  by  many 
surgeons.  The  anterior  layer 
of  the  rectus  sheath  is  opened 
longitudinally,  the  rectus  is 
drawn  inward,  and  any  ex- 
isting portion  of  the  posterior 
rectus  sheath  with  the  trans- 
versalis  fascia  and  peritoneum 
is  incised. 

I  have  used  Davis's  trans- 
verse incision  (Figs.  531  and 
532)  in  many  interval  cases 
with  entire  satisfaction 
(Gwilym  G.  Davis,  in  "An- 
nals of  Surgery, "Jan.,  igo6). 
This  incision  does  not  divide 
arteries,  and  it  divides  the 
deep  muscles  in  the  direction 
of  the  nerves,  hence  the 
nerves  are  not  injured.  The 
center  of  this  incision  is  al- 
most over  the  base  of  the  ap- 
pendix. Davis  describes  his 
incision  as  follows  ("Annals 
of  Surgery,"  Jan.,  igo6): 

^^For  easy  cases  the  incision  is  made  directly  transverse,  one  and  a  half 
inches  long.  Its  center  is  to  be  on  the  semilunar  line  on  a  level  with  the 
anterior-superior  spine.  The  aponeurosis  of  the  external  oblique  is  divided 
in  the  Hne  of  the  skin  incision,  but  obliquely  to  the  direction  of  its  fibers. 
The  fibers  of  the  internal  oblique  and  transversalis  muscles  are  parted — not 
cut — in  the  same  line  as  the  structures  above.  The  peritoneum  is  then 
opened  and  the  incision  carried  inward,  first  through  the  anterior  layer  of 
the  sheath  of  the  rectus.  A  blunt  retractor  three-quarters  of  an  inch  wide 
is  then  inserted  and  the  muscle  drawn  toward  the  median  line.  This  exposes 
the  transversalis  fascia  and  peritoneum  posteriorly,  which  are  then  also  divided. 
Thus  is  obtained  a  triangular  opening  with  its  base  of  three-quarters  of  an 
inch  and  two  sides  of  about  an  inch  long  which  is  ample  for  simple  cases. 

For  Difficult  Cases. — If  the  case  is  a  difficult  one,  the  outer  end  of  the  inci- 
sion is  prolonged  to  the  anterior  spine  or  even  above  and  inwardly  through 


Fig.  530.— Resection  of  the  vermiform  appendix,  inci- 
sion through  the  abdominal  wall:  a.  External  oblique  mus- 
cle; b,  internal  oblique  muscle;  c,  aponeurosis  of  external 
oblique;  d,  aponeurosis  of  internal  oblique;  e,  peritoneum; 
/,  outer  border  of  rectus  abdominis  muscle  (under  it  the 
deep  epigastric  vessels)  (Kocher). 


io^6 


Diseases  and  Injuries  of  the  Abdomen 


the  sheath  of  the  rectus  to  within  an  inch  of  the  median  hne.  This  will 
give  an  opening  four  to  five  inches  long  according  to  the  size  of  the  patient, 
sufficiently  large  to  insert  the  hand  if  necessary  and  through  which  the  appen- 
dix can  be  extracted  under  almost  all  circumstances." 

After  opening  the  peritoneum  examine  very  gently  to  detect  the  situation 


JJmliUeua. 


j4ntu-ior     \ 
j3u/xrior~  - 


Fig-  531 — Davis's  small  transverse  incision  for  simple  cases. 


UmlilieuS. 


Atter'iQr     % 
Spine        '■ 


Fig.  532. — Davis's  large  transverse  incision  for  difficult  cases. 


of  the  appendix,  and  if  there  are  or  are  not  adhesions.  In  a  very  recent 
case  and  in  a  ver}'  acute  case  there  will  probably  be  no  adhesions  unless 
there  have  been  previous  attacks.  Surround  the  region  of  infection  with 
strips  of  iodoform  gauze,  each  strip  being  two  and  one-half  inches  wide,  fif- 
teen inches  long,  and  four  layers  in  thickness.     The  edges  of  the  wound 


Operation  for  Appendicitis 


1057 


should  be  lifted  up  by  retractors  and  the  strips  inserted  around  the  cut,  between 
the  parietal  peritoneum  and  intestines  and  to  a  distance  of  three  inches  from 
the  wound.  Strips  of  gauze  are  passed,  when  possible,  below  the  apj)endix 
to  prevent  entrance  of  infected  material  into  the  pelvis,  and  a  piece  is  pushed 
upward  toward  the  hver  (Van  Hook).  Over  the  iodoform  gauze  which 
it  may  be  necessary  to  leave  in  place  after  the  operation  gauze  pads  are 
packed.  The  appendix  is  sought  for  by  finding  the  colon.  The  cok)n  is 
found  by  following  the  parietal  peritoneum  with  the  finger.  The  course  of 
the  finger  is  first  outward,  next  backward,  and  finally  inward;  the  first  ob- 
struction it  encounters  is  the  colon.  The  fact  that  it  is  the  colon  can  be 
confirmed  by  finding  the  longitudinal  bands.  The  anterior  longitudinal 
band  leads  directly  to  the  appendix.  Pass  the  finger  down  to  the  head  of  the 
colon,  find  the  appendix,  usually  posterior  and  internal,  and  Uft  it  and  the  head 


Fig.  533- — Radical  operation  for  appendicitis  (Kocher). 


of  the  colon  into  the  wound.  In  some  cases  it  will  be  advisable  to  deliver  the  head 
of  the  colon  from  the  belly  (Fig.  533) ;  in  other  cases  this  will  not  be  necessary. 
If  adhesions  exist,  they  must  be  gently  and  carefully  separated.  Barker's 
method  (Fig.  535)  is  a  very  satisfactory  mode  of  removing  the  appendix.  It  is 
done  as  follows:  Turn  up  acufT  of  peritoneum,  pulldown  the  other  coats,  Hgate 
at  the  base,  cut  through  the  tube,  let  the  musculomucous  stump  retract,  and 
tie  or  suture  the  peritoneal  cuff  over  the  stump.  Another  method,  which  is  the 
one  I  usually  employ,  is  as  follows:  Pass  a  ligature  through  the  meso-appendix 
as  shown  in  Fig.  534,  a.tA,  tie  the  Hgature,  and  cut  off  the  meso-appendix  below 
the  threads.  Crush  the  stump  of  the  appendix  with  strong  straight  hemostatic 
forceps.  This  divides  the  mucous  membrane,  submucous  tissue,  and  muscular 
coat,  and  leaves  the  peritoneal  coat  undivided.  Remove  the  forceps.  Sur- 
67 


lO: 


Diseases  and  Injuries  of  the  Abdomen 


round  the  appendix  with  a  catgut  ligature  and  tie  the  Hgature  in  the  groove 
produced  by  the  crushing.  When  the  hgature  is  tied,  peritoneum  is  brought 
against  peritoneum  (Fig.  534) .  Cut  off  the  appendix  between  the  Hgature  and 
a  clamp  with  the  cauter}',  a  knife,  or  scissors.  Disinfect  the  stump  of  appen- 
dix \\'ith  pure  carbohc  acid.  The  stump  beyond  the  ligature  contains  mucous 
membrane  and  muscle,  which  are  hfted  out  \\-ith  forceps  and  scissors.  Suture 
the  fringe  of  the  meso-appendix  and  invert.  Fig.  534  shows  an  older  method 
still  used  by  many.  The  meso-appendix  is  tied  oft  by  one  ligature,  the  appen- 
dix is  not  crushed,  but  is  tied  off  by  another  hgature,  and  both  structures  are 
cut  off  below  their  respective  ligatures.  The  stump  is  disinfected  \\ith  pure 
carboUc  acid  or  the  cauter}-,  inverted,  and  the  fringe  of  the  meso-appendix 
is  sutured.  This  method  does  not  entirely  remove  the  appendix,  but  inverts 
glandular  tissue  into  the  wall  of  the  bowel.  The  stump  may  not  be  completely 
asepticized  by  the  carbolic  acid  and  hence  may  lead  to  postoperative  abscess, 
dense  adhesions,  or  fecal  fistula,  or  the  undestroyed  lymphoid  structure  may 
cause  future  trouble,  even  persistent  ill  health  (Joseph  Price) .     Some  remove 


Fig.  534- — Ligation  of  appendix  and  meso-appendix. 


Fig.  535.— Barker's  technic  of 
operation  for  removal  of  the  ajv 
pendix. 


the  appendix  by  an  elhptical  incision  around  its  base,  and  close  the  colon 
wound  by  Lembert  sutures.  This  method,  of  course,  removes  the  appendix 
completely.  Dawbam  surrounds  the  appendix  with  a  continuous  Lembert 
purse-stiing  suture  of  silk.  This  is  inserted  in  the  superficial  layers  of  the 
cecum,  half  an  inch  from  the  appendix.  The  appendix  is  divided  so  as  to 
leave  a  stump  never  shorter  than  half  an  inch.  The  lumen  of  the  stump  is 
gently  stretched  by  inserting  a  pair  of  mouse-toothed  forceps  and  opening  the 
blades.  The  stump  is  then  invaginated  into  the  cecum — that  is,  it  is  turned 
"outside  in."  The  sutures  are  tightened,  and  while  this  is  being  done,  the 
mouse-tooth  forceps  used  in  eft'ecting  inversion  are  \\ithdrawn.  Finally,  the 
.sutures  are  tied  (Robt.  H.  M.  Dawbam,  in  "Internat.  Jour,  of  Surg.,"  May, 
1895).  In  this  method  the  stump  is  not  Ugated  and  hemorrhage  is  liable  to 
take  place  into  the  gut.  Deaths  from  such  hemorrhage  are  on  record.  The 
retained  bit  of  appendix  drains  into  the  colon.  I  beheve  it  is  a  mistake  to 
trust  to  simple  hgation  and  to  fail  to  bury  the  stump  left  after  appendectomy. 


Operation  for  Appendicitis  1059 

If  a  surgeon  follows  this  plan  in  any  large  number  of  cases,  he  will  be  apt  now 
and  then  to  have  a  case  in  which  the  ligature  slips  and  feces  pass  into  the  peri- 
toneal cavity,  or  cases  of  temporary  fecal  fistula,  or  cases  of  intestinal  obstruc- 
tion from  adhesion  of  some  portion  of  the  bowel  to  the  exposed  stump  (see 
Murat  Willis,  in  "Annals  of  Surgery,"  July,  1908).  I  do  not  believe  that  a 
buried  stump  increases  postoperarive  pain. 

If  there  is  no  pus  or  no  extra vasated  feces,  if  the  peritoneum  is  not  seriously 
affected,  if  the  appendix  is  not  gangrenous  or  perforated,  and  if  there  is  no  pus 
within  the  appendix,  remove  the  pads,  irrigate  with  hot  salt  solution,  remove 
the  strips  of  gauze,  and  close  the  wound.  If  any  of  the  above  condidons  were 
found,  remove  the  infected  pads,  but  leave  the  iodoform  strips  in  place  to 
limit  infection  and  secure  drainage.  Pass  sutures  through  the  wound  edges, 
tie  some  of  the  sutures  and  leave  some  untied  until  gauze  is  removed  at  a  later 
period  (Van  Hook). 

If  an  operation  is  performed  in  a  distinct  interval,  pus  is  absent,  and  the 
surgeon  can  proceed  mthout  apprehension.  If  there  is  any  question  of  the 
presence  of  pus,  surround  the  region  with  gauze,  as  suggested  above,  before 
breaking  down  adhesions  and  liberating  the  appendix.  An  inten^al  opera- 
tion should  not  be  performed  until  three  weeks  after  an  attack.  In  an  interval 
case  McBumey  proceeds  as  follows:  He  makes  the  skin  incision  in  the  direc- 
tion of  the  fibers  of  the  external  oblique  muscle,  separates  the  fibers  of  this 
muscle  by  blunt  dissection,  retracts  them,  separates  the  fibers  of  the  internal 
oblique  and  the  transversalis  muscles  in  the  same  way  and  retracts  them,  and 
opens  the  transversalis  fascia  and  peritoneum.  Xo  muscle  fibers  are  cut  and 
hernia  is  not  apt  to  follow.  Such  a  wound  is  closed  as  follows:  a  continuous 
catgut  suture  for  the  peritoneum,  sutures  of  kangaroo-tendon  for  the  transver- 
salis fascia,  the  muscles  are  restored  to  place,  the  aponeurosis  of  the  ex- 
ternal obHque  is  sutured  with  kangaroo-tendon,  and  the  skin  is  closed  by 
a  subcuticular  stitch. 

If  an  abscess  is  believed  to  exist,  make  an  incision  parallel  with  Poupart's 
ligament  and  over  the  area  of  dulness  on  percussion  (Willard  Parker's  oblique 
incision).  If  the  abscess  is  adherent  to  the  anterior  abdominal  wall,  such  an 
incision  will  not  enter  the  free  peritoneal  cavity.  If,  after  opening  the  abdo- 
men, an  abscess  is  thought  to  exist,  although  it  is  not  adherent  to  the  anterior 
abdominal  wall,  smround  the  abscess  with  gauze  before  opening  it,  as  directed 
under  acute  appendicitis.  The  gauze  is  placed  under  the  margins  of  the 
incision  in  the  peritoneum  all  around  the  appendix  area;  a  piece  is  carried 
toward  the  pelvis  and  another  piece  toward  the  liver.  Overlay  this  gauze 
with  gauze  pads  (Van  Hook).  Adhesions  are  broken  through  with  the  finger, 
and  when  pus  appears,  it  is  at  once  wiped  away.  Remove  the  appendix  in 
most  cases,  but  not  in  all.  If  the  appendix  lies  loose  in  the  abscess-cavity, 
if  it  is  sloughed  off  or  but  loosely  attached  to  the  abscess-wall,  remove  it.  If 
the  appendix  is  fiamly  fixed  in  the  abscess-wall  and  must  be  dug  out  of  a  mass 
of  inflammatory  material,  do  not  remove  it.  To  remove  it  under  these  cir- 
cumstaruies  may  rupture  the  wall  and  disseminate  the  pus  into  regions  not 
protected  by  pads  and  gauze.  Deaver  and  others  tell  us  always  to  remove 
the  appendix.  I  do  not  believe  this  to  be  a  safe  rule  to  follow.  To  insist 
on  removing  the  appendix  may  cause  death.     When  the  appendix  is  left,  it 


io6o  Diseases  and  Injuries  of  the  Abdomen 

usually  sloughs  away.  It  is  true,  a  fecal  fistula  may  result,  but  this  is  in  the 
large  boWfel  and  usually  heals  spontaneously.  Even  if  a  fecal  fistula  forms  and 
does  not  heal,  the  surgeon  acted  properly  in  not  removing  the  appendix,  be- 
cause a  fecal  fistula  may  be  remedied  by  another  operation.  It  is  rarely  that 
secondary  abscess  forms,  and  there  are  not  a  great  many  cases  recorded  in 
which  an  appendix  has  subsequently  given  serious  trouble  when  left  after  opera- 
tion. In  fact,  in  many  cases  the  appendix  is  destroyed  or  obliterated  by  inflam- 
mation. In  some  cases,  however,  a  secondary  operation  will  be  required 
because  of  a  fecal  fistula,  a  persistent  sinus,  or  an  acute  inflammatory  attack. 
When  Deaver  decides  to  remove  such  an  appendix,  he  makes  an  incision 
in  the  median  line  of  the  abdomen,  packs  around  the  periphery  of  the  ab- 
scess with  gauze,  opens  the  abdomen  by  another  incision,  removes  the  appen- 
dix, disinfects,  inserts  drainage,  and  then  removes  the  surrounding  gauze 
and  closes  the  median  incision.  Irrigation  should  not  be  employed  in  appen- 
dicular abscess.  The  force  of  the  stream  may  break  down  barriers  of  lymph 
and  spread  infection.  After  the  evacuation  of  the  pus,  whether  the  appen- 
dix was  removed  or  not,  take  out  the  pads,  but  leave  the  long  strands  of 
iodoform  gauze  in  place  (Van  Hook).  Introduce  iodoform  gauze  into  the 
abscess-cavity  and  insert  a  rubber  tube,  partially  suture  the  wound,  and 
dress  with  dry  gauze.  In  forty-eight  hours  all  the  strands  of  gauze  are 
removed  and  fresh  pieces  are  inserted  for  drainage.  After  this  period  the 
gauze  drain  is  changed  daily.  An  interval  case  should  be  up  and  about  in 
from  ten  days  to  two  weeks  after  operation.  An  abscess  case  may  require 
a  much  longer  time  for  complete  recovery.  A  fecal  fistula  sometimes  results 
in  cases  in  which  the  appendix  was  not  removed,  and  occasionally  forms 
when  it  was  removed.  Morris  maintains  and  proves  that  these  large  pieces 
of  iodoform  gauze  sometimes  cause  intestinal  obstruction  and  sometimes 
iodoform-poisoning,  but  the  risk,  it  seems  to  me,  should  be  taken. 

If  on  opening  the  abdomen  pus  is  found,  unlimited  by  adhesions  but 
wide-spread  in  the  peritoneal  cavity,  remove  the  appendix,  and  then  bear 
in  mind  Murphy's  wise  counsel  as  to  how  to  treat  general  peritonitis  (page 
1006).  Put  a  drainage-tube  in  the  pelvis,  place  the  patient  in  Fowler's 
position,  and  administer  salt  solution  by  continuous  proctoclysis  at  a  low 
pressure.  The  after-treatment  of  an  ordinary  appendix  operation  is  advised 
after  celiotomy  (page  1053). 

Mortality  ajter  Operations  for  Appendicitis. — The  interval  operation  is 
practically  without  mortality.  In  over  1000  cases  Treves  had  2  deaths.  In 
acute  cases  the  mortality  is  large.  In  100  consecutive  cases  collected  by 
Hearn  and  operated  upon  in  the  Jefferson  Hospital  by  Keen,  Hearn,  and 
DaCosta,  there  were  8  deaths.  As  previously  stated,  Maurice  H.  Richardson 
reports  a  death-rate  of  18  per  cent,  in  750  cases.  Deaver  reports  from  the 
German  Hospital  144  cases  with  a  mortaUty  of  17.8  per  cent.  He  eliminates 
one  death  from  diabetes,  one  from  pneumonia,  and  one  from  phthisis,  and 
estunates  his  personal  mortality  at  15.9  per  cent.  (Deaver  and  Ross,  in 
"Jour.  Amer.  Med.  Assoc,"  Oct.  5,  igoi).  In  124  cases  (including  all 
chronic  cases  and  those  acute  cases  in  which  the  inflammation  had  not  ex- 
tended beyond  the  peritoneal  coat)  there  was  i  death.  The  usual  causes  of 
death  are  intestinal  obstruction,  septic  peritonitis,  septic  endocarditis,  pylo- 


Enterorrhaphy,  or  Suture  of  the  Intestine 


1061 


phlebitis,  he])atic  suppuration,  metastatic  abscesses,  endocarditis,  and  gan- 
grene of  the  bowel.  In  a  further  report  from  September  i,  1902,  to  September 
I,  1903,  Deaver  reports  566  cases  in  the  German  Hospital,  with  an  aggregate 
mortality  of  5  per  cent.  In  cases  with  diffuse  peritonitis  the  mortality  was 
31  per  cent.  In  abscess  about  a  necrotic  and  perforated  appendix  it  was 
12  per  cent.  In  early  appendicitis  or  when  disease  was  confined  to  the  appen- 
dix it  was  0.8  per  cent. 

Appendicostomy  (Weir's  Operation).— This  operation  was  devised 

by  Weir,  of  New  York,  in  1902,  It  consists  in  opening  the  abdomen,  finding 
the  appendix,  fastening  this  structure  to  the  skin,  closing  the  rest  of  the  wound, 
opening  the  appendix  to  see  that  it  is  patent,  and  applying  a  temporary  ligature 
to  prevent  leaking.  The  temporary  ligature  is  removed  in  a  day  or  two, 
and  a  few  days  later  the  adherent  and  open  appendix  is  used  as  a  route  for 
the  introduction  of  irrigating  fluids.  The  operation  is  of  the  greatest  value 
in  chronic  ulcerative  colitis,  as  it  enables  us  thoroughly  to  irrigate  the  large 
bowel.  Daily  a  large  tube  is  passed  into  the  rectum  and  a  small  tube  into 
the  appendix.  The  fecal  matter  is  washed  out  of  the  bowel  with  salt  solu- 
tion, and  then  a  i :  5000  solution  of  silver  nitrate  or  bismuth  and  starch  water 
(5j  to  the  5)  is  used  to  irrigate.  It  is  used  for  the  same  purpose  in  some 
cases  of  tuberculous  rectal  or  anal  fistulas.  A  most  extraordinary  sugges- 
tion is  that  appendicostomy  be  performed  in  epileptics,  so  that  the  opening 
may  be  used  to  flush  the  bowel,  a  suggestion  which  I  will  not  act  upon. 
When  the  fistula  exists,  it  does  not  leak  to  any  appreciable  degree. 
When  we  wish  to  close  it,  we  insert  within  the  lumen  of  the  tube  the  Paquelin 
cautery  at  a  red  heat.  This  destroys  the  mucous  membrane  and  the  fistula 
closes  (Robt.  Weir  in  "Med.  Record,"  August  9,  1902). 

Enterorrhaphy,  or  Suture  of  the  Intestine.— Surgical  opinion  has 
greatly  altered  in  regard  to  this  operation  since  the  day  when  John  Bell  wrote 
his  famous  attack  on  Benjamin  Bell.  John  Bell  said:  "If  in  all  surgery  there 
is  a  work  of  supererogation,  it  is  this  operation  of  sewing  up  a  wounded  gut.  '* 
To-day  we  know  that  if  in  all  surgery  there  is  a  proceeding  of  imperative 
necessity,  it  is  the  sewing  up  of  a  wound  in  the  intestine.  To  perform  this 
operation  take  fine  sterile  silk  and  thread  a  thin,  round,  straight,  calyx-eyed 


Fig.  536 — Eye  of  the 
calyx-eyed  needle. 


Fig-  537  —Enterorrhaphy  : 


A,    Lembert's  suture ; 
suture. 


B,  Dupuytren's 


needle  with  it  (Fig.  536).  The  needle  is  very  useful,  as  it  can  be  threaded 
rapidly  by  pushing  the  calyx  eye  down  upon  the  silk  thread  while  the  latter  is 
kept  taut.  Lembert's  suture  (Figs.  537,  A,  543,  and  544)  was  devised  in 
1823.      Lembert  used  it  on  animals,  but  never  on  man.     It  is  inserted  at  right 


io62 


Diseases  and  Injuries  of  the  Abdomen 


angles  to  the  wound.     It  goes  down  to,  but  not  through,  the  mucous  mem- 
brane.    It  is  formed  by  picking  up  a  fold  of  the  intestine  (one-twelfth  to  one- 


Fig.  538. — Cushing's  right-angled  suture  (Senn). 


Fig.  539.— Ford's  stitch,  showing  a  Lembert 
insertion  and  the  needle  passed  so  as  to  tie  a 
single  knot  by  drawing  it  on  through. 


::  1      i 


eighth  of  an  inch  wide)  one-eighth  of  an  inch  from  the  edge  on  one  side  of  the 
wound,  passing  the  needle  through,  picking  up  a  fold  on  the  opposite  side  of 
the  wound,  and  passing  the  needle  through.  On  tying  the  threads  the  serous 
membrane  is  inverted  and  peritoneum  is  brought  into  contact  with  peritoneum. 
For  many  years  it  was  taught  that  this  suture  should  include  only  the  serous 
coat,  but  Halsted,  in  1887,  showed  that  it  must  include  the  tough  submucous 
coat.     The  submucous  coat  is  strong,  and  will  hold  a  suture.     The  other  coats 

are  thin,  tear  easily,  and  will  not  hold  a  suture. 
^  ^  So  thin  are  the  coats  that  a  surgeon  coxild  not 

suture  the  serous  coat  alone  were  he  to  try. 
Sutures  which  include  only  the  muscular  and 
serous  coats  tear  out  easily.  Dupuytren's 
suture  (Fig.  537,  b)  is  simply  a  continuous 
Lembert  suture  running  obliquely  across  the 
wound.  Cushing's  right-angled  suture  (Fig. 
538)  is  a  continuous  suture  catching  up  the 
submucous  coat  and  serving  to  invert  the 
serous  layer.  Ford,  of  San  Francisco,  em- 
ploys a  continuous  inversion  suture,  which 
is  tied  in  a  single  knot  each  time  it  is  drawn 
through  (Fig.  539).  Downes,  of  Philadel- 
phia, uses  a  similar  stitch.  Halsted 's  mat- 
tress or  quilt  suture  is  shown  in  Fig.  540. 
Each  stitch  picks  up  the  submucous  coat.  Mattress  sutures  do  not  tear  out 
easily,  they  appose  evenly  considerable  surfaces,  and  do  not  constrict  the 
tissue  as  much  as  Lembert  stitches.  The  Czerny-Lembert  suture  is  a  suture 
passed  through  the  serous  membrane  on  one  side  of  the  wound,  made  to  per- 
forate the  mucous  membrane,  and  to  emerge  at  a  corresponding  point  of  the 


:: ) 


) 


Fig.  540. — A,  Halsted  sutures  un- 
tied ;  B,  Halsted  sutures  tied  and 
serous  surface  inverted. 


Digital  Dilatation  of  Pyloris  for  Cicatricial  Stenosis  1063 

serous  membrane.  A  Lembert  suture  is  added  (Fig.  541).  As  at  present 
used,  the  Czerny  suture  is  carried  to,  but  not  through,  the  mucous  membrane. 
Gussenbauer's  suture  is  similar  to  the  Czerny- Lembert  suture,  except  that  it 
applies  the  Czerny  and  the  Lembert  with  one  suture,  and  this  suture  does 
not  pass  through  the  mucous  membrane  (Fig.  546).     In  Connell's  suture 


Fig.  541.— Czerny-Lembert  suture. 


Fig.  542. — Czerny-Lembert  suture 
as  at  present  used. 


(F.  Gregory  Connell,  in  "Phil.  Med.  Jour.,"  Jan.,  1899)  the  knots  are  placed 
within  the  lumen  of  the  bowel  (Plate  10).  Connell's  very  useful  and  ingenious 
stitch  seems  to  be  a  modification  of  a  stitch  described  by  Frederick  Holme 
Wiggin  ("Med.  Record,"  Nov.  19,  1898).  Wolfler's  suture  unites  broad 
layers  of  the  serous  coat,  the  knots  being  tied  internally  (Fig.  545)-  Senn 
says  that  after  suturing  a  large  wound  of  the  stomach  or  of  the  intestine  a 
strip  of  omentum  ought  to  be  laid  over  the  wound  and  fastened  by  catgut 
sutures  (omental  graft).  These  grafts  adhere  and  are  a  safeguard  against 
leakage.  (For  other  methods  of  enterorrhaphy  see  Intestinal  Resection  and 
Anastomosis.) 

Operations  upon  the  Stomach. — A  patient  must  be  carefully  pre- 
pared for  an  operation  upon  the  stomach.  The  Johns  Hopkins  method, 
founded  on  the  researches  of  Harvey  Cushing  regarding  steriHzation  of  the 
stomach,  is  to  be  used.  During  the  two  or  three  days  immediately  preceding 
operation  clean  the  mouth  and  teeth  several  times  during  the  day  with  a  car- 
bolic solution.  Give  only  sterile  water  and  sterile  liquid  food  by  the  mouth, 
and  for  twelve  hours  before  operation  give  no  food  whatever.  During  the 
two  or  three  days  before  operation  wash  the  stomach  with  boiled  water  night 
and  morning.  I  do  not  wash  immediately  before  operation,  as  it  sometimes 
leads  to  annoying  vomiting  and  thus  may  interfere  with  anesthetization. 
After  operation  give  no  food  whatever  for  thirty-six  hours.  Small  quantities 
of  hot  water  are  allowed  as  soon  as  the  patient  recovers  from  ether.  During 
the  first  twenty-four  hours  give  an  enema  of  hot  salt  solution  and  coffee  every 
five  hours  and  then  alternate  nutritive  enemata  with  salt  enemata.  After 
thirty-six  or  forty-eight  hours  usually  begin  to  give  food — at  first  small  doses  of 
albumin-water,  and,  if  this  is  tolerated,  broth  and  milk.  Solid  food  should 
not  be  given  for  two  weeks. 

If  the  patient  is  advanced  in  emaciation  and  much  exhausted  we  should  not 
wait  for  thirty-six  hours  to  feed  him,  but  should  give  milk  and  broth  as  soon  as 
the  patient  recovers  from  ether.  The  bowels  should  be  moved  by  enema  the 
day  after  the  operation.     If  the  enema  fails,  calomel  is  given  (gr.  3  or  4). 

Digital  Dilatation  of  Pylorus  for  Cicatrical  Stenosis  (Loreta*s 
Operation,  or  Pylorodiosis). — Place  the  patient  recumbent  and  admin- 
ister  ether.     Make  a  vertical  incision   in   the   Hnea   alba   or   through    the 


1064 


Diseases  and  Injuries  of  the  Abdomen 


right  rectus  muscle.  The  median  incision  begins  one  inch  below  the  ensiform 
cartilage.  The  cut  in  either  case  should  be  five  inches  in  length.  .When  the 
peritoneum  has  been  opened,  the  stomach  is  drawn  out  of  the  wound,  any 
adherent  omentum  is  separated,  and  the  pylorus  is  carefully  examined.  The 
stomach,  after  being  surrounded  with  gauze  pads,  is  opened  near  the  center  of 
its  anterior  surface,  "but  rather  nearer  to  its  pyloric  end"  (Jacobson). 


Serous 


Fig.  543, — Lembert's  suture. 


'^yi 


Fig.  544.— Lembert's  suture  closed. 


Fig.  545.— Wolfler's  suture. 


Fig.  546.— Gussenbauer's  suture. 

Insert  the  index-finger  through  the  stomach  wound  and  into  the  pylorus, 
and  follow  that  with  the  middle  finger.  The  pylorus  can  be  well  dilated  by 
separating  the  fingers.  If  the  stenosis  is  so  tight  as  to  prevent  the  entry  of  a 
finger,  first  introduce  a  pair  of  hemostatic  forceps  and  open  the  blades  a  little 
when  they  are  within  the  lumen  of  the  constricted  area.  The  wound  in  the 
stomach  is  closed  by  a  continuous  silk  suture  of  the  mucous  membrane  and 
two  layers  of  Halsted  sutures,  to  invert  and  approximate  the  peritoneal  sur- 
faces.    After  closure  of  the  stomach  wound  the  abdominal  wound  is  sutured. 


EXPLANATION  OF  PLATE  10 

■    Intestinal  suture,  all  knots  inside  (Connell). 

a,  Suspending  loops  2,  3,  and  4  are  made  with  one  thread  inserted  at  a  point  two  thirds 
of  the  distance  from  mesenteric  to  convex  border.  The  needle  with  suture  is  passed 
through  the  four  walls  of  the  cut  ends,  and  that  portion  of  suture  within  each  lumen  is 
drawn  up  to  a  sufficient  length,  then  cut,  and  the  contiguous  threads  tied  at  the  points 
indicated  by  the  arrows;  thus  having  as  a  result  four  suspending  loops  dividing  the  cir- 
cumference of  each  cut  end  into  thirds.  Instead  of  employing  four  suspending  loops 
which  divide  the  circumference  of  the  bowel  into  thirds,  we  may  use  but  two  loops,  and 
thus  divide  the  circumference  into  halves;  or,  if  available,  the  "holder"  devised  by  Dr. 
E.  H.  Lee  can  be  recommended  highly,  and  will  be  found  a  most  efficient  aid  in  main- 
taining the  cut  edges  in  apposition.  (The  description  of  the  instrument  will  be  found  in 
the  "Annals  of  Surgery,"  January,  1901.) 

b,  Loop  2  has  been  cut  away,  and  loop  i  takes  its  place  in  one  hand  of  the  assistant, 
with  loops  3  and  4  held  in  the  other  hand,  thereby  bringing  into  apposition  that  portion 
of  the  walls  to  be  included  in  the  second  third  of  the  suture.  The  operator  continues 
the  suture  to  the  points  of  insertion  of  loops  3  and  4,  where  again  a  back  stitch  is  taken, 
to  fix  the  suture  and  prevent  a  purse-string  contraction  of  the  same.  The  white  eleva- 
tion in  the  center  of  illustration,  representing  mesentery,  shows  that  that  portion  of  the 
intestinal  wall  not  covered  by  peritoneum,  at  the  mesenteric  border,  has  been  secured 
in  the  suture. 

c,  The  needle,  after  having  entered  the  lumen,  is  passed  out  again  on  the  same  side 
J  inch  distant;  then  over  to  the  opposite  cut  end,  where  it  is  inserted  from  without  in, 
and  again  emerges  from  within  out,  on  the  same  side.  This  step — the  taking  of  a  bite 
— is  repeated  alternately  on  opposing  margins  until  the  necessary'  number  of  stitches 
have  been  inserted.  It  will  be  observed  that  when  the  needle  enters  the  lumen  the  last 
time,  it  makes  what  might  be  termed  a  half-stitch,  as  it  does  not  return  again  through 
the  wall;  but  having  reached  the  point  where  the  suture  was  commenced,  the  free  end 
and  the  needle  end  will  complete  the  last  stitch,  when  tied,  on  the  mucosa.  The  needle 
at  this  point  is  then  brought  out  of  the  lumen  at  the  angle  of  wound  alongside  of  the  free 
end  of  the  suture.  The  cross-over  stitches  are  next  carefully  drawn  up,  thus  bringing 
into  contact  the  opposing  serous  surfaces  at  every  point  except  where  the  suture  ends 
still  protrude. 

d,  The  eye-end  of  threaded  needle  is  made  to  emerge  alongside  of  the  suture  ends, 
and  is  then  withdrawn  a  little,  which  causes  its  thread  to  form  a  loop,  through  which  the 
assistant  passes  the  ends  of  the  suture.  The  operator  next  withdraws  the  threaded 
needle,  at  the  same  time  bringing  with  it  the  suture  ends,  and  they  present  externally  at 
the  point  of  withdrawal  of  the  needle.  The  serous  coats  throughout  the  entire  circum- 
ference are  now  in  apposition,  and  the  suture  ends  can  be  tied. 

e,  By  slight  traction  on  the  suture  ends  the  opposing  mucous  surfaces  are  brought 
in  close  contact;  the  suture  ends  are  then  tied  firmly,  and  deep  between  the  serous  coats, 
thus  tying  the  knot  upon  the  mucous  coat,  and  the  ends  then  cut  off  short. 


INTESTINAL   SUTURE. 


Plate  io. 


Pyloroplasty 


1065 


Divulsion  by  the  fingers  or  by  an  instrument  is  no  longer  practised,  because 
experience  has  shown  that  the  constriction  is  sure  to  return. 

Pyloroplasty  (Heineke=Mikulicz  Operation).— The  first  opera- 
tion was  performed  by  Heineke  in  1886.  Early  in  1887  Mikulicz,  not  know- 
ing of  Heineke's  antecedent  operation,  did  the  same  thing.  Open  the  abdo- 
men in  the  middle  line,  or,  better,  through  the  right  rectus  muscle.  Draw 
up  the  pylorus  as  well  as  possible,  and  pack  warm  moist  gauze  pads  around  it ; 
make  an  incision  through  the  stricture  and  in  a  direction  corresponding  to  the 
long  axis  of  the  stomach  and  bowel  (Fig.  547).  Catch  an  aneurysm-needle 
under  the  upper  margin  of  the  incision  and  draw  it  up,  and  an  aneurysm-needle 
under  the  lower  margin  and  draw  it  down.  The  effect  of  traction  is  to  convert 
the  transverse  wound  into  a  vertical  one.     The  sutures  are  applied  so  as  to 


Fig.  547.— Heineke-Mikulicz's  pyloroplasty  : 
the  incision. 


Fig.  548,— Heineke-Mikulicz's  pyloroplasty. 
The  axis  of  the  incision  is  changed  by  traction 
from  horizontal  to  vertical ;  sutures  in  position  ; 
only  one  of  the  two  rows  of  sutures  is  shown. 


maintain  the  wound  in  a  vertical  line  (Fig.  548).  The  mucous  membrane  is 
sutured  with  a  continuous  suture  of  silk,  and  interrupted  Lembert  or  Halsted 
sutures  of  silk  close  the  peritoneal  and  muscular  coats  (Figs.  548  and  549). 
Drain  for  twenty-four  hours,  because  there  is  danger  of  leakage.  A.  W.  Mayo 
Robson  inserts  a  bone  bobbin  and 
then  appHes  the  sutures.  The  oper- 
ation of  pyloroplasty  shows  a  mor- 
tality about  the  same  as  or  sHghtly 
less  than  gastro-enterostomy.  In 
some  cases  it  is  a  very  satisfactory 
procedure,  but  there  are  objections 
to  it,  and  in  30  per  cent,  of  cases  it 
faUs  to  give  relief  (Wm.  J.  Mayo). 
The  outlet  is  not  at  the  most  depen- 
dent part  of  the  stomach,  hence  the 
stomach  may  not  empty  itself.  Fur- 
ther, as  Finney  points  out,  it  cannot 
be  performed  if  there  are  firm  adhe- 
sions or  active  ulceration,  and  the  scar  may  contract  and  give  rise  to  stenosis. 
Again,  it  is  difficult  to  suture  so  as  certainly  to  provide  against  leakage.  The 
Mayos  reported  21  pyloroplasties  without  a  death,  but  7  cases  required 
secondary    operations     ("Annals     of     Surgery,"     Nov.,     1905).      Pyloro- 


Fig.  549.— Heineke-Mikulicz's  pyloroplasty: 
after  tying  the  sutures. 


io66 


Diseases  and  Injuries  of  the  Abdomen 


plasty  has  been  abandoned  by  many  surgeons ;  J.  Rutherford  Morison  still  ad- 
vocates it.  Finney  has  devised  an  operation  to  correct  the  objections  to 
pyloroplasty. 

Gastro=duodenostomy  by  Finney's  Method. — This  operation  is  usu- 
ally called  a  method  of  pyloroplasty,  but  it  is  rather  a  gastro-duodenostomy. 


Fig.  550. — Finney's  pyloroplasty.    The  retractor 
sutures. 


Fig.  551.— Finney's    pyloroplasty.     Suture    of 
greater  curvature  of  stomach  to  duodenum. 


This  operation  was  described  in  the  "Johns  Hopkins  Hospital  Bulletin," 
July,  1902,  and  was  then  called  pyloroplasty.  It  is  performed  as  follows: 
Thoroughly  free  the  first  portion  of  the  duodenum  and  the  pyloric  end  of  the 
stomach.     Insert  three  retractor  sutures  (Fig.   550)   and  draw  upon  them. 


Fig.  552.— Finney's  pyloroplasty.  Shows  the 
three  retractor  sutures,  the  posterior  line  of  su- 
tures tied  and  the  anterior  line  of  sutures  untied. 


Fig.  553'— Finney's  pyloroplasty.     The  anterioi 
sutures  gathered  and  lifted. 


Suture  together,  as  far  posterior  as  possible,  the  peritoneal  surface  of  the 
duodenum  and  the  peritoneal  surface  of  the  stomach  along  its  greater  curva- 
ture (Fig.  551).  Insert  an  anterior  row  of  mattress  sutures,  but  do  not  tie 
them  as  yet  (Fig.  552).     Make  a  horseshoe-shaped  incision  (Fig.  553) ;  arrest 


Pylorectomy 


1067 


bleeding;  excise  as  much  scar-tissue  as  possible  on  either  side  of  the  incision,  and 
trim  ofif  the  redundant  mucous  membrane.  Insert  a  continuous  catgut  suture 
on  the  posterior  side  of  the  incision  and  carry  it  through  all  the  coats  (Fig.  554). 
Straighten  out  the  anterior  sutures  and  tie  them  (Fig.  555) .  The  Mayos  report 
58  Finney  operations  with  4  deaths  and  2  secondary  operations  (Wm.  J.  Mayo 
in  "Annals  of  Surgery,"  Nov.,  1905). 

The  mortality  is  greater  than  after  gastro-enterostomy,  due  probably  to  the 
necessity  of  separating  adhesions  and  setting  the  duodenum  free.     The  opera- 


F'g-  554 — Finney's  pyloroplasty.     The  continu- 
ous posterior  catgut  suture. 


Fig-  555 — Finney's  pyloroplasty  completed  by 
tying  the  anterior  sutures. 


tion  .should  be  restricted  to  cases  in  which  adhesions  are  not  widespread  and 
firm  and  in  which  the  gastrohepatic  omentum  is  of  fair  length.  In  properly 
selected  cases  it  is  an  excellent  operation. 

Pylorectomy  (Excision  of  the  Pylorus).— The  removal  of  a  por- 
tion of  the  stomach  is  a  partial  gastrectomy,  and  pylorectomy  is  a  partial 


Fig.  556. — Billroth's  method  of  pylorectomy. 


tig.  557.— Pylorectomy. 


gastrectomy  in  which  the  pylorus  and  also   a  portion  of  duodenum  are 
removed. 

The  experiments  of  Gussenbauer  and  von  Winiwarter  on  dogs  in  1876  lead 
them  to  suggest  this  operation.  It  was  first  performed  by  Pean  in  1879.  It 
was  next  performed  by  Rydygier  in  1880.  Billroth  did  the  first  successful 
pylorectomy  in  188 1.     The  operation  is  usually  performed  for  cancer,  but  some- 


io68 


Diseases  and  Injuries  of  the  Abdomen 


times  for  pyloric  ulcer  and  its  results.  In  many  cases  of  pyloric  cancer  the 
abdomen  is  opened  after  a  palpable  tumor  is  detected,  and  when  a  palpable 
tumor  is  detectable  it  is  usually  too  late  to  perform  pylorectomy.*  The  lesson 
is  to  explore  suspected  cases  earlier  than  has  been  our  custom. 

Keen  agrees  with  Hemmeter  that  stenotic  symptoms,  even  when  no  tumor 
is  palpable,  call  for  exploratory  laparotomy;  if  the  stomach  is  dilated,  if  there 
is  cachexia,  if  there  is  no  free  hydrochloric  acid  in  the  gastric  juice,  if  there  is 
an  excess  of  lactic  acid  in  the  gastric  juice,  if  the  patient  is  at  or  beyond  forty 
years  of  age,  when  there  is  vomiting  of  blood,  when  the  Opj)ler  bacillus  is 
present,  when  blood  examinadon  shows  a  diminution  in  red  corpuscles  and 

hemoglobin,  and  also  shows 
that  there  is  no  increase  in 
white  corpuscles  after  a  full 
meal.  After  the  abdomen  has 
been  opened  the  stomach  is 
examined,  and  if  a  tumor  ex- 
ists, the  surgeon  must  decide 
between  the  performance  of 
pylorectomy  and  gastro- 
enterostomy. If  the  tumor  is 
not  very  extensive,  if  there  is 
no  glandular  involvement  or 
only  involvement  which  can 
be  removed,  and  if  adhesions 
are  not  extensive,  pylorectomy 
is  chosen;  otherwise  gastro- 
enterostomy is  selected. 

Until  very  lately  the  mor- 
tality from  pylorectomy  was 
estimated  to  be  25  per  cent., 
even  in  favorable  cases.  In  9 
complete  pylorectomies,  with 
closure  of  both  the  stomach 
and  duodenal  ends,  communication  being  reestablished  by  the  performance 
of  gastrojejunostomy.  Mayo  reports  i  death,  and  in  14  pylorectomies  and 
partial  gastrectomies  he  reports  2  deaths,  or  14  per  cent.  (Wm.  J.  Mayo,  in 
"Annals  of  Surgery,"  Aug.,  1902).  Prepare  the  patient  for  pylorectomy  as 
for  any  stomach  operation.  The  best  incision  through  the  abdominal  wall 
is  a  vertical  one  in  or  by  the  median  line.  A  small  incision  is  made  first  to 
permit  of  exploration,  and  if  the  growth  is  found  to  be  removable,  the  incision 
is  enlarged.  In  some  cases  it  will  be  found  necessary  to  divide  the  rectus 
muscle  by  a  transverse  cut. 

Method  of  the  Mayos. — This  is  the  best  operation.  The  Billroth  method, 
which  was  long  employed,  does  not  remove  enough  of  the  stomach  in  a  case  of 
malignant  disease,  the  opening  left  in  the  stomach  is  much  larger  than  the 
duodenal  opening,  and  in  suturing  so  as  to  make  the  two  openings  of  equal 
size  an  angle  is  left  which  is  apt  to  leak.     Billroth 's  operation  is  shown  in 


Fig.  558. — Pylorectomy  by  the  Mayo  method.  Clamps 
applied,  duodenum  divided,  and  continuous  catgut  stitch 
introduced  (Mayo). 


*  Keen's  "  Cartwright  Lectures  "  for  i^ 


Pylorectomy  by  the  Mayo  Method 


T069 


Figs.  556  and  557.  In  Mayo's  method,  after  exposing  the  stomach  ligate 
the  gastric  artery  close  to  the  stomach,  tie  the  lesser  omentum  in  several 
segments  close  to  the  liver  and 


divide  it,  and 
artery.  Apply 
the  duodenum 
I    inch    apart. 


tie  the  pyloric 
two  clamps  to 
and  have  them 
and    divide    the 

means    of    the 


Fig.  559.— Pylorectomy  by  the  Mayo  method.  End 
of  divided  duodenum  buried  by  a  purse-string  suture. 
Row  of  lock  stitches  inserted  in  stomach  stump  (Mayo). 


duodenum    by 
cautery  (Fig.  558). 

Close  the  right  end  of  the 
duodenum  by  means  of  a  con- 
tinuous catgut  suture,  remove 
the  clamp,  and  invert  the  closed 
end  by  a  purse-string  suture 
(Fig.  559).  Pass  a  hand  from 
above  back  of  the  stomach  and 
lift  the  great  omentum  forward. 
Tie  the  right  gastro-epiploic 
artery  close  to  the  stomach. 
Tie  the  left  gastro-epiploic  ar- 
tery distinctly  to  the  left  of  any 
enlarged  glands  in  the  great 
omentum.  Tie  the  great  omen- 
tum in  several  segments.  Di- 
vide the  great  omentum,  leaving 

any  enlarged  glands  attached  to  the  portion  of  the  stomach  it  is  the  intention 
to  remove.  The  stomach  is  to  be  divided  to  the  left  of  all  lymphatic  glands 
into  which  the  cancerous  region  drains.  The  clamps  are  applied  as  shown 
in  Fig.  558.  The  stomach  is  divided  between  the  clamps  with  a  cautery, 
and  as  the  division  is  being  carried  out  catch  the  stump  here  and  there  with 
hemostatic  forceps  to  prevent  it  slipping  through  the  clamps.  Slipping  is 
disastrous  and  will  cause  leaking  and  entrance  of  air  into  the  stomach,  and 
entrance  of  air  is  apt  to  be  followed  by  pulmonary  difficulty. 

A  row  of  locking  stitches  is  passed  through  all  the  coats  of  the  stump. 
The  stitches  are  tied  and  a  second  row  is  passed  and  tied  (Fig.  559).  The 
clamp  is  removed  and  the  stump  is  buried  by  Cushing's  right-angled  suture  or 
Dupuytren's  suture.  A  gastrojejunostomy  is  then  performed  to  the  posterior 
wall  of  the  portion  of  stomach  which  remains. 

Such  a  patient  is  usually  much  dehydrated,  and  if  he  is,  salt  solution  should 
be  given  intravenously  during  the  operation,  and  an  enema  of  warm  salt 
solution  should  be  administered  every  six  hours  for  several  days  after  the 
operation.  Active  stimulation  is  usually  necessary  and  8  ounces  of  coffee 
should  be  given  by  rectum  at  the  completion  of  the  operation.  The  patient 
must  be  placed  erect  or  semi-erect  in  bed  as  soon  as  the  effects  of  the  ether  pass 
away.  Twelve  hours  after  operation  begin  to  give  small  amounts  of  hot  water 
by  the  mouth.  Nourish  by  the  rectum  from  four  to  six  days,  when  fluid  food 
may  be  given  by  the  mouth,  starting  with  small  doses  of  albumin -water,  and 
if  this  is  tolerated,  giving  dessertspoonful  doses  of  peptonized  milk  every 
hour. 


1070  Diseases  and  Injuries  of  the  Abdomen 

Total  Gastrectomy. — The  entire  stomach  was  first  removed  by  Conner, 
of  Cincinnati,  in  1883.  The  first  successful  operation  was  performed  by 
Schlatter,  of  Zurich,  in  1897.  Total  gastrectomy  will  rarely  be  required,  but  in 
certain  unusual  cases  it  will  be  proper  to  perform  it.  In  some  cases  the  duod- 
enal end  can  be  sutured  to  the  divided  esophagus;  in  others  it  will  be  necessary 
to  close  the  end  of  the  divided  first  portion  of  the  duodenum,  and  anastomose 
the  esophagus  to  the  jejunum. 

The  cases  suitable  for  total  gastrectomy  are  those  in  which  the  entire 
v-iscus,  or  almost  the  entire  \nscus,  is  cancerous,  the  stomach  being  still  freely 
movable,  and  the  glands  not  so  much  impHcated  as  to  forbid  attempts  at 
removal.  It  is  a  remarkable  fact,  first  demonstrated  in  Schlatter's  case, 
that  an  indiudual  can  digest  food  very  well  without  a  stomach.  This  state- 
ment is  true  only  if  the  stomach  function  has  been  gradually  aboUshed  by  disease. 
During  this  period  the  functions  of  the  stomach  have  been  assumed  to  a 
greater  or  less  degree  by  other  parts.  In  a  recent  injury  of  the  stomach  com- 
plete removal  would  almost  certainly  be  followed  by  death,  as  in  such  a  case 
other  parts  would  have  had  no  chance  to  learn  how  to  assume  gastric  duties. 
The  reported  cases  of  total  gastrectomy  show  10  deaths  out  of  27  cases,  but, 
as  Robson  truly  says,  if  all  cases  were  reported,  the  mortaUty  would  probably 
be  found  to  be  50  per  cent. 

Qastrotomy. — This  term  is  used  to  designate  the  operation  of  opening 
the  stomach  for  the  accomphshment  of  some  puq^ose,  and  immediately 
closing  the  incision  in  the  gastric  wall  when  that  purpose  is  accomplished. 
Gastrotomy  may  be  performed  to  permit  of  the  removal  of  foreign  bodies, 
of  exploration  of  the  stomach  and  its  extremities,  of  divulsion  of  the  pyloric 
orifice,  of  the  treatment  of  bleeding,  of  an  esophageal  stricture,  or  a  stricture  of 
the  cardiac  orifice  of  the  stomach,  or  of  the  removal  of  a  foreign  body  lodged 
in  the  esophagus.  The  first  case  on  record  was  in  1602  when  Matthis 
removed  from  the  stomach  of  a  juggler  a  knife  which  had  been  accidentally 
swallowed. 

The  patient  is  prepared  as  for  pylorectomy.  The  incision  may  be  vertical 
in  the  middle  line  or  identical  with  the  incision  for  pylorectomy.  If  a  large 
foreign  body  can  be  felt,  the  incision  is  made  directly  over  it.  When  the 
peritoneal  cavity  is  opened,  the  surgeon  decides  as  to  the  point  where  the 
stomach  is  to  be  incised,  and  draws  this  portion  out  through  the  wound, 
packing  gauze  pads  under  and  around  it.  The  stomach  is  opened  by  means 
of  scissors,  the  cut  being  at  a  right  angle  to  the  long  axis  of  the  viscus  (Jacob- 
son).  Bleeding  vessels  are  ligated  ^vith  catgut.  The  purpose  for  which  the 
stomach  was  opened  is  now  to  be  carried  out,  the  interior  of  the  stomach 
and  the  surface  of  the  extruded  portion  are  irrigated  ^\^th  hot  salt  solution, 
the  mucous  membrane  is  sutured  \\ath  a  continuous  suture  of  silk,  and  two 
rows  of  Halsted  sutures  are  inserted.  The  abdominal  wound  is  closed, 
drainage  being  employed  for  twenty-four  hours. 

Gastrostomy  is  the  making  of  a  permanent  gastric  fistula,  through 
which  opening  the  patient  can  be  fed.  Gastrostomy  was  first  proposed  by 
Egebert  in  1837  (Keen),  and  was  first  performed  by  Sedillot  in  1849.  In 
1875  Sydney  Jones  operated  upon  the  twenty-ninth  case  and  obtained  the 
first  recovery  (Keen).  Up  to  1884  the  estimated  mortahty  was  80  per  cent. 
At  present  the  mortality  in  malignant  cases  is  from  20  to  25  per  cent.,  and 


Gastrostomy 


1071 


in  non-malignant  cases  from  8  to  lo  per  cent.     Gastrostomy  is  employed 
in  cases  of  esophageal  obstruction  or  obstruction  of  the  cardiac  end  of  the 


Fig.  .'^60. — Witzel's  method  of  gastrostomy, 
showing  application  of  sutures  in  wall  of  stom- 
ach, embedding  tube  obliquely  therein. 


Fig.  561.— Sutures  tied,  completely  embedding 
tube  obliquely  therein. 


stomach.     In  many  cases  of  malignant  disease  the  operation  is  performed 
too  late,  and  if  performed  when  the  patient  is  greatly  emaciated  and  exhausted, 


Fig.  562. — Kader's  method  of  gastros- 
tomy. Tube  in  place  and  first  row  of  su- 
tures inserted. 


Fig.  563. — Kader's  method  of  gastrostomy. 
First  row  of  sutures  tied  and  second  row  in- 
serted. 


the  operation  has,  of  course,  a  high  mortality.     An  early  operation  is  far 
safer  and  confers  the  maximum  of  relief.     The  operation  should  be  per- 


I072 


Diseases  and  Injuries  of  the  Abdomen 


formed,  as  Mikulicz  advises,  when  the  patient  is  steadily  losing  weight  and 
there  is  beginning  to  be  difficulty  in  swallowing  semisolids  or  liquids.  The 
surgeon  must  endeavor  to  perform  an  operation  which  will  not  permit  of 
leakage.     Prepare  the  patient  as  for  any  stomach  operation. 

WitzePs  Method. — This  operation  was  first  practised  in  189 1.  An  incision 
is  made  four  inches  long,  running  to  the  left  from  the  middle  line,  just  below 
the  border  of  the  ribs.  After  opening  the  peritoneal  cavity  seize  the  stomach, 
bring  it  out  of  the  wound,  and  pack  gauze  around  it.  Introduce  a  rubber 
tube  into  the  stomach  and  enfold  it  by  a  double  row  of  Lembert  sutures 
(Figs.  560,  561).  This  tube  should  be  five  inches  long  and  of  the  same 
diameter  as  a  No.  25  French  bougie.  The  opening  is  made  in  the  stomach 
toward  the  cardiac  extremity,  the  tube  is  placed  parallel  with  the  belly-wound, 
and  the  outer  end  of  the  tube  emerges  in  the  median  line.  The  tube  is  re- 
tained in  place  by  a  catgut  stitch  carried  through  the  tube  and  the  stomach- 
wall.  The  stomach  is  returned  and  is  stitched 
by  three  sutures  to  the  abdominal  wall.  The 
abdominal  incision  is  sutured  and  a  clamp  is 
placed  on  the  tube.  When  the  patient  is  fed, 
a  funnel  is  slipped  into  the  tube,  the  clamp 
is  removed,  and  liquid  food  is  poured  into  the 
funnel.  After  the  wound  heals  it  is  not  neces- 
sary permanently  to  retain  the  tube.  It  is 
passed  when  the  patient  desires  food. 

Kader's  Method. —  This  operation  was 
devised  in  1896.  It  is  a  modification  of 
Witzel's  method.  A  small  incision  is  made 
in  the  stomach  and  a  tube  is  introduced 
and  fastened  to  the  stomach  by  one  catgut 
stitch.  Four  Lembert  sutures  are  passed  so 
as  to  form  a  fold  on  each  side  of  the  tube 
and  turn  the  stomach-wall  inward  around 
the  tube  (Fig.  562).  Lembert  sutures  are 
inserted  in  the  furrow  on  each  side  of  the 
tube.  Two  more  folds  are  formed  over 
the  first  two  (Figs.  563  and  564).  The 
stomach-wall  is  stitched  to  the  parietal  peritoneum  and  sheath  of  the  rec- 
tus muscle  (Willy  Meyer). 

The  Ssabanejeiv-Frank  Method. — This  operation  is  preferred  by  many 
surgeons.  I  usually  employ  it  if  the  stomach  is  not  so  shrunken  as  to  ren- 
der the  pulling  out  of  a  sufficient  cone  impossible.  It  was  first  performed 
by  Ssabanejew  in  1890  and  was  performed  independently  by  Frank  in  1893. 
Fenger's  incision  is  made  (a  curved  incision  at  the  margin  of  the  costal 
cartilages  of  the  left  side).  A  cone  of  the  stomach  is  pulled  out  of  the 
wound  and  is  passed  under  a  bridge  of  skin  which  has  been  prepared 
for  it.  The  stomach  is  fixed  above  the  margin  of  the  ribs  and  opened 
(Figs.  565,  566).  Von  Hacker  makes  the  gastric  fistula  through  the  left 
rectus  muscle,  and  Hahn  between  two  of  the  rib  cartilages  (Willy  Meyer). 

The  Younger  Semi's  Method. — Emanuel  Senn  devised  the  following 
method:  A  cone  of  the  stomach  is  pulled  out  of  the  abdominal  wounds  and 


Fig.  564. — Kader's  method  of  gas- 
trostomy. Second  row  of  sutures 
tied. 


Gastro-enterostomy  or  Gastrojejunostomy 


1073 


t'  is  cone  is  piukered  by  liie  insertion  of  two  drawing-string  sutures  of  chromi- 
c"zed catgut  through  the serousand muscular  coats.  Acuff  of  gastrocoHc omen- 
tum is  sutured  by  silk  around  the  neck  of  the  puckered  cone.  The  stomach 
is  sutured  to  the  belly-wall  with  silk,  the  sutures  including  the  omental  cuff, 
ths  serous  and  muscular  coats  of  the  stomach,  and  the  structures  of  the  belly- 
wall,  except  the  skin.  The  skin  is  partly  sutured.  The  stomach  may  be 
opened  at  any  time. 

Gastro=enterostomy  or  gastro=jejunostomy  is  the  establishment  ot 
a  permanent  fistula  between  the  stomach  and  the  small  intestine,  in  order 
to  side-track  the  pylorus.  The  operation  is  performed  for  cancer  of  the 
pylorus,  for  non-cancerous  stenosis  of  the  pylorus,  in  some  cases  of  ulcer 
of  the  stomach,  and  for  tetany.     Anterior  gastro-enterostomy  was  proposed 


Fig.  565.  Fig.   566. 

Figs.  565,  566. — The  Ssabanejew-Frank  method  of  gastrostomy  in  carcinoma  of  the  esophagus. 


by  Nicoladoni  in  1881  and  was  first  performed  by  Wolfler  the  same  year. 
In  Wolfier's  early  operations  the  jejunum  was  so  placed  that  the  proximal  end 
was  to  the  right  of  the  anastomosis  opening.  Hence  peristalsis  in  the  stomach 
was  from  left  to  right  and  in  the  jejunum  from  right  to  left,  and  this  was  sup- 
posed to  be  responsible  for  the  common  occurrence  of  regurgitant  vomiting. 
It  was  sought  to  prevent  this  by  altering  the  direction  of  the  loop  (Liicke), 
then  by  entero-anastomosis  (Braun),  and  finally  by  a  posterior  anastomosis. 
Posterior  gastro-enterostomy  was  first  proposed  by  Courvoisier  in  1883. 
His  suggestion  was  that  the  posterior  surface  of  the  stomach  be  reached 
through  the  transverse  mesocolon.  His  plan  necessitated  a  transverse  division 
of  the  mesocolon,  but  it  was  found  that  this  impaired  the  blood-supply  of  a 
part  of  the  colon  and  might  lead  to  gangrene.  Von  Hacker,  in  1885,  devised 
an  improved  po.sterior  operation.  As  a  matter  of  fact,  the  transverse  meso- 
colon has  a  marginal  artery,  unUke  other  parts  of  the  colon,  and  the  danger  of 
68 


10/4  Diseases  and  Injuries  of  the  Abdomen 

gangrene  from  a  transverse  incision  is  probably  not  very  great.  In  the  earlier 
operations  by  the  posterior  method  a  long  loop  was  used  and  results  were  not 
notably  better  than  after  the  anterior  operation.  In  1890  Czerny  and  Peter- 
son ad\nsed  the  making  of  the  jejunal  opening  close  to  the  duodenojejunal 
flexure.  The  results  from  this  operation  are  vastly  better  than  from  the 
anterior  operarion.  Posterior  gastro-enterostomy  has  been  signally  im- 
proved in  technic  by  the  Mayos,  Moynihan,  and  others.  In  the  earlier  opera- 
tions of  anterior  gastro-enterostomy  the  mortality  was  40  per  cent.  In  non- 
malignant  condirions  the  mortality  after  gastro-enterostomy  is  now  ver^'  low 
(under  3  per  cent.),  the  hyperacidity  of  the  gastric  juice  disappears,  and  the 
functions  of  the  stomach  are  restored.  In  malignant  cases  the  mortality  is 
about  20  per  cent.,  but  even  in  such  cases,  if  operation  is  done  early,  life  may 
be  prolonged  and  made  comfortable  for  months.  Wm.  J.  ^Nlayo  makes  the 
follo\nng  report  upon  421  cases  of  gastrojejunostomy:  "Benign,  307  cases, 
19  deaths  (6.18  per  cent.).  In  the  last  140  there  were  4  deaths,  a  mortality 
of  2.85  per  cent.;  the  last  80  gave  but  i  death.  Malignant,  114  cases,  with 
21  deaths  (18.5  per  cent.).  Of  these  114  cases,  63  were  in  connection 
with  pylorectomy  and  partial  gastrectomy,  with  8  deaths  (12.6  per  cent.). 
The  ver)'  unfavorable  cases  of  cancer  obstruction  were  subjected  to  gastro- 
enterostomy, so  that  this  operation  gives  a  higher  mortality  than  radical 
excision.  In  the  last  40  gastrojejunostomies  for  malignant  disease  the  mor- 
tality was  8  per  cent.  In  the  421  gastrojejunostomies  there  were  21  reoperated 
cases  (5  per  cent.)"  ("Annals  of  Surger)',"  Nov.,  1905).  In  about  5  per 
cent,  of  cases  of  gastro-enterostomy  for  benign  disease  secondary  operation 
has  been  required.  In  Kronlein's  clinic,  51  cases  of  malignant  disease  sub- 
jected to  gastro-enterostomy  showed  an  average  duration  of  hfe  of  192  days; 
470  days  after  operation  17  ca.ses  were  living.  The  causes  of  death,  accord- 
ing to  ]Mayo,  are.:  exhaustion,  exhaustion  with  vomiting,  pneumonia,  and  de- 
tachment of  the  anastomosed  intesrine. 

Treatment  After  Gastro-enterostomy. — On  returning  the  patient  to 
bed  at  once  establish  continuous  enteroclysis  with  one-half  strength  salt 
solution,  the  reservoir  being  only  6  inches  above  the  level  of  the  bed.  This 
is  Murphy's  plan.  As  soon  as  patient  is  out  of  ether  place  him  semi-erect. 
Mayo  begins  in  from  sixteen  to  twenty  hours  to  administer  by  the  mouth  one 
ounce  of  hot  water  every  hour,  and  if  it  is  well  tolerated,  the  amount  is  quickly 
increased,  and  in  thirt)'-six  hours  liquid  food  is  given  and,  if  tolerated,  is  con- 
tinued. 

Complications  Following  Gastro-enterostomy. — Among  them  are 
lung  complications.  These  are  not  due  to  the  anesthetic,  for  they  tend  to 
occur  even  when  local  anesthesia  has  been  employed.  They  are  not  due  to  the 
epigastric  incision  interfering  with  cough  and  expectoration,  for  they  are 
not  nearly  so  common  after  operations  upon  the  gall-bladder  (Wm.  J.  Mayo). 
Mayo  says  that  the  latest  theory  is  that  some  of  the  venous  blood  returning 
from  the  stomach  does  not  pass  through  the  liver,  and  infected  emboU  are 
deposited  in  the  lungs.  The  suture  line  may  leak  after  gastro-enterostomy 
because  of  imperfect  suturing,  or  the  anastomosed  intestine  may  become 
detached;  20  per  cent,  of  the  deaths  among  Mayo's  cases  resulted  from 
this  cause.     Contraction  of   the  anastomosis  opening   may   gradually  take 


Complications  Following  Gastro-enterostomy  1075 

place.  This  has  been  held  by  some  to  be  particularly  common  in  cases 
of  dilated  stomach,  shrinking  of  the  stomach  being  the  efficient  cause;  but 
evidence  upon  this  point  is  not  conclusive.  In  cases  in.  which  the  pylorus 
is  not  obstructed  shrinking  often  occurs,  but  it  rarely  takes  place  when  the 
pylorus  is  obstructed.  In  some  ca.ses  after  operation  a  spur  forms  in  the 
jejunum  because  of  angulation;  in  other  cases  adhesions  produce  obstruc- 
tion; and  in  rare  instances  ulceration  takes  place  in  the  jejunum.  The  most 
common  complication  after  gastro-enterostomy  is  persistent  vomiting,  which 
may  or  may  not  be  expressive  of  the  formation  of  a  vicious  circle. 

Peptic  Ulcer  of  the  Jejunum. — The  first  case  was  reported  by  Braun  in 
1899.  F.  Gregory  Connell  has  collected  38  cases  and  reported  one  of  his  own, 
39  in  all  ("Surg.,  Gynecol.,  and  Obstet.,"  Jan.,  1908).  Connell  points  out 
that  in  many  of  the  reported  cases  acute  perforation  occurred.  Most  of  the 
reported  cases,  it  is  found,  suffered  from  non-malignant  trouble  and  had  hyper- 
acid gastric  juice.  It  very  seldom  occurs  after  operations  for  cancer.  Most 
®f  the  reported  cases  happened  after  the  anterior  operation  and  when  the 
anastomosis  was  very  near  to  the  pylorus.  It  has  happened,  however,  in  9 
cases  after  the  posterior  operation,  and  cases  have  been  reported  following 
both  the  anterior  and  posterior  methods  associated  with  entero-anastomosis. 
It  is  probable  that  more  cases  seem  to  follow  the  anterior  method  because 
until  late  years  it  has  been  the  operation  commonly  performed.  In  most  of  the 
reported  cases  the  ulcer  was  single;  in  3  out  of  24  cases  it  was  multiple.  It  is 
usually  in  the  distal  loop,  but  may  be  in  the  proximal  loop.  It  may  be  situ- 
ated at  the  anastomosis  level,  a  little  way  below  it,  or  even  5  or  6  inches  below 
it.  The  ulcer  may  appear  a  few  days  after  the  operation,  weeks  after,  months 
after,  or  even  years  after.  The  condition  results  from  hyperacid  gastric  juice 
passing  directly  into  the  jejunum  before  it  has  been  neutraHzed  by  admixture 
with  bile  and  pancreatic  juice.  It  is  possible  that  the  condition  is  predisposed 
to  by  a  twist  in  the  jejunum  and  by  such  a  small  anastomosis  opening  that 
hyperacidity  was  not  corrected. 

There  may  be  no  symptoms  at  all  until  there  is  a  severe  hemorrhage  or 
perforation,  or  symptoms  similar  to  those  which  called  for  the  gastro-enter- 
ostomy may  return.  Connell's  table  shows  that  acute  perforation  took  place 
in  14  of  the  39  reported  cases.  In  chronic  cases  treatment  is  first  medical; 
if  this  fails,  operation  is  indicated.  In  perforation,  operation  must  be  imme- 
diate. 

The  Vicious  Circle  and  Regurgitation. — Vomiting  may  occur  after  the 
performance  of  gastro-enterostomy.  It  may  soon  cease,  may  be  productive 
of  disastrous  consequences,  and  may  be  expressive  of  an  existing  complication 
of  great  gravity.  In  some  cases  of  gastro-enterostomy  vomiting  arises  because 
the  anastomosis  has  been  made  high  up  on  the  anterior  wall  and  the  stomach 
is  not  drained.  In  other  cases  ether  induces  vomiting,  and  the  mechanical 
efforts  force  the  contents  of  the  duodenum  and  even  of  the  jejunum  into 
the  stomach.  The  true  "vicious  circle"  is  a  condition  in  which  the  contents 
of  the  stomach  pass  through  the  anastomosis  opening  into  the  duodenal 
side  of  the  loop  of  intestine,  mix  with  the  duodenal  secretions,  and  return 
to  the  stomach  (Fowler,  in  "  Annals  of  Surgery, "  Nov.,  1902).  The  following 
conditions  are  often  classified  under  the  same  head,  but  each  is  called  by 


10/6 


Diseases  and  Injuries  of  the  Abdomen 


Fowler  a  regurgitation  or  reflex:  (i;  When  the  duodenal  secredons  pass  back 
into  the  stomach  through  a  permeable  pylorus  (as  in  cases  of  gastroptosis, 
non-cancerous  pyloric  stenosis,  and  gastric  dilatation);  (2)  when  the  duodenal 
secretions  enter  the  stomach  through  the  anastomosis  opening;  (3)  when  the 
contents  of  the  jejunum  pass  into  the  stomach,  because  of  efforts  at  vomiting 
or  as  a  result  of  reversed  peristalsis.  In  some  cases  the  contents  of  the  jeju- 
num may  pass  into  the  afferent  loop  of  intestine  and  distend  it.  It  was  long 
thought  to  be  due  to  bile  passing  into  the  stomach  from  the  proximal  (afferent) 
loop  of  the  jejunum.  Dastre's  experiments  on  dogs  show  that  bile  in  the 
stomach  does  not  impair  either  digestive  power  or  the  general  health,  and 
Moynihan  has  confirmed  these  experiments  by  cHnical  observation.  It  has 
been  held  that  the  cause  of  this  condition  is  the  making  of  an  anastomosis 
with  a  long  loop  between  the  duodenojejunal  flexure  and  the  anastomatic 
opening  into  the  jejunum,  the  loop  being  unable  to  propel  its  contents  down- 
ward and  tending  by  its  weight  to  produce  a  bend  or  kink  at  the  seat  of  anas- 
tomosis.    This  is  a  very  doubtful  theor}\ 

Persistent  vomiting  may  be  due  to  spur  formation,  which  de\-iates  stomach- 
contents  into  the  duodenal  side  of  the  loop.    It  is  in  some  cases  due  to  kinking 


Fig.  567. — Gastroenterostomy  (after  Lucke). 


Fig.  568.— Implantation  of  duodenum  into 
jejunum  and  jejuimm  into  stomach  (after 
Wolfler). 


or  twisting  of  the  distal  loop;  in  others,  to  failure  of  peristalsis  in  the  proximal 
loop;  in  still  others,  to  contraction  of  the  opening  in  the  stcmach-wall  (Chlum- 
sky  on  Gastro-enterostomy  in  the  Breslau  CHnic;  article  by  Charles  L.  Gibson, 
in  "Annals  of  Surger}-,"  Aug.,  1908).  I  cordially  agree  with  the  statement  of 
Herbert  J.  Patterson,  viz.:  "Most,  if  not  all,  fatal  cases  of  regurgitant  vomiting 
are  due  to  mechanical  obstruction  at  the  afferent  opening"  (The  Hunterian 
Lectures  dehvered  before  the  "Royal  College  of  Surgeons  of  England,"  Feb. 
19,  21,  and  23,  1906).  In  order  to  lessen  the  danger  of  vomiting  after  gastro- 
enterostomy, use  a  local  anesthetic  whenever  possible;  and  in  order  to  prevent 
regurgitant  vomiting  take  every  care  in  the  operation  to  prevent  the  forma- 
tion of  a  spvir  on  the  mesenteric  border  of  the  jejunum  (Herbert  J.  Patterson, 
Ibid.). 

After  Billroth's  operation  (Fig.  569),  and  in  all  the  earlier  methods,  the 
contents  of  the  duodenum  certainly  pass  into  the  stomach,  mix  with  the 


Anterior  Gastro-cnterostomy  1077 

stomach-contents,  and  usually,  but  not  always,  pass  into  the  efferent  loop.  In 
all  these  oi)erations  there  is  great  danger  of  the  development  of  a  vicious 
circle. 

Liicke  devised  an  operation  with  the  idea  of  preventing  sucii  a  comi)lica- 
tion.  In  the  Liicke  operation  the  direction  of  peristalsis  in  the  efferent 
loop  is  the  same  as  in  the  stomach  (Fig.  567).  McGraw  points  out  that 
the  crossing  of  the  loop  which  is  effected  is  dangerous.  The  Wolller-Liicke 
operation  is  shown  in  Fig.  577.  Wolfier  devised  the  operation  pictured  in 
Fig.  568.  Von  Hacker's  posterior  operation  is  thought  by  some  to  be  less 
apt  than  the  anterior  method  to  be  followed  by  the  vicious  circle  (Fig.  578), 
Kocher  devised  an  operation  in  which  a  valve  is  formed,  but,  as  Fowler 
points  out,  this  valve  does  not  prevent  filling  of  the  duodenum  and  imbi- 
bition of  the  material  by  the  stomach;  and,  further,  that  the  valve  does  not 
work  when  the  parts  become  cicatricial  (Fig.  571). 
The  combination  of  gastro-enterostomy  with 
entero-anastomosis  does  tend  to  prevent  the  vicious 
circle.  This  operation  is  shown  in  Figs.  575  and 
576.  I  do  not  believe  it  should  ever  be  a  primary 
operation.  It  permits  acid  gastric  juice  to  flow  di- 
rectly into  the  jejunum  and  keeps  away  the  bile  which 
would  normally  protect  mucous  membrane.  Hence 
such  an  operation  exposes  the  patient  to  the  danger  p-j^  569.— Billroth's  method 
of  jejunal  ulceration.  Another  defect  in  such  an  of  gastro-enterostomy. 
operation  is  that  there  is  still  a  communication  be- 
tween the  stomach  and  the  efferent  loop.  Fowler's  operation  (Fig.  579) 
corrects  this  defect.  McGraw's  operation  (Figs.  572  and  573)  tends  to  pre- 
vent the  formation  of  a  vicious  circle.  It  seems  certain  that  the  danger  of 
the  formation  of  a  vicious  circle  is  greatest  after  a  long-loop  anterior  operation 
and  least  after  a  short-loop  posterior  operation.  The  shorter  the  loop,  the 
less  the  danger,  hence  the  latter  is  the  operation  of  choice.  The  safest  opera- 
tion of  all  is  the  short-loop  operation  of  Moynihan  or  Scudder  (page  1083), or 
the  "no-loop  "  operation  of  the  Mayos  (page  1086) . 

Treatment  of  Persistent  Vomiting  after  Gastro-enterostomy. — If  vomiting 
persists  in  spite  of  gastric  lavage  and  rectal  feeding  after  the  operation  of 
gastro-enterostomy  with  a  long  loop  without  entero-anastomosis,  open  the 
abdomen  again  and  perform  anastomosis  between  the  afferent  and  efferent 
loops  of  intestine.  This  was  suggested  by  Braun  in  1892,  and  both  he  and 
Jaboulay  performed  it  in  the  same  year.  The  operation  has  saved  lives. 
In  a  short-loop  operation  we  should  assume  that  the  jejunum  has  been  twisted, 
open  the  abdomen,  and  endeavor  to  correct  the  condition.  Herbert  L.  Patter- 
son (Ibid.)  points  out  that  slight  cases  of  regurgitant  vomiting  not  immediately 
following  an  operation  may  be  due  purely  to  constipation,  and  may  be  re- 
covered from  if  care  is  taken  to  secure  daily  a  free  bowel  movement.  In  Patter- 
son's opinion  constipation  causes  reversed  peristalsis,  and  as  both  the  duodenal 
"siphon-trap  and  the  pyloric  sphincter  are  put  out  of  service,"  regurgitation 
takes  place  from  the  efferent  loop  into  the  stomach. 

Anterior  Gastro-enterostomy.— ^e^nn'.f  Method.— h.  median  incision  is 
made  through  the  abdominal  wall,  from  below  the  xiphoid  cartilage  to  the 


1078 


Diseases  and  Injuries  of  the  Abdomen 


umbilicus.  An  opening  is  made  in  the  lower  part  of  the  anterior  wall  of  the 
stomach  in  the  direction  of  the  long  axis  of  the  viscus,  and  its  edges  are  stitched 
with  a  continuous  catgut  suture.  The  contents  of  the  jejunum  are  forced 
along  to  below  the  point  where  an  incision  is  to  be  made.  The  duodenal  loop 
of  jejunum  should  be  from  1 2  to  14  inches  in  length.  A  rubber  tube  is  fastened 
around  the  bowel  above  this  point,  and  another  below  it;  an  incision  is  made 
in  the  long  axis  of  the  bowel,  and  the  margins  of  the  wound  are  sutured  in  the 
same  manner  as  the  stomach-wound.  Bone  plates  are  introduced  into  the 
stomach  and  intestine,  and  the  hgatures  are  tied  as  in  intestinal  anastomosis. 
Catgut  rings  or  rubber  rings  may  be  used. 

Mayors  Anterior  Method  (Fig.  570).— Open  the  abdomen,  and  pick  up  the 
small  intestine  and  find  a  point  of  jejunum  about  14  inches  from  the  point  at 
which  it  emerges  from  under  the  mesocolon.     Efi'ect  the  union  to  the  inferior 

border  of  the  stomach  close 
to  the  greater  curvature  and 
at  the  lowest  portion  of  the 
stomach  pouch.  When  the 
anastomosis  is  completed, 
the  stomach  pouch  is  funnel- 
shaped.  The  usual  custom 
has  been  to  place  the  open- 
ing higher  on  the  anterior 
wall.  It  sometimes  led  to 
the  formation  of  a  pouch  on 
the  anterior  wall,  did  not 
drain  the  stomach,  and 
caused  vomiting.  After  the 
performance  of  gastro-en- 
terostomy  the  edges  of  the 
omentum  are  caught  upon 
each  side  of  the  anastomosis 
and  are  sutured  to  each  other 
and  to  the  stomach- wall  one 
inch  above  the  opening.  The 
edges  are  then  united  to  each 
other  in  a  downward  direc- 
tion for  about  three  inches 
so  as  to  form  an  apron  over 
the  anastomosis,  yet  not  con- 
nected with  it.  Catgut  is 
used  for  suturing.  If  leak- 
age occurs,  the  omentum  is 
adjacent  and  "available."  If  leakage  does  not  occur,  the  omentum  soon  re- 
turns to  its  normal  position  (Wm.  J.  Alayo,  in  "Annals  of  Surgery,"  Aug., 
1902). 

Kocher's  Method  (Fig.  571).— After  opening  the  abdomen,  lift  up  the 
omentum,  pull  up  a  loop  of  intestine,  and  find  the  point  where  the  jejunum 
appears  from  under  the  mesocolon.  Select  a  loop  sixteen  inches  from  the 
origin  of  the  jejunum  and  prepare  to  attach  it  to  the  stomach.     Wolfler 


Fig.  570. — Mayo's  method  of  gastro-enterostomy,  show- 
ing proper  and  improper  locations  of  openings:  a.  Proper  po- 
sition, leaving  no  pouch;  d,  usual  position,  forming  intra- 
gastric pouch  ("Annals  of  Surgery  "). 


Jaboulay's  Gastro-duodenostomy 


1079 


believed  that  the  intestine  should  be  applied  to  the  stomach  in  such  a  manner 
that  the  direction  of  peristalsis  in  the  bowel  must  correspond  to  the  direction 
of  the  stomach-tide.  This  can  be  accomplished  by  having  the  proximal 
portion  of  gut  to  the  left,  and  the  distal  portion  to  the  right.  The  operation 
is  to  be  so  performed  that  after  its  completion  the  stomach-contents  pass 
into  the  distal  portion  of  the  gut,  and  the  intestinal  contents  do  not  tend  to 
enter  the  stomach.  In  order  to  accompHsh  this  Kocher  hangs  the  intestine  to 
the  stomach-wall  in  such  a  manner  that  the  proximal  portion  of  the  loop  is 
posterior  and  ascending,  and  the  distal  portion  is  anterior  and  descending. 
The  bowel  is  hung  to  the  stomach  by  a 
continuous  serous  suture  of  silk,  the  ends 
of  which  are  left  long.  The  intestine  is 
opened  by  a  curved  incision,  the  con- 
vexity of  which  is  downward.  The 
stomach  is  opened  so  that  the  convexity 
of  the  cut  is  upward.  The  valve-like 
portion  of  the  bowel-wall  is  sutured  to 
the  stomach  below  the  incision  in  that 
viscus.  The  two  openings  are  well  ap- 
proximated by  sutures. 

Operation  by  McGraw's  Elastic 
Ligature  (Figs.  572-574). • — The  elas- 
tic ligature  was  introduced  by  Sil- 
vestri  in  1862  and  was  first  used 
in  intestinal  anastomosis  by  the  same 
surgeon.  McGraw  perfected  the  opera- 
tion in  189 1  (see  Dudley  Tait, 
in  "Annals  of  Surgery,"  Feb.,  1906). 
The  operation  may  be  anterior  or  poste- 
rior. The  intestine  and 
sutured  together  by  Lembert  stitches. 
The  elastic  cord,  which  is  3  to  5  mm.  in 

diameter,  is  passed  through  the  stomach  and  then  the  bowel,  in  the  long  axis 
of  each,  and  is  tightly  tied,  and  the  knot  is  fastened  with  a  silk  thread.  An- 
other row  of  Lembert  sutures  buries  the  elastic  cord  from  sight.  The  cord 
cuts  through  in  from  forty-eight  to  seventy-two  hours  and  makes  the  anasto- 
mosis. Thus  the  danger  of  infection  is  greatly  lessened,  for  when  the  anasto- 
mosis opening  is  formed,  it  is  completely  encompassed  by  firm  adhesions. 
Further,  the  danger  of  the  formation  of  a  vicious  circle  is  greatly  lessened, 
because  there  is  no  communication  between  the  stomach  and  bowel  for  between 
forty-eight  and  seventy-two  hours,  the  period  in  which  vomiting  of  the  type 
previously  described  is  most  apt  to  occur.  The  method  is  not  suitable  for 
absolute  pyloric  occlusion.  In  this  condition  it  is  imperative  to  give  nourish- 
ment early,  and,  again,  an  ordinar}^  gastro-enterostomy  allays  autointoxication 
and  this  operation  cannot  until  the  ligature  cuts  through.  It  is  particularly 
valuable  in  the  performance  of  lateral  intestinal  anastomosis. 

Jaboulay's  Gastro-duodenostomy. — This  operation  was  devised  by 
Jaboulay  in  1892.  It  aims  to  obviate  some  of  the  objections  to  pyloroplasty 
and  at  the  same  time  to  retain  the  advantages  this  operation  possesses  over 


Fig-  571-— Kocher's  method  of  gastro- 
enterostomy: a.  Places  of  posterior  annular 
suture  through  entire  wall  of  stomach  and 
intestine;  i,  places  of  anterior  annular  suture 
through  the  entire  wall;  c,  valve  at  the  jeju- 
num by  arch-formed  incision;  d,  posterior  an- 
Stomach  are  ""'^''  suture  of  the  serosa;  e,  thread  ends  for 
continuing  anterior  suture  of  the  serosa. 


io8o  Diseases  and  Injuries  of  the  Abdomen 


Fig.  572.— McGraw's  method  of  lateral  anastomosis.     The  elastic  ligature  is  introduced  (Walker), 


Fig.  573.— McGraw's  method  of  lateral  anastomosis.    One  tie  of  the  elastic  ligature  with  a  strong 
silk  ligature  underneath  ready  to  fasten  the  elastic  ligature  where  it  is  drawn  taut  (Walker). 


Posterior  Gastro-enterostomy 


1081 


gastro-jejunostomy.  Jaboulay's  gastro-duodenostomy  has  never  become 
popular  with  surgeons,  and  Finney's  method  is  much  more  satisfactory^ 
(page  1066). 

Posterior  Gastro-enterostomy  (Fig.  578).— In  a  thin  subject  with  a  long 
mesocolon  posterior  gastro-enterostomy  is  to  be  chosen,  but  if  the  mesentery  is 


Tig:.  574.— McGraw's  method  of  lateral  anastomosis.     The  operation  completed  (Walker). 


short  or  contains  much  fat,  or  if  the  vascular  loop  coming  from  the  superior  mes- 
enteric artery,  and  which  supplies  the  transverse  colon  with  blood,  is  small,  so 
that  on  opening  the  posterior  layer  of  the  gastro-colic  omentum  it  would  be  close 
to  the  artery,  the  anterior  operation  is  employed  (Wm.  J.  Mayo,  in  "  Annals  of 
Surgery,"  Aug.,  1902).     If  a  Murphy  button  is  used,  the  posterior  operation 


Fig- 575 -—Jaboulay's  method  of  gastro-enter- 
ostomy. 


Fig.  576.— Braun's  method  of  gastro-enterostomy. 


is  selected.  The  operation  is  commonly  performed  as  follows:  After  the  abdo- 
men has  been  opened,  the  stomach  and  omentum  are  raised;  a  portion  of  the 
upper  jejunum  is  seized,  emptied,  and  a  site  selected  for  the  clamp.  This 
site  must  be  within  5  inches  of  the  flexure.     If  there  is  a  broad  mesocohc  band 


io82 


Diseases  and  Injuries  of  the  Abdomen 


preventing  a  near  approach  to  the  flexure  the  band  must  be  divided.  A  clamp 
is  appHed  on  the  side  opposite  the  mesenteric  attachment.  A  spot  is  selected  on 
the  transverse  mesocolon  where  there  are  no  vessels,  and  an  opening  is  made 
through  the  mesocolon  with  a  dry  dissector.  The  posterior  wall  of  the  stom- 
ach is  j)ulled  into  the  opening  and  sutured  to  its  edges.  This  prevents  down- 
ward disj)lacement  of  the  stomach  and  obstruction  of  the  loop  of  gut.  A 
portion  of  the  posterior  wall  of  the  stomach  is  pulled  out  into  a  cone  and 
clamped.  Openings  are  made  and  the  sutures  applied  as  directed  on  page 
1083.  Regurgitation  is  less  common  after  posterior  than  after  anterior  gastro- 
enterostomy. In  250  posterior  operations  in  Czerny's  clinic  there  was  not  one 
case  of  regurgitant  vomiting.  One  hundred  and  seventy  cases  were  button 
operations  and  45  were  by  sutures  alone  (Peterson).  Von  Hacker  had  one 
instance  of  regurgitation  in  60  posterior  operations. 

Operation  by  the  Murphy  Button. — Gastro-enterostomy  may  be  quickly 
performed  by  the  use  of  a  large-sized  Murphy  button.  Murphy  says  that  in 
some  reported  cases  the  button  has  slipped  back  into  the  stomach,  but  this 
accident  can  be  prevented  by  the  use  of  an  oblong  button  and  by  making  the 
anastomosis  on  the  posterior  stomach-wall.     The  same  surgeon  advises  us  to 


i'ig- 577-^W61fler-Lucke    method   of  gastro- 
enterostomy. 


Fig.  578. — Von  Hacker's  posterior  gastro-enteros- 
tomy. 


scarify  the  peritoneum  to  hasten  union,  and  says  supporting  sutures  about  the 
button  are  not  required,  except  when  considerable  tension  exists.  There  is  no 
question  that  an  anastomosis  on  the  anterior  wall,  accomplished  by  a  Murphy 
button,  can  be  speedily  performed.  Anastomosis  on  the  posterior  wall  cannot 
be  performed  so  speedily,  and  it  sacrifices  to  some  extent  the  great  advantage 
of  the  button  operation — that  is,  speed.  In  spite  of  the  reported  cases  we  can 
positively  assert  that  the  danger  of  the  button  producing  grave  trouble  is  slight. 
In  some  cases  it  drops  into  the  stomach  and  remains  there,  but  seems  to  do  no 
harm.  In  other  cases  it  takes  a  long  time  to  pass.  In  one  of  the  author's 
cases  it  did  not  pass  until  the  eighty-sixth  day.  If  it  does  not  pass  in  two  or 
three  weeks,  the  rectum  should  be  explored  with  the  finger  from  time 
to  time  to  see  if  it  is  lodged  there.       The  .T-rays   may  determine  whether 


Moynihan's  Method  of  Gastro-enterostomy 


1083 


the  button  is  in  transit.  If  the  wall  of  the  stomach  is  thick,  the  incision 
should  be  made  in  the  stomach-wall  before  the  suture  is  passed,  and  this 
suture  should  pick  up  only  a  small  portion  of  the  stomach-wall,  otherwise 
the  button  may  be  retained  in  place  for  a  very  long  time  (Wm.  J. 
Mayo).  "In  many  cases  in  which  the  button  passes,  vomiting  with  symp- 
toms of  obstruction  may  appear  in  the  second  or  third  week  while  it 
is  in  transit.  Gastric  lavage  and  rectal  feeding  for  a  day  or  two  cause 
these  symptoms  to  subside"  (Wm.  J.  Mayo,  in  "Annals  of  Surgery,"  Aug., 
1902).  Mayo  considers  the  suture  operation  as  good  as  the  button,  and 
thinks  the  results  are  about  the  same.  Mikulicz  says  that  in  the  suture 
operation  entero-anastomo- 
sis  is  necessary,  but  not  in 
the  button  operation,  be- 
cause the  button,  while  in 
place,  prevents  angulation. 
The  last-named  surgeon  uses 
the  button  in  malignant 
cases  and  the  suture  in 
benign  cases.  Czerny  is  an 
advocate  of  the  button. 
Every  button  should  be 
tested  before  it  is  used. 
Mayo  finds  nearly  20  per 
cent,  of  buttons  imperfect 
and  dangerous. 

Fowler's  Method  (Fig. 
579). — Anastomose  the  pos- 
terior wall  of  the  stomach 
to  the  jejunum  and  do  an  en- 
tero-anastomosis  between  the 
afferent  and  efferent  loops  of 
jejunum.  Pass  a  No.  20 
silver  wire  two  or  three  times 

around  the  afferent  loop  of  jejunum  and  draw  it  sufficiently  tight  to  occlude 
the  lumen  without  strangulating  the  wall  of  the  gut.  The  ends  are  twisted, 
cut  short,  rolled  into  a  flat  coil,  the  cut  ends  being  in  the  coil.  (See  Geo. 
Ryerson  Fowler  on  the  "Circulus  Vitiosus"  following  gastro-enterostomy, 
"Annals  of  Surgery,"  Nov.,  1902.)  This  operation  positively  prevents  the 
entrance  of  material  from  the  duodenal  loop  into  the  stomach  and  also  drains 
that  loop. 

Moynihan's  Method. — This  is  the  plan  I  usually  employ.  It  is  easy, 
rapid,  and  clean:  JMake  a  4-inch  incision  i  inch  to  the  right  of  the  middle 
line  and  above  the  umbiUcus.  Open  the  anterior  sheath  of  the  rectus  and 
separate  it  from  the  front  of  the  muscle  as  far  as  the  middle  fine.  Draw  the 
entire  muscle  outward,  open  the  posterior  portion  of  the  sheath,  and  then 
open  the  belly.  Inspect  and  feel  the  entire  stomach.  Lift  the  omentum 
and  transverse  colon  out  of  the  abdomen  and  make  the  mesocolon  taut  by 
raising  the  stomach  and  colon  vdth  the  left  hand.       Find  "a  bloodless  spot  in 


Fig.  579.— Fowler's  method  of  gastro-enterostomy. 


1084 


Diseases  and  Injuries  of  the  Abdomen 


the  arch  of  the  middle  coUc  artery,"  pick  up  a  bit  of  the  under  surface  of  the 
mesocolon  with  a  pair  of  hemostatic  forceps,  lift  it  from  the  posterior  stomach- 
wall,  and  open  the  lesser  sac  of  peritoneum  with  the  scissors.  Enlarge  the 
opening  by  dilatadon  or  tearing  unUl  it  admits  three  fingers.  Inspect  and 
feel  the  posterior  stomach-wall.  Place  the  stomach  in  its  natural  position, 
mark   with   the  thumb  the  lowest  part  of  the  posterior  stomach-wall,  and 

again  turn  the  viscus  over.  From  the 
spot  marked  by  the  thumb  a  fold  is  raised. 
The  fold  is  obHque  and  its  upper  end 
is  to  approach  the  cardia  and  lesser 
curvature.  A  stomach  clamp  (Fig.  580) 
having  a  rubber  tube  bent  over  each 
blade  is  applied  obliquely  so  as  to  grasp 
the  base  of  this  fold.  In  apply- 
ing the  clamp  the  tip  should  point  to  the 
right  shoulder  and  the  handle  to  the 
outer  side  of  the  left  hip,  and  the  lowest 
portion  of  the  stomach  is  grasped  in 
the  tip  of  the  blade  of  the  clamp  (Fig. 
581).  The  clamp  is  now  put  in  a  hori- 
zontal posirion.  The  duodenojejunal 
flexure  is  found  with  the  finger,  the 
jejunum  is  identified  and  its  natural 
posidon  is  noted.  The  jejunum  is 
picked  up  and  "drawn  tight"  and  a  spot 
is  noted  which  reaches  the  greater  curva- 
ture of  the  stomach  when  the  jejunum 
is  in  its  natural  posirion.  The  point 
noted  is  5  inches  from  the  flexure  and 
the  jejunum  above  the  spot  is  where 
the  anastomosis  is  made.  The  clamp 
is  apphed  in  the  side  of  the  gut  oppo- 
site the  mesentery.  The  surgeon  must 
be  sure  that  the  jejunum  is  not  twisted 
around  its  longitudinal  axis.  If  it  is, 
the  clamps  are  not  rightly  applied,  and 
they  must  be  placed  so  that  after  the 
anastomosis  the  jejunum  lies  in  its 
natural  position  without  a  twist.  The 
clamped  gut  is  placed  by  the  side  of  the 
clamped  stomach,  a  bit  of  gauze  being 
put  between  them  (Fig.  582).  The  stom- 
ach (except  the  clamped  portion),  the 
omentum,  and  transverse  colon  are  returned  to  the  abdomen  and  the  clamps 
are  surrounded  with  gauze.  Each  clamp  holds  a  fold  3^  to  4  inches  in  length. 
Pagenstecher's  celluloid  thread  is  used  for  suturing.  The  first  line  of  sutures 
is  passed  as  shown  in  Fig.  583.  In  front  of  these  sutures  an  incision  is  made 
into  the  stomach  and  jejunum,  the  serous  and  muscular  coats  being  first  divided, 


Fig.  580. — Moynihan's  clamp  for  gas- 
tric and  intestinal  operations  (made  by 
Down  Brothers,  London) 


Fig.  581.— Moynihan's  method  of  gastro-enterostomy.     The  oblique  applicaiiuii  of  iiie  clamp  to  the 

sloniach  (Moynihan). 


tig-SSa.  —  Moynihan's  method  of 
gastro-enterostomy.  The  strip  of 
gauze  between  the  clamps  ( Moynihan). 


Fig.  583.— Moynihan's  method 
of  gastro-enlerostomy.  The  first 
layer  of  serous  suture  (Moynihan). 


io86 


Diseases  and  Injuries  of  the  Abdomen 


and  an  ellipse  of  mucous  membrane  being  removed  (Fig.  584).  The 
next  row  of  sutures  is  inserted  as  shown  in  Fig.  585.  When  this  row  is 
completed  the  clamps  are  removed  and  the  long  suture  of  the  first  row  is 
picked  up  again  and  the  operation  is  completed  (Fig.  586).  Finally,  the 
edges  of  the  mesocolic  opening  are  sutured  to  the  jejunum.  The  parts  are 
cleansed  with  salt  solution,  the  suture  line  is  inspected,  the  parts  are  re- 
turned to  the  belly,  and  the  abdomen  is  closed.  (See  Moynihan's  "Abdominal 
Operations.") 

The  No-loop   Operation  of   the   Mayos. — (Figs.   587-589). — In  this 
operation  the  gastric  opening,  which  is  placed  in  the  line  advised  by  Moyni- 


Fig.  584  — Moynihan's  method  of  gastro- 
enterostomy. Removal  of  the  ellipse  of  mu- 
cous membrane  (Moynihan). 


Fig.  585.— Moynihan's  method  of  gastro-enter- 
ostomy.  The  inner  suture,  continued  (Moyni- 
han). 


han,  extends  one-fourth  or  one-half  inch  into  the  anterior  wall  of  the  stomach, 
and  thus  the  lowest  part  of  the  opening  will  be  the  lowest  part  of  the  stomach 
(Fig.  587).  The  incision  in  the  intestine  begins  from  i  to  3  inches  from  the 
origin  of  the  jejunum,  the  measure  beingmadeon  the  anterior  surface  (Fig.  587). 

The  object  is  to  get  as  short  a  piece  of  jejunum  as  can  be  attached  with- 
out tension.  The  operation  is  described  as  follows  (Wm.  J.  Mayo  in 
"Annals  of  Surgery,"  Nov.,  1905). 

"(a)  The  abdominal  incision  is  made  4  inches  in  length,  |  inch  to  the 
right  of  the  middle  Hne,  the  fibers  of  the  rectus  muscle  being  separated.  The 
lower  end  of  the  external  wound  Hes  opposite  the  umbihcus.     This  opening 


The  No-loop  Operation  of  the  Mayos 


1087 


also  enables  inspection  of  the  duodenum  and  gall-bladder  and  is  reliable 
against  hernia  when  closed. 

"(b)  The  transverse  colon  is  pulled  out  and  the 
mesocolon  made  taut  by  traction  upward  and  to 
the  right,  in  this  manner  bringing  the  jejunum  into 
view  at  its  origin. 

"(c)  About  3  to  4  inches  of  the  jejunum  oppo- 
site the  mesentery  are  drawn  into  a  slightly  curved 
clamp.  The  handles  of  the  clamps  should  be  to 
the  right,  to  enable  a  short  grasp  on  the  intestine. 
Three-fourths  of  the  circumference  of  the  bowel  is 
pulled  through;  the  posterior  border  is  not  in- 
cluded, to  prevent  entanglement  of  the  suture 
with  the  redundant  posterior  mucous  membrane. 
The  holding  clamps  are  applied  sufficiently 
tight  to  check  hemorrhage  and  prevent  extrava- 
sation of  intestinal  contents. 

"(d)  The  ligament  of  Treitz  is  a  short  muscular 
mesentery  covered  by  a  variable  peritoneal  fold 
(too  variable  for  a  reliable  landmark)  extending 
upward  from  the  origin  of  the  jejunum  on  to  the 
mesocolon.  This  peritoneal  fold  lies  at  the  base 
of  the  arterial  loop  of  the  middle  colic  artery  which 
suppHes  the  transverse  colon.  The  mesocolon  is 
opened  within  the  vascular  loop  and  the  pos- 
terior inferior  border  of  the  stomach  pushed  through.  A  small  separation 
of  the  greater  omental  attachment  to  the  stomach  enables  the  anterior  gas- 


Fig.  586.— Moynihan's  meth- 
od of  gastro-enterostomy.  The 
serous  suture  resumed  (Moyni- 
han). 


Fig.  587.— Mayo's  method  of  gastro-enterostomy.  Showing  posterior  wall  of  the  stomach  drawn 
through  a  rent  in  the  transverse  mesocolon.  Note  slight  separation  of  gastrocolic  omentum  from  its 
attachment  to  the  stomach,  permitting  anterior  wall  of  stomach  to  appear,  and  insuring  drainage  at 
lowermost  level.     Black  lines  mark  site  of  proposed  anastomosis;  the  jejunum  shows  at  its  origin. 


io88 


Diseases  and  Injuries  of  the  Abdomen 


trie  wall  to  be  drawn  out  posteriorly.  The  posterior  gastric  wall  is  drawn 
into  a  clamp,  with  the  handles  to  the  right,  in  such  a  manner  as  to  just  ex- 
pose the  anterior  wall  at  the  base. 


Fig,  588.— Mayo's  method  of  gastro-enterostomy.    Forceps  in  place  and  anastomosis  half  completed 

by  suture. 


Fig.  589. — Mayo's  method  of  gastro-enterostomy.    Completed  operation  from  behind  margin  of  torn 
mesocolon  attached  by  several  interrupted  sutures  to  line  of  union. 


"(e)  The  two  clamps  are  laid  side  by  side  and  the  field  carefully  protected 
by  moist  gauze  pads.  With  fine  celluloidal  Hnen  thread  on  a  straight 
needle  the  intestine  is  sutured  to  the  stomach  from  left  to  right  by  a  Gushing 
suture  at  least  2^  inches. 


Gastrogastrostomy 


1089 


"(/)  The  stomach  and  intestine  are  incised  ^  inch  in  front  of  the  suture 
line  and  the  redundant  mucous  membrane  excised  flush  with  the  retracted 
peritoneal  and  muscular  coats.  With  a  No.  i  chromic  catgut  on  a  straight 
needle  the  posterior  cut  margins  of  the  entire  thickness  of  the  gastric  and 
jejunal  wall  arc  united  by  a  button-hole  suture  from  right  to  left;  at  the 
extreme  left  the  suture  changes  to  one  which  passes  through  all  the  coats, 
of  each  side  alternately,  from  the  peritoneal  to  the  mucous,  then  directly  back 
on  the  same  side  from  the  mucous  to  the  peritoneal.  This  acts  as  a  hemo- 
static suture,  and  also  turns  the  peritoneal  coats  into  apposition.  It  passes 
around  the  anterior  surface  and  is  tied  to  the  original  end,  which  has  been 
left  long  for  the  purpose.  If  silk  or  linen  is  used  for  this  suture,  it  may  hang 
in  situ,  suppurating  for  months. 

"(§)  The  clamps  are  now  removed  and  the  Hnen  thread  continued  around 
until  it  is  tied  to  the  original  end,  firmly  catching  the  blood-vessels  in  sight 
along  the  suture  line.     The  parts  are  carefully  cleansed  and  inspected.     If 


Fig.  590.— Bircher's  method  of  gastroplicatioii. 


necessary,  a  suture  or  two  is  applied  to  accurately  coapt  or  to  check  the 
oozing. 

"(h)  The  margins  of  the  incised  mesocolon  are  now  united  to  the  suture 
line  by  3  or  4  interrupted  sutures,  and  the  parts  returned  into  the  abdomen." 
In  this  operation  the  greatest  care  must  be  taken  to  avoid  twisting  the  gut 
around  its  longitudinal  axis. 

Qastro=anastomosis  or  gastrogastrostomy  is  an  operation  per- 
formed for  hour-glass  contraction  of  the  stomach,  a  condition  which  occa- 
sionally ensues  on  the  healing  of  an  ulcer.  In  this  operation  an  anastomosis 
is  effected  between  the  pyloric  and  cardiac  pouches.  It  was  devised 
and  practised  by  Wolfler  in  1894.  I  have  practised  it  twice  with  success. 
Watson  folds  the  two  stomachs  over  each  other,  using  the  narrow  isthmus 
as  a  hinge;  sutures  the  pouches  together  and  leaves  the  ends  of  the  sutures  long. 
He  incises  the  anterior  wall  of  the  anterior  stomach  in  order  to  obtain  access 
to  the  double  septum  between  the  two  pouches.  He  makes  an  anastomosis 
opening  through  the  double  septum,  sutures  the  edges,  and  closes  the  wound 
69 


1 090 


Diseases  and  Injuries  of  the  Abdomen 


in  the  anterior  wall  of  the  anterior  stomach.  Wolfler  made  a  vertical  cut  in 
each  pouch  and  united  these  openings  to  make  an  anastomosis.  The  best  plan 
is  to  apply  clamps  on  each  side  of  the  isthmus  and  operate  as  we  would  for 
gastro-enterostomy. 


Fig.  591. — Hour-glass  stomach.  The  application  of  clamps  and  the  method  of  suture  in 
gastrogastrostomy.  The  details  are  the  same  as  in  the  operation  of  gastro-enterostomy  (Moyni- 
han). 

Qastroplication  (Brandt's  Operation  of  Stomach=reefing  for 
Dilated  Stomach). — Apply  sutures  in  the  anterior  wall  so  as  to  form  reefs, 
then  tear  through  the  great  omentum  and  apply  sutures  in  the  posterior  wall. 
The  sutures  pass  through  the  serous  and  muscular  coats.  A  continuous 
suture  may  be  used  on  the  anterior  wall  and  another  on  the  posterior  wall, 
or  numerous  interrupted  sutures  may  be  inserted.  This  operation  is  of  ques- 
tionable value,  and  must  never  be  used  if  stenosis  of  the  pylorus  exists,  and 
stenosis  of  the  pylorus  is  the  most  common  cause  of  gastric  dilatation. 

Bircher's  method  of  gastroplication  is  shown  in  Fig.  590. 

Qastropexy  (Duret's  Operation  for  Qastroptosis).— It  has  been 
shown  by  Duret  that  dyspepsia  of  a  peculiarly  severe  type  may  be  produced 
by  prolapse  or  downward  displacement  of  the  stomach.  In  this  condition  he 
advised  the  following  operation:  Perform  a  median  laparotomy,  but  do  not 
incise  the  peritoneum  in  the  upper  portion  of  the  wound.  E.xpose  the  stomach 
and  fix  it  by  means  of  a  silk  suture  to  the  undivided  but  exposed  peritoneum. 
The  suture  should  be  parallel  to  the  lesser  curvature  and  near  the  pylorus 
should  be  horizontal.*  The  operations  of  Duret,  of  Rovsing,  of  Hartman,  and 
*  Rev.  de  Chir.,  June,  1896. 


Duodenostomy  and  Jejunostomy 


1091 


of  Eve,  of  London,  fix  and  distort  the  stomach.  This  seems  to  me  an  objec- 
tional  procedure  and  liable  to  be  followed  by  pain.  To  fix  an  organ  which 
undergoes  active  ])eristalsis  must  surely  be  productive  of  difficulty.  Byron 
Davis  advises  the  suturing  of  the  gastrohef)adc  omentum  near  its  attachment 
to  the  lesser  curvature  to  the  stomach-wall  as  high  as  possible.  Beyea  has 
devised  an  operation  which  is  free  from  the  objections  which  may  be  urged 
against  Buret's  operation. 

Beyea's  Operation  for  Qastroptosis.— Insert  three  rows  of  inter- 
rupted silk  sutures  through  the  gastrohepatic  omentum  and  the  gastrophrenic 
ligament.  Each  suture  is  passed  from  above  downward  and  the  row  begins  at 
the  right  and  passes  to  the  left  (Fig.  592).     When  the  sutures  are  tied,  a  fold 


Fig.  592.— Beyea's  operation  for  gastroptosis  :  i,  Position  of  one  suture  of  first  row  ;  2,  one  suture 
of  second  row ;  3,  one  suture  of  tiiird  row.  Others  of  each  row  introduced  at  intervals  to  and 
including  the  gastrophrenic  ligament. 


or  plication  is  formed  in  the  ligaments,  the  supports  of  the  stomach  are  short- 
ened, and  the  viscus  is  elevated  to  a  normal  position  without  any  disturbance 
of  its  physiological  mobility  ("Univ.  of  Penna.  Med.  Bull.,"  Feb.,  1903). 

Duodenostomy  and  Jejunostomy. — It  has  been  suggested  that  one  of 
the  above  operations  should  be  performed  in  a  case  of  pyloric  obstruction  in 
which  pylorectomy  is  not  feasible.  Duodenostomy  is  an  easy  operation  be- 
cause of  the  mobility  of  the  pylorus  and  first  part  of  the  duodenum,  and  it  is 
not  only  easier,  but  is  safer,  than  jejunostomy,  because  it  makes  the  fistula  above 
the  opening  of  the  common  bile-duct  ("Bull,  et  Mem.  de  la  Soc.  de  Chir.  de 
Paris,"  No.  39,  1901).  Cackove  advocates  the  operation  in  some  cases  of 
gastric  ulcer  with  repeated  hemorrhages  and  some  cases  of  gastric  cancer.  In 
the  latter  cases  he  asserts  that  the  mortality  is  about  the  same  as  from  gastro- 


1092  Diseases  and  Injuries  of  the  Abdomen 

enterostomy  and  the  prolongation  of  life  is  greater  ("Arch.  f.  klin.  Chir.," 
Bd.  Lxv,  Heft  2).  Hartman's  case  of  duodenostomy  lived  two  months.  The 
operation  was  performed  for  extreme  cicatricial  stenosis  of  the  pylorus  due  to 
swallowing  hydrochloric  acid.  Moynihan  points  out  that  if  the  operation  i.s 
done  at  all,  the  indication  for  jejunostomy  is  cancer  involving  the  entire  stom- 
ach or  leather-bottle  stomach.  He  operated  on  2  cases.  One  lived  one  month 
and  one  seven  weeks  (B.  G.  A.  Moynihan,  "Brit.  Med.  Jour.,"  June  28, 
1902). 

Jacobson  disapproves  of  both  procedures,  and  objects  particularly  to 
duodenostomy,  because  it  involves  a  portion  of  the  intestine  which  is  difficult 
to  deal  with,  and  because  important  fluids  escape  constantly  from  the  fistula.* 

The  same  author  objects  to  jejunostomy  because  of  the  inevitable  leakage 
of  nutritive  fluids. 

Reported  cases  of  duodenostomy  and  jejunostomy  certainly  do  not  indicate 
that  the  operations  prolong  life  to  any  considerable  degree. 

Enterectomy,  or  Resection  of  the  Intestine  with  Approxima= 
tion  by  Circular  Enterorrhaphy. — How  much  of  the  intestine  can  be  re- 
moved without  the  patient  dying  from  lack  of  nutrition  ?  The  question  is  not 
settled.  It  has  been  stated  that  the  removal  from  an  adult  of  more  than  six 
and  two-thirds  feet  produces  intestinal  disturbance,  and  that  a  child  tolerates 
the  removal  01  a  piece  relatively  larger  better  than  does  an  adult.  Certain 
it  is  that  great  lengths  have  been  successfully  removed,  and  the  patients  have 
not  only  lived,  but  have  been  well  nourished.  Ruggi  removed  eleven  feet 
successfully.  Hayes  removed  eight  feet  four  and  one-half  inches  from  a  boy 
of  ten  years  of  age,  and  the  patient  was  well  eight  months  later.  Dressman 
reported  26  cases  in  each  of  which  more  than  three  feet  three  inches  had  been 
removed  (Alexander  Blaney,  in  "Brit.  Med.  Jour.,"  Nov.  16,  1901).  Blaney 
adds  7  cases  from  literature,  and  tells  us  that  in  9  of  the  ^;}  cases  death  oc- 
curred soon  after  operation. 

Alexander  Blaney,  in  the  previously  quoted  article,  reviews  the  subject 
of  the  resection  of  great  lengths  of  intestine.  He  tells  us  that  how  much  re- 
mains after  a  resection  is  important  but  uncertain.  It  is  uncertain  because,  as 
Treves  has  shown,  the  length  of  the  intestine  varies  from  fifteen  feet  six 
inches  to  thirty-one  feet  ten  inches. 

Resection  of  the  jejunum  is  much  more  dangerous  than  resection  of  an 
equal  length  of  ileum.  If  resection  is  employed,  all  diseased  or  injured  bowel 
must  be  removed  irrespective  of  ultimate  bad  consequences  (Blaney).  The 
operation  is  performed  as  follows:  After  opening  the  abdomen  isolate  the 
loop  of  intestine  we  intend  to  resect.  Push  a  rubber  tube  through  the  mes- 
entery close  to  the  bowel,  above  the  seat  of  operation,  and  pass  a  rubber 
tube  through  the  mesentery  below  the  seat  of  operation.  Empty  this  segment 
of  bowel  by  squeezing  and  stroking,  tighten  the  rubber  tubes,  and  clamp  them 
to  keep  the  bowel  empty  (Fig.  593).  Instead  of  tubes,  strips  of  iodoform 
gauze  may  be  used  to  encircle  the  bowel.  The  diseased  intestine  is  resected, 
each  incision  being  carried  through  a  healthy  segment,  and  care  being  taken 
that  the  cuts  are  so  arranged  that  at  each  end  a  blood-vessel  from  the  mes- 
entery reaches  the  edge  of  the  cut   bowel.     Otherwise  repair  can  scarcely 

*Jacobson's  "Operations  of  Surgery." 


Enterectomy 


1093 


occur.  The  lumen  of  each  end  of  the  divided  gut  is  irrigated  with  salt  solu- 
tion. The  divided  surfaces  are  ai)i)roximated  by  a  double  row  of  sutures — a 
continuous  suture  for  the  mucous  membrane,  and  Lembert's,  Dupuytren's, 
or  Cushing's  suture  to  effect  inversion.  Thoroughly  satisfactory  approx- 
imation can  be  effected  by  one  row  of  Halsted  sutures.  If  a  redundant  fold 
of  mesentery  is  left,  it  can  be  stitched  at  its  raw  edge  (Fig.  594)-  Many  sur- 
geons remove  a  V-shaped  piece  of  mesentery  and  tie  the  divided  mesenteric 
vessels  (Fig.  593)-  The  tubes  are  removed,  and  the  wound  is  cleansed, 
closed,  and  dressed. 

Senn  effects  invagination  by  means  of  a  bone  ring  (Fig.  597)- 
If  the  two  segments  of  bowel  are  unequal  in  size,  the  narrow  part  of  the 
bowel  should  be  cut  obliquely  and  the  larger  part  should  be  cut  transversely. 
To  meet  this  complication  Billroth  devised  lateral  implantation  (Fig.  626). 
Suppose  the  cecum  has  been  resected;  its  lower  end  is  closed  by  Lembert 
sutures,  an  opening  is  made  in  the  long  axis  of  the  periphery  of  the  colon 
opposite  the  attachment  of  the  mesocolon,  and  the  end  of  the  ileum  is  sutured 
into  this  incision.  This  is  called  end-to-side  approximation,  or  implantation. 
It  is  used  in  the  sigmoid,  in  the  cecum,  and  in  any  intestinal  segment  in  which 
the  circulation  is  deficient.     Eugene  A.  Smith  ("Amer.  Med.,"  May  10,  1902) 


Fig.  593.  — Excision  oi  oowei  ;   iirsl  step 
(Esmarch  and  Kowalzig). 


Fig.  594. — Excision  of  bowel  with  enteror- 
rhaphy  and  stitching  of  the  redundant  mesen- 
tery;  second  step   {Esmarch  and  Kowalzig). 


sums  up  the  advantages  of  end-to-side  approximation  as  follows:  The  strain 
of  peristalsis  is  less  than  in  end-to-end  union;  the  circulation  of  each  end  of  the 
bowel  and  the  parts  of  bowel  adjacent  is  better;  each  cut  edge  of  mesentery 
is  free  to  recover  its  circulation,  and  there  is  no  dead  space  at  the  mesenteric 
border  to  lead  to  leakage. 

Senn  advises  the  insertion  of  an  anastomosis-ring  in  the  ileum,  the  in- 
vagination of  the  colon  as  the  ring  is  pulled  into  place,  and  firm  suturing  of  the 
line  of  junction.  By  Senn's  method  the  ileum  may  be  implanted  into  the  end 
of  the  colon  or  into  a  sHt  in  the  wall  of  the  large  bowel  after  the  end  of  the 
colon  has  been  closed.  In  some  cases,  where  one  portion  of  bowel  is  larger 
than  the  other,  lateral  anastomosis  is  the  preferable  method.  For  a  full  week 
after  an  intestinal  resection  the  patient  is  fed  chiefly  by  nutrient  enemata. 
During  the  first  twenty-four  hours  nothing  is  given  by  the  stomach  but 
small  amounts  of  hot  water,  and  for  the  next  six  days  but  a  little  liquid  food 
is  allowed  to  be  swallowed. 


I094 


Diseases  and  Injuries  of  the  Abdomen 


Fig.  595. — Resection  of  intestine  :  a,  b.  The  two  halves  of  the  button  ;  c,  the  two  portions  clamped 
together;  rf,  introduction  of  the  sutures  for  holding  each  half  of  the  button  in  place.  The  lower 
figure  shows  the  completed  union  of  the  intestine  by  the  Murphy  button  ;  the  slit  in  the  mesentery 
has  been  closed  by  linear  union  (after  ZuckerkandU. 


Fig.  596. — Comparison  of  old  (a)  and  new  (6)  Murphy  buttons. 


Enterectomy 


1095 


Fig.  597. — Senn's  modification  of  Joberl's  invagi- 
nation method :  A,  Upper  end  lined  with  ring;  B, 
invagination  sutures  in  place  ;  C,  lower  end. 


The  use  of  Murphy's  button  permits  of  rapid  approximation  after  resection 

(Fig.  595,  b  and  r).  Tliis  button 
closely  approximates  the  portions 
of  the  intestine  within  its  bite, 
rapid  adhesion  taking  place. 
The  diaphragm  of  tissue  under- 
goes pressure-atrophy  and  lib- 
erates the  button,  which  is 
passed  per  anum.  It  is  claimed 
that  the  button-opening  contracts 
but  slightly.  For  end-to-end  or 
side-to-side  approximation  of  the 
small  intestine  a  No.  3  button  is 
used.  For  similar  operations  on 
the  large  intestine  a  No.  4  button 
is  employed  (Murphy).  After 
the  resection  one  half  of  a  but- 
ton is  inserted  into  each  segment,  and  is  held  in  place  by  a  purse-string  suture 
of  silk  which  passes  through  all  the  coats  (Fig.  595).  The  redundant  mucous 
membrane  is  tucked  in  or 
clipped  off,  so  that  it  will 
not  be  interposed  between 
the  serous  surfaces.  The 
serous  surfaces  are 
scratched  with  a  needle 
and  the  halves  of  the  but- 
ton are  locked  (Fig.  595). 
It  is  not  necessary  to  sur- 
round the  margin  of  junc- 
tion with  sutures.  Mur- 
phy says  that  liquid  nour- 
ishment should  be  given 
as  soon  as  the  patient  has 
recovered  from  the  effect 
of  the  ether,  and  that  the 
bowels  should  be  moved 
at  an  early  period,  and 
frequent  evacuations 
should  be  maintained.  If 
the  button  does  not  pass 
in  four  weeks,  examine  the 
rectum  for  it.*  The  situa- 
tion of  the  button  can  be 
ascertained  by  the  .r-rays. 
An  objection  to  the  but- 
ton is  that  it  introduces  a 
foreign  body  which  must 
pass  per  rectum  to  complete  the  operation  successfully.  It  may  not  pass,  but 
*  John  B.  Murphy,  in  Med.  News,  Feb.  9,  1895. 


Fig.  598. — Maunsell's  method  of  anastomosis  (after  Wiggin). 


1096 


Diseases  and  Injuries  of  the  Abdomen 


trouble  does  not  of  necessity  follow.  But  in  some  cases  its  retention  leads  to 
trouble,  and  obstruction  ensues.  If  the  caliber  of  the  button  blocks  before 
dislodgment,  obstruction  follows;  hence  the  rule  to  give  saline  purgatives 
the  day  after  the  operation. 


Fig.  599- — The  segmented  ring  of  Harrington  and  Gould. 

Some  surgeons  have  sought  to  make  a  button  which  would  come  apart 
and  be  absorbed  after  it  had  accomplished  its  purpose.  The  best  of  these 
appliances  is  Frank's  coupler,  which  is  made  of  bone,  the  compression  being 
furnished  by  rubber.  In  this  apparatus,  however,  the  amount  of  pressure 
obtained    is    always  uncertain  and  the  rubber  is  apt  to    wear    out.     The 

button  gives  a  lower  mortality  than 
the  suture  operation,  and  many  sur- 
geons now  use  it  who  once  con- 
demned it.  Czerny  is  a  strong 
advocate  of  the  button. 

After  intestinal  resection  Hal- 
sted  performs  circular  enterorrhaphy 
by  means  of  mattress  sutures  (Figs. 
605  and  606). 

Harrington  and  Gould  use  a 
segmented  aluminum  ring.  This 
ring  collapses  into  small  segments 
after  the  anastomosis  has  been 
effected.  By  its  use  the  authors 
believe  that  the  operation  is  made 
more  rapidly  and  safely  ("Annals 
of  Surgery,"  Nov.,  1904)-  During 
the  suturing  the  ring  is  held  by 
means  of  a  handle,  which,  after  the  anastomosis  has  been  effected,  is  removed. 
The  ring  in  the  handle  is  shown  in  Fig.  599  and  the  operation  in  Figs.  600,  601. 
Maunsell  has  devised  a  most  ingenious  method  of  circular  enterorrhaphy. 
The  two  portions  of  bowel  are  attached  by  two  hxatlon  sutures  which  penetrate 
all  the  coats  (Fig.  598).    An  incision  one  and  one-half  inches  in  length  is  made 


Fig.  600 End-to-end  union  with  aid  of  seg- 
mented ring.  Continuous  stitch  beginning  at  one 
side  of  the  handle  (Harrington  and  Gould). 


Enterectomy 


1097 


Fig.  601. — End-to-end  union  with  aid  of  segmented  ring.    Handle  unscrewed,  suture  completed  (Har- 
rington and  Gould). 


Fig.  602^— Robson's  decalcified  bone  bobbin. 


Fig.  603. — Allingham's  decalcified  bone 
bobbin. 


Fig.  604 — Harris's  method  of  circular  enterorrhaphy. 


1098 


Diseases  and  Injuries  of  the  Abdomen 


through  the  wall  of  the  proximal  segment  of  gut,  about  one  inch  from  its  edge. 
The  fixation  sutures  are  brought  through  this  opening,  traction  is  made  upon 
them,  the  distal  portion  of  the  bowel  is  invaginated  into  the  proximal  portion, 
and  the  ends  emerge  from  the  opening,  their  peritoneal  surface  being  in 
contact  (Fig.  598).  Sutures  of  silk  are  passed  through  both  sides  of  the  area 
of  invagination,  the  threads  are  caught  up  in  the  center,  cut,  and  tied  on  each 
side.  The  fixation  sutures  are  cut  off.  The  invagination  is  reduced  by 
traction.     The  longitudinal  cut  is  closed  by  Lembert  sutures. 


fig-  605.— Use  of  Halsted's  inflated  rubber  cylinder  in  circular  enterorrhaphy. 

A.  W.  Mayo  Robson  performs  circular  enterorrhaphy  and  brings  the 
ends  of  the  gut  together  over  a  bobbin  of  decalcified  bone  (Fig.  602).  Alling- 
ham  uses  a  bone  bobbin  the  shape  of  two  cones  joined  at  their  apices.  The 
bobbin  is  decalcified,  except  an  area  at  the  center  (Fig.  603).  Kocher  per- 
forms circular  enterorrhaphy  as  follows:  A  fixation  suture  is  introduced 
through  the  bowel  at  the  mesenteric  attachment  and  another  is  inserted 

at  an  opposite  point.  The  in- 
testinal ends  are  approximated 
by  a  continuous  silk  suturt, 
which  passes  through  all  of 
the  coats,  but  which  includes 
more  of  the  serous  than  of  the 
mucous  coat.  The  suture-line  is 
overlaid  by  a  continuous  Lem- 
bert suture  which  includes  the 
serous  and  a  portion  of  the 
muscular  coat.  Harris  removes 
a  portion  of  mucous  membrane 
from  the  distal  end  by  means  of 
a  curet.  Three  needles  are 
threaded  with  fine  silk.  The 
first  needle  is  pushed  through 
the  bowel-wall   to   one   side  of   the   mesentery.     The  point  of   the  needle 


Fig.  606.— Suture  of  the  mesentery   after  circular  en- 
terorrhaphy (Halsted). 


Enterectomy 


1099 


Fig.  607.— Moynihan's 
method  of  end-to-end  anas- 
tomosis (Moynihan). 


Fig.  608. — Moynihan's 
method  of  end-to-end  anas- 
tomosis continued. 


Fig.  609.— Moynihan's 
method  of  end-to-end  anas- 
tomosis continued. 


picks  up  a  portion  of  the  distal  end  transversely.  The  needle  is  used  as  a 
lever  to  invaginate  the  distal  end  into  the  proximal  end.  The  same  pro- 
cedure is  carried  out  with 
the  other  needles.  When 
invagination  is  effected  the 
needles  are  pulled  through 
and  the  threads  are  tied.  The 
free  end  of  the  bowel  is  now 
sutured  to  the  invaginated 
part  by  interrupted  inversion 
sutures  or  by  a  continuous 
inversion  suture  broken  once 
(Fig.  604).* 

In  doing  an  end-to-end 
approximation  I  prefer  to 
use  the  clamps  of  Moynihan, 
as  shown  in  Figs.  607,  608, 
and  609.  We  thus  are  able 
to  hold  the  parts  and  keep 

them  clean,  rapidly  make  an  even  and  secure  stitch  line,  and  have  no  free- 
edged  septum. 

*  Chicago  Med.  Recorder,  Jan.,  1897. 


Fig.  610. — Laplace's  forceps  for  intestinal  anastomosis. 


IIOO 


Diseases  and  Injuries  of  the  Abdomen 


Some  surgeons  employ  inflatable  rubber  cylinders  in  making  an  end-to-enci 
anastomosis  (Halsted,  Downes,  and  others).  The  method  was  devised  by 
Treves,  but  was  subsequently  abandoned  by  him.  Halsted  maintains  that 
the  use  of  the  inflatable  rubber  cyHnder  enables  the  surgeon  to  finish  the  opera- 
tion more  quickly  and  to  dispense  with  clamps;  arrests  the  vermicular 
motion  of  the  intestine ;  makes  easy  the  adjustment  of  two  pieces  of 
intestine  of  unequal  size;  and  renders  it  possible  to  apply  stitches 
rapidly,  evenly,  and  securely.*  Three  presection  sutures  are  inserted;  a 
portion  of  bowel  and  a  V-shaped  piece  of  mesentery  are  resected,  the 
mesenteric  incision  being  so  made  as  to  leave  a  vessel  uncut  at  each 
edge  to  supply  each  end  of  the  divided  intestine.  The  mesenteric  vessels 
are  ligated  and  the  ends  of  the  bowel  are  pulled  together  by  the  presection 
stitches,  two  of  which  are  tied.  The  collapsed  rubber  cylinder  is  pushed 
into  the  bowel  by  means  of  forceps  and  is  inflated  with  a  syringe  (Fig. 
605).     Twelve  mattress  sutures  are  inserted,  the  bag  is  collapsed  and  with- 


Fig.  611. — End-to-end  anastomosis  with  the  aid 
of  Laplace's  forceps. 


Fig.  612.— Senn's  entero-anastomosis:  A, 
Senn's  bone  plate  ;  B,  intestinal  anastomosis  ;  C, 
operation  complete. 


drawn  and  the  sutures  are  tied,  the  stitch  a  being  tied  first  (Fig.  605). 
The  sht  in  the  mesentery  is  sewed  in  such  a  way  that  the  mesenteric  ves- 
sels which  nourish  the  bowel  are  not  interfered  with  (Fig.  606). 

Connell  has  devised  a  method  which  places  the  knots  in  the  lumen  of  the 
bowel  (F.  Gregory  Connell,  "Medicine,"  April,  1901).  He  maintains  that 
the  placing  of  the  knots  within  the  lumen  of  the  gut  has  the  following  advan- 
tages: there  is  no  foreign  body;  the  suture  passes  away  early;  adhesions  to 
neighboring  organs  are  few;  the  serous  approximation  is  perfect;  the  suture- 
line  is  more  secure;  the  septum  is  smaller  and  the  danger  of  necrosis  is  less. 
The  suture  is  shown  in  Plate  10. 

Laplace  has  devised  forceps  which  greatly  facilitate  suturing,  which  make 
it  easy  to  obtain  an  even  suture-line,  and  which  can  be  withdrawn  after  the 
suturing  is  finished,  the  small  opening  through  which  the  instrument  emerged 
being  closed  with  a  stitch  (Figs.  610,  611).  By  aid  of  Laplace's  forceps  the 
operation  can  be  neatly  and  rapidly  performed,  but  a  large  diaphragm  is 
*Phila.  Med.  Jour.,  Jan.  8,  1898. 


Enterectomy 


IIOI 


formed,  a  considerable  area  is  exposed  to  infection,  the  tissues  of  the  dia- 
phragm arc  bruised  and  may  slough,  the  raw  ends  may  grow  together  and 


Fig.  613.— Method  of  passing  the  silk  sutures 
in  inserting  the  rings  of  Abbe. 


Fig.  614. — O'Hara's  anastomosis  forceps 
(about  one-third  original  size). 


Fig.  615.— Showing  the  manner  of  placing  forceps  in  resection  of  bowel;  dotted  lines  show  the   in- 
cision to  be  made  (O'Hara). 


cause  obstruction,  and  it  seems  probable  that  considerable  contraction  will 
follow.  Another  objection  is  that  an  infected  instrument  is  withdrawn  from  the 
boweland  may  contaminate  the  peritoneum.   O'Hara's  forceps  (Fig.  614)  permit 


II02 


Diseases  and  Injuries  of  the  Abdomen 


of  rapid  and  accurate  suturing,  but  possess  the  same  disadvantages  as  the 
Laplace  forceps.  In  one  case  within  my  knowledge  absolute  obstruction 
from  adhesion  of  the  raw  edges  of  the  septum  followed  its  employment.  Figs. 
615  and  616  show  the  use  of  O'Hara's  forceps.  Of  the  operations  previ- 
ously set  forth,  I  prefer  the  clamp  and  suture  as  employed  by  Moynihan, 


Fig.  616.— End-to-end  anastomosis.    Forceps  brought  together  and  held  by  serre-fine  (not  shown); 
sutures  introduced,  some  of  which  are  tied  (O'Hara). 


'/./I 


Fig.  617.— Showing  relative  size  of  incision  and  method  of  introducing  sutures  in  lateral  approxima- 
tion with  Murphy's  button. 


the  operation  of  Halsted  (although  distention  by  an  inflated  cylinder  is  not 
a  necessary  adjunct),  or  the  operation  with  the  Murphy  button. 

Lateral  Intestinal  Anastomosis.— Approximation  may  be  efifected  by 
other  methods  than  by  end-to-end  junction  or  implantation.  In  fact  I  pre- 
fer in  most  cases  of  resection  to  close  each  end  of  the  divided  gut  and  per- 
form lateral  anastomosis.  By  this  operation  we  can  obtain  as  large  an- 
opening   as  we  desire.     Again,  after   lateral  anastomosis  the  parts  obtain 


Lateral  Intestinal  Anastomosis  1103 

a  better  blood-supply  than  after  end-to-end  suturing,  because  in  the  former 


Fig.  6i8.-Suturing  intestines  in  apposition  be-    Fig.  619.— Showing  the  four-inch  incision  and  sew- 
fore  incision  (Abbe).  ing  of  the  edges  (Abbe). 


operation  the  mesenteric  vessels  are  not  interfered  with.  Further,  in  lateral 
anastomosis  there  is  little 
tendency  to  cicatricial  con- 
traction. Lateral  anas- 
tomosis may  be  performed 
in  some  cases  without  a  pre- 
liminary resection  for  the 
purpose  of  short-circuit- 
ing the  fecal  current, 
throwing  a  diseased  por- 
tion of  the  bowel  out  of 
action,  and  thus  avoiding 
obstruction  (Fig.  612). 
This  operation  has  the  dis- 
advantage that  the  diseased 
structure  is  not  removed. 

Operation  with 
Rings. — In  this  operation 
a  portion  of  bowel  above 
the  obstruction  and  a  loop 
below  the  obstruction  are 
brought  into  the  wound. 
These  segments  are  emp- 
tied, and  are  kept  empty 
by  fastening  around  them 
rubber  tubes  or  iodoform 

strips.  Two  tubes  are  needed  for  each  loop  of  bowel.  Pack  in  gauze  pads. 
Make  an  incision  in  one  loop,  in  the  long  axis  of  the  bowel,  on  the  surface 
away  from  the  mesentery,  permit  the  contents  to  escape  externally;  irrigate 
this  segment  with  sahne  solution;  and  introduce  the  bone  plate  of  Senn  (Fig. 
612,  a)  or  Abbe's  catgut  ring  (Fig.  613).  Calyx-eyed  needles  are  used  to  pass 
the  silk,  and  the  threads  of  the  ring  are  carried  through  the  coats  of  the  bowel 
and  are  gathered  together  in  the  bite  of  a  pair  of  forceps.  The  other  loop  of 
intestine  is  treated  in  a  similar  manner.  The  two  segments  of  intestine  are 
so  brought  together  that  the  two  wounds  are  opposite  each  other,  the  posterior 


Fig.  620.— Halsted's  operation  for  lateral  anastomosis,  show- 
ing four  steps  of  same  (Jessett,  from  Halsted). 


1I04 


Diseases  and  Injuries  of  the  Abdomen 


Fig.  621. — Represents  the  em  Is  ot  tlie  nitestine  in  posi- 
tion and  grasped  by  the  artery  forceps.  The  first  row  of 
sutures  has  been  partially  applied,  the  septum  partly  cut 
away,  and  the  second  row  of  overhand  sutures  begun, 
a,  b,  are  the  two  ends  of  the  intestine  ;  c,  c',  the  first  row  of 
sutures  (Gushing) ;  d,  the  second  row  of  sutures  (over- 
hand) ;  e,  the  septum;  f&nd  g-,  the  mesentery  (J.  Sheltoa 
Horsley). 


sutures  being  tied  first,  the  upper  next,  then  the  lower,  and  finally  the  anterior 
threads.  The  ends  of  the 
threads  are  cut  ofi'  and  the 
entire  anastomosis  is  sur- 
rounded by  a  layer  of  Lem- 
bert  or  Halsted  sutures  or  is 
encircled  by  Cushing's  suture. 
Fig.  612,  B,  shows  an  intes- 
tinal anastomosis  partly  fin- 
ished, and  Fig.  612,  c,  shows 
an  anastomosis  complete. 
Fig.  613  shows  the  passing  of 
the  sutures  when  the  catgut 
rings  of  Abbe  are  employed. 
After  an  intestinal  resection 
each  end  can  be  closed  and 
anastomosis  efifected  as  de- 
scribed above.  Lateral  anas- 
tomosis can  be  accomplished 
with  a  Murphy  button,  the  in- 
testine being  prepared  for  the 
button  as  is  shown  in  Fig.  617. 

Abbe's  method  of  anastomosis  without  mechanical  aid  is   as   follows: 

After  resecting  the  bowel  and  mes- 
entery and  closing  the  ends  of  the 
bowel  he  places  the  extremities  side 
by  side  and  appHes  two  rows  of  a 
Dupuytren  suture,  one-quarter  of 
an  inch  apart.  These  rows  of 
sutures  are  an  inch  longer  than  the 
slit  in  the  bowel  will  be  (Fig.  618), 
the  thread  at  the  end  of  each  row 
being  left  long.  An  incision  is  made 
in  the  bowel,  one-quarter  of  an  inch 
from  the  sutures,  both  rows  of 
threads  being  on  the  same  side  of 
the  cut.  This  incision  is  foiu-  inches 
long.  The  other  portion  of  the 
bowel  is  then  incised  in  the  same 
way.  The  adjacent  cut  edges  are 
united  by  a  whip-stitch  which  goes 
through  all  the  coats,  and  the  free 
cut  edges  are  stitched  in  the  same 
manner  (Fig.  619).  The  surgeon  now  utilizes  the  long  threads  of  the  first 
sutures,  and  brings  the  serous  surfaces  of  the  opposite  sides  together  by  means 
of  Dupuytren's  suture.  Halsted  performs  anastomosis  as  follows :  He  places 
the  two  portions  of  bowel  with  their  mesenteric  borders  in  contact.  Six 
quilted  sutures  of  silk  are  introduced,  tied,  and  cut  off  (Fig.  620,  a).  At 
each  end  of  this  row  of  sutvires  two  quilted  sutures  are  introduced,  tied,  and 


Fig.  622. — Operation  nearly  completed.  The 
septum  has  been  cut  away,  and  the  row  of  o\er- 
hand  sutures  has  been  brought  almost  to  its  point 
of  commencement.  The  cut  also  shows  the  first 
row  of  sutures  (Gushing)  as  it  should  be  continued 
after  the  overhand  sutures  are  finished  (J.  Shelton 
Horsley). 


Lateral  Intestinal  Anastomosis 


1 105 


Fig.  623. — Lateral  anastomosis  with  the  aid  of  Laplace's  forceps. 


cut  (Fig.  620,  b).  A  number  of  quilted  sutures  are  introduced,  as  is  shown 
in  Fig.  620,  c.  The  intestinal  openings  are  made  with  scissors,  and  the 
'sutures  last  introduced  are  tied  and  cut  off  (Fig.  620,  d). 

J.  Shelton  Horsley  has  suggested  an  ingenious  method  of  intestinal  anasto- 
mosis which  secures  for  the  su- 
tured portion  a  greater  diameter 
than  that  normal  to  the  intes- 
tine.* After  resection  of  the 
intestine  and  a  V-shaped  piece  of 
mesentery,  the  ends  of  the  bowel 
are  placed  side  by  side,  the  open- 
ings being  in  the  same  direction, 
and  are  clamped  in  place  (Fig, 
621).  The  first  stitch  approxi- 
mates the  two  limbs  of  the  bowel 
near  the  mesenteric  attachment, 
is  carried  obliquely  for  about 
two  inches  to  the  border  oppo- 
site the  mesenteric  attachment, 
and  continued  over  the  other 
side  (Fig.  621).  The  septum  is 
cut  away,  a  margin  being  left 
one-third  of  an  inch  wide.  The 
edge  of  the  shelf  made  by  cutting  the  septum  is  sutured.  When  the  suture 
reaches  the  end  of  the  shelf,  it  is  continued  by  invaginating  about  the  rest 
of  the  resected  ends  (Fig.  622). 

Bodine's  method  of  intestinal  anastomosis  is  referred  to  on  page  11 12. 
Laplace,  of  Philadelphia,  has  devised  an  operation  in  which  temporary 
approximation  is  effected  by  means  of  forceps,  the  instrument  being  with- 
drawn before  the  abdomen  is  closed.     Junction  of  two  segments  of  intestine 

*New  York  Polyclinic. 
70 


Fig.  624.— Withdrawal  of  Laplace's  forceps. 


ii.o6 


Diseases  and  Injuries  of  the  Abdomen 


can  be  quickly  and  neatly  effected  by  this  method  and  the  suture  line  is 
even  and  secure.  The  objections  are  that  an  infected  instrument  is  with- 
drawn from  the  bowel  and  may  contaminate  the  surface;  that  the  septum  is 
tightly  squeezed  and  this  septum  may  slough  or  may  become  infected,  con- 
ditions which  will  be  followed  by  infection  of  the  suture  line;  and  that  con- 
traction of  the  collar  may  ensue.  The  operation  is  more  liable  to  be  fol- 
lowed by  leakage  or  by  partial  or  complete  obstruction  than  is  the  opera- 
tion without  forceps.  Figs.  623  and  624  illustrate  the  use  of  Laplace's  forceps  in 
lateral  anastomosis.    I  usually  perform  lateral  anastomosis  with  the  assistance 

of  Moynihan's  clamps,  the 
method  being  identical  with 
the  operation  of  gastro-enter- 
ostomy.  Moynihan's  opera- 
tion is  shown  in  Fig.  625. 

Consideration  of 
Methods  of  Intestinal  Ap- 
proximation.— At  least  250 
methods  of  uniting  a  divided 
intestine  have  been  devised 
and  the  best  method  is  a  mat- 
ter of  dispute.  The  essentials 
of  a  good  method  are:  rapidity 
of  execution,  the  formation  of 
an  even  and  reliable  line  of 
junction,  and  the  absence  of 
any  considerable  permanent 
septum  The  Murphy  button 
can  be  applied  with  great 
rapidity,  and  rapid  operation 
is  of  immense  importance  in 
intestinal  work.  The  opening 
left  by  the  Murphy  button  is 
small  (too  small,  some  sur- 
geons think),  but  it  does  not 
strongly  tend  in  most  instances 
to  contract  because  the  tis- 
sue-diaphragm is  separated  by 
tissue-atrophy  and  not  by  in- 
flammatory gangrene.  The 
separation  of  the  diaphragm  is 
a  most  valuable  feature.  No  other  instrument  thus  cuts  away  the  objectionable 
septum.  Occasionally  the  opening  made  by  the  button  contracts  and  gives 
trouble;  occasionally  the  lumen  of  the  button  blocks  with  feces;  occasionally 
the  button  is  retained,  this  latter  complication  being  especially  frequent  after 
anterior  gastro-enterostomy.  If  the  button  is  used,  liquid  food  should  be 
given  soon  after  the  effect  of  the  anesthetic  has  passed  off,  and  movement  of 
the  bowels  should  be  obtained  at  an  early  period  after  operation  and  frequent 
evacuations  should  be  maintained.  The  button  gives  better  results  in  end- 
to-end   approximation    than    in    lateral   anastomosis.     Moynihan's   forceps, 


Fig.  625.— Moynihan's  inner  suture  in  lateral  anasto- 
mosis to  show  the  infolding  of  the  mucosa  which  results. 
A  loop  of  the  suture  lies  on  the  mucous  surface  (Moynihan). 


Local  Intestinal  Exclusion 


1 107 


Laplace's  forceps,  O'Hara's  forceps,  the  decalcified  bone  plates  of  Senn,  the 
catgut  rings  of  Abbe,  the  segmented  ring  of  Harrington,  the  catgut  strands 
inside  of  rubber  tubing  of  Brokaw,  Chaput's  button,  AUingham's  bone  bobbin, 
Robson's  bone  bobbin,  Frank's  coupler,  Clark's  bobbin,  tubes  or  plates  of 
potato  or  carrot,  and  rings  or  plates  of  leather,  all  have  their  adherents.  Of 
mechanical  appliances,  the  best  are  Murphy's  button,  the  bone  ring,  Moy- 
nihan's  forceps,  and  the  intlatal)le  rubber  cylinder.  Of  recent  years  many 
surgeons  have  abandoned  all  mechanical  aids,  and  have  returned  to  closure 
by  simple  sutures.  The  ideal  operation  is  without  mechanical  contrivances. 
But  such  devices  are  time-savers,  and  to  lessen  the  time  of  operation  will 
often  save  life.  Further,  Moynihan's  forceps  prevent  fecal  extravasation 
and  consequent  infection.  What  method  to  follow  must  be  determined 
in  each  particular  case  by  a  study  of  the  necessities  of  the  situation.  Never- 
theless, it  may  be  possible  to  formulate  a  few  general  rules:  If  the  condition 
of  the  patient  is  excellent  and  the  bowel  is  in  a  fairly  healthy  condition,  well 


FifT.  626.— Operation  of  complete  exclusion  of  tlie  cecum  :  a  and  b^  Lines  of  incision  ;  f  is  implanted 
into  c  ;  e  and  d  are  sutured  to  the  abdominal  wall. 

above  and  well  below  the  seat  of  trouble,  end-to-end  approximation  should 
be  performed  by  circular  enterorrhaphy  with  the  aid  of  Moynihan's  clamp, 
or  each  end  can  be  closed  after  resection  and  a  lateral  anastomosis  be  effected 
with  the  aid  of  the  clamp.  If  the  condition  of  the  patient  is  such  as  to  make 
haste  necessary,  use  a  Murphy  button.  If  the  bowel  below  the  seat  of  trouble 
is  much  contracted  and  haste  is  necessary,  do  not  use  a  Murphy  button,  but 
use  Senn's  bone  plate  or  Robson's  bobbin.  If  haste  is  not  imperatively 
necessary,  do  enterorrhaphy.  If  the  surgeon  is  obliged  to  join  a  very  much 
distended  bowel  to  a  very  much  contracted  bowel,  perform  end-to-end  ap- 
proximation (implantation)  with  the  bone  plate  of  Senn  or  by  simple  suturing, 
or  el^e  effect  side-to-side  junction  by  the  method  of  Abbe  or  of  Moynihan.* 

Local  Intestinal  Exclusion.— This  operation  was  introduced  by  Salzer 
in  1 89 1.  It  excludes  the  fecal  current  from  a  portion  of  the  intestine.  In 
complete  exclusion  the  intestine  is  cut  through  above  and  below  the  diseased 
portion  and  the  ends  of  the  healthy  gut  are  united  to  each  other  or  the  end 
of  one  portion  of  gut  is  implanted  into  the  side  of  the  other.     Both  ends 

*  See  the  discussion  of  this  subject  by  the  late  J.  Greig  Smith  in  his  "  Abdominal  Surgery." 


iio8  Diseases  and  Injuries  of  the  Abdomen 

of  the  excluded  portion  may  be  fastened  to  the  skin,  making  a  double  fistula 
(Von  Eiselberg) ;  the  distal  end  or  the  proximal  end  alone  may  be  fastened  to 
the  skin,  the  other  end  being  closed  by  sutures  and  replaced  within  the  abdo- 
men. Sometimes  each  end  is  closed  and  dropped  back,  and  a  fistula  is 
made  in  the  middle  of  the  excluded  portion  to  permit  of  drainage.  Some 
operators  close  each  end  by  suture  and  drop  them  back,  and  do  not  drain  the 
excluded  portion;  and  others  aim  at  the  same  end  by  suturing  together  the 
two  ends  of  the  excluded  part.  It  seems  wisest  to  suture  both  ends,  or  at  least 
one  end  to  the  skin  (LeDentu,  in  "Rev.  de  Gyn.  et  de  Chir.,"  Jan.  and  Feb., 
1899).  It  is  true  this  makes  a  permanent  fistula,  but  if  it  is  not  done,  the 
loop  may  become  distended  with  secretion  containing  virulent  bacteria,  a 
condition  which  may  lead  to  perforation  and  death.  Exclusion  is  rarely 
performed  upon  the  small  intestine.  It  is  best  suited  to  the  large  intestine. 
If  it  is  done  at  all,  complete  exclusion  is  the  best  operation  (Fig.  626).  Par- 
tial exclusion  is  rarely  satisfactory.  Exclusion  has  been  performed  instead 
of  colostomy  in  cases  of  intestinal  obstruction,  but  it  is  best  suited  to  inflam- 
matory areas  or  tumors,  irremovable  because  of  adhesions  or  some  other 
cause.  After  the  operation  the  diseased  area  may  improve  because  of  drain- 
age and  freedom  from  irritant  fecal  matter.  In  many  cases  it  can  be  irri- 
gated through  the  fistula.  Sometimes  the  diseased  part  improves  suffi- 
ciently after  a  time  to  permit  of  extirpation. 

Surgical  Treatment  of  Ascites  Resulting  from  Hepatic  Cirrho= 
sis  (Epiplopexy). — The  portal  system  communicates  with  the  vena  cava  by 
means  of  a  number  of  small  vessels.  '  Normally  only  an  insignificant  amount 
of  portal  blood  passes  by  this  route  to  the  general  circulation.  When  cir- 
rhosis obstructs  the  flow  of  blood  through  the  liver,  the  radicles  of  com- 
munication between  the  portal  system  and  the  vena  cava  enlarge  and  an 
increased  amount  of  blood  is  thus  sent  direct  to  the  systemic  circulation. 
Adhesions  develop  between  the  parietal  peritoneum  and  some  of  the  viscera 
and  the  collateral  circulation  is  further  increased.  Thus,  nature  seeks 
to  prevent  ascites.  If,  however,  the  obstruction  to  the  passage  of  portal 
blood  becomes  so  great  that  "the  collateral  circulation  is  no  longer  able 
to  maintain  an  equilibrium  in  the  blood-pressure  in  the  portal  radicles,  the 
pressure  thus  rises  to  a  point  at  which  transudation  takes  place  and  ascites 
develops"  (M.  L.  Harris,  paper  read  before  Chicago  Medical  Society,  Feb., 
1902).  The  theory  above  set  forth  is  the  "mechanical  theory";  but,  as 
Harris  points  out,  increased  portal  tension  is  not  the  only  factor  concerned 
in  the  production  of  ascites,  chronic  inflammatory  changes  in  the  peritoneum 
being  "materially  instrumental"  in  maintaining  ascites  by  lessening  the 
absorbing  power  of  the  peritoneum.  Influenced  by  the  mechanical  theory 
of  causation,  Talma,  of  Utrecht,  devised  an  operation  to  cure  ascites  by 
establishing  more  free  communication  between  the  portal  system  and  the 
systemic  circulation.  Drummond  and  Morison  about  the  same  time  devised 
a  like  procedure  independently.*  This  operation  is  called  epiplopexy.  In 
some  cases  the  abdomen  has  been  opened  and  the  omentum  sutured  in  the 
abdominal  wound;  in  others  between  the  layers  of  the  anterior  abdominal 
wall.  The  results  are  slightly  better  when  the  omentum  is  sutured  between 
the  layers  of  the  abdominal  wall.  The  gall-bladder  may  be  sutured  to  the 
*  Brit.  Med.  Jour.,  Sept.  19,  1896. 


Operation  for  Intussusception  nog 

abdominal  wall  as  well  as  the  omentum.  The  liver  and  spleen,  under  surface 
of  the  diaphragm,  and  parietal  peritoneum  about  the  liver  and  spleen  are 
usually  rubbed  harshly  with  a  piece  of  gauze.  Drainage  is  not  to  be  used. 
It  does  not  appear  to  contribute  any  favorable  chances  and  it  exposes  the 
patient  to  the  danger  of  infection. 

The  operation  ought  to  be  performed  early,  before  the  onset  of  chronic 
inflammation  of  the  peritoneum.  In  a  great  majority  of  cases  the  operation 
proves  futile,  and  not  uncommonly  death  soon  follows  from  complications  or 
because  the  disease  is  very  far  advanced.  In  exceptional  cases  the  operation 
proves  of  distinct  benefit.  The  operation  shows  the  least  mortality  and  the 
greatest  number  of  apparent  cures  when  the  liver  is  large;  the  greatest  mor- 
tality and  the  fewest  cures  when  the  liver  is  contracted.  The  greatly  lowered 
vital  resistance  of  these  patients  is  the  imminent  danger  (Greenough).  Renal 
disease,  cardiac  disease,  other  grave  complications,  and  the  absence  of  suffi- 
cient functionating  liver  substance  to  maintain  life  contraindicate  operation 
(Greenough,  in  "Am.  Jour.  Med.  Sciences,"  Dec,  1902). 

Harris,  in  the  paper  previously  quoted,  collected  46  cases.  Twenty- 
three  of  these  were  instances  of  alcoholic  cirrhosis.  Thirty  per  cent,  were 
dead  within  fourteen  days;  52  per  cent,  were  dead  within  two  months;  56 
per  cent,  were  dead  within  six  months.  Ascites  hJid  returned  in  all  of  those 
who  died  late.  At  the  end  of  one  year  or  longer  13  per  cent,  had  recovered 
from  ascites.  The  remaining  30  per  cent,  were  either  unimproved  or  were 
said  to  be  improved  with  some  ascites. 

Of  the  group  of  mixed  cases  constituting  the  remainder  of  those  Harris 
collected,  10  per  cent,  were  dead  in  four  days,  25  per  cent,  were  dead  in 
four  months.  In  40  per  cent,  no  improvement  took  place.  In  10  per  cent, 
the  report  was  too  early  to  give  any  information.  About  15  per  cent,  were 
free  of  ascites  after  one  year  or  longer,  and  5  per  cent,  were  cured  of  intestinal 
hemorrhage,  ascites  never  having  been  present.  Greenough  collected  105 
operations;  42  per  cent,  were  improved;  58  per  cent,  were  not  improved; 
29.5  per  cent,  died  within  thirty  days.  Two  years  after  operation  9  cases 
were  apparently  in  good  health  ("Am.  Jour.  Med.  Sciences,  Dec,  1902). 

Operation  for  Intussusception. — Air  distention  and  hydrostatic  pres- 
sure are  uncertain;  in  an  advanced  case  may  rupture  the  gut;  even  in  a 
recent  case  may  fail  or  may  reduce  the  bulk  of  the  intussusception,  but  not 
its  apex.  Russell  ("Intercol.  Med.  Jour,  of  Australasia,"  March  20,  1902) 
alludes  to  the  uncertainty  of  the  method.  He  used  hydrostatic  pressure 
in  5  cases.  Two  died  and  two  recovered.  In  one  case  the  method  failed 
and  operation  was  then  performed.  It  is  safer  and  better  to  operate  early, 
but  if  the  conservative  plan  is  tried  and  fails,  operation  should  certainly 
be  done  at  once,  because  an  early  operation  enables  the  surgeon  easily  to 
effect  reduction,  and  also  because  early  complications  are  unusual.  The 
incision  is  made  in  the  mid-Hne  above  the  umbilicus.  The  surgeon  endeavors 
by  manipulation  to  reduce  the  intussusception  by  pushing  it  back,  not  by 
pulling  it  out.  If  the  intussusception  is  gangrenous,  perform  intestinal 
resection  and  circular  enterorrhaphy.  The  same  rule  maintains  when  malig- 
nant disease  of  the  gut  exists  (D'Arcy  Power).  It  is  inadvisable  to  make 
an  artificial  anus.  M aimseW s  operation  is  suited  to  cases  of  irreducible 
intussusception.     It  is  performed  as  follows :  A  longitudinal  incision  is  made 


I  no  Diseases  anrl  Injuries  of  the  Abdomen 

in  the  intussuscipiens.  The  intussusception  is  gently  pulled  upon  and  is 
caused  to  protrude  from  this  opening.  Two  straight  needles  threaded  with 
horse-hair  are  passed  so  as  to  transfix  the  base,  and  one-fourth  of  an  inch 
above  the  needles  the  intussusception  is  cut  off.  The  needles  are  carried 
completely  through,  the  sutures  are  hooked  up  in  the  middle  and  cut,  and 
the  two  ends  are  tied  on  each  side.  These  sutures  unite  the  intussusception 
to  the  intussuscipiens.  The  two  surfaces  are  now  carefully  approximated 
by  sutures.  The  sutures  are  cut.  The  stump  is  replaced.  The  longitudinal 
incision  is  closed  with  Lembert  sutures.* 

Russell  reports  i6  cases  operated  upon:  12  recovered  and  4  died.  In 
every  one  of  the  4  fatal  cases  the  diagnosis  was  not  made  until  the  disease 
had  lasted  several  days.  In  2  of  the  successful  cases  the  diagnosis  was  made 
late  ("Intercolonial  Med.  Jour,  of  Australasia,"  ]\Iarch  20,  1902).  If  opera- 
tion is  done  in  the  first  twelve  hours  the  mortahty,  even  in  infants,  will  scarcely 
exceed  15  per  cent.  If  gangrene  exists  the  mortality  is  enormous  (at  least 
90  per  cent.). 

Senn's  Operation  for  Fecal  Fistula. — Suture  the  opening  trans- 
versely with  Czerny  sutures  of  silk  in  order  to  prevent  infection.  Cleanse 
the  surface  thoroughly.  Open  the  abdomen  and  separate  the  edges  of  the 
bowel  from  the  parietes.  *  Dehver  the  portion  of  bowel  which  contains  the 
fistula  and  apply  Lembert  sutures  over  the  Czerny  sutures.  Another  method 
is  to  open  the  abdomen  above  the  fistula,  insert  the  fingers,  cut  out  the  skin 
and  tissues  around  the  fistula  in  an  eUiptical  course,  leaving  them  attached 
to  the  bowel,  draw  the  bowel  from  the  abdomen,  pack  gauze  around,  remove 
the  tissues  adherent  to  it,  and  suture  the  fistula  transversely  (Hearn). 

Enterostomy  is  the  making  of  an  artificial  anus.  If  performed  in  the 
large  bowel,  it  is  called  colostomy.  In  some  cases  of  intestinal  obstruction 
it  is  necessary  to  open  the  small  intestine,  and  if  this  is  required,  the  artificial 
anus  should  be  made  as  near  as  possible  to  the  cecum.  The  nearer  to  the 
stomach  it  is  made,  the  more  apt  is  the  patient  to  die  of  lack  of  nourishment. 
The  anus  may  be  made  in  the  middle  fine  or  in  the  right  iliac  region.  The 
bowel  is  fixed  and  opened  as  directed  under  colostomy.  In  acute  intestinal 
obstruction  it  may  be  necessary  to  open  the  bowel  at  once.  In  such  a  case 
Paul's  tube  is  very  useful.  Paul's  tube  is  made  of  glass,  is  bent  to  a  right 
angle,  and  has  a  rim  near  each  end.  The  large  tube  is  used  in  the  colon,  the 
small  tube  in  the  small  intestine.  A  small  opening  is  made  in  the  intestine, 
the  tube  is  introduced,  and  is  tied  in  place  by  a  silk  suture  which  surrounds 
all  the  coats  of  the  bowel,  a  gush  of  feces  is  caught  in  a  basin,  a  rubber  tube  is 
fastened  to  the  glass  tube,  and  fluid  feces  are  collected  in  a  bottle  and  beneath 
an  antiseptic  fluid.f  In  from  three  or  four  days  to  a  week  the  tube  becomes 
loose  and  can  be  removed.  Stewart's  method  of  enterostomy  was  outlined 
on  page  977. 

Inguinal  Colostomy. — Maydl's  Operation  (Fig.  629). — In  this  opera- 
tion a  vertical  or  obHque  incision  four  inches  long  is  made  over  the  portion  of 
colon  to  be  incised.  In  all  cases  where  it  is  ;DOssible,  do  a  left  inguinal  colostomy. 
In  right  inguinal  colostomy  it  is  difficult  to  deliver  the  bowel  as  in  a  left  inguinal 
colostomy,  because  of  shortness  or  absence  of  mesocolon  at  this  point  of  the 

*T.  Pickering  Pick,  Quarterly  Med.  Jour.,  Jan.,  1897. 
t  Paul,  in  Liverpool  Med.-Chir.  Jour.,  July,  1892. 


Inguinal  Colostomy 


mi 


colon.  Right  inguinal  colostomy  has  been  performed  for  chronic  amebic 
dysentery.  It  puts  the  colon  at  rest  and  permits  of  free  irrigation.  It  is  kept 
open  until  the  dysentery  is  well.    Appendicostomy  has  replaced  it  for  dysentery. 


liimt'iM  ■■■i'«  II  utrlfratrr^^r"**^'^ 


Fig.  627. — Stevenson's  bag  for  inguinal  colostomy. 

It  has  also  been  employed  for  the  treatment  of  ulceration  of  the  colon.  After 
the  incision  on  the  left  side  the  colon  usually  bulges  into  the  wound,  but  if  it 
does  not,  it  may  easi'y  be  found  by  following  with  the  finger  the  parietal 
peritoneum  outward,  backward,  and  inward,  the  first  obstruction  it  encounters 


Fig.  628. — Stevenson's  bag  applied. 


being  the  mesocolon.  Draw  the  colon  out  of  the  wfjund  unril  its  mesenteric 
attachment  is  level  with  the  abdominal  incision.  Push  a  glass  bar  through  a 
slit  in  the  mesocolon  near  the  bowel,  and  wrap  the  ends  of  the  bar  with  iodo- 


III2 


Diseases  and  Injuries  of  the  Abdomen 


form  gauze  to  prevent  slipping.  Instead  of  the  bar,  a  piece  of  gauze  can  be 
employed,  or  a  bridge  of  skin  can  be  made  under  the  bowel  by  suturing  the 
two  skin  edges.  The  two  parts  of  the  flexure  are  stitched  together  by  sutures 
which  penetrate  to  and  catch  the  submucous  coat  (Fig.  629).  Stitch  the  serous 
coat  of  the  bowel  to  the  parietal  peritoneum.  Whenever  possible,  wait  from 
twenty-four  to  forty-eight  hours  before  opening  the  gut.  The  colon  is  opened 
by  the  cautery  or  by  scissors.  If  the  artificial  anus  is  to  be  permanent,  make 
a  transverse  incision  through  the  bowel.  Cut  one-fourth  way  through  the 
colon  when  it  is  first  opened,  and  entirely  across  at  a  later  period.  If  the  arti- 
ficial anus  is  to  be  temporary,  the  incision  should  be  longitudinal.  Maydl's 
operation  has  great  advantages:  it  is  quick,  certain,  reasonably  safe,  satisfac- 
torily prevents  fecal  accumulation  below  the  opening,  and  is  rarely  followed  by 
absolute  fecal  incontinence.     In  many  cases  the  bowels  move  but  two  or  three 

times  a  day.  The  movements, 
however,  come  quickly  with  but  lit- 
tle warning.  Sometimes  there  is 
no  warning.  If  diarrhea  develops, 
there  will  be  fecal  incontinence  as 
long  as  it  lasts.  An  air-pad  cov- 
ered with  gauze  and  held  in  place 
by  a  firm  belt  is  the  best  form  of 
permanent  apparatus  to  wear. 

Bodine's  Operation  (Fig. 
630). — Bodine's  method  of  colos- 
tomy permits  of  a  future  restora- 
tion of  the  fecal  current  by  an  easily 
performed  anastomosis.  This  sur- 
geon maintains  that  the  spur  after 
colostomy  should  reach  to  and  remain  at  the  level  of  the  skin,  a 
condition  impossible  of  attainment  by  hanging  the  bowel  over  a  rod 
or  piece  of  gauze,  because  a  spur  thus  formed  is  not  thick  and 
rigid  and  is  inevitably  dragged  below  the  skin-level,  and  when  this  drag- 
ging has  taken  place,  some  fecal  matter  will  pass  into  the  bowel  below  the 
artificial  anus.  Bodine  opens  the  abdomen,  sutures  the  parietal  peritoneum 
to  the  skin,  seeks  for  the  lesion,  and  draws  it  with  six  inches  of  healthy  bowel 
out  of  the  incision.  He  lays  the  Hmbs  of  the  loop  side  by  side.  He  inserts 
a  silk  stitch,  beginning  at  the  point  where  exsection  is  to  be  made,  and  for  six 
inches  unites  the  two  segments  close  to  their  mesenteric  borders.  The  loop 
is  dropped  into  the  abdomen  until  the  beginning  of  the  suture  is  on  a  level 
with  the  skin,  and  at  this  point  it  is  fastened  to  the  abdominal  wound  with  a 
continuous  catgut  suture.  The  protruding  lesion  is  cut  off  along  the  dotted 
line  (Fig.  630).  The  artificial  anus  is  thus  established.  When  it  is  desired 
to  close  the  artificial  anus,  divide  the  septum  with  scissors  or  a  Grant  clamp 
(Fig.  631)  and  close  the  abdominal  wound.* 

Lumbar  Colostomy. — Lumbar  colostomy  is  a  most  unsatisfactory  oper- 
ation.    It  does  not  completely  intercept  the  fecal  current,  and  it  leaves  the 
])atient  in  a  condition  of  wretched  discomfort  because  fecal  incontinence  is 
inevitable.     A  patient  who  has  had  lumbar  colostomy  performed  upon  him 
*New  York  Polyclinic,  Feb.  15,  1897. 


Fig.  629. — Inguinal  colostomy    (after  Zuckerkaiidl). 


Incision  for  Operations  upon  Gall-l)ladder  and  Bile-ducts     1113 

cither  obtains  little  benefit  because  the  feces  pass  into  the  bowel  below  the 
opening  which  was  made  to  intercept  them  or  else  they  pour  out  of  the  open- 
ing uncontrolled,  making  the  poor  unfortunate  a  living  horror  to  himself  and 
others.     It  is  rarely  performed  at  the  present  day. 

The  Healthy  Qall=biadder.— xA.  healthy  gall-bladder  has  a  capacity 
of  about  I  ounce,  and  its  hue  is  bluish.  If  a  gall-bladder  contains  calculi  or 
has  contained  them,  its  hue  is  grayish-white  or  yellowish  (Moynihan). 

Congenital  Absence  of  the  Qall=bladder.— When  the  gall  bladder  is 
shrunken  and  buried  in  adhesions,  it  is  very  hard  to  find  at  operation.  Some- 
times it  is  not  found  and  one  may  jump  to  the  conclusion  that  it  is  congenitally 
absent.  This  is  occasionally,  but  very  seldom  the  case.  Gray  collected 
19  instances  of  congenital  absence  of  the  gall-bladder  ("Trans,  of  Chicago 


•Fig.  630.'-Bodine's  method  of  colostomy, 
showing  one  side  of  the  loop  after  it  haa  been  su- 
tured, passed  back  into  the  cavity,  and  stitched 
into  the  abdominal  wound.  The  lesion  is  left  pro- 
truding, and  the  dotted  line  indicates  where  the 
protrusion  is  to  be  clipped  off. 


Fig.  631. — Bodine's  method  of  colos- 
tomy, showing  the  septum  to  be  divided  in 
restoring  ihe  fecal  current ;  Grant's  clamp 
in  position  for  the  division.  (In  permanent 
colostomy  this  septum  remains  as  a  rigid 
and  effective  spur.) 


Path.  Soc, "  1902).  When  it  is  absent  the  subject  seems  to  get  along  perfectly 
well  without  it. 

The  Incision  for  Operations  upon  the  QalUbladder  and  Bile= 
ducts.— I  have  employed  several  methods,  but  for  some  years  have  been  most 
content  with  Bevan's  incision  (Fig.  632).  The  primary  portion  of  the  incision 
is  shaped  like  the  italic  letter/.  It  is  by  the  side  of  or  through  the  right  rectus 
muscle,  and  is  shown  by  the  double  line  in  Fig.  632.  The  primary  incision 
is  used  for  exploration  and  cholecystotomy.  The  primary  incision  is  from 
three  to  four  inches  long,  and  the  extended  portions,  shown  by  heavy  lines 
in  Fig.  632,  are  added  if  required  (Arthur  Dean  Bevan,  "Annals  of  Surgery," 
July,  1899).  This  incision  gives  most  sadsfactory  exposure,  its  edges  can  be 
separated  without  tension,  and  it  injures  but  few  of  the  nerves  of  the  abdominal 
walls. 

I  believe  it  to  be  superior  to  Kocher's  incision  (Fig.  632),  which  cuts  the 


III4 


Diseases  and  Injuries  of  the  Abdomen 


two  obliques  and  the  transversalis  muscle  and  divides  intercostal  nerves, 
and  to  Mayo  Robson's  (Fig.  632)  incision,  v^^hich  damages  the  right  rectus 
muscle  and  the  nerve  supply  of  its  inner  part.  None  of  these  incisions  are 
entirely  sat  sfactory.  CoUins's  incision  ("Surgery,  Gynecol,  and  Obstet.," 
March,  1909)  seems  to  largely  correct  the  defects  of  the  previous  operations. 
CoUins  thus  describes  his  incision: 

"  The  incision  for  the  bile  tracts  begins  at  the  inner  edge  of  the  right  mus- 
cle, one  or  two  inches  from  the  ensiform  cartilage,  and  extends  diagonally 
downward  and  outward  to  the  outer  edge  of  the  right  rectus,  close  to  the  level 
of  the  umbilicus.  It  cuts  through  the  skin,  fat,  and  anterior  wall  of  the  sheath 
of  the  rectus  (Fig.  633).  A  short  transverse  incision  about  one  inch  in  length 
mav  be  made  inward  from  the  upper  end  of  the  diagonal  incision  through  the 
skin,  felt,  and  linea  alba;  and  a  similar  one  through  the  linea  semilunaris  at 


iffy^^:.^^ 


Fig.  632. — Incisions  for  the  surgery  of  the  bile-tracts:  A,  Kocher's  incision;   B,  Bevan's  incis- 
ion;  C,  Collins'  incision;   D,  Mayo  Robson's  incision. 


the  lower  end.  In  case  more  room  is  required  the  upper  transverse  incision 
may  be  extended  further  into  the  anterior  and  posterior  walls  of  the  sheath  of 
the  left  rectus. 

"  The»  rectus  muscle  is  then  separated  from  its  sheath.  It  is  easily  sepa- 
rated from  the  posterior  portion  of  its  sheath  by  blunt  •  dissection,  but  the 
anterior  portion,  presents  some  difficulty  at  the  insertion  of  the  linea  transversse, 
one  of  which  is  found  about  midway  between  the  ensiform  cartilage  and 
umbilicus  and  is  cros.sed  by  this  incision.  The  attachment  of  the  muscle  to 
the  anterior  wall  of  its  sheath  is  very  close  at  this  linea  transversa,  and  requires 
sharp  dissection  with  knife  or  scissors. 

"  When  the  muscle  is  thoroughly  freed  from  its  sheath,  except  at  its  outer 
border,  it  is  easily  retracted  outward  and  allows  the  posterior  wall  of  its  sheath 


Cholecystostomy 


1115 


and  the  peritoneum  to  be  incised  in  the  same  direction  as  the  skin  and  ante- 
rior wall.  The  upper  end  of  this  diagonal  incision  through  the  posterior 
wall  extends  into  the  short,  transverse  incision  across  the  linea  alba.  When 
this  last  cut  is  made  the  incision  pulls  open  and  gives  ready  access  to  the 
right  upper  abdomen."  This  incision  does  not  damage  the  intercostal  nerves, 
hence  muscular  atrophy  is  avoided.  The  opening  through  the  different 
planes  of  the  abdominal  wall  are  not  continuous,  hence  closure  will  be  more 
solid.  The  opening  in  the  posterior  portion  of  the  rectus  sheath  is  protected 
by  uninjured  muscle. 

Cholecystostomy  or,  as  many  call  it,  cholecystotomy  is  the  oper- 
ation of  opening  and  draining  the  gall-bladder  in  order  to   remove  gall- 


Fig.  633.— A,  anterior  wall  of  sheath  of  rectus  muscle;  B,  posterior  wall  of  sheath;  C, 
rectus  muscle;  D,  intercostal  nerves.  The  direction  of  the  incision  through  the  skin,  fat,  and 
anterior  wall  of  the  sheath  of  the  rectus  muscle  (Collins). 

stones  or  secure  the  removal  of  infectious  material.  In  the  hands 
of  the  Mayos,  operations  for  stone  exhibit  a  mortality  of  less  than  i  per  cent.; 
Kocher's  mortality  is  2  per  cent.  When  death  follows  an  operation  on  the  gall- 
bladder or  ducts,  in  about  one-half  the  cases  it  is  due  to  duct  infection  and  is 
preceded  by  grave  nervous  symptoms  (Mayo) .  Cholecystostomy  is  performed 
in  cases  of  acute  cholecystitis,  in  hydrops,  and  in  empyema  of  the  gall-bladder; 
in  gall-stone  cases  in  which  jaundice  has  lasted  for  four  weeks  or  more,  and  in 
colic  of  the  gall-bladder  with  fever,  the  colic  having  recurred  a  second  or  third 
time  (Carl  Beck).  The  operation  completed  in  one  stage  is  performed  as  fol- 
lows: The  patient  is  placed  recumbent  with  a  sand-pillow  under  the  back  and 


iii6  Diseases  and  Injuries  of  the  Abdomen 

the  incision  is  made.  The  peritoneum  is  opened.  If  the  gall-bladder  is  dis- 
tended, it  is  surrounded  with  pads  and  aspirated,  and  is  then  opened.  (Gall- 
stones are  removed  by  forceps,  the  scoop,  or  irrigation.  The  gall-ducts  are 
examined  by  the  fingers  external  to  them,  and  are  sounded,  if  possible.  If  a 
stone  is  wedged  in  the  duct,  try  to  manipulate  it  back  into  the  gall-bladder. 
If  this  fails,  introduce  an  instrument  from  the  gall-bladder  and  break  up  the 
stone;  if  this  fails,  open  the  duct,  remove  the  stone,  and  close  the  incision  in 
the  duct  (A.  W.  Mayo  Robson).  The  only  way  to  be  certain  that  stones  have 
been  entirely  removed  from  the  cystic  duct  is  to  insert  a  finger  and  dilate. 
Sounds  are  unreliable.  After  the  removal  of  all  stones  and  fragments  pass  a 
rubber  tube  which  has  no  side  perforations  into  the  gall-bladder,  cut  it  off" 
level  with  the  cutaneous  surface,  purse  up  the  cut  in  the  gall-bladder  around 
the  tube  by  means  of  a  catgut  suture,  and  suture  the  gall-bladder  to  the  abdomi- 
nal aponeurosis.  If  sutured  to  the  skin,  a  permanent  biliary  fistula  is  apt  to 
follow.  It  will  seldom  follow  if  the  gall-bladder  is  sutured  to  the  aponeurosis. 
The  gauze  is  now  removed  and  the  drainage-tube  can  usually  be  dispensed 
with  in  from  one  week  to  ten  days.  It  should  not  be  dispensed  with  until 
the  bile  becomes  sterile. 

Some  surgeons  have  advocated  immediate  suture  of  the  gall-bladder  after 
removing  a  stone  {ideal  clwlecystotomy).  I  believe  this  is  never  advisable 
when  the  stones  are  active  for  harm,  because  small  calculi  may  be  in  the  ducts,, 
and  minute  fragments  of  stone  are  often  left  in  the  bladder,  and  the  drainage 
will  remove  them  and  relieve  the  diseased  condition  of  the  gall-ducts  and 
bladder.  In  Kocher's  31  operations  by  this  method,  gall-stones  re-formed 
in  3  cases.  Further,  the  operation  with  immediate  suture  is  decidedly  more 
dangerous  when  infection  exists.  The  Mayos  only  employ  it  in  latent  cases 
of  gall-stone  disease  when  the  existence  of  stones  is  discovered  during  the 
performance  of  an  abdominal  operation. 

It  is  advised  by  some  that  the  operation  of  cholecystostomy  be  performed 
in  two  stages.  First,  the  bladder  is  exposed  and  sutured  to  the  parietal  peri- 
toneum. When  adhesion  takes  place,  the  gall-bladder  can  be  opened  without 
risk  of  infecting  the  general  peritoneal  siirface.  Riedel  advocates  operation 
in  two  stages,  and  so  did  Christian  Fenger  in  certain  cases.  The  two-stage 
operation  is  objectionable  because  it  does  not  permit  of  satisfactory  explora- 
tion of  the  ducts.  The  biliary  fistula  which  is  left  by  cholecystostomy  usually 
closes  spontaneously,  but  may  not.  If  it  does  not  close  and  the  secretion  is 
pure  mucus,  it  is  evident  that  the  cystic  duct  is  absolutely  blocked  and 
cholecystectomy  should  be  performed. 

If  the  secretion  from  a  persistent  fistula  is  bile  and  if  the  common  duct  is  not 
obstructed,  separate  the  edges  of  the  gall-bladder  opening  from  the  parietal 
peritoneum,  endeavoring  to  avoid  entering  the  abdominal  cavity,  and  close 
the  fistula  with  Lembert  or  Halsted  sutures.  If  the  secretion  is  bile  and 
the  common  duct  is  obstructed  permanently,  perform  cholecystenlerostoniy. 
In  214  cases  of  cholecystotomy  for  stone  in  the  gall-bladder,  in  the  cystic 
duct,  or  both,  the  Mayos  had  2  deaths  (Wm.  J,  Mayo,  "Annals  of  Surgery," 
June,  1902).  At  the  end  of  1907  Hans  Kehr  placed  his  mortality  at  2  per 
cent.  ("Jour,  de  Chir.,"  Oct.,  1908). 

Cholecystenterostomy  consists  in  making  an  anastomosis  between  the 
gall-bladder  and  intestine,  preferably  the  duodenum,  or,  if  this  cannot  be 


Cholecystectomy 


1117 


done,  to  the  jejunum.  It  isemployed  in  cases  of  irremovable  obstruction  of 
the  cystic  or  common  duct.  It  is  done  chiefly  in  cases  of  mahgnant  obstruc- 
tion. It  is  not  a  suitable  operation  for  gall-stones  impacted  in  the  common 
duct,  because  it  does  not  remove  the  cause  of  trouble,  infection  of  the  bile- 
passages  may  follow,  and  the  fistula  is  Hable  to  contract.  In  those  rare  cases 
of  common  duct  obstrucdon  from  gall-stones  in  which  the  gall-bladder  is 
distended  and  the  patient  is  desperately  ill,  it  may  be  done  (Robson).  In 
such  a  case  Robson  attaches  the  gall-bladder  to  the  colon  because  the  operation 
is  easier  and  because  he  considers  it  as  useful  as  the  attachment  to  the  duo- 
denum. Cholecystenterostomy  can  be  done  most  rapidly  and  successfully 
by  means  of  a  small  Murphy  button.  Before  the  gall-bladder  is  incised  it  is 
aspirated.     Murphy's  operation  is  shown  in  Fig.  634,  and  is  similar  in  per- 


Fig-  634. — Showing  method  of  holding  parts  while  approximating  a  Murphy  button  in  chole- 
cystenterostomy. 


formance  to  intestinal  anastomosis.  I  believe  that  Brentano  is  right  and 
that  it  is  best  to  do  posterior  cholecystenterostomy,  bringing  the  jejunum 
through  an  opening  made  in  the  transverse  mesocolon. 

Cholecystectomy  is  the  extirpation  of  the  gall-bladder.  It  was  first 
performed  by  Langenbuch  in  1682.  Sometimes  primary  extirpation  is  per- 
formed; at  other  times  cholecystectomy  is  performed  as  a  secondary  opera- 
tion, cholecystostomy  for  drainage  having  been  first  performed.  Its  per- 
formance may  be  demanded  by  the  existence  of  phlegmonous  inflammation 
or  gangrene,  ulceration,  "in  chronic  cholecystitis  from  gall-stones  where  the 
gall-bladder  is  shrunken  and  too  small  to  safely  drain,  and  where  the  common 
duct  is  free  from  obstruction  "  (A.  W.  Mayo  Robson),  in  empyema  with  greatly 
damaged  walls,  in  fistula  associated  with  irremediable  obstruction  of  the  cystic 


iii8  Diseases  and  Injuries  of  the  Abdomen 

duct,  the  common  duct  being  free,  in  cancer,  and  in  some  wounds  of  the  gall- 
bladder. Objections  to  the  operation  are  that  drainage  can  only  be  obtained 
by  putting  a  tube  into  the  hepatic  or  the  common  duct  and  that,  should  renewed 
drainage  be  subsequently  required,  the  necessary  operation  will  prove  difficult 
and  dangerous  (IMaurice  H.  Richardson,  "Medical  News,"  May  2,  1903). 

After  opening  tlie  abdomen  the  gall-bladder  is  found  and  is  drawn  into 
the  wound.  If  it  is  distended  and  tense  or  if  it  is  thought  "to  contain  infec- 
tious fluid"  (Lilienthal),  it  is  packed  about  with  iodoform  gauze  and  emptied 
by  an  aspirating  trocar.  "When  the  walls  are  very  friable,  it  is  even  wise 
to  incise  and  empty  the  viscus,  closing  the  opening  by  ligature  or  clamp 
before  proceeding  with  the  extirpation.  The  gall-bladder  is  usually  quite  a 
tough  organ,  and  in  the  majority  of  cases  it  may  be  grasped  with  an  ovarian 
ring-clamp  apphed  near  its  fundus,  which  at  the  same  time  closes  the  aspira- 
tion puncture"  (Lilienthal,  "Annals  of  Surgery,"  July,  1904).  The  peri- 
toneum which  covers  the  gall-bladder  must  be  divided  just  below  the  liver, 
the  gall-bladder  is  dissected  from  the  liver  until  the  cystic  duct  is  reached, 
the  cystic  artery  is  tied  and  divided,  and  if  the  liver  ducts  are  healthy,  the 
cystic  duct  is  ligated  with  silk  and  divided,  the  stump  is  touched  with  pure  car- 
boUc  acid  and  is  covered  with  a  layer  of  peritoneum  fastened  by  sutures  of 
fine  silk.  In  cases  free  from  infection  it  is  not  necessary  to  drain  the  bile- 
ducts.  In  cases  with  cholangitis  external  drainage  is  necessary  and  it  is 
obtained  by  incising  the  hepatic  duct  and  inserdnga  drainage-tube,  or,  better, 
by  leaving  the  stump  of  the  cystic  duct  open.  Wm.  J.  Mayo  reports  ;^;^  cases 
of  cholecystectomy  with  i  death  ("Annals  of  Sargery,"  June,  1902).  Howard 
Lilienthal  reports  42  cases  with  i  death  ("Annals  of  Surgery,"  July,  1904). 
Hans  Kehr's  mortality  at  the  end  of  1907  was  3.6  per  cent.  ("Jour,  de  Chir.," 
Oct.,  1908). 

Removal  of  the  Mucous  Membrane  of  the  Qall=b!adder.— :Mayo 

has  suggested  the  removal  of  the  fundus  and  of  all  the  mucous  membrane 
of  the  gall-bladder  as  an  occasional  substitute  for  cholecystectomy.  By 
this  operation  we  are  enabled  to  drain  the  cystic  duct  and  through  it  the  hepatic 
ducts.  A  serious  objecdon  to  the  operation  is  that,  as  glands  pass  from  the 
mucous  coat  to  and  through  the  muscular  coat,  it  is  impossible  absolutely  to 
remove  the  mucous  membrane  of  the  gall-bladder  alone  (Emil  Ries). 

Drainage  of  the  Hepatic  Duct. — This  operation  is  employed  for 
certain  hepatic  infections.  It  was  first  performed  by  Cabot  in  1892.  If  the 
cystic  duct  is  dilated  throughout,  it  may  be  carried  out  through  that.  After 
opening  the  gall-bladder  a  tube  is  passed  through  the  cystic  and  into  the 
hepatic  duct.  It  is  often  done  after  opening  the  common  duct,  a  tube  being 
carried  up  into  the  hepatic  duct.  The  hepatic  duct  may  be  exposed  and 
opened  directly,  a  tube  being  carried  into  it  for  a  short  distance  and  stitched 
to  the  edges  of  the  incision  in  the  duct  by  catgut.  The  tube  should  be  sur- 
rounded by  iodoform  gauze. 

Choledochotomy  is  the  operation  of  incising  the  common  duct  for  the 
removal  of  a  stone.  It  is  also  called  choledochouthotomy.  It  was  first  per- 
formed by  Courvoisier  in  1890. 

Cases  upon  which  this  operation  is  done  are  often  deeply  jaundiced  and 
there  is  grave  danger  of  infection  and  of  fatal  oozing  of  blood.  In  one  of 
my  cases  this  happened.     The  patient  was  laboring  under  stones  in  the  com- 


Cholcdochotomy  1119 

raon  duct,  associated  with  cancer  of  the  head  of  the  pancreas.  In  every  case 
in  which  operation  is  contemplated  for  obstruction  of  the  bile-ducts,  take  the 
coagulation  time  of  the  blood.  Normal  coagulation  time  (taken  by  Wright's 
coagulometer)  is  from  three  to  six  minutes.  Prolongation  to  seven  or  eight 
minutes  calls  for  pre-operadve.treatment  to  hasten  coagulability.  If  jaundice 
exists,  it  is  customary  to  endeavor  to  prevent  hemorrhage  by  em[)loying 
Robson's  plan:  Give  by  the  mouth  from  30  to  60  grains  of  chlorid  of  calcium 
three  times  a  day  during  the  twenty-four  or  forty-eight  hours  preceding  the 
operation,  and  60  grains  by  enema  three  times  a  day  for  the  forty-eight  hours 
following  the  operation.  I  have  followed  this  course  in  a  number  of  cases,  but 
am  not  convinced  of  its  value.  Instead  of  this  method  we  may  follow  the 
plan  of  giving  thyroid  extract  (gr.  v  three  times  a  day)  for  several  days  preced- 
ing the  operation. 

The  plan  I  now  pursue  I  am  certain  does  reduce  the  coagulation  time  dis- 
tinctly. I  give  an  injection  of  diphtheria  antitoxin  (horse  serum)  the  day 
before  operation  and  another  the  morning  of  the  operation. 

When  ready  to  operate,  a  sand-bag  should  be  placed  under  the  lower  ribs. 
This  will  bring  the  liver  at  least  two  inches  nearer  to  the  abdominal  wound. 
The  abdominal  incision  must  be  longer  than  that  employed  for  cholecys- 
tostomy.  The  pylorus  and  stomach  are  drawn  to  the  left,  the  colon  and  omen- 
tum are  drawn  downward,  and  the  liver  and  ribs  are  lifted  strongly  upward. 
Gauze  packs  are  inserted. 

"The  operator  should  now,  after  having  separated  adhesions,  have  a 
good  view  of  the  common  duct  within  the  free  border  of  the  lesser  omentum, 
and  on  inserting  his  left  index-finger  into  the  foramen  of  Winslow,  or  on 
grasping  the  duct  between  the  index-finger  and  thumb,  he  can,  without  diffi- 
culty, bring  the  duct  well  within  reach,  the  concretion  making  a  distinct  pro- 
jection."* A  longitudinal  incision  is  made,  the  stone  is  removed,  and  a  probe 
is  introduced  into  the  duct  to  determine  whether  other  stones  are  present. 

Stones  in  the  second  and  third  pordons  of  the  duct  are  often  missed  and  the 
second  portion  of  the  duodenum  should  always  be  palpated  with  the  utmost 
care.  If  the  lowermost  stone  removed  from  the  common  duct  is  faceted  we 
should  always  search  most  carefully  to  find  a  concretion  which  is  lower  still 
(F.  Gregory  Connell,  "Annals  of  Surg.,"  April,  1908). 

If  a  calculus  is  found  in  the  lower  part  of  the  common  duct  the  surgeon 
tries  to  push  it  up  so  that  he  may  reach  it.  This  can  usually  be  accomplished. 
If  he  fails  to  push  the  stone  up  into  reach,  he  must  try  and  force  it  into  the 
duodenum.  This  attempt  will  sometimes,  but  seldom,  succeeed.  If  it  does 
not  succeed  he  must  perform  a  transduodenal  or  a  retroduodenal  operation. 
Only  in  cases  so  shocked  that  further  operation  is  impossible  is  it  proper  to 
do  cholecystostomy  or  cholecystenterostomy.  If  either  of  these  palliative 
operations  is  performed  a  radical  operation  must  be  done  later. 

Many  surgeons  suture  the  incision  in  the  duct.  This  procedure  is  ren- 
dered easier  by  the  use  of  Halsted's  hammer,  which  draws  the  duct  toward 
the  surface  and  keeps  it  under  control  (Fig.  635). 

Interrupted  sutures  of  fine  catgut  are  used.  The  muscular  and  serous 
coats  may  be  included  in  each  suture,  and  over  this  layer  Lembert  or  Halsted 
sutures  are  applied.  A  drainage-tube  is  inserted  and  a  piece  of  iodoform 
*  A.  W.  Mayo  Robson's  "  Treatise  on  Diseases  of  the  Gall-bladder  and  Bile-ducts." 


IT20 


Diseases  and  Injuries  of  the  Abdomen 


gauze  is  placed  upon  the  suture  hue,  the  other  end  being  brought  out  of  the 
abdominal  wound.  This  precaution  is  taken  because  leakage  may  occur. 
If  it  is  found  impossible  to  suture  the  wound  in  the  duct,  the  operation  then 
becomes  a  choledoclwstomy  (although  this  term  is  usually  used  only  when 
the  incised  duct  is  stitched  to  the  abdominal  wall),  and  the  surgeon  carries 
a  glass  tube  down  to  the  opening  and  surrounds  it  with  iodoform  gauze, 


Fig.  635. — Suture  of  duct  over  Halsted's  hammer. 

or  inserts  a  rubber  drainage-tube  into  the  opening  and  carries  it  up  toward 
the  hepatic  duct,  or  makes  an  incision  into  the  right  loin  after  the  plan  of 
Rutherford  Morison,  and  carries  a  tube  into  the  right  kidney  pouch,  which  is 
the  most  dependent  part  of  the  peritoneal  cavity  when  the  patient  is  recumbent. 
Personally  I  always  drain  the  duct,  when  I  have  opened  it  for  stone,  carrying 
the  tube  up  to  the  hepatic  duct.  The  same  reasons  which  cause  us  to  drain  the 
gall-bladder  after  removing  stones  should  influence  us  in  this  case. 

Robson  ("Lancet,"  April  12,  1902)  has  performed  the  operation  of  chole- 
dochotomy  60  times.  In  10  cases  of  stone  in  the  common  duct  he  manipu- 
lated the  stone  back  into  the  gall-bladder  and  removed  it  through  an  incision 
in  that  viscus  by  means  of  a  scoop.  The  above  maneuver  is  impossible  unless 
the  cystic  duct  is  dilated.  In  30  cases  he  crushed  the  stones  between  his  finger 
and  thumb,  but  this  is  only  possible  when  the  the  stones  are  soft,  and  it  has  the 
objection  that  it  may  leave  fragments.  If  a  stone  is  lodged  in  the  common 
duct  and  cannot  be  manipulated  back  into  the  gall-bladder,  choledochotomy 
should  be  performed.  Robson's  mortality  in  60  cases  of  choledochotomy  was 
16.6  per  cent.  Since  1900  his  mortality  has  been  7.1  per  cent.  Before  that 
it  was  23.8  per  cent.  In  49  choledochotomies  the  Mayos  had  2  deaths. 
Kehr's  mortality  is  4.1  per  cent. 

Hepaticotomy. — By  this  term  we  mean  the  opening  of  the  hepatic  duct. 
If  the  opening  is  drained,  the  procedure  is  in  reahty  hepaticostomy,  although 
this  term  is  seldom  used  to  designate  it.     Hepaticotomy  is  performed  for 


Retroduodenal  Choledochotomy  1121 

stone  in  the  hepatic  duct.  The  operation  was  first  performed  by  Kocher 
in  1889.  There  were  7  cases  on  record  in  1903  (Delageniere,  in  "Bull,  et 
Mem.  de  Chir.  de  Paris,"  No.  10,  1903). 

Duodenocholedochotomy  {McBurneys  Operation;  the  Transduodenal 
Route). — This  ()])eration  is  seldom  necessary.  In  the  more  than  2000  opera- 
tions performed  by  the  Mayos  on  the  gall-bladder  and  ducts,  this  operation 
was  only  re(|uircd  in  4  cases.  I  have  never  j)erformed  it.  In  1891  McBurney 
proposed  this  method  for  the  removal  of  gall-stones  impacted  near  the  papilla 
("Annals  of  Surgery,"  Oct.,  1898).  McBurney's  original  suggestion  was  to 
open  the  duodenum,  dilate  or  incise  the  papilla,  remove  the  stone,  and  suture 
the  duodenum.  If  the  stone  is  located  in  the  diverticulum  of  Vater  it  may, 
in  some  few  cases,  be  removed  by  simply  .stretching  the  opening  of  the  duct  with 
forceps  (CoUins's  method) .  If  this  is  not  possible,  the  opening  in  the  papilla 
may  be  enlarged  by  cutting  or  the  duodenal  mucous  membrane  over  the  stone 
may  be  incised  (McBurney's  plan).  When  the  stone  is  not  impacted  at  the 
outlet,  but  is  lodged  a  litde  higher  up,  and  when  dense  adhesions  render 
access  by  the  ordinary  supraduodenal  route  difficult  or  impossible,  the  anterior 
wall  of  the  duodenum  may  be  opened  longitudinally,  the  posterior  wall  of  the 
duodenum  and  the  common  duct  incised  over  the  stone,  the  stone  removed, 
the  duodenum  and  common  duct  sutured  together  (Kocher's  method,  or 
internal  dwledochoduodenostomy),  and  the  anterior  wall  of  the  duodenum 
closed.  (See  Charles  Otto  Thienhaus,  in  "Annals  of  Surgery,"  Dec,  1902.) 
After  finding  and  removing  a  stone  by  the  transduodenal  route  we  must  make 
a  careful  search  to  see  no  stones  are  left  before  closing  the  duodenal  incision. 
Robson  opposes  the  transduodenal  route  and  says  he  has  abandoned  it  because 
of  the  danger  of  sepsis.  Thienhaus  ("Annals  of  Surgery,"  Dec,  1902)  opposes 
this  view  of  Robson  and  shows  that  in  29  operations  by  the  transduodenal  route 
there  were  but  2  deaths. 

Connell  ("Annals  of  Surgery,"  Jan.,  1908)  has  collected  77  cases  in  which 
stones  were  removed  by  the  transduodenal  route.  There  were  10  deaths.  In 
2  of  these  cases  duodenal  fistula  preceded  death. 

Retroduodenal  Choledochotomy. — In  this  operation  the  second  por- 
tion of  the  common  duct  is  incised  back  of  the  duodenum  without  opening  the 
gut.  That  this  may  be  done  the  duodenum  must  first  be  drawn  toward  the 
midline  of  the  body,  and  this  can  be  done  only  by  "mobilizing"  the  duodenum, 
incising  the  posterior  layer  of  the  parietal  peritoneum  one  inch  to  the  right  of  the 
descending  portion  of  the  duodenum.  After  freeing  the  gut  and  retroperitoneal 
structures  the  duodenum  becomes  sufficiently  free  to  lift  toward  the  left  with  a 
rotation.  We  thus  expose  the  posterior  aspect  of  the  duodenum,  the  head  of 
the  pancreas,  and  the  common  duct. 

The  duct  is  opened,  the  stone  removed,  the  duct  sutured,  and  a  drain  in- 
serted. 

This  operation  has  been  successfully  performed  by  a  number  of  surgeons, 
but  there  is  a  great  objection  to  it.  In  nearly  all  cases  the  common  bile-duct 
passes  through  the  pancreas  rather  than  back  of  it.  Bungner  found  this  to  be 
the  case  in  55  out  of  58  dissections  ("  Gray's  Anatomy,"  Seventeenth  American 
edition,  p.  1352).  Hence,  incision  of  the  common  duct  in  this  situation  means 
in  nearly  all  cases  incision  of  the  pancreas  and  all  the  grave  dangers  of  leaking 
of  pancreatic  fluid.  The  transduodenal  operation  is  a  much  better  procedure. 
71 


1 1 22  Diseases  and  Injuries  of  the  Abdomen 

Total  Splenectomy. — This  operation  is  performed  for  wounds  and 
rupture  of  the  spleen,  tumors,  cysts,  floating  spleen,  and  nondeukemic  splenic 
hypertrophy.  Twisting  of  the  pedicle  of  an  ectopic  or  wandering  spleen  calls 
imperatively  for  operation.  It  should  not  be  performed  for  hypertrophy  in 
leukemia. 

In  view  of  the  bone-marrow  changes  in  splenomyelogenous  leukemia,  we 
cannot  hope  to  cure  a  patient  by  removing  the  spleen.  In  a  leukemic  patient 
the  operation  has  a  very  high  mortality  from  shock  and  hemorrhage.  Geo. 
Ben  Johnston  ("Annals  of  Surgery,"  Jan.,  1908)  has  collected  49  splenectomies 
in  leukemia  with  only  6  operative  recoveries  (a  mortahty  of  87.7  per  cent.). 
One  of  the  6  cases  lived  eight  months,  i  Hved  four  years,  and  it  is  claimed  that 
I  was  cured. 

Splenectomy  has  been  performed  for  malarial  hypertrophy  (ague  cake). 
The  operation  has  been  advocated  on  the  theory  that  by  removing  the  spleen 
we  would  get  rid  of  the  lurking  place  of  the  malarial  parasites,  but  they  also 
lurk  in  the  bone-marrow  and  in  the  capillaries  of  the  liver.  The  operadon 
should  not  be  performed  for  malarial  spleen  unless  the  organ  is  movable, 
unless  it  gready  interferes  with  the  patient's  comfort  or  occupation,  or  unless  we 
fear  rupture,  and  then,  if  it  is  done,  it  is  for  the  movability,  the  discomfort,  or  the 
danger,  and  not  for  the  malaria.  It  is  to  be  noted  that  the  operation  does  not 
cure  the  malaria.  Johnston  (Ibid.)  collected  58  splenectomies  performed  for 
malarial  hypertrophy  since  1900.  There  were  50  recoveries  and  8  deaths. 
To  these  he  adds  3  successful  ones  of  his  own,  making  61  cases,  with  8  deaths 
(a  mortality  of  13. i  per  cent.). 

A  number  of  operations  have  been  done  for  splenic  anemia  or  its  terminal 
stage,  which  is  known  as  Band's  disease.  It  is  improbable  that  splenic  disease 
is  the  cause  of  the  anemia,  but  it  is  much  more  probable  that  some  underlying 
condition  causes  splenic  enlargement  and  anemia.  The  operation  does  not 
seem  to  be  founded  on  sound  pathologic  indicadons,  although  it  is  proper  to 
state  that  Cushing's  case  was  alive  and  well  eight  years  after  the  operadon. 

Johnston  (Ibid.)  has  collected  61  splenectomies  for  splenic  anemia  or  Ban- 
ti's  disease.  There  were  49  recoveries  and  12  deaths,  a  mortality  of  19.5  per 
cent. 

Johnston  (Ibid.)  notes  12  splenectomies  for  sarcoma  of  the  spleen  with  9 
recoveries.  One  Hved  eight  and  one-half  years  and  died  of  heart  disease. 
Three  are  known  to  have  died  from  recurrent  sarcoma. 

It  is  stated  that  there  are  on  record  4  splenectomies  for  cancer.  Moynihan 
doubts  the  diagnostic  accuracy  of  the  three  eariier  reports.  Mary  A,  Smith 
records  a  case  of  colloid  cancer  occurring  in  a  woman  who  had  been  operated 
on  ten  years  before  for  ovarian  cyst  associated  with  pseudomyxoma  of  the 
peritoneum.  The  pathologist  reported  that  the  growth  in  the  spleen  was 
a  metastasis  of  colloid  carcinoma.  This  patient  died  seven  months  after  the 
splenectomy  from  peritoneal  and  omental  cancer  ("Annals  of  Surgery,"  Jan., 
,1908). 

In  Johnston's  (Ibid.)  table  of  708  splenectomies  for  various  causes  the 
mortaUty  is  27.4  per  cent.  In  the  cases  operated  upon  from  1900  to  1907 
inclusive  the  mortahty  is  18.5  per  cent. 

In  order  to  remove  the  spleen  make  an  incision  from  the  anterosuperior 
spine  of  the  ihum  to  the  ribs,  open  the  peritoneum,  and  divide  adhesions 


Abdominal  Hernia  or  Rupture  1123 

between  ligatures.  If  the  spleen  is  adherent  to  the  pancreas,  it  may  be  neces- 
sary to  remove  a  fragment  of  the  last-named  organ.  It  is  a  very  undesirable 
thing  to  have  to  do,  and  I  lost  a  case  from  pancreatic  leakage  after  having 
done  it.  Ligate  the  suspensory  ligament  and  divide  it.  Bring  the  spleen 
well  out  of  the  wound.  Surround  it  with  gauze  pads.  Transfix  the  pedicle 
with  stout  silk.  Tie  it  firmly,  leaving  the  ends  of  the  ligature  long  for  a  time, 
and  cut  through  the  pedicle  beyond  the  ligature.  Ligate  the  vessels  separately 
with  catgut.  Cut  off  the  long  ends  of  the  .silk  ligature  and  drop  the  pedicle 
back,  unle.ss  apprehensive  of  bleeding,  when  it  may  be  fastened  to  the  surface. 
The  wound  is  closed  without  drainage.  Traction  upon  and  ligation  of  the 
vessels  in  the  pedicle  may  cause  profound  shock  by  injuring  the  splenic  plexus, 
which  is  in  close  relation  with  the  solar  plexus  (Jordan,  in  "Lancet,"  Jan. 
22,  1899J. 

Changes  After  Splenectomy. — About  two  week.-;  after  the  removal  of  a 
normal  spleen  certain  definite  changes  happen  in  adults,  but  not  in  children. 
These  changes  last  for  several  weeks  and  are  manifested  by  enlargement  of  the 
lymph-glands,  tenderness  of  bones,  blood-changes,  loss  of  weight,  weakness, 
thirst,  polyuria,  abdominal  pain,  elevation  of  temperature,  and  rapid  pulse.* 
Tizzoni  says  that  these  changes  are  not  obvious  in  children,  because  in  them 
compensatory  organs  act  at  once,  whereas  in  adults  compensatory  organs  act 
slowly  and  with  painful  effort.  Such  symptoms  are  noticed  when  the  spleen  is 
removed  because  of  a  wound  or  a  rupture,  but  rarely  after  removal  of  a  dis- 
eased spleen.  It  is  likely  that  compensating  organs  become  active  when  the 
spleen  is  diseased,  and  consequently  are  in  full  operation  when  such  a  spleen 
is  removed.  After  partial  splenectomy  these  changes  are  not  noted  (Jordan). 
Changes  can  be  prevented  after  splenectomy  by  the  administration  of  tablets 
of  extract  of  spleen  and  red  bone-marrow  (Ballancej . 

The  blood  changes  after  splenectomy  consist  of  diminution  in  hemoglobin 
and  red  blood-cells.  The  coloring  matter  and  cells  do  not  become  normal  for 
two  or  three  months. 

Splenopexy. — This  is  the  operation  of  anchoring  a  movable  .spleen. 
It  can  only  be  used  when  the  spleen  is  not  enlarged  and  is  not  diseased.  Ry- 
dygier  in  1895  published  the  first  case,  although  both  Tuffier  and  Kouwer 
operated  before  this  date.  Sutures  should  not  be  passed  through  the  spleen: 
the  structure  is  so  soft  the  stitches  are  bound  to  loosen  and  the  insertion  will 
cause  bleeding.  A  promising  method  is  to  create  adhesions  by  the  use  of 
iodoform  gauze,  as  is  done  for  movable  kidney,  and  as  was  done  by  Kouwer. 
Some  advocate  making  a  pocket  outside  of  the  peritoneum  and  bringing  the 
spleen  into  this  pocket,  thus  placing  it  extraperitoneal. 

Abdominal  Hernia  or  Rupture.— A  hernia  is  a  protrusion  of  peri- 
toneum liable  to  contain,  containing  at  times,  or  permanently  containing  any 
viscus  or  part  of  a  \iscus  from  the  abdominal  caxity.  MacCormac  says  the 
term  implies  that  the  protruded  viscus  is  covered  with  integument;  hence  a  pro- 
trusion of  viscera  through  a  wound  does  not  constitute  a  hernia.  A  hernia  has 
three  parts — the  .sac,  the  sac-contents,  and  the  sac-coverings  (Fig.  636).  The 
sac  is  formed  of  peritoneum.  A  congenital  sax  is  due  to  developmental  defect, 
and  may  be  in  the  inguinal  region,  the  umbilical  region,  the  lumbar  region, 
or  in  the  epigastric  region  as  a  result  of  a  congenital  slit  in  the  transversalis 
*Ballance,  in  Practitioner,  April,  1898  ;   H.  Martyn  Jordan,  in  Lancet,  Jan.  22,  1898. 


1 1 24 


Diseases  and  Injuries  of  the  Abdomen 


fascia.  It  used  to  be  stated  that  femoral  hernia  was  never  congenital,  but 
Russell  and  Coley  both  say  that  a  femoral  hernia  may  have  a  congenital  sac. 
In  I  GO  necropsies  Murray  found  20  potential  femoral  sacs  (sacs  into  which  a 
hernia  had  not  entered).  An  acquired  sac  is  due  to  intra-abdominal  pres- 
sure bulging  the  peritoneal  covering  of  an  abdominal  ring  and  converting 
it  into  a  pouch.  The  sac  comprises  a  body,  a  neck,  and  a  month.  A  sac 
once  formed  is  almost  certain  to  persist,  because  it  adheres  by  its  outer  sur- 
face to  surrounding  parts,  and  hence  the  sac  of  a  hernia  is  usually  irreduc- 
ible even  when  the  contents  are  reducible.  The  neck  of  the  sac  is  due  to  the 
constriction  through  which  the  sac  passes;  it  becomes  furrowed  and  folded, 

and  the  adhesion  of  these  folds  causes 
thickening  and  rigidity.  Hernia  of  the 
bladder  or  of  the  cecum  may  have  no  sac 
or  but  a  partial  sac.  A  ventral  hernia 
following  an  abdominal  operation  may 
be  without  a  sac.  The  contents  of 
the  sac  depend  chiefly  on  the  situa- 
tion, a  portion  of  the  ileum  being  the 
usual  contents.  The  colon,  the  stom- 
ach, the  great  omentum,  the  bladder, 
and  other  structures  may  enter  the 
hernial  sac.  An  enter ocele  contains  only 
intestine;  an  eplplocele  contains  only 
omentum;  an  entero-epiplocele  contains 
both  omentum  and  intestine;  a  cysto- 
cele  contains  a  portion  of  the  bladder. 
The  coverings  of  the  sac,  which  vary 
with  its  situation,  will  be  set  forth  during 
the  consideration  of  special  forms  of 
hernia.  In  old  hernia  the  layers  are 
never  distinct,  fat  and  muscle  waste, 
tissues  adhere,  and  the  skin  stretches 
and  atrophies.  The  sac  of  an  old  her- 
nia occasionally  becomes  tuberculous, 
and  the  disease  may  remain  local  in 
the  hernia  sac  or  spread  to  the  general  peritoneum.  Renault  tells  us  that 
tuberculosis  of  a  hernia  is  made  manifest  by  increase  in  size,  pain  on  pressure, 
and  loss  of  body-weight. 

Causes  of  Hernia. — Hernia  is  a  common  trouble.  According  to  Berger, 
in  1000  people  4.4  per  cent,  suffer  form  hernia.  It  occurs  at  all  periods  of 
life,  and  hereditary  predisposition  sometimes  seems  to  exist.  The  male  sex  is 
three  times  as  Hable  to  hernia  as  the  female  sex.  That  increase  of  intra- 
abdominal tension  is  a  common  cause  in  children  has  been  amply  demon- 
strated. (See  Hernia  in  Childhood,  page  1152.)  Excessive  length  of  the 
mesentery  has  been  assigned  as  a  cause.  In  some  instances  a  mass  of  fat 
forms  (fat  hernia)  and  advances  before  the  hernia,  and  seems  to  bear  a  causa- 
tive relation  to  it.  Lucas-Championniere  explains  this  as  follows :  when  a  person 
begins  to  take  on  fat,  it  is  deposited  not  only  under  the  skin,  but  also  in  the 
omentum,  mesentery,  and  subperitoneal  tissues.     This  semifluid  fat  is  easily 


Hg.  636.— A  diagrammatic  representa- 
tion of  the  coverings  of  a  hernia  (Sultan): 
a,  The  skin  ;  d,  the  superficial  fascia ;  c,  the 
muscular  layer — e.  ,?-.,  the  cremaster  muscle 
in  an  inguinal  hernia ;  d.  the  transversalis 
fascia  ;  c,  d,  have  also  been  called  the  fascia 
propria  hernise  ;  e,  the  peritoneum — z.  ^.,the 
sac  of  the  hernia. 


Reducible  Hernia  1125 

influenced  l)y  pressure.  The  deposit  of  fat  within  the  abdomen  lessens  the  size 
of  that  cavity,  intra-iabdominal  pressure  is  increased,  and  fat  protrudes  at  any 
weak  spot  in  the  wall.  The  protruding  mass  of  fat  adheres  to  and  makes 
traction  uj)on  the  peritoneum,  and  this  membrane  is  drawn  uy)on  to  form 
a  sac,  and  the  sac  is  surrounded  by  fat.  This  method  of  formation  is  fre- 
quently noticed  in  umbilical  hernia",  and  occasionally  in  inguinal  hernial. 
Any  laborious  occupation  predisposes  to  rupture.  Any  condidon  which 
weakens  the  abdominal  wall  predisposes  to  rupture  (muscular  relaxation  from 
ill-health,  relaxadon  of  abdominal  walls  following  the  termination  of  pregnancy, 
the  removal  of  a  large  tumor,  or  tapping  for  ascites,  and  wounds  or  abscesses 
of  the  abdominal  wall).  The  common  cause  is  repeated  muscular  effort 
which  increases  intra-abdominal  tension  (straining  at  stool,  coughing,  lifting 
weights,  jumping,  the  sexual  act,  and  straining  during  micturition).  In  25  per 
cent,  of  cases  the  cause  is  supposed  to  have  been  lifdng  or  carrying  a  weight 
(Coley).  A  hernia  may  appear  gradually  or  suddenly.  Berger  and  Coley 
state  that  nearly  70  per  cent,  of  hernia  in  adult  males  appear  gradually.  The 
sac  of  an  acquired  hernia  exists  for  a  longer  or  shorter  time  before  the  hernia 
enters  it.  The  sac  of  a  congenital  hernia  is  present  at  birth.  The  sac  of  an 
acquired  hernia  gradually  forms.  A  sac  may  exist  for  years  and  yet  remain 
empty.  When  bowel  or  omentum  enters  it  from  some  strain  or  effort,  the 
parts  were  long  prepared  to  receive  the  extruded  mass.  This  extrusion  may 
occur  gradually  or  it  may  occur  suddenly.  If  it  occurs  suddenly,  the  sufferer 
believes  that  his  hernia  was  formed  then  and  there,  but,  as  a  matter  of  fact, 
the  extrusion  of  bowel  or  omentum  and  its  entrance  into  the  sac  are  but  the 
last  of  a  long  series  of  antecedent  and  preparatory  changes.  Finally,  a  hernia 
appears,  and  usually  does  so  during  effort.  In  rare  cases  traumatism  may 
cause  a  hernia  immediately,  no  sac  exisdng  before  the  accident.  It  does  so 
in  the  inguinal  region  by  stretching  or  tearing  the  internal  ring,  the  inguinal 
canal  at  once  enlarging.  Such  a  condidon  is  a  true  traumatic  hernia,  trau- 
matism being  the  sole  cause  and  not  simply  the  exciting  cause. 

The  old  and  erroneous  idea  was  that  a  hernia  was  always  formed  by 
tearing  of  the  peritoneum;  hence  the  term  rupture.  This  mode  of  formadon 
is  extremely  unusual,  but  occasionally  does  occur.  Coley  saw  such  a  case.  An 
ordinary  non-traumatic  hernia,  when  the  bowel  suddenly  and  for  the  first  time 
enters  the  sac,  is  the  seat  of  some  pain,  but  the  pain  is  not  disabling  and  the 
lump  disappears  on  recumbency.  In  many  cases  the  bowel  or  omentum 
gradually  finds  a  way  into  the  sac,  and  in  such  cases  pain  is  usually  trivial  and 
often  absent.  In  true  traumatic  hernia  there  are  violent  pain,  collapse,  vomit- 
ing, inability  to  walk  and  stand,  and  the  mass  does  not  return  to  the  belly  on 
recumbency,  but  must  be  reduced  by  taxis  or  operation.  True  traumatic 
hernic-e  may  occur  anywhere  in  the  abdomen,  but  are  most  common  in  the 
inguinal  region,  where  they  are  direct  herniae.  (The  relation  born  by  accidents 
to  the  development  of  hernia  is  discussed  by  Paul  Berger,  in  "Rev.  de  Chir.," 
April  and  May,  1906,  and  by  Wm.  B.  Coley,  in  "Internat.  Jour,  of  Surg.," 
Feb.,  1908).  All  congenital  hernias  are  due  to  structural  defects.  Hernia 
are  divided  clinically  into  reducible,  irreducible,  incarcerated,  inflamed,  and 
strangulated. 

Reducible  Hernia. — In  this  form  of  hernia  the  contents  of  the  sac  can 
be  reduced  into  the  abdominal  cavity.     At  a  known  hernial  opening  the 


1 126  Diseases  and  Injuries  of  the  Abdomen 

patient  has  a  smooth  enlargement  (narrower  above  than  below),  which 
began  to  grow  above  and  extended  downward.  A  distinct  neck  can  often 
be  felt.  In  enterocele,  straining,  hfdng,  or  standing  enlarges  the  mass;  the 
protrusion  becomes  smaller  and  may  disappear  on  lying  down;  cough  causes 
impulse  or  succussion,  the  protrusion  is  elasdc,  and  may  be  tympanitic  on 
percussion,  and  on  reduction  the  mass  suddenly  disappears  and  there  is 
a  gurgling  sound.  In  epiplocele  the  mass  is  often  irregular  and  compres- 
sible, and  feels  boggy  rather  than  elastic;  muscular  effort  does  not  have  much 
influence  in  enlarging  it;  impulse  on  coughing  is  slight;  percussion  gives 
a  dull  note,  and  reduction  is  accompHshed  gradually  and  produces  no  gurgling 
sound.  In  entero-epiplocele  some  parts  of  the  mass  are  smooth,  elastic,  and 
tympanitic;  others  are  dull  on  percussion,  irregular,  and  flabby,  but  the  diag- 
nosis of  this  especial  form  is  uncertain.  The  victims  of  reducible  hernia  com- 
plain of  some  pain  on  exerdon,  of  dyspepsia,  and  often  of  constipadon. 

When  a  hernia  is  beginning  to  form,  there  is  often  premonitory  uneasi- 
ness. The  patient  complains  of  muscular  pain  in  the  lower  abdomen,  and 
this  condition  may  exist  for  weeks  before  it  is  recognized  that  a  hernia  is 
present.  An  inguinal  hernia  can  be  recognized  before  it  protrudes  from 
the  external  ring.  The  tip  of  the  finger  is  inserted  in  the  ring  and  the  patient 
is  asked  to  cough.  If  a  hernia  has  entered  the  canal,  succussion  will  be 
detected  on  coughing.  In  a  healthy  man  the  external  ring  should  admit 
the  tip  of  the  little  finger,  but  not  the  end  of  the  index-finger.  If  the  end 
of  the  index-finger  can  be  made  to  enter  the  ring,  that  aperture  is  dilated, 
and  even  if  there  is  no  hernia  in  the  canal,  in  future  a  hernia  will  probably 
descend.  In  a  man,  if  the  surgeon  desires  to  examine  the  ring,  he  inverts 
the  skin  of  the  scrotum  over  the  finger  and  carries  the  finger  to  or  in  the  ring. 
When  the  hernia  first  appears,  there  may  be  pain,  faintness,  and  some  sick 
stomach;    but  often  there  is  no  pain  or  any  discomfort. 

Treatment  of  Reducible  Hernia. — Palliative  Treatment. — Prevent  con- 
stipation, forbid  sudden  strains  and  violent  exercise,  and  order  a  truss.  The 
continued  employment  of  a  truss  in  young  persons  may  bring  about  a  cure. 
The  day  truss  should  be  applied  before  rising  in  the  morning  and  be  removed 
after  lying  down  at  night,  when  a  light  truss  should  be  substituted.  A  special 
truss  is  applied  before  bathing.  In  very  fat  people  there  is  always  trouble 
in  adjusting  a  truss.  A  femoral  hernia  is  more  difficult  to  keep  reduced 
than  an  inguinal  hernia.  In  a  hernia  in  which  the  gut  is  replaceable,  but 
a  portion  of  omentum  is  irreducible,  it  is  difficult  to  maintain  reduction 
of  the  gut  with  a  truss,  and  an  operation  should  be  performed.  In  an  oblique 
inguinal  hernia  the  pad  of  the  truss  fits  over  the  internal  abdominal  ring; 
in  a  direct  inguinal  hernia,  over  the  external  abdominal  ring;  in  a  femoral 
hernia,  over  the  femoral  ring  at  the  level  of  Gimbernat's  ligament.  Mac- 
Cormac's  method  of  measuring  for  a  truss  is  as  follows:  in  either  inguinal 
or  femoral  hernia  start  the  tape  from  the  lower  part  of  the  hernial  opening, 
carry  it  up  to  the  anterior-superior  iliac  spine  of  the  same  side,  then  take 
it  around  the  body,  one  inch  below  the  crest  of  the  ilium,  to  the  other  ante- 
rior-superior iliac  spine,  and  then  to  the  upper  part  of  the  hernial  opening.* 
A  well-fitting  truss  will  keep  the  hernia  up  even  when  the  patient  sits  in  a 
position  to  relax  the  abdominal  walls  and  coughs  and  strains.     A  truss  is 

*Treves's  "Manual  of  Surgery,"  "Hernia." 


Radical  Treatment  of  Reducible  Hernia  1127 

always  uncomfortable  at  first,  hut  a  person  usually  becomes  accustomed  to 
it.     It  should  be  kept  scrupulously  clean,  and  borated  talc  powder  should 
be  dusted  upon  the  skin  under  the  pad  at  least  once  a  day.     A  truss  which 
does  not  keep  the  hernia  up  or  which  causes  pain  does  harm.  Too  strong  a  spring 
tends  to  enlarge  the  hernial  orifice,  and  thus  aggravates  the  case.     Even  after 
an  ay)parent  cure  with  a  truss  the  instrument  must  be  worn  for  a  long  time. 
Radical  treatment  of  reducible  and  of  non-strangulated  hernia  seeks  to 
obtain  cure  by  plugging  the  mouth  of  the  sac  or  by  obHterating  the  canal 
of  descent.     Radical  operations  should  be  performed  when  a  strangulated 
hernia  is  operated  upon,  in  ordinary  cases  of  reducible  hernia  in  which  a 
truss  is  very  painful  or  does  not  keep  the  bowel  up,  in  most  cases  of  irre- 
ducible hernia,  and  in  any  case  of  hernia  in  which  there  are  occasional 
attacks  of  obstruction.    It  was  formerly  believed  that  a  cure  would  fail  if  the 
subject  was  under  three  years  of  age,  but  Coley  and  others  have  proved  that  it 
is  a  very  successful  operation  in  childhood.     It  is  rarely  recommended  under 
the  age  of  four,  because  in  two-thirds  of  the  cases  a  truss  will  cure.     It  is  ad- 
vised after  the  age  of  four  when  a  truss  has  failed,  when  there  is  irreducible 
omentum,  or  when  there  is  a  reducible  hydrocele  which  prevents  the  truss  from 
folding  (Wm.  B.  Coley,  in  "Annals  of  Surgery,"  June,  1903).     The  radical 
operation  is  almost  without  danger  in  properly  selected  cases,  and  is  one  of  the 
most  successful  of  surgical  procedures,     ^^'e  are  justified  in  doing  the  oper- 
ation upon  an  individual  under  fifty  years  of  age  and  free  from  complica- 
tions, purely  to  relieve  him  or  her  from  the  annoyance  of  wearing  a  truss. 
If,  however,  a  patient  is  sixty  years  of  age  or  over  and  a  truss  keeps  the  her- 
nia up  satisfactorily,    the  operation  should  not  be  performed  unless  it  is 
demanded  by  some  complication.     Organic  diseases  of  the  heart,   lungs, 
and  kidneys  are  contraindications.     Enormous  herniae  (Figs.  670  and  674) 
are  unfavorable   for  operation.     Restoration  is  diflficult  or  impossible,  the 
forcible  handling  produces  much  shock,  and  recurrence  is  to  be  expected. 
Restoration  is  difficult  or  impossible  because  the  abdominal  cavity  has  con- 
tracted and  holds  with  difficulty  or  cannot  hold  the  huge  hernia.    As  J.  L.  Petit 
said,  the  hernia  \\a.s  forfeited  the  right  of  domicile.     In  an  operation  for  an  enor- 
mous hernia  a  great  quantity  of  omentum  will  require  removal,  and  it  may 
be  necessary  to  resect  a  considerable  piece  of  intestine.    If  we  decide  to  operate 
upon  an  enormous  hernia,  treat  the  patient  some  time  before  with  the  object 
of  making  him  lose  flesh.     The  absorption  of  mesenteric  fat  lessens  intra- 
abdominal pressure.     That  operation  may  succeed  in  such  cases  is  shown 
by  Figs.  637  and  638.     In  any  operation  for  the  radical  cure  of  inguinal 
hernia  always  remember  that  the  bladder   may  be  part  of  the  hernia,  and 
be  on  the   lookout  for  it.     Eggenberger's  table  of  6778  hernia  operations 
shows  75  bladder  hernias  (i  per  cent.).     As  a  rule,  it  is  covered  wath  cellular 
fat,  which  differs  in  color  and  consistence  from  omental  fat  and  from  other  fat 
which  may  be  found  about  a  hernia.     The  presence  of  a  quantity  of  extra- 
peritoneal fat  outside  of  the  sac  suggests  the  adjacency  of  the  bladder  and 
warns  us  not  to  tie  off  the  sac  very  high  up.     It  was  the  author's  misfortune  on 
two  occasions  to  open  a  bladder  in  operating  upon  an  inguinal  hernia.     In  each 
case  the  bladder  was  sutured,  and  both  patients  recovered.     It  has  been 
estimated  that  the  mortality  after  this  accident,  even  when  the  bladder  is 
sutured,  is  from  6  to  16  per  cent.    Among  other  possible  accidents  which  may 


II2< 


Diseases  and  Injuries  of  the  Abdomen 


occur  during  hernia  operations  are:  injury  of  an  iliac  vessel,  of  a  femoral  vessel, 
or  of  an  epigastric  vessel. 

The  success  of  an  operation  for  the  radical  cure  of  a  hernia  depends 
upon  the  attainment  of  primary  union.    Primary  union  is  favored  by  thorough 


Fig.  637. — Oblique  inguinal  hernia  of  large  size  (duration,  sixteen  years). 


Fig.  638. — The  case  shown  ir.  Fig.  637  six  months  after  operation. 


cleanliness;  by  wearing  gloves  while  operating;  by  cutting  the  parts  with  a 
sharp  knife  instead  of  tearing  them  with  a  dissector;  by  removing  some  fat  and 


Radical  Treatment  of  Reducible  Hernia 


1129 


any  superfluous  tissue-fragments;  by  tying  the  stitches  firmly,  but  not  tightly 
(a  tight  stitch  causes  necrosis  and  creates  a  point  of  least  resistance);  by  careful 
closure;  by  dressing  with  pressure;  and  by  keeping  the  patient  recumbent  for 
three  weeks. 

A  truss  is  not  to  be  used  after  operation.  Wm.  B.  Coley  ("Anna4s  of 
Surg.,"  June,  1903)  has  operated  upon  1075  cases  of  inguinal  and  femoral 
hernia.  In  his  report  he  does  not  consider  operations  performed  within  the 
last  six  months,  and  so  presents  a  study  of  1003  cases.     Of  these,  937  cases 


Fig.  639. — Hernia  which  has  sacrificed  "  the  right  of  domicile. 


were  inguinal,  66  cases  were  femoral.  In  the  1003  cases,  647  were  traced  and 
were  found  well  from  one  to  eleven  years  after  operation;  705  were  well  from 
six  months  to  eleven  years;  460  were  well  from  two  to  eleven  years.  If 
the  patient  is  well  one  year  after  operation,  he  will  probably  remain  well. 
This  is  proved  by  Coley's  study  of  relapses,  an  investigation  which  shows 
that  65  per  cent,  of  relapses  occur  within  six  months  of  operation  and  80  per 
cent,  within  the  first  year.  Only  13!  per  cent,  occur  from  one  to  two  years, 
and  only  6|  per  cent,  after  two  years.  Coley  had  2  deaths  in  1075  cases 
(less  than  one-fifth  of  i  per  cent.) .  After  Bassini's  operation  there  are  about 
I  per  cent,  of  relapses.  Coley  reports  that  from  Dec,  1891,  to  Jan.,  1909,  there 
were  performed  by  Drs.  Bull,  Walker,  and  himself,  in  the  Hospital  for  Ruptured 


II30 


Diseases  and  Injuries  of  the  Abdomen 


and  Crippled,  2384  operations  for  the  radical  cure  of  hernia.  Of  these  2218 
were  inguinal  (only  445  in  females).  In  the  1773  male  cases  the  typical  or 
modified  Bassini  operation  was  done  with  12  relapses  or  .68  per  cent.  ("Pro- 
gressive Medicine,"  June,  1909). 

Lannelongues  Method. — Lannelongue  has  for  certain  cases  returned  to 
the  old  injection  plan,  using  a  10  per  cent,  solution  of  chlorid  of  zinc  instead 
of  white  oak  bark.  The  hernia  is  first  reduced  and  is  held  up  by  an  assistant 
who  closes  the  internal  ring  with  a  finger,  and  also  holds  the  cord  aside. 
Several  injections  of  10  minims  each  are  thrown  in  the  region  of  the  internal 
pillar,  the  region  of  the  external  pillar,  and  into  the  canal  behind  and  outside 
of  the  cord.     The  surgeon  must  be  careful  that  no  zinc  solution  escapes 

into  the  subcutaneous  tissue.  The  effect  of 
the  chlorid  of  zinc  is  to  cause  the  formation 
of  quantities  of  fibrous  tissue.  It  is  scarcely 
to  be  expected  that  a  cure  so  produced  will 
be  permanent  in  an  adult,  though  it  may  be 
in  a  child. 

Macewen's  Operation  for  Ingnhial 
Hernia. — The  instruments  required  in  this 
operation  are  scalpels,  a  blunt,  straight  bis- 
toury, a  dr}^  dissector,  a  grooved  director,  scissors,  a  hernia  director  (Fig. 
640,  b),  hernia  needles  (Fig.  640,  a),  dissecting  forceps,  toothed  forceps,  hemo- 


>40.— A.  Hcinia  needles  ;  B,  hinged 
hernia  director. 


Fig.  641. — Macewen's  operation  for  radical  cure  of  ing:uinal  hernia  :  a,  Stripping  of  the  sac;  b, 
purse-string  suture ;  c,  fastening  the  purse-string  suture  ;  d,  passing,  and  E,  tying,  the  sutures  for  the 
internal  ring. 


Bassini's  Operation  for  Oblique  Inguinal  Hernia  1131 


static  forceps,  an  aneurysm  needle,  blunt  hooks,  half-curved  needles,  needle- 
holder,  and  chromicized  catgut  sutures.  The  patient  lies  recumbent,  the 
thigh  being  abducted  and  partly  flexed  and  resting  on  a  pillow  beneath  the 
knee.  The  bowel  is  reduced,  and  an  incision  three  inches  long  is  made  in  the 
direction  of  the  inguinal  canal,  the  center  of  the  incision  corresponding  to  the 
external  ring.  The  sac  is  freed  from  its  attachments  below  and  is  lifted  up. 
The  surgeon  introduces  a  finger  into  the  inguinal  canal  and  separates  the  sac 
from  the  cord  and  from  the  walls  of  the  canal,  and  then  carries  the  finger 
through  the  internal  ring  and  separates  the  peritoneum  for  one  inch  about  the 
peripher}^  of  this  aperture  (Fig.  641,  a).  A  chromicized  catgut  stitch  is 
fastened  to  the  lowest  portion  of  the  sac,  and  is  passed  through  the  sac  several 
times,  so  that  pulling  on  the  stitch  will  purse  the  sac  (Fig.  641,  b).  The  free 
end  of  this  stitch  is  carried  through  the  internal  ring  into  the  belly,  and  is 
pushed  out  through  the  abdominal  muscles  one  inch  above  the  internal  ring, 
the  skin  being  pushed  aside  so  as  to  escape  perforation  by  the  needle.  The 
thread  is  tightened  so  as  to  fold  up  the  sac  and  pull  it  into  the  belly.  This 
plugs  the  ring  (Fig.  641,  c).  The  thread  is  handed  to  an  assistant  to  keep 
tight  until  the  sutures  are  introduced  into  the  ring,  when  the  sac  is  perma- 
nently anchored  by  taking  several  stitches  in  the  external  oblique  muscle. 
A  strong  catgut  suture  is  passed  with  a  Macewen  needle  through  the  conjoined 
tendon  from  below  upward,  the  ends  of  this  suture  being  carried  through 
Poupart's  ligament  and  the  outer  border  of  the  internal  ring  from  within 
outward.  This  suture  is  tightened,  and  closes  the 
internal  ring.  The  external  ring  is  sutured  and  the 
skin  is  stitched  (Fig.  641,  e). 

In  congenital  hernia  the  sac  is  divided  in  its  middle, 
and  the  lower  part  is  closed  by  stitches  of  chromicized 
catgut,  forming  a  tunica  vaginalis.  The  upper  part  of 
the  sac  is  slit  posteriorly  to  permit  the  escape  of  the 
cord,  and  is  closed  by  stitches  of  chromicized  catgut. 
The  operation  is  finished  as  in  the  acquired  form 
(Fig.  642).  After  Macewen's  operation  the  patient 
should  stay  in  bed  for  at  least  three  weeks,  and  must 
not  work  for  eight  or  nine  weeks.  Workmen  after 
this  operation  should  always  wear  for  a  time  a  pad 
and   a   spica    bandage.     Children  require   no    pad. 

Never  apply  a  truss,  as  strong  pressure  will  produce  atrophy  of  the  curative 
scar. 

Bassini's  Operation  Jor  Oblique  Inguinal  Hernia. — (See  E.  Wyllys  An- 
drews, in  "Med.  Record,"  Oct.  28,  1899,  who  describes  from  personal  ob- 
servation how  Bassini  does  his  operation.  I  have  drawn  upon  his  description 
in  the  following  section.)  Bassini's  operation  displaces  the  spermatic  cord 
from  the  old  canal  and  places  it  in  a  new  canal,  and  this  new  canal  is  oblique. 
The  instruments  employed  are  the  same  as  for  Macewen's  operation,  except- 
ing the  special  needles,  which  are  not  needed.  Curved  and  rounded  needles 
are  employed  to  insert  the  stitches.  The  suture  material  is  kangaroo-tendon 
or  chromicized  catgut.  Silk  or  silver  wire  is  apt  to  make  trouble — it  may 
be,  long  after  the  operation.  The  patient  is  placed  supine  with  the  thighs 
extended.     An  incision  is  made  parallel  to  Poupart's  ligament  and  extending 


Fig.  642.— Macewen's 
operation  for  the  radical 
cure  of  congenital  hernia. 


II32 


Diseases  and  Injuries  of  the  Abdomen 


from  the  external  rhig  to  a  point  external  to  the  internal  ring.  The  incision 
is  about  one  and  one-half  inches  above  the  ligament  and  is  from  five  to  seven 
inches  in  length.  By  this  incision  the  aponeurosis  of  the  external  oblique 
and  the  pillars  of  the  external  ring  are  exposed.  All  bleeding  is  arrested, 
the  aponeurosis  is  incised  in  the  direction  of  its  fibers  and  from  above  down- 
ward, and  the  inguinal  canal  is  opened.  The  aponeurosis  of  the  external 
oblique  is  dissected  up  with  a  blunt  instrument  until  Poupart's  ligament 
is  exposed.  We  speak  of  this  ligament  as  the  shelf.  A  mass  containing 
the  sac  of  the  hernia,  the  cord,  the  cremaster  muscle,  and  considerable  fat 
is  lifted  up,  Bassini  employs  blunt  dissection.  Coley  advocates  the  use  of 
the  knife.  Masses  of  fat  and  usually  the  cremaster  muscle  are  removed. 
The  sac  is  isolated  first  at  its  neck  and  the  neck  is  stripped  from  the  inner 
aspect  of  the  internal  ring  for  the  distance  of  four-fifths  of  an  inch.  The 
object  of  this  stripping  is  to  permit  the  removal  of  the  sac  at  a  high  level. 


Fig.  643.— A-c,  Bassini's  operation  for  the 
cure  of  inguinal  hernia. 


Fig.  644.' — Bassini's  operation  (deep  sutures),  show- 
ing extra  suture  above  the  cord. 


High  removal  obviates  the  leaving  of  a  funnel-shaped  depression  of  peri- 
toneum. Such  a  depression  predisposes  to  relapse.  The  sac  is  opened  at 
the  fundus,  the  interior  is  investigated,  and  if  the  contents  are  reducible, 
they  are  restored  to  the  abdominal  cavity  and  the  neck  of  the  sac  is  clamped 
high  up.  If  adherent  masses  of  omentum  are  found,  the  adhesions  are 
separated,  bleeding  is  arrested,  and  the  omentum  is  restored  to  the  abdo- 
men unless  it  is  in  a  hard  and  thick  mass,  when  it  is  tied  off  and  removed. 
Bassini  ties  off  the  neck  of  the  sac  above  the  clamp  with  a  strong  ligature 
of  silkworm-gut.  If  the  sac  is  large  and  thick,  he  also  threads  both  ends 
of  a  ligature  upon  a  needle,  passes  the  strand  through  the  stump,  and  ties 
around  over  the  first  loop.  (See  E,  Wyllys  Andrews,  "Med.  Record,"  Oct. 
28,  1899.)  Dr.  Coley  and  many  other  operators  prefer  to  tie  off  the  sac  with  a 
catgut  suture  rather  than  with  silkworm-gut  or  silk.  It  is  my  usual  custom  to 
employ  fine  black  silk,  catching  it  to  prevent  shpping  by  running  a  stitch 
through  the  wall  of  the  neck  of  the  sac.     After  Ugating  the  neck  of  the  sac  the 


Bassini's  Operation  for  Oblique  Inguinal  Hernia  ii  33 

sac  is  cut  across  and  removed.  The  cord  is  now  lifted  out  of  the  way  (Fig.  643, 
a),  the  inner  surface  of  Poupart's  ligament  is  exposed  by  retraction,  and  the 
deep  sutures  are  passed  (Fig.  643,  A).  Bassini  uses  silk  which  has  been  boiled 
in  glycerin.  Most  American  operators  use  kangaroo-tendon  or  chromicized 
catgut.  Bassini  inserts  first  the  sutures  nearest  to  the  pubes.  The  first  suture 
— and  sometimes  also  the  second — includes  part  of  the  rectus  sheath  and 
rectus  muscle.  Each  stitch  includes  the  internal  obliaue  and  transversalis 
muscle  in  the  upper  edge  and  the  shelf  of  Poupart's  ligament  below  the  lower 
margin,  and  from  four  to  six  stitches  are  passed  behind  the  cord  (Fig.  643,  b). 
The  last  stitch  narrows  the  internal  ring  so  that  it  fits  tightly  around  the  cord 
(E.  Wyllys  Andrews,  "  Med.  Record, "  Oct.  28,  1899).  Coley's  rule  for  passing 
this  suture  is  to  insert  it  so  "  that  it  just  touches  the  lower  border  of  the  cord 


Fig-  645 — The  skin  incision,  retractors  in  the 
lower  angle  of  the  wound  dislocating  the  opening 
in  the  skin  and  subcutaneous  fat  downward,  ex- 
posing the  aponeurosis  of  the  external  oblique 
and  external  ring.  The  dotted  line  within  the 
wound  represents  the  direction  of  the  division  of 
aponeurosis  of  external  oblique  (Bloodgood). 


Fig.  646. — The  aponeurosis  of  external  ob- 
lique has  been  divided  and  retracted,  uncovering 
the  internal  oblique  muscle  and  inguinal  canal. 
The  lines  on  the  muscle  represent  the  direction 
and  extent  of  the  division.  The  dotted  line  in  the 
inguinal  canal  is  the  direction  and  extent  of  the 
division  of  the  cov-erings  of  sac  (Bloodgood). 


when  the  latter  is  brought  vertically  to  the  plane  of  the  abdomen"  ("Annals 
of  Surgery,"  June,  1903).  Coley  always  places  a  suture  above  the  cord, 
and  believes  it  tends  to  prevent  relapse  (Fig.  644).  The  sutures  are  tied 
from  above  downward.  The  cord  is  laid  upon  this  new  floor  and  the  apo- 
neurosis of  the  external  oblique  is  sutured  over  it  (Fig.  643,  c).  Coley  uses 
a  continuous  suture  of  fine  kangaroo-tendon  and  closes  the  skin  with  inter- 
rupted sutures  of  catgut.  Drainage  is  not  used.  The  wound  is  covered 
with  a  roll  of  iodoform  gauze  and  some  pieces  of  sterile  gauze,  and  compression 
is  made  by  strips  of  adhesive  plaster,  and  a  piece  of  adhesive  plaster  run  from 
one  thigh  to  the  other  acts  as  a  shelf  for  the  testicles  to  rest  upon.  The  adhesive 
plaster  is  overlaid  with  dry  gauze,  and  this  is  covered  with  absorbent  cotton 
and  the  dressing  is  retained  in  place  by  a  firm  spica  of  the  groin  {Coley's 
dressing).     The  wound  is  dressed  on  the  seventh  day  and  the  patient  is  kept 


II34 


Diseases  and  Injuries  of  the  Abdomen 


in  bed  for  two  weeks  and  is  allowed  to  get  about  in  two  and  one-half  weeks 
to  three  weeks,  wearing  a  bandage  until  four  weeks  after  operation. 

In  this  operation  some  surgeons  treat  the  sac  as  in  Macewen's  operation, 
carrj-ing  out  the  rest  of  the  procedure  as  directed  above.  In  a  pure  Bassini 
operation  the  funnel-shaped  depression  in  the  peritoneum  at  the  point  of 
emergence  of  the  cord  mav  remain  and  predispose  to  hernia,  but  the  use  of 

Macewen's  plan  for  treating  the 
sac  obviates  this. 

Halsted's  Old  Operation  (as 
described  by  J.  C.  Bloodgood, 
in  "Johns  Hopkins  Hosp.  Report," 
vol.  vii).  —  The  skin  incision 
is  not  parallel  to  Poupart's 
ligament,  but  at  an  angle  of  25 
degrees  to  it  (Fig.  645).  Pou- 
part's hgament  is  well  exposed 
to  ^^•ithin  2  cm.  of  the  pubic  spine. 
The  aponeurosis  of  the  external 
obhque  muscle  is  divided.  Free 
the  lower  border  of  the  internal 
obhque  muscle  and  divide  the 
edge  of  the  muscle  at  a  right 
angle  to  its  fibers  (Fig.  646).  and 
as  far  as  possible  from  the  linea 
semilunaris.  The  coverings  of 
the  sac  near  the  neck  are  picked 
up   with    mouse-toothed    forceps   and   are   divided.      The    division   of   the 


Fig.  647.— The  internal  oblique  muscle  and  the 
coverings  of  the  sac  have  been  divided,  the  sac  with 
the  veins  and  vas  deferens  are  drawn  out  of  the  wound 
preparatory  to  the  excision  of  the  sac  and  the  ligation 
and  excision  of  the  veins  (Bloodgood). 


Fig.  648.  —The  method  of  excision  of  veins  in 
operations  for  hernia  and  varicocele.  The  vas 
deferens  and  its  "immediate"  vessels  and  the 
mesocord  have  not  been  disturbed  (Bloodgood). 


Fig.  649.— The  insertion  of  the  deep  silver 
wire  sutures,  one  above  and  four  below  the 
cord.  The  veins  have  been  ligated  and  ex- 
cised. The  mesocord  has  been  torn  gently  in 
hs  center  only  (Bloodgood). 


Halsted's  Operation  for  Inguinal  Hernia 


113: 


fasciae  is  continued  from  the  neck  of  the  sac  downward  toward  the  pubes. 

The  sac  is  then  Hfted  from  the 
inguinal  canal  and  it  brings 
with  it  "the  larger  bundle  of 
veins  and  the  vas  deferens  "  (Fig. 
647).  The  sac  is  separated  from 
the  veins  and  the  vas  with  a  knife 
or  scissors,  and  the  separation  is 
carried  to  and  beyond  the  neck 
of  the  sac.  In  '^  certain  cases  the 
larger  bundle  of  veins  Ls  separated 
from  the  vas  deferens,  ligated,  and 
excised"  (Fig.  648).  Whether 
the  veins  are  excised  or  not,  the 
sac  is  opened,  its  contents  re- 
duced, the  opening  into  the  peri- 
toneal cavity  closed  with  a  con- 
tinuous silk  suture,  and  the  excess 
of  sac  excised.  During  the 
entire  operation  the  vas  and 
its  vessels  "should  be  handled 
very  little,  and  should  not  be  torn 
from  their  bed  in  the  inguinal 
canal."  Every  point  of  bleed- 
ing should  be  ligated.  At  this 
stage  the  vas  is  gently  picked 
up    and    a  blunt-pointed    hook 

is  used  to  tear  the  mesocord.       The  freed  vas  is  hfted  into  the  upper  angle 

of    the    divided    internal    oblique 

muscle,  and  is  held  there  until  the 

sutures  are  inserted.       The    deep 

sutures    of    silver    ^^•ire    are    next 

inserted.     Usually  five  are  needed. 

The    upper    one    is    passed    first. 

These  sutures   are  shown  in   Fig. 

649.       The  cord  emerges  from  the 

cut  in  the  internal  obhque  muscle 

between  the   first  and  second  su- 

tin-es.       Sutures  No.  i  and  No.  2 

pierce   the   mesocord,    but    care   is 

taken  to  see  that  they  do  not  in- 
jure the  vas  or  its  vessels.      Each 

suture  is  drawn  upon  and  twisted 

about  six  times.  Thecutt\s-istedends 

are  caught  with  forceps  and  turned 

in.     The    skin-wound    is     closed 

Wath   a  subcuticular  stitch   of  silver  Fig.  651.— The  transplanted  rectus  included  by 

\\-ire.     It  is  covered  with  silver-foil  ^^^  '^^^p  ^"'"""^s-   I"  '^'^  illustration  the  cord  has 

J    J  ,  ,  been  excised  in  order  to  demonstrate  the  operation 

and  dry  gauze,  and  often  a  plaster-   more  dearly  (Eioodgood). 


Fig.  650.— The  method  of  transplanting-  the  rectus 
muscle.  The  sac  has  been  excised  and  the  peritoneal 
cavity  closed ;  internal  oblique  muscle  has  been  di- 
vided, the  rectus  exposed  and  transplanted  ;  at  this 
stage  the  wound  is  ready  for  the  deep  sutures.  This 
illustration  shows  how  perfectly  the  transplanted 
rectus  muscle  lines  the  lower  half  of  the  wound 
(Bloodgood). 


InToU. 


/ItlacJtlTifnt 

TieeTiiS  to  Sym  >■ 


11^6  Diseases  and  Injuries  of  the  Abdomen 


Mohl 


Fig.  652.— Exposure  of  the  sac,  the  vas,  and  the  spermatic  veins  (Halsted). 


Pig  653  .—Suture  of  the  cremaster  to  the  internal  oblique  (Halsted). 


Fig.  654. -Suture  of  the  lower  edge  of  the  internal  oblique  to  Poupart's  ligament  (Halsted). 


Modified  Halsted  Operation 


^^37 


Fig-  655 — Suture  of  the  aponeurosis  of  the  external 
oblique  (Halsted). 


of-Paris  bandage  and  splints  are  used,  "the   splints  extending  from  just 
above  the  knee  to  near  the  costal  margins." 

The  Modified  Halsted  Operation. — The  operation  at  present  performed 
by  Professor  Halsted  and  his  assistants  has  been  evolved  from  the  former 
operation  so  long  associated  with  his  name,  and  has  been  greatly  modified 

by  himself  and  by  Dr.  Bloodgood. 
In  this  operation  the  skin  and 
the  aponeurosis  of  the  external 
obHque  are  incised  exactly  as  in 
performing  Bassini's  operation; 
and  flaps  of  aponeurosis  are 
raised.  Next,  the  cremaster  mus- 
cle and  the  cremaster  fascia  are 
incised  in  a  line  slightly  above 
the  center  of  the  spermatic  cord. 
The  internal  oblique  muscle  is 
then  brought  into  distinct  view  at 
the  side  of  the  inguinal  canal,  and 
the  hernia  is  carefully  inspected 
(Fig.  652).  If  the  veins  are  found 
to  be  large,  they  should  be  excised; 
but  the  surgeon  does  not  Hft  the  vas 
from  its  bed,  and  even  avoids  touching  it,  if  he  possibly  can,  for  fear  that  thrombo- 
sis may  occur  in  its  veins.  The  veins  are  tied  above,  well  up  in  the  abdomen; 
and  below,  well  above  the  testicle,  and  excised  between  the  ligatures.  The  sac 
is  then  ligated  or  sutured  with  a  purse-string  suture.  One  end  of  the  thread 
that  ties  or  sutures  the  sac  is  carried,  by  means  of  a  long,  curved  needle,  in  an 
outward  direction  under  the  in- 
ternal oblique  muscle,  through 
which  it  is  then  pulled.  'The 
other  end  of  the  thread  is  also 
pulled  through  the  muscle,  one- 
eighth  of  an  inch  from  the  first 
end;  and  these  two  ends  are  tied 
together.  It  will  be  observed 
that  this  treatment  of  the  neck  of 
the  sac  is  somewhat  similar  to  the 
method  practised  by  Kocher. 

The  next  step  is  to  carry  the 
inferior  flap,  composed  of  cre- 
master muscle  and  fascia,  under 
the  internal  oblique  muscle,  and 
suture  it  there  (Fig.  653).  We 
next  suture  the  internal  oblique  muscle  and  the  conjoined  tendon  to  Pou- 
part's  ligament,  the  lower  edge  of  the  internal  oblique  being  tucked  under 
the  edge  of  the  ligament  (Fig.  654).  In  order  to  accompHsh  this,  it  may 
be  necessary  to  release  the  muscle  by  incising  the  anterior  rectal  sheath.  The 
incision  in  the  external  oblique  is  now  closed  with  sutures  that  overlap  the 
margins  (Figs.  655  and  656),  and  the  skin  wound  is  also  closed. 
72 


Fig.  656.— Suture  of  the  margin  of  aponeurosis  to 
Poupart's  ligament  (Halsted). 


II38 


Diseases  and  Injuries  of  the  Abdomen 


Halsted's  Operation  plus  Bloodgood's  Method  of  Transplanting  the  Rectus 
Muscle. — (See  Jos.  C.  Bloodgood,  in  "Johns  Hopkins  Hosp.  Reports," 
vol.  vii.)  When  the  conjoined  tendon  is  very  thin  or  obhterated,  the  ordi- 
nary operation  is  not  enough.  Insufl&ciency  of  the  conjoined  tendon  is  known 
to  exist  when  a  finger  does  not  meet  any  obstruction  after  passing  through 
the  external  abdominal  ring,  but  can  be  introduced  for  some  distance  into  the 
abdominal  cavity  (Bloodgood).  To  meet  this  condition  of  affairs,  Bloodgood 
devised  "a  plastic  operation  on  the  rectus  muscle,  bringing  this  muscle  down 
and  suturing  it  with  the  other  available  tissue  to  Poupart's  ligament  and  to 
the  aponeurosis  of  the  external  obHque  from  the  arch  of  the  pubis  up  to 
the  position  of  the  trans- 
planted cord"  (Bloodgood, 
in  previously  mentioned  re- 
port). The  fhst  steps  of 
the  operation  are  identical 
with  those  previously  de- 
scribed, but  before  the  in- 
sertion of  the  deep  stitches 
the  rectus  sheath  is  exposed 
and  divided  in  the  direction 
of  the  muscle-fibers,  from 
the  pubic  insertion  upward 
for  5  cm.  The  muscle 
bulges  from  the  cut  and  is 
caught  with  silk  sutures 
(Fig.  650).  Deep  sutures 
are  now  introduced  as  in 
Halsted's  operation,  except  that  they  include  the  rectus  and  its  sheath  (Fig. 
651).  The  operation  is  completed  as  is  Halsted's.  I  have  performed  this 
operation  a  number  of  times  with  entire  satisfaction. 

KocJier's  Operation. — Kocher  exposes   the  aponeurosis  of  the  external 

oblique,  makes  a  small  in- 
cision through  the  aponeu- 
rosis above  and  external 
to  the  internal  ring,  and 
draws  the  sac  through  this 
incision  and  sutures  it  in 
place. 

Fowler's  operation  is  as 
follows :  an  incision  is  made 
parallel  with  Poupart's 
ligament  from  the  spine  of 
the  pubis  to  the  level  of  the 
internal  ring,  and  a  flap  is 
turned  up.  The  inguinal 
canal  is  opened  and  the  sac 
and  cord  are  isolated.  The 
sac  is  opened,  its  contents 
reduced,  it  is  cut  off,  and  its  edges  grasped  with  forceps.     The  deep  epigas- 


Fig.  657.- 


Ferguson's  operation  :  the  semilunar  skin  incision 
("Jour.  Am.  Med.  Assoc"). 


LX-A.S-S.p 


Fig.  658. — Ferguson's  operation  :  flap  turned  back  expos- 
ing the  aponeurosis  and  the  sac  of  the  hernia  ("Jour.  Am. 
Med.  Assoc"). 


Ferguson's  Operation 


1139 


trie  artery  and  vein  are  sought  for,  each  is  tied  in  two  places 
and  divided  between  the  ligatures.  The  index-finger  is  introduced 
into  the  belly,  and  on  this  as  a  guide  the  floor  of  the  canal 
is  divided  (transversalis  fascia,  subserous  tissue,  and  peritoneum). 
The  cord  is  placed  in  the  peritoneal  cavity.  The  edges  of  the  opening  are 
sutured  so  that  broad  serous  surfaces  are  approximated,  through-and-through 
sutures  being  passed  from  side  to  side.  The  cord  is  brought  out  at  the  inner 
end  of  the  incision,  the  lower  angle  of  the  cut  being  at  such  a  level  that  the 
cord  curves  upward  and  forward  as  it  leaves  the  abdomen.     The  inguinal 

canal,  the  gap  in  the  apo- 
neurosis, and  the  skin- 
wound  are  closed.* 

Ferguson's  Operation. — 
In  studying  a  number  of 
recurrences  after  operation 
A.  H.  Ferguson  observed 
that  a  hernial  protrusion  is 
apt  to  return  at  the  upper 
and  outer  portion  of  the 
scar,  above  the  cord  and 
near  Poupart's  ligament. 
When  he  operated  upon 
relapsed  cases,  he  discov- 
ered a  slit  of  the  aponeu- 
rosis of  the  external  ab- 
dominal wall,  through 
which  the  sac  and  some 
fat  protruded.  In  order 
to  determine  the  cause  of  the  failure  of  these  operations,  he  thought  it  proper 
to  make  a  semilunar  incision,  and  raise  a  flap  of  skin,  fascia,  and  aponeurosis 
of  the  external  oblique. 
On  doing  this,  he  was  sur- 
prised to  find  an  angle 
between  the  lower  border 
of  the  internal  oblique  mus- 
cle and  the  inner  aspect 
of  Poupart's  ligament  ab- 
solutely unprotected  by 
the  internal  oblique  or 
the  transversalis  muscle. 
In  some  cases  this  angle 
extended  upward  and  out- 
ward to  the  anterior  supe- 
rior iliac  spine.  He  there- 
fore determined  positively 
that  the  cause  of  a  rup- 
ture returning  in  this 
angle  after  an  operation  for  radical  cure  is  deficient  origin  of  the  internal  ob- 
*  Annals  of  Surgery,  Nov.,  1897. 


Fig.  659. — Ferg:uson's  operation  :  dealing  with  the  sac  and  its 
contents  ("Jour.  Am.  Med.  Assoc"). 


Ass 


p4:x  ^ 


Fig.  660.— Ferguson's  operation  ;  suture  of  the  slack  in  the 
transversalis  fascia  ("  Jour.  Am.  Med.  Assoc"). 


1 140 


Diseases  and  Injuries  of  the  Abdomen 


lique  muscle  and  of  the  transversalis  muscle  at  Poupart's  ligament.  He 
is  now  persuaded  that  in  all  cases  of  hernia  there  is  a  deficient  origin  of  these 
muscles,  and  he  has  demonstrated  the  same  thing  in  a  series  of  dissections  in 
the  inguinal  region.  Ferguson  describes  his  operation  as  follows  ("Jour. 
Am.  Med.  Assoc,"  July  i,  1899):  He  begins  his  incision  over  Poupart's 
ligament,  an  inch  and  a  half  below  the  anterior-superior  iliac  spine,  carries  it 
inward  and  downward  in  a  semilunar  curve,  and  terminates  it  over  the  con- 
joined tendon,  near  the  pubic  bone.  This  incision  goes  down  to  the  aponeu- 
rosis of  the  external  obliquCj  and  the  flap,  with  its  fat  and  fascia,  is  turned 
downward  and  outward  (Figs.  657  and  658).  The  next  step  is  to  incise  the  ex- 
ternal abdominal  ring  to  the  intercolumnar  fascia  and  separate  the  longitudinal 
fibers  of  the  external  oblique  over  the  inguinal  canal  to  beyond  the  internal  ring, 
at  a  point  nearly  opposite  the  anterior-superior  spine  of  the  ilium.  Any  trans- 
verse fibers  that  may  be  encountered  are  severed.  The  separated  aponeurosis 
of  the  external  oblique  muscle  is  then  retracted.  One  has  then  brought  into 
view  the  contents  of  the  inguinal  canal,  the  hernial  sac  and  its  adhesions,  the 
spermatic  cord,  the  ilio-inguinal  nerve,  the  internal  abdominal  ring,  the  sub- 
serous fat,  the  cremaster  muscle,  the  conjoined  tendon,  the  internal  oblique 
and  its  deficient  origin  at  Poupart's  ligament,  the  transversalis  fascia,  and  the 
internal  surface  of  Poupart's  ligament.  The  sac  is  now  dissected  from  the 
cord  and  the  internal  ring.     It  is  opened  and  its  contents  are  inspected  and 

properly  dealt  with.  It  is 
tied  high  up  and  cut  off, 
and  the  stump  is  dropped 
into  the  abdomen  (Fig. 
659).  If  the  sac  is  congeni- 
tal, it  is  divided  into  two 
parts:  the  distal  portion  is 
used  to  make  a  tunic  for  the 
testicle,  and  the  proximal 
portion  is  treated  as  above 
directed.  The  cord  is  not 
disturbed,  and  it  is  beyond 
doubt  that  Ferguson  is 
right  in  saying  that  the 
testicle  frequently  comes  to 
harm  after  operations  that 
disturb  the  cord.  The 
veins  in  the  cord  should 
not  be  touched  unless  a  varicocele  also  exists.  Any  excessive  quantity 
of  subserous  adipose  tissue  should  be  removed.  The  next  step  in  the  op- 
eration is  to  restore  the  structures  to  their  normal  position;  and  one  should 
remember  that  in  the  transversalis  fascia  is  the  internal  ring.  In  hernia 
the  internal  ring  is  large  and  the  transversalis  fascia  bulges  outward;  one 
must,  therefore,  take  up  the  slack  in  this  fascia  and  make  a  well-fitting  ring 
for  the  cord,  by  means  of  a  catgut  suture,  either  interrupted  or  continuous 
(Fig.  660).  After  this  has  been  accomplished,  the  internal  oblique  and 
transversalis  muscle  are  sutured  to  ihe  internal  aspect  of  Poupart's  ligament, 
after  the  lower  borders  of  the  muscles  have  been  freshened  and  Poupart's 


Fig.  661.— Ferguson's  operation:  suture  of  the  internal 
oblique  and  of  the  transversalis  muscle  to  the  internal  aspect 
of  Poupart's  ligament  ("Jour.  Am.  Med.  Assoc"). 


Mayo's  Operation  for  Umbilical  Hernia 


1141 


ligament  has  been  scarified.  The  sutures  must  be  carried  two-thirds  of 
the  way  down  Poupart's  ligament,  which  is  about  the  normal  origin  of  this 
muscle  in  the  female  (lug.  661).  The  next  step  is  to  suture  the  edges  of  the 
divided  aponeurosis  of  the  external  oblique;  this  restores  the  external  abdomi- 
nal ring.     The  skin-flap  is  then  carefully  sutured. 

Radical  Cure  of  Direct  Inguinal  Hernia. — If  the  hernia  goes  through  the 
conjoined  tendon  or  pushes  that  structure  before  it  the  operation  should  consist 
in  transplanting  the  rectus  muscle  as  practised  by  Bloodgood  (page  1138)  and 
suturing  the  arched  fibers  of  the  internal  oblique  and  conjoined  tendon  to 
Poupart's  ligament  and   beneath  the  cord. 

If  the  hernia  passes  around  the  outer  edge  of  the  conjoined  tendon  an 
overlapping  operation,  like  the  Mayo  operation  for  umbilical  hernia,  should 
be  performed  (G.  G.  Davis,  in  "Annals  of  Surgery,"  Jan.,  1906). 

Radical  Cure  of  Umbilical  Hernia. — The  results  of  operations  for  umbilical 
hernice  have  not  been  satisfactory.  Recurrences  are  frequent.  This  is  prob- 
ably due  to  the  fact  that 
most  of  the  subjects  are 
fat,  and  that  the  muscles 
are  thin  and  flabby.  The 
usual  operation  may  be 
thus  described:  ^lake  a 
longitudinally  elliptical  in- 
cision through  the  skin 
around  the  mass.  En- 
deavor to  separate  the  sac 
from  the  superficial  tissue. 
If  this  cannot  be  done, 
open  the  sac  and  separate 
it  from  the  contents.  Even 
if  the  sac  can  be  stripped 
from  the  skin,  always  open 
it  and  separate  the  con- 
tents. Return  any  bowel 
which  may  be  present,  and 
do  not  forget  that  there 
may  be  a  small  portion  of 
bowel  com.pletely  encased 
in  omentum.  Tie  into  seg- 
ments and  cut  off  the  su- 
perfluous omentum  and  return  the  stump  into  the  belly.  Excise  the  umbiHcus 
{omphalectomy).  Suture  the  peritoneum  with  a  continuous  catgut  suture. 
Close  the  musculofascial  wall  with  two  layers  of  interrupted  kangaroo-tendon 
sutures  or  one  layer  of  silver  ware  mattress  sutures.  Close  the  skin  by  inter- 
rupted sutures  of  silkworm-gut  or  a  subcuticular  stitch. 

Mayors  Operation. — This  is  a  vast  improvement  on  the  older  operation. 
It  gives  a  firm  cicatrix  free  from  disastrous  traction.  ^Slayo  believes  that  the 
defect  in  the  old  operation  is  that  the  recti  muscles  are  naturally  separated  at 
the  level  of  the  umbilicus,  and  in  bringing  the  recti  together  we  have  virtually 
performed  muscle  transplantation,  and  these  thin  muscles  are  of  no  great  value 


Fig.  662. — Mayo's  operation  for  the  radical  cure  of  umbili- 
cal hernia.      Exposure  of  hernia  and  lateral  incision. 


II42 


Diseases  and  Injuries  of  the  Abdomen 


in  preventing  relapse,  and  in  a  large  hernia  it  is  not  even  possible  to  cover  the 
gap  by  muscle.  ]SIayo  now  operates  as  follows:  Transverse  elliptical  incisions 
are  made  around  the  umbilicus  and  hernia  and  the  base  of  the  protrusion  is 
exposed  (Fig.  662).     The  surface  of  the  aponeurosis  is  cleared  for  one  and 

one-half  inches  around  the  neck  of 
the  sac.  The  fibrous  and  perito- 
neal coverings  of  the  hernia  are 
divided  by  a  circular  incision 
around  the  neck  of  the  sac. 
Intestine  is  freed  from  adhesions 
and  placed  within  the  abdomen. 
Omentum  is  Mgated  and  removed 
with  the  sac.  The  margins  of  the 
ring  are  grasped  and  overlapped 
in  order  to  indicate  in  which  way 
it  can  be  most  easily  done.  Thus 
is  the  direction  of  the  closure  indi- 
cated. An  incision  is  made  through 
the  fibrous  and  peritoneal  cover- 
ings of  the  ring,  one  inch  or  more 
transversely  on  each  side,  and 
the  peritoneum  is  stripped  from 
the  under  surface  of  the  upper 
flap.  Several  mattress  sutures  of  silver  ^^^re  are  introduced  one  inch  above 
the  edge  of  the  upper  flap  and  are  carried  through  the  margin  of  the  lower 
flap;  suflacient  traction  is  made  to  permit  of  the  closing  of  the  peritoneum 
with  a  continuous  catgut  suture  (Fig.  663).     When  this  has  been  accom- 


Fig.  663. — Maj-o's  operation  for  the  radical  cure 
of  umbilical  hernia.     Peritoneum  sutured. 


Fig.  664.— Mayo's  operation  for  the  radical  cure 
of  umbilical  hernia.     Aponeurosis  sutured. 


Fig.  665. — Mayo's  operation  for  the  radical 
cure  of  umbilical  hernia.  Aponeurosis  sutured 
second  time  with  gut  sutures. 


phshed,  the  silver  wire  sutures  are  drawn  so  as  to  slide  the  lower  flap  into 
the  pocket  between  the  peritoneum  and  the  under  surface  of  the  upper  flap 
(Fig.  664).  The  free  margin  of  the  upper  flap  is  fixed  by  catgut  sutures  to 
the  aponeurosis  (Fig.  665) ,  and  the  superficial  incision  is  closed  as  usual.     Wm 


Fabricius's  Operation  for  Femoral  Hernia 


"43 


J.  Mayo  ("Jour.  Am.  Med.  Assoc,"  June  i,  1907)  reports  upon  88  operations 
for  umbilical  hernia  by  this  method  between  1894  and  1905.     Seventy-five 


■f 


Fig.  660. — Fabiiv,;us  j  upci^Alion  for  the   radical  cure  oi  femoral  hernia.     Xeck  of  sac  shown.     Sac 
cut  away.     Dotted  line  shows  line  of  separation  of  Poupart's  ligament  and  fascia  lata  (Fowler). 


Fig.  667. — Fabricius's  operation  for  femoral   hernia.       Fascia  lata   turned  back,   exposing  crural 
sheath  and  origin  of  i>ectineus  muscle  (Fowler). 

were  traced.  One  had  a  partial  relapse.  One  was  supposed  to  have  a  relapse, 
but  operation  disclosed  a  second  opening  above  and  outside  of  the  closed  um- 
bilical opening. 


II44 


Diseases  and  Injuries  of  the  Abdomen 


Radical  Cure  of  Femoral  Hernia. — Cheyne  ligates  the  neck  of  the  sac, 
stitche?  the  stump  to  the  abdominal  wall,  dissects  out  a  flap  from  the  pec- 
tineus  muscle,  stitches  this  flap  to  Poupart's  ligament  and  to  the  abdominal 


Fig.  668.— Fabricius's  operation  for  femoral  hernia.  Crural  shcatli  and  vessels  retracted  and  kan- 
garoo-tendon sutures  applied  to  Poupart's  ligament  and  origin  of  pectineus,  ready  for  tying.  Two 
sutures  are  placed  in  position  to  approximate  the  pillars  of  the  external  ring  (Fowler). 


wall,  and  thus  fifls  up  the  crural  canal.  Bassini  makes  an  incision  parallel 
with  Poupart's  ligament,  ties  the  neck  of  the  sac,  cuts  below  the  ligature, 
and  returns  the  stump  into  the  belly.  He  attaches  by  deep  sutures  Poupart's 
ligament  to  the  pectineal  aponeurosis  as  high  up  as  the  pectineal  eminence, 

the  cord  or  round  ligament  being  drawn  out 
of  the  way.  Superficial  sutures  are  passed 
between  the  pubic  portion  and  the  iliac  portion 
of  the  fascia  lata. 

The  Operation   of  Fahricius. — The  opera- 
tion  of   Fabricius  is  very    satisfactory.     It  is 
performed  as  follows:  An  incision  is  begun  over 
the  pubic  spine  and  is  carried  outward  for  five 
inches  parallel  with  Poupart's  ligament.     The 
sac  is  exposed,  isolated,  and  opened,  and  its  con- 
tents are  reduced,  its  neck  is  ligated,  the  sac  is 
cut  off,  and  the  stump  is  dropped  back  (Fig. 
666).     An   incision  is  now  made   below  Pou- 
part's ligament  so  as  to  separate  this  structure 
and     the      fascia     lata,    and     the     flap      of 
fascia  is  turned  down  (Fig.  667).     The  crural 
sheath  and  the  vessels  are  retracted  outward.     The  surgeon  is  careful  not 
to  injure  the  obturator  artery  and  vein.     The  origin  of  the  pectineus  muscle 
is  sutured  to  Poupart's  ligament.     The  lower  stitches  include  the  periosteum 


Fig.  66g.— Outline  of  peritoneal 
lining  of  sac  utilized  as  a  flap  to 
cover  posterior  surface  after  it  has 
been  freed  by  dissection  (Weir). 


Inflamed  Hernia  1145 

of  the  horizontal  ramus  of  the  pubes  as  well  as  the  beginning  of  the  muscle 
(Fig.  668).  Care  must  be  taken  in  ])assing  some  of  them  to  avoid  injuring 
the  deep  epigastric  vessels.  When  these  stitches  are  tied,  the  femoral  canal 
is  obliterated.  The  flap  of  fascia  lata  is  sutured  to  the  aponeurosis  of  the 
external  oblique,  and  the  skin  is  sutured. 

Operative  Treatment  of  Sliding  Hernia  of  the  Ascending  and  Descending 
Colon. — My  personal  experience  consists  of  four  cases  of  right  and  one  case  of 
left  inguinal  hernia.  The  sac  is  deficient  posteriorly  and  externally  (page 
1 1 55) .  In  order  to  restore  the  bowel  many  operators  have  sought  to  force  up  the 
adherent  bowel  to  the  external  ring,  and  others  have  stripped  the  bowel 
from  the  subperitoneal  tissues  in  order  to  permit  of  reduction.  This  first  plan 
should  never  be  followed,  as  sutures  will  fail  to  hold  the  bowel  up.  The 
second  plan  is  risky  and  may  be  followed  by  gangrene  of  the  bowel.  In  my 
3  cases  I  followed  Wier's  plan  ("Med.  Record,"  Feb.  24,  1900),  and  after 
dissecting  up  the  peritoneum  on  each  side  to  a  little  above  the  internal  ring, 
freed  the  bowel  frohi  its  bed,  and  covered  the  new  surface  with  the  peritoneal 
flaps  (Fig.  669).     The  bowel  was  then  restored  and  a  radical  cure  was  made. 

Irreducible  Hernia. — The  swelling  in  irreducible  rupture  presents  the 
usual  evidences  of  hernia,  imparts  an  impulse  on  coughing,  but  cannot  be  re- 
placed in  the  abdomen.  Sometimes  a  portion  is  reducible  and  a  portion  is 
irreducible.  A  hernia  may  become  irreducible  because  of  the  size  of  the  mass, 
because  of  adhesions,  or  because  of  excessive  growth  of  omental  fat.  An  irre- 
ducible hernia  is  liable  to  be  bruised  and  to  cause  much  distress  and  pain, 
and  is  always  a  menace  to  life  because  of  the  danger  of  obstruction  and  strangu- 
lation. It  was  formerly  the  custom  to  support  a  small  irreducible  hernia  by  a 
hollow,  padded  truss,  but  at  present  operation  is  advised.  A  large  hernia  of 
this  variety,  if  operation  is  refused,  must  be  carried  in  a  bag  truss.  The  patient 
must  not  take  yery  active  exercise,  must  keep  the  bowels  regular,  and  must 
live  upon  a  plain  diet.  Most  cases  of  irreducible  hernia  should  be  treated 
by  operation. 

Incarcerated  or  Obstructed  Hernia. — Obstruction  takes  place  by  the 
damming  up  of  feces  or  of  undigested  food,  the  fecal  current  being  arrested, 
but  the  blood-current  in  the  wall  of  the  bowel  not  being  cut  off.  Incarcera- 
tion is  commonest  in  irreducible  hernia,  umbilical  hernia,  and  during  the 
existence  of  constipation.  The  hernia  enlarges  and  becomes  tender,  painful, 
and  dull  on  percussion;  pressure  diminishes  it  in  size;  it  is  irreducible,  but 
still  presents  impulse  on  coughing.  The  abdomen  is  somewhat  distended 
and  painful;  there  are  nausea,  constipation,  and  not  unusually  slight  vomit- 
ing. Constitutional  disturbance  is  trivial  and  constipation  is  not  absolute, 
gas  at  least  usually  passing.  Vomiting  is  not  fecal.  The  treatment  is  rest 
in  bed  in  a  position  to  relax  the  belly,  an  ice-bag  over  the  hernia  for  a  very  few 
hours,  and  a  little  opium  for  pain.  Do  not  give  a  particle  of  food  for  twenty- 
four  hours;  when  the  active  symptoms  subside,  give  an  enema,  and  after  this 
acts  a  dose  of  castor  oil.  Do  not  employ  taxis,  as  bruising  the  bowel  may  produce 
strangulation.  If  improvement  does  not  rapidly  occur,  operate.  Prompt  oper- 
ation saves  the  patient  from  the  danger  of  strangulation  and  cures  the  hernia. 

Inflamed  Hernia. — Inflammation  of  a  hernia  is  local  peritonitis  due 
to  injury  of  an  irreducible  hernia.     The  mass  becomes  tender  and  painful, 


1 146 


Diseases  and  Injuries  of  the  Abdomen 


and  perhaps  heat  is  noted.  In  enterocele  much  fluid  forms;  in  epiplocele  the 
mass  becomes  hard.  The  hernia  cannot  be  reduced;  there  is  constipation, 
often  vomiting,  usually  elevated  temperature,  but  the  mass  still  shows  impulse 
on  coughing.  Vomiting  is  not  fecal.  Some  gas  is  usually  passed  through 
the  bowels.  Constitutional  symptoms  are  slight.  The  treatment  usually 
recommended  is  rest  in  bed  with  abdominal  relaxation,  an  ice-bag  to  the  tumor 
for  a  few  hours,  a  small  amount  of  opium  by  the  mouth  if  pain  is  severe,  an 
enema,  and,  after  this  acts,  a  saline.  In  an  inflamed  hernia  there  is  great 
danger  of  strangulation,  and  operation  should  be  performed  in  preference  to 
relying  upon  the  conservative  plan. 

Strangulated  hernia  is  a  condition  ;n  which,  if  the  hernia  contains 
bowel,  not  only  is  the  fecal  circulation  arrested  and  gas  prevented  from  passing, 
but  the  circulation  of  blood  in  the  bowel-wall  is  also  arrested.  The  bowel  is 
irreducible  and  obstructed,  and  the  blood  ceases  to  circulate.  If  the  hernia 
contains  omentum,  the  omental  vessels   are  tightly  constricted.     In   both 


Fig.  670. — Strangulated  umbilical  hernia  containing  nearly  all  the  intestines  and  part  of  the 
stomach.     Strangulation  under  bands  within  the  sac. 


bowel  and  omentum  gangrene  soon  occurs,  but  sooner  in  bowel  than  in  omentum. 
Strangulation  is  commonest  in  old  inguinal  ruptures  in  active,  middle-aged  men, 
and  is  more  frequent  in  enteroceles  than  in  epiploceles.  It  is  most  common 
when  the  hernial  orifice  is  small  and  is  seldom  seen  in  large  ruptures.*  Stran- 
gulation is  much  more  dangerous  if  bowel  is  present  in  the  sac  than  if  only 
omentum  is  present.  If  the  abdominal  pressure  is  suddenly  increased,  as  by 
a  \'iolent  cough  or  a  muscular  effort,  the  hernial  orifice  is  dilated  for  a  moment, 
more  intestine  or  omentum  may  enter  the  sac,  and  if  it  does,  it  may  be  caught 
and  constricted  by  the  now  constricted  hernial  orifice  and  strangulation  begins. 
Strangulation  so  caused  is  called  clastic  strangulation.     A  sudden  increase  of 

*  Strangulation  developed  in  the  large  herniae  shown  in  Figs.  637  and  670. 


Strangulated  Hernia 


1 147 


intra-abdominal  pressure  may  force  a  quantity  of  fecal  matter  into  the  her- 
niated intestine.  The  sudden  entry  of  a  quantity  of  fluid  and  gas  into  the 
herniated  coil  causes  fecal  strangulation,  the  mechanism  of  which  is  obscure. 
By  retrograde  strangulation  we  mean  a  condition  in  which  the  end  of  a  loop  of 
bowel  or  a  piece  of  omentum  in  a  hernia  re-enters  the  abdomen  and  then  be- 
comes strangulated,  the  balance  of  the  hernia  not  being  strangulated.  Strangu- 
lation may  be  due  to  active  peristalsis  or  to  congestion,  and  it  may  arise  from 
inflammation  or  from  incarceration.  The  constriction  may  be  at  the  neck  of 
the  sac,  in  the  outside  tissues,  or  even  in  the  sac  itself.  In  an  hour-glass  hernia 
the  constriction  is  in  the  body  of  the  sac.  In  inguinal  hernia  a  tight  external 
ring  is  a  common  cause  of  strangularion  and  is  the  commonest  cause  in 
children.  As  Coley  shows,  the  neck  of  the  sac  is  very  seldom  the  cause 
in  children.  Adhesions  within  the  sac  may  cause  strangulation.  Spasmodic 
contraction  of  the  tissues  about  the  neck  of  the  sack  is  an  exploded  hypothesis. 
The  obstructed  veins  dilate  and  the  blood  in  them  ceases  to  move,  the  bowel 
becomes  deep  bluish  and  finally  black,  efifusions  of  blood  occur  beneath  the 
peritoneum,  and  the  intestinal  wall  becomes  edematous.  Fluid  transudes 
into  the  sac,  and  the  fluid,  at 
first  clear,  assumes  a  bloody 
hue,  and  finally  becomes  dry 
and  foul.  The  peritoneum 
ceases  to  glisten,  becomes  dry 
and  rough,  and  coated  here 
and  there  with  lymph.  Stran- 
gulated omentum  undergoes 
edema  and  hemorrhagic  in- 
farction and  thrombosis  occurs. 
When  strangulation  once  be- 
gins, the  hernia  swells,  a  fur- 
row forms  on  the  bowel  at  the 
seat  of  constriction,  the  bowel 
and  omentum  below  the  con- 
striction become  deeply  con- 
gested and  edematous,  and, 
finally,  the  hernia  passes  into 
a  state  of  moist  gangrene  (Fig.  671).  The  gangrene  may  be  in  spots  or  the 
entire  mass  may  be  gangrenous.  The  mucous  membrane  may  be  gangrenous 
when  the  serous  coat  looks  fairly  sound.  When  gangrene  is  once  established, 
the  bowel  is  in  danger  of  rupturing.  At  the  point  of  constriction  there  may 
be  a  line  of  ulceration  or  of  gangrene.  A  strangulated  femoral  hernia  becomes 
gangrenous  more  rapidly  than  does  a  strangulated  inguinal  hernia. 

Symptoms. — This  condition  is  sometimes  preceded  by  diarrhea  and  un- 
easiness or  pain  about  the  hernial  orifice.  When  strangulation  begins,  the 
victim  is  seized  with  pain  in  and  about  the  hernia  and  with  violent  colicky 
pain  about  the  umbilicus,  and  the  paroxysms  of  colic  become  more  and 
more  frequent,  until  finally  the  pain  may  become  continuous.  The  hernia 
is  found  to  be  irreducible;  larger  than  usual,  tender,  painful,  dull  on  per- 
cussion, without  impulse  on  coughing,  and  the  skin  above  it  may  be  red- 


Fig.  671.— a  strangulated  coil  of  intestine  after  the 
strangulation  existed  for  a  considerable  period  of  time. 
The  color  has  become  almost  black  and  the  peritoneal 
surface  is  dull  and  covered  with  flakes  of  fibrin.  The  con- 
striction-rings are  deeply  sunken,  their  walls  markedly- 
thinned,  relaxed,  and  dirty  gray  in  color.  Both  con- 
striction-rings are  gangrenous  and  hemorrhages  are  ob- 
served in  the  mesentery  (Sultan). 


1 148  Diseases  and  Injuries  of  the  Abdomen 

dened.  Eructations  of  gas  are  frequent  and  generally  uncontrollable  vomiting 
and  prostration  come  on.  Vomiting,  as  a  rule,  is  an  early  symptom,  and  one 
which  increases  in  severity.  Occasionally  it  only  follows  the  swallowing  of 
liquids.  Not  unusually  there  is  retching  rather  than  vomiting.  In  rare  cases 
vomiting  does  not  begin  for  twenty-four  to  forty-eight  hours.  During  the 
course  of  a  strangulation  vomiting  may  cease  for  a  day  or  more,  and  it  not 
unusually  ceases  toward  the  end,  when  prostration  is  profound.  The  early 
vomiting  is  due  to  reflex  causes;  the  later  vomiting  is  due  to  waves  of  peri- 
stalsis which  produce  regurgitation  (Macready).  The  vomiting  is  first  of 
the  alimentary  contents  of  the  stomach,  next  of  mucus  and  bilious  matter, 
and  finally  of  the  contents  of  the  small  bowel  {fecal  or  stercoraceous  vomiting). 
Stercoraceous  vomiting  rarely  arises  until  strangulation  has  lasted  forty -eight 
hours,  and  may  not  appear  undl  much  later.  "  It  is  seldom  met  with  in 
inguinal,  more  often  in  femoral,  and  more  often  still  in  obturator  hernia" 
(Macready).  Prostration  is  a  marked  symptom  of  a  strangulated  hernia, 
and  it  increases  hour  by  hour  and  goes  on  to  collapse.  Early  in  the  case 
there  may  be  some  elevation  of  temperature,  but  later  it  becomes  normal 
or  subnormal.  The  pulse  is  small,  irregular,  rapid,  and  very  weak;  the 
extremities  cold;  the  face  Hippocratic.  Constipation  is  absolute,  no  gas  even 
being  passed,  though  in  the  very  beginning  there  may  be  some  diarrheal 
passages  from  below  the  constriction.  The  urine  is  scanty  and  high-colored, 
and  contains  only  a  small  amount  of  the  chlorids;  the  tongue  becomes  dry 
and  brown;  the  thirst  is  torturing;  and  the  patient  often  has  an  imperative 
desire  to  go  to  stool.  Pains  in  the  abdomen  and  in  the  hernia  become  more 
and  more  violent,  and  collapse  rapidly  increases.  When  gangrene  begins, 
the  symptoms  apparently  lessen  in  violence:  there  is  a  ^^  delusive  calm." 
Vomiting  usually  ceases,  though  regurgitation  may  take  its  place;  hiccough 
begins;  the  pain  abates  or  disappears;  the  pulse  becomes  very  frequent,  feeble, 
and  intermittent;  collapse  deepens,  and  delirium  is  usual.  It  is  a  safe  clinical 
rule  that  in  strangulated  hernia  cessation  of  pain  without  the  relief  of  con- 
striction, the  disappearance  of  the  lump,  or  the  use  of  opiates  means  that 
gangrene  has  begun.  In  some  cases  of  strangulation  there  are  muscular 
cramps  in  the  legs  (Berger).  In  children  convulsions  are  not  unusual.  In 
a  pure  omental  hernia  strangulation  produces  similar  but  less  decided  symp- 
toms. It  may  be  that  only  a  portion  of  the  circumference  of  the  bowel  is 
caught  and  constricted  in  a  hernial  orifice  (Fig.  678,  A).  Such  a  condition  is 
encountered  occasionally  in  the  femoral  ring,  and  is  called  partial  enterocele 
or  Richter's  hernia.  The  name  Littre's  hernia  is  often  wrongly  given  to  this 
condition.  What  Littre  described  was  a  hernia  of  Meckel's  diverticulum 
(Fig.  678,  B).  In  a  strangulated  Richter's  hernia  constipation  is  rarely 
absolute  and  a  protrusion  is  often  undiscovered. 

Treatment. — In  treating  strangulated  hernia  place  the  patient  upon  his 
back,  bend  the  knees  over  a  pillow,  and  rigidly  interdict  the  administration 
of  food.  An  attempt  is  to  be  made  to  effect  reduction  by  gentle  manipulation 
or  taxis.  In  applying  taxis  to  a  femoral  or  inguinal  hernia,  flex  and  adduct 
the  thigh  of  the  affected  side.  In  applying  taxis  to  an  umbilical  hernia, 
both  thighs  should  be  flexed  upon  the  abdomen.  Always  lower  the  shoulders 
and  head  and  raise  the  pelvis,  and  accomplish  this  by  lifting  the  foot  of  the 


Strangulated  Hernia  1149 

bed  and  placing  pillows  under  the  pelvis.  In  some  cases  raise  the  entire 
body  and  lower  the  head.  Grasp  the  neck  of  the  sac  with  the  fingers  and 
thumb  of  one  hand,  and  employ  the  other  hand  to  squeeze  the  hernia  and 
urge  it  toward  the  belly.  In  direct  inguinal  hernia  the  pressure  should 
be  backward  and  a  little  upward;  in  umbilical  hernia  it  should  be  back- 
ward; in  oblique  inguinal  hernia  it  should  be  upward,  outward,  and  back- 
ward; in  femoral  hernia  it  should  be  downward  until  the  hernia  enters  the 
saphenous  opening,  and  then  "backward  toward  the  pubic  spine"  (Mac- 
Cormac).  If  the  bowel  is  reduced,  it  passes  from  the  hand  with  a  sudden 
slip  and  enters  the  belly  with  an  audible  gurgle;  omentum,  when  reduced, 
slowly  glides  back  without  gurgling.  Taxis  is  never  to  be  continued  long, 
and  it  ig  not  even  to  be  attempted  in  cases  of  great  acuteness,  in  cases  where 
strangulation  has  lasted  for  several  days,  in  cases  known  to  have  been  pre- 
viously irreducible,  in  cases  associated  with  stercoraceous  vomiting,  or  in 
inflamed  or  gangrenous  hernia^. 

If  taxis  fails,  obtain  the  patient's  permission  to  operate.  Anesthetize; 
try  taxis  again  while  ether  is  being  dropped  upon  the  hernia  to  cause  cold; 
if  reduction  fails,  at  once  perform  herniotomy.  Taxis  possesses  certain 
dangers:  It  may  rupture  the  bowel;  it  may  rupture  the  neck  of  the  sac  and 
force  the  bowel  through  the  rent  into  the  tissues  of  the  abdominal  wall;  it 
may  strip  the  peritoneum  from  around  the  hernial  orifice  and  force  the  bowel 
between  the  detached  peritoneum  and  the  abdominal  wall;  it  may  reduce  a 
hernia  into  the  belly  when  the  bowel  is  still  strangulated  by  adhesions;  it  may 
reduce  the  hernia  en  masse  or  en  bloc.  By  the  term  reduction  en  masse  we 
mean  that  the  sac  has  been  separated  and  dislocated  and  with  the  constricted 
bowel  within  it  has  been  forced  through  the  internal  ring.  By  reduction  en 
hissac  is  meant  the  forcing  of  a  congenital  hernia  into  a  congenital  pouch  or 
diverticulum.  Reducdon  en  masse  is  a  rare  accident.  Corner  and  Howitt 
collected  137  cases  of  reduction  en  masse  of  strangulated  hernia  ("Annals  of 
Surgery,"  vol.  xlvii).  Of  these  no  were  males;  113  were  inguinal,  22  femoral, 
and  2  obturator.  No  ventral  or  umbihcal  cases  are  recorded.  The  accident  is 
a  very  dangerous  one.  According  to  Corner  and  Howitt  (Ibid.)  the  mortality 
after  inguinal  reductions  en  masse  is  48  percent.,  and  after  femoral  reductions, 
72  per  cent.  Strange  to  say,  reduction  en  masse  can  occur  spontaneously. 
The  subject  most  Hable  to  reduction  en  masse  is  an  elderly  person  with  an  old 
hernia.  In  acute  cases  the  small  bowel  is  the  viscus  which  was  reduced.  In 
subacute  and  chronic  reductions  en  masse  the  omentum,  large  bowel,  or  bladder 
was  reduced  (Corner  and  Howitt,  Ibid.).  Subacute  and  chronic  cases  may 
happen  in  non-strangulated  hernia.  In  any  of  the  above  accidents  obstruction 
may  persist  after  apparent  reduction  by  taxis.  Persisting  obstruction  means 
strangulation  or  peritonitis  and  calls  for  instant  laparotomy — in  most  instances 
through  the  hernial  aperture.  If  taxis  is  successful,  put  the  patient  to  bed, 
apply  a  pad  and  bandage,  allow  no  food  until  vomiting  ceases,  merely  permit 
him  to  take  a  Httle  hot  water  for  twenty-four  hours,  and  keep  him  on  a  Hquid 
diet  for  several  days.  At  the  end  of  the  first  week  give  solid  food.  Do  not 
disturb  the  bowels  for  a  few  days,  but  if  they  have  not  acted  when  four  or 
five  days  have  elapsed  since  the  operation,  give  a  sahne  cathartic  and  an  enema. 
There  is  usually  a  spontaneous  movement  within  twenty-four  hours. 


1 150 


Diseases  and  Injuries  of  the  Abdomen 


Herniotomy. — If  there  has  been  stercoraceous  vomiting,  the  stomach 
must  be  washed  out  before  giving  the  anesthetic,  and 
during  the  administration  of  the  anesthetic  the  head 
should  be  turned  upon  its  side.  In  most  cases  a  gen- 
eral anesthetic  can  be  given,  but  in  some  desperate 
cases  it  is  not  justifiable  to  give  ether  or  chloroform,, 
and  a  local  anesthetic  must  be  used  (eucain,  cocain,  or 
Schleich's  fluid).  Wrap  the  patient  up  in  blankets. 
In  most  cases  try  gentle  taxis  for  a  brief  time  after  the 
patient  has  been  anesthetized,  and  while  ether  is  being 
dropped  upon  the  hernia  to  cause  cold.  Never  try 
taxis  if  stercoraceous  vomiting  has  occurred.  If  taxis 
fails,  at  once  sterilize  the  parts  and  operate.  The  in- 
struments required  in  herniotomy  are  a  scalpel,  a  hernia 
knife  (Fig.  672)  and  director  (Fig.  640,6),  hemostatic  and 
dissecting  forceps,  retractors,  scissors,  a  dry  dissector, 
partly  curved  needle,  a  needle-holder,  and  Murphy 
buttons.  Drainage-tubes  should  be  ready.  During 
the  operation  the  patient  lies  upon  his  back  with  the 
shoulders  raised,  the  surgeon  standing  to  the  patient's 
right  side.  In  oblique  inguinal  hernia  it  has  been  the 
custom  since  the  days  of  Scultetus  to  raise  a  fold  of 
skin  at  a  right  angle  to  the  axis  of  the  external  ring  and 
transfix  it,  the  wound  which  results  being  extended  until 
it  becomes  three  inches  in  length.  This  incision  pos- 
sesses no  special  merit.  It  is  better  to  cut  from  without 
inward,  and  to  make  the  same  incision  as  for  the  per- 
formance of  a  radical  cure  in  a  non-strangulated  case.  The  superficial  tis- 
sues are  divided,  the  aponeu- 
rosis is  opened  as  in  Bassini's 
operation  and  the  sac  is 
reached.  In  most  cases  the 
constriction  is  relieved  as  soon 
as  the  external  ring  is  nicked, 
and  in  many  cases  fibrous  ad- 
hesions will  be  found  in  that 
region,  gluing  the  sac  to  the 
ring.  The  sac  must  be 
identified;  and  it  is  known  by 
the  fat  which  usually  covers 
it,  by  the  arborescent  arrange- 
ment of  its  vessels,  by  the 
fact  that  it  can  be  pinched 
up  between  the  finger  and 
thumb,  and  the  layers  rolled 
over  each  other,  and  by  the 
fluid  within  the  sac.  Should 
the  sac  be  opened?  It  may  not  be  actually  necessary  in  every  recent  case,, 
but  if  there  is  any  doubt  as  to  the  condition  of  the  bowel  or  if  a  radical  cure  is 


Fig.  672.  —  Cooper's 
curved  herniotome. 


Fig-  673. — The  division  of  the  constriction  from  within 
outward  (Sultan). 


Herniotomy  1151 

to  be  attempted,  open  the  sac  and  be  certain  as  to  the  condition  of  its  contents. 
As  there  is  always  some  doubt  as  to  the  condition  of  the  contents,  and  as  a 
radical  cure  is  to  be  made,  make  it  a  rule  to  always  open  the  sac.  The  sac  is 
opened  and  the  contents  examined  for  fecal  odor  (which  is  not  unusual)  and  for 
gangrenous  smell;  the  thickness  of  the  bowel  is  estimated  and  the  color  and 
lustre  are  determined.  If  a  constriction  exists  at  the  neck  the  constriction  is 
nicked  with  a  hernia  knife.  In  oblique  inguinal  hernia  nick  the  constriction 
upward  and  outward  or  directly  upward,  as  sho\\Ti  in  Fig.  673.  In  direct 
inguinal  hernia  the  cut  is  made  upward  and  inward.  Always  pull  the  bowel 
do\\Ti  and  examine  the  seat  of  constriction  to  see  what  damage  has  been  in- 
flicted at  that  point.  If  the  bowel  glistens;  if  the  proper  color  comes  back 
after  irrigation  with  very  hot  water;  and  if  there  are  no  spots  of  gangrene,  re- 
store the  bowel  to  the  abdomen  and  do  a  radical  cure.  If  the  bowel  is  in  a 
doubtful  condition,  fasten  it  to  the  incision,  apply  a  dressing,  and  watch  the 
development  of  events.  If  the  bowel  is  gangrenous,  our  action  depends  upon 
the  condition  of  the  patient.  If  the  patient  is  in  good  condition,  resect  the 
gangrenous  portion,  and  perform  end-to-end  approximation  If  the  patient's 
condition  is  bad,  draw  the  gangrenous  portion  well  out,  anchor  it  to  prevent 
leakage  and  retraction,  make  an  artificial  anus,  and  at  a  later  period  perform 
anastomosis.  An  artificial  anus  can  be  made  by  the  method  of  Bodine  (page 
1 1 12).  Vnfortunately  in  these  cases  the  artificial  anus  must  usually  be  made  in 
the  small  intestine.  In  many  cases  in  which  there  is  some  uncertaint}'  as  to 
the  need  for  an  artificial  anus  prepare  the  bowel  for  the  opening,  but  do  not 
open  at  once,  because  the  bowel  may  recover  in  a  day  or  two,  when  it 
can  be  restored  to  the  belly;  or  it  may  slough  and  form  an  artificial 
anus.  In  such  doubtful  cases  fasten  the  bowel  to  the  belly  wall  with 
sutures,  dust  it  with  iodoform,  dress  it  with  hot  antiseptic  fomentations, 
and  await  future  developments.  Gangrenous  omentum  requires  ligation 
and  resection.  If  the  bowel  is  fit  to  reduce,  push  it  just  inside  the  ring, 
irrigate  the  parts,  suture,  and  perform  a  radical  cure.  In  femoral  hernia  we 
can  make  the  incision  one  inch  internal  to,  and  parallel  with,  the  femoral 
vessels,  and  crossing  the  tumor  and  ligament  (Barker) ;  but  it  is  better  to  make 
the  incision  of  Fabricius  for  radical  cure.  Divide  the  constriction  by  cutting 
upward  and  a  little  inward.  If  the  gut  is  found  gangrenous  or  in  a  doubtful 
condition  follow  Blake's  ad\'ice  ("Surg.,  GvTiecol.,  and  Obstet.,"  May,  1906), 
make  an  incision  at  the  edge  of  the  rectus,  draw  the  affected  portion  of  gut  into 
the  abdomen  and  out  of  the  incision  and  either  resect,  fix  it  under  or  out  of  the 
incision,  or  wait  for  return  of  circulation,  as  may  be  indicated  in  the  case. 
To  draw  the  gut  out  of  the  femoral  ring  makes  so  much  traction  that  return  of 
circulation  may  be  prevented  and  any  intestinal  operation  is  difficult  in  this 
region  without  splitting  Poupart's  ligament.  In  lanbilical  hernia  make  a 
slightly  curved  incision  a  little  to  one  side  of  the  middle  of  the  tumor,  open  the 
sac,  separate  adhesions,  and  di-\-ide  the  constriction  by  cutting  upward  or 
dowmward,  and  sometimes  also  laterally. 

After  an  operation  for  stran.gulated  hernia  put  the  patient  to  bed;  bend 
the  knees  over  a  pillow:  give  no  food  by  the  mouth  for  thirt\--six  hours  (^Slac- 
Cormac),  only  allowing  hot  water,  and  give  an  enema  of  salt  solution  contain- 
ing brandy  even'  sixth  hour.  Abdominal  pain  and  tenderness  call  for  the 
administration  of  saline  cathartics  and  enemata  containing  turpentine  or  oil 


II52 


Diseases  and  Injuries  of  the  Abdomoi 


of  me.  Tlie  enema  rute  is  a  favorite  prepaiatifm  in  St.  Geoi^ge's  H<K{ntaL, 
Londcm.  It  is  made  as  folkm^:  Take  sixteen  ounces  of  an  infusion  of  camo- 
mile, warm  it,  and  pour  it  upcm  3iij  of  OHifectifHi  of  senna  (Sheild).  If  thoe 
are  no  abdominal  pain  and  tenderness,  the  bowds  need  not  be  disturbed  for 
a  few  days;  but  if  at  the  end  of  four  or  five  davs  th^  have  not  acted,  give 
a  saline  cathartic  and  an  enana.  At  the  end  of  about  three  we^s  get  the 
patient  up.  If  a  radical  cure  has  not  beoi  attempted,  apply  a  pad  and  a 
spica  bandage  to  the  groin,  and  later  a  truss.  A  truss  ^ould  not  be  worn  if 
a  radical  cure  has  beoi  made. 

MortalUy. — Cases  of  strangulated  hernia  irreducible  by  taxis  will  prac- 
tically all  die  without  opraation.  The  mortality  following  operation  is  large; 
it  is  not  due  to  operation,  but  is  due  to  the  condition,  and  is  due  particularh'  to 
delay  in  operating  or  to  forcible  antecedent  taxis.    SuUan,  from  a  total  of 


Fig.  674. — Double  ingiiinal  rupture. 


1429  herniotomies,  estimates  the  mortality  at  20.7  per  cent.  Estimating  the 
mortality  according  to  the  time  of  strangulation,  Henggeler  reaches  the  follow- 
ing conclusions:  The  mortality  of  cases  operated  upon  ''the  first  day  after 
the  strangulation  is  8.09  per  cent.;  during  the  second  day,  22.2  per  cent.; 
during  the  third  day,  45.5  per  cent.;  during  the  fourth  day,  60  per  cent." 
("Atlas  and  Epitome  of  Abdominal  Hernias,"  by  Dr.  George  Sultan.  Trans- 
lated and  edited  by  \Vm.  B.  Coley,  M.D.)  The  mortality  in  children  is 
smaller  than  in  adults.  In  Coley's  12  cases  of  children  under  two  years  of  age 
there  was  not  a  death. 

Hernia  in  Childhood. — Hernia  is  extremely  common  in  children,  but 
it  is  an  interesting  fact  that  if  one  conducts  a  careful  investigation  of  hernia 
in  adults,  it  will  be  found  that  but  5  or  6  per  cent,  of  them  have  suffered 
with  the  hernia  in  childhood  This  fact  seems  to  demonstrate  positively 
that  the  majority  of  cases  of  hernia  in  childhood  are  recovered  from.  \.  J. 
Ochsner  ("Jour.  .\mer.  Med.  Assoc,"  Dec.  22, 1900),  in  commenting  upon  the 


Hernia  in  Childhood  1153 

frequency  of  hernia  in  ihildhood,  alludes  to  Malgaigne's  statistics.  Malgaigne 
estimated  that  during  the  first  year  of  life  one  child  in  every  twenty-one 
has  hernia,  and  that  this  proportion  is  maintained  until  the  age  of  six. 
Then  it  diminishes  rapidly  until  the  age  of  thirteen,  at  which  age  there  is 
one  hernia  in  every  seventy-seven  children.  It  is,  therefore,  obvious  that  75 
per  cent,  of  all  hernia.^  in  children  of  six  years  will  heal  spontaneously  before 
the  age  of  thirteen.  Ochsner  states  that  95  per  cent,  of  hernia;  in  children 
will  be  cured  without  operation.  He  points  out  that  between  the  ages  of 
thirteen  and  twenty  hernia  is  fairly  common  among  boys,  but  very  rare 
among  girls.  The  reason  for  this  tendency  to  cure  is  somewhat  uncertain. 
The  view  advocated  by  Thomas  C.  Martin  is  that,  as  the  pelvis  broadens, 
the  parietal  peritoneum  enlarges.  It  does  this  at  the  expense  of  the  mesen- 
tery, which  is  shortened,  and  the  internal  abdominal  ring  is  displaced.  In 
a  very  instructive  analysis  of  this  condition  Ochsner  shows  that  in  25  per 
cent,  of  cases  of  hernia  in  childhood  hereditary  weakness  exists;  that  the 
condition  is  commoner  among  the  poorer  classes  than  among  the  richer; 
that  in  many  cases  there  is  an  undescended  testicle;  and  that  the  chief  cause 
is  an  excess  of  intra-abdominal  pressure.  This  excess  of  intra-abdominal 
pressure  may  result  from  flatulent  distention  of  the  stomach  and  intestines, 
the  product  of  bad  feeding;  constipation  and  straining;  straining  on  urinating, 
due  to  the  existence  of  phimosis;  vomiting,  or  cough.  He  thinks  that,  as 
a  rule,  indigestion  causes  flatulence  and  pain;  that  the  child  cries;  that  this 
increases  the  pressure;  that  the  mother  then  feeds  it,  in  order  to  keep  it  quiet, 
and  that  this  makes  it  worse.     Strangulation  is  rare  in  childhood. 

Treatment. — Strangulated  herniae,  irreducible  herniae,  herniae  with  very 
large  rings,  cases  in  which  trusses  fail,  and  cases  associated  with  reducible 
hydrocele  require  operation  (Ochsner).  Most  cases  are  curable  without 
operation,  the  ring  being  guarded  by  a  truss  of  rubber  or  a  pad  of  lamb's  wool. 
Ochsner  beheves  that  many  cases  can  be  cured  by  keeping  the  child  re- 
cumbent, with  the  foot  of  the  bed  raised,  from  four  to  six  weeks.  If  phi- 
mosis exists,  it  should  be  operated  upon,  and  any  other  causative  condition 
should  be  treated  (cough,  vomiting,  constipation,  flatulent  indigestion,  etc.). 
An  umbilical  hernia  can  usually  be  cured  by  the  use  of  a  cork.  The  cork 
should  be  one  inch  in  diameter  and  one  and  one-fourth  inches  in  length, 
and  shaped  like  a  cone.  The  smaller  end  is  pushed  into  the  ring  and  the 
cork  is  held  in  place  by  adhesive  plaster.  In  two  weeks  a  smaller  cork  must 
be  used,  and  in  six  or  eight  weeks  it  can  usually  be  dispensed  with.  Radical 
cure  operations  are  seldom  done  before  the  age  of  four  (page  1 127). 

73 


IIS4 


Diseases  and  Injuries  of  the  Abdomen 


Varieties  of  Hernia. — Direct  inguinal  hernia  comprises  less  than  2  per 
cent,  of  cases  of  inguinal  hernia.  In  direct  hernia  the  contents  pass  out 
through  Hesselbach's  triangle  internal  to  the  deep  epigastric  artery.  They 
enter  the  inguinal  canal  low  down,  and  pass  outside  the  conjoined  tendon  or 
force  the  conjoined  tendon  before  them  or  split  through  the  tendon.  They 
do  not  enter  the  scrotum.  The  neck  of  the  sac  is  internal  to  the  deep  epi- 
gastric artery.  The  protrusion  is  globular  in  shape,  unless  it  emerges  around 
the  edge  of  the  tendon,  in  which  case  it  is  pear  shaped.     The  coverings  of 

this  hernia,  when  it  passes  exter- 
nal to  the  conjoined  tendon,  are 
the  same  as  those  of  an  indirect 
inguinal  hernia,  except  that  the 
transversahs  fascia  instead  of  the 
infundibuliform  process  of  the 
transversahs  fascia  is  one  of  the 
layers.  When  a  direct  hernia 
pushes  before  it  the  conjoined 
tendon,  its  coverings  are  skin, 
superficial  fascia,  intercolumnar 
fascia,  conjoined  tendon,  trans- 
versahs fascia,  subserous  tissue, 
and  peritoneum. 

In  indirect  inguinal  hernia  the 
contents  pass  through  the  internal 
abdominal  ring  external  to  Hes- 
selbach's triangle  and  external  to 
the  deep  epigastric  artery.  They 
pass  down  the  inguinal  canal  and 
emerge  from  the  external  ring;  and 
may  or  may  not  enter  the  scrotum 
or  labium  {scrotal  or  labial  hernia) . 
The  protrusion  is  pear  shaped. 
The  neck  of  the  sac  is  external  to 
the  deep  epigastric  artery.  Its  cov- 
erings are  skin,  superficial  fascia, 
intercolumnar  fascia,  cremaster 
muscle,  infundibuliform  fascia, 
subserous  tissue,  and  peritoneum. 
Congenital  inguinal  hernia  is  a  portion  of  bowel  within  an  unclosed 
vaginal  process.  The  bowel  in  congenital  hernia  has  one  layer  of  peritoneum 
in  front  of  it.  The  tesricle  is  posterior  and  below  (Fig.  675,  h).  Always  re- 
member that  bowel  may  not  enter  the  sac  of  a  congenital  hernia  for  several 
months  after  birth.  Congenital  hernia  conceals  or  buries  the  tesdcle;  acquired 
hernia  does  not.  If  a  vaginal  process,  open  above  and  closed  below,  contains 
a  hernia,  the  condition  is  called  hernia  into  the  funicular  process. 

If  the  funicular  process  is  closed  at  the  abdominal  end,  but  not  below,  a 
hernia  in  a  special  sac  may  descend  back  of  the  vaginal  tunic.  This  condi- 
tion is  known  as  infantile  hernia.  In  infantile  hernia  there  are  three  layers 
of  peritoneum  in  front  of  the  bowel — the  two  layers  of  the  vaginal  tunic  and 
the  one  layer  of  sac.     The  testicle  is  in  front  (Fig.  675,  d). 


Fig.  675. — a.  Scrotal  hernia;  b,  congenital 
hernia;  c,  funicular  hernia;  d,  infantile  hernia; 
e,  encysted  hernia.  , 


Varieties  of  Hernia  1155 

If  the  tunica  vaginalis  is  closed  above  and  not  below,  and  a  hernia  pushes 
down  the  vaginal  process  and  causes  it  to  double  on  itself,  the  condition  is 
known  as  encysted  infantile  hernia  (Fig.  675,  e), 

In  femoral  hernia  the  contents  descend  along  the  femoral  canal,  and  the 
neck  of  the  sac  is  at  the  femoral  ring.  The  neck  of  a  femoral  rupture  is  always 
external  to  the  pubic  spine;  the  neck  of  an  inguinal  rupture  is  always  inter- 
nal to  the  pubic  spine.  Femoral  hernia  contains  omentum,  but  seldom  intes- 
tine, except  in  strangulated  cases.  It  used  to  be  said  that  femoral  hernia 
is  never  congenital.  Russell  and  Coley  show  that  it  may  be  (page  11 24). 
The  coverings  of  a  femoral  hernia  are  skin,  superficial  fascia,  cribriform  fascia, 
crural  sheath,  septum  crurale,  subserous  tissue,  and  peritoneum. 

Umbilical  hernia  may  be  congenital  (the  ventral  plates  having  closed 
incompletely),  infantile  (the  cicatrix  of  the  umbiUcus  having  stretched),  or 
acquired. 

Ventral  hernia  is  a  protrusion  through  any  part  of  the  anterior  abdominal 
wall  except  at  the  umbilical  or  inguinal  regions.  A  ventral  hernia  may  be 
median  {hernia  of  the  linea  alba)  or  lateral.     The  treatment  is  radical  operation. 

Epigastric  hernia  is  a  form  of  ventral  hernia.  In  this  condition  there  is 
a  protrusion  of  the  peritoneum  in  the  space  bounded  by  the  ensiform  cartilage, 
the  ribs,  and  the  umbilicus.  The  sac  of  peritoneum  may  be  empty,  may 
contain  omentum,  or  omentum  and  bowel.  The  stomach  very  rarely  passes 
into  the  sac.  The  protrusion  is  usually,  but  not  invariably,  through  the  linea 
alba.  The  condition  may  be  due  to  a  congenital  gap  in  the  transversalis 
fascia  or  to  the  growth  of  a  fat  hernia. 

Cecal  hernia  is  very  uncommon  in  women.  It  may  be  either  congenital, 
infantile,  or  acquired.  If  a  vaginal  process  is  open  the  cecum  may  readily 
enter  in,  it  may  be  drawn  in  by  the  plica  vascularis  as  the  testicle  descends 
(Wrisberg) ,  it  may  be  drawn  in  by  a  descending  testicle  the  posterior  perito- 
neum over  which  has  formed  adhesions  to  the  cecum.  Most  acquired  cecal 
hernia  are  preceded  and  caused  by  hernia  of  the  small  gut,  but  they  may 
occur  alone.  In  the  simple  form  the  cecum  is  completely  covered  by  a  coat  of 
peritoneum  and  lies  within  the  sac.  Usually  there  is  a  complete  surrounding 
sac,  but  sometimes  the  sac  partially  covers  the  cecum  lying  in  front  and  to  the 
inner  side.  In  these  cases  the  cecum  is  on  the  posterior  and  external  aspect 
of  the  wall  of  the  sac.  The  appendix  may  be  in  the  sac,  outside  of  the  sac,  or 
part  may  be  within  and  part  without.  If  the  sac  is  incomplete,  it  means  that 
we  have  one  of  the  18  per  cent,  of  cases  in  which  the  cecum  is  not  completely 
covered  with  peritoneum.  A  cecal  hernia  may  be  and  usually  is  right  inguinal, 
but  may  be  right  femoral,  left  inguinal,  or  left  femoral.  It  is  most  common 
in  advanced  Hfe  and  is  frequendy  irreducible. 

Hernia  of  the  appendix  may  occur  alone,  and  Merigot  de  Treigney  collected 
22  cases  of  it  ("These  de  Paris,"  1887).  In  17  the  hernia  was  inguinal;  in 
5  it  was  femoral.  I  operated  upon  a  case  of  appendicitis  in  which  the  inflamed 
appendix  was  the  sole  occupant  of  an  incomplete  right  inguinal  hernia  sac. 
In  some  cases  the  appendix  accompanies  the  cecum  into  a  hernia. 

Sliding  hernia  of  the  ascending  colon  is  due  to  the  looseness  of  the  perito- 
neum of  the  iliac  region,  which  permits  a  portion  of  the  large  bowel  to  slide 
into  a  hernia.  In  such  a  case  the  posterolateral  aspect  of  the  sac  is  absent 
(Figs.  676  and  677).     The  descending  bowel  carries  with  it  into  the  scrotum 


II56 


Diseases  and  Injuries  of  tlie  Abdomen 


a  fold  cf  loosened  peritoneum,  just  as  in  the  descent  of  the  testis  (see  Weir,  in 
"Med.  Record,"  Feb.  24,  1900).  Sliding  hernia  of  the  ascending  colon  is 
wrongly  called  sliding  hernia  of  the  cecum.  Sliding  hernia  of  the  descending 
colon,  wrongly  called  sliding  hernia  of  the  sigmoid,  may  occur.  In  most  cases 
the  descending  colon  is  dragged  into  a  preexisting  hernia  sac  containing  small 
bowel,  omentum,  or  both.  The  large  bowel  is  covered  with  peritoneum  except 
posteriorly,  where  the  mesocolon  is  attached.  This  form  is  nearly  always 
irreducible  and  occurs  particularly  in  elderly  men.     In  another  group  of  cases 


Fig.  676. — The  large  intestine  behind  the  peri- 
toneum (Weir). 


Connectwe  tissue 


Fig.  677. — The  retroperitoneal  large  intes- 
tine in  a  cross-section  of  the  hernia  with  its  in- 
complete sac  (Weir). 


the  large  bowel  makes  a  direct  inguinal  hernia  and  the  sac  is  limited  to  the 
anterior  surface  of  the  protruded  gut. 

In  properitoneal  hernia  the  sac  is  between  the  peritoneum  and  trans- 
versalis  fascia.  The  form  of  hernia  is  sometimes  produced  by  making  taxis 
on  an  inguinal  hernia,  when  the  internal  ring  is  small  or  is  blocked  by  an 
undescended  testicle.  In  properitoneal  inguinal  hernia,  which  is  the  most 
common  form,  there  are  two  sacs  detectable,  one  in  the  scrotum,  the  other 
parallel  with  Poupart's  ligament,  and  as  one  sac  is  emptied,  the  other  distends 
(Breiter,  of  Zurich). 

In  interstitial  or  interparietal  inguinal  hernia  the  hernia  sac  is  between  the 
transversalis  muscle  and  fascia,  or  between  the  external  and  internal  oblique 
muscles,  or  between  the  fibers  of  the  internal  oblique  muscle,  or  between  the 
external  oblicjue  muscle  and  the  transversalis  fascia,  the  internal  oblique  and 
transversalis  muscles  being  pushed  aside  (Sultan's  "Atlas  of  Abdominal 
Hernias"). 

In  superficial  inguinal  hernia  the  sac  is  between  the  aponeurosis  of  the 
external  oblique  muscle  and  the  superficial  fascia.  This  variety  of  hernia 
is  always  congenital  and  the  tesdcle  is  invariably  misplaced. 

Obturator  hernia  passes  through  the  obturator  membrane  or  the  obturator 
canal,  and  is  felt  below  the  horizontal  ramus  of  the  pubes,  internal  to  the 
femoral  vessels.  The  obturator  nerve  is  pressed  upon  and  pain  arises  in  its 
trajectory. 


Varieties  of  Hernia 


1157 


A. 


Lumbar  hernia  is  a  very  rare  condition.  It  may  be  congenital,  traumatic, 
or  spontaneous,  and  may  follow  a  lumbar  abscess.  Baracz  collected  68  cases. 
It  occurs  through  the  triangle  of  Petit,  or  just  below  the  twelfth  rib  through 
the  superior  lumbar  triangle,  or  through  a  congenital  defect  in  the  aponeurosis 
of  the  latissimus  dorsi  muscle,  or  through  a  defect  near  the  triangle  of  Petit 
(Dowd,  in  "Annals  of  Surgery,"  Feb.,  1907).  A  lumbar  hernia  may  be 
present  at  the  edge  of  or  through  the  quadratus  lumborum  muscles. 

The  triangle  of  Petit 
is  bounded  in  front  by 
the  external  oblique,  be- 
hind by  the  latissimus 
dorsi,  below  by  the  iliac 
crest,  and  its  floor  is 
formed  by  the  internal 
oblique.  The  superior 
lumbar  triangle  (of  Gryn- 
felt  and  Lesshaft)  is 
bounded  anteriorly  by 
the  external  oblique,  pos- 
teriorly by  the  iliocostal 
muscle,  above  by  the 
serratus  posticus  inferior 
and  the  end  of  the  twelfth 
rib,  and  below  by  the  in- 
ternal oblique.  The  latis- 
simus dorsi  overlies  it. 

Sciatic  or  gluteal  her- 
nia passes  through  the 
great  sacrosciatic  fora- 
men, above  or  below  the 
pyriformis  muscle,  or 
through  the  lesser  sacro- 
sciatic foramen. 

Pudendal  hernia  pro- 
trudes into  the  lower  part 
of  the  labium,  the  bowel 
having  descended  be- 
tween the  ischial  ramus 
and  the  vagina. 

Perineal  hernia  pre- 
sents   in    the    perineum, 

between  the  rectum  and  the  prostate  gland  or  between  the  rectum  and  the 
vagina. 

Internal,  retroperitoneal,  or  intra-abdominal  her  nice  include  hernia  into  the 
foramen  of  Winslow,  hernia  into  the  retroduodenal  fossce,  the  retrocecal  fosscE, 
and  the  inter  sigmoid  fossa. 

Vaginal  hernia  is  associated  with  uterine  prolapse  or  ensues  upon  destruc- 
tion of  the  vaginal  wall. 

Richter's  hernia  is  the  catching  of  a  portion  of  the  circumference  of  the 


B. 

Fig.  678. — A.  Diagrammatic  representation  of  Richter's  her- 
nia of  the  intestinal  wall.  B.  Diagrammatic  representation  of  a 
hernia  of  Meckel's  diverticulum  (Sultan). 


1 158  Diseases  and  Injuries  of  the  Abdomen 

bowel.  It  is  also  called  partial  enlcrocele  or  hernia  of  the  intestinal  u'olL 
Strangulation  of  a  partial  enterocele  does  not  produce  stercoraceous  vomiting 
or  absolute  constipation,  and  the  protrusion  is  barely  perceptible  or  cannot  be 
palpated. 

Littre's  hernia  is  hernia  of  Meckel's  diverticulum  (Fig.  678,  b).  This  di- 
verticulum is  the  persistent  vitelline  duct  and  comes  off  from  the  ileum  from  12 
to  36  inches  above  the  ileocecal  valve.  It  arises  from  the  convex  side  of  the  gut 
and  rarely  has  a  mesentery  (pp.  398  and  973). 

Rokitansky's  diverticular  hemise  are  due  to  separation  of  the  muscular 
fibers  of  the  bowel,  permitting  the  sacculation  of  mucous  membrane  and  peri- 
toneum. These  false  diverticula  may  be  no  larger  than  peas  or  may  be  larger 
than  walnuts,  and  there  may  be  scores  of  them  in  one  patient.  They  may 
produce  no  symptoms  or  may  lead  to  peritonitis  or  to  symptoms  of  intestinal 
obstruction. 

Hernia  of  the  Bladder. — This  is  a  protrusion  of  a  pordon  of  the  bladder- 
wall  through  a  hernial  opening.  Eggenberger  adds  no  cases  to  Brunner's 
182  cases,  a  total  of  292  cases  ("Deutsche  Zeitschr.  f.  Chir.,"  Oct.,  1908). 
Most  cases  are  instances  of  false  hernia,  there  being  no  sac  of  peritoneum. 
The  protrusion  may  or  may  not  be  covered  with  peritoneum,*  and  in  most  cases 
it  is  not  so  covered,  but  lies  by  the  side  of  a  hernial  sac  and  not  inside  of  it. 
Brunner's  table  shows  only  5  cases  of  true  bladder  hernia,  that  is,  of  intraperi- 
toneal hernia.  It  is  most  frequently  met  with  in  the  inguinal  region.  Brunner 
describes  three  forms:  (i)  Entirely  without  a  peritoneal  covering  (extraperi- 
toneal) ;  (2)  partly  covered  with  peritoneum  (paraperitoneal — the  commonest 
form);  (3)  completely  covered  with  peritoneum  (intraperitoneal).  The  blad- 
der may  constitute  the  hernia,  or  there  may  be  an  ordinary  hernia  and  also  a 
cystocele.  •  In  an  inguinal  hernia  the  bladder  will  be  internal  and  somewhat 
behind  the  other  constituent  pares  of  the  protrusion.  Hernia  of  the  bladder 
is  much  more  common  in  men  than  in  women. 

A  hernia  of  the  bladder  may  become  strangulated.  In  some  cases  a 
diagnosis  of  hernia  of  the  bladder  can  be  made  by  the  fact  that  the  protrusion 
lessens  in  size  when  the  patient  micturates,  and  increases  in  size  as  urine 
gathers  or  when  the  bladder  is  injected  with  fluid.  The  treatment  should 
be  operative.  When  the  bladder  is  exposed  it  is  replaced  with  or  without 
resection  of  a  portion. 

Diaphragmatic  Hernia. — The  majority  of  cases  are  congenital  and  in 
90  per  cent,  of  them  there  is  no  sac.  The  hernia  may  pass  through  a  natural 
opening  or  through  a  gap  due  to  congenital  defect.  Th»  hernia  is  most  com- 
mon on  the  left  side,  and  the  stomach  is  the  organ  which  is  most  often  found  in 
the  hernia,  but  the  colon,  the  omentum,  the  small  intestine,  the  spleen,  liver, 
duodenum,  cecum,  pancreas,  or  kidney  may  be  found  (Cranwell,  "Rev.  de 
Chir.,"  1908,  No.  i).  Violent  traumatism  may  be  the  cause.  When  the 
stomach  passes  suddenly  through  the  left  side  of  the  diaphragm,  there  \\-ill 
be  dyspnea,  cyanosis,  displacement  of  the  heart  to  the  right,  pain  in  the  upper 
abdomen,  thirst,  and  in  most  cases  rapid  death.  When  the  stomach  or  in- 
tesdne  has  entered  the  left  side  of  the  thorax,  there  is  a  tympanitic  note  on 
percussing  over  that  area  of  the  thorax,  the  heart  is  displaced  to  the  right,  and 

*  Brunner.  in  Deutsch.  Zeitschr.  f.  Chir.,  1898,  vol.  xlvii. 


Hernia  of  the  Uterus  1159 

the  side  of  the  chest  is  unduly  prominent.  The  upper  border  of  the  tympanitic 
area  does  not  move  with  respiration.  There  are  no  breath  sounds  audible  over 
the  tym[)anitic  area,  but  gurgUng  is  heard.  In  250  cases  of  traumatic  dia- 
phragmatic hernia  collected  by'Leichtcnstern  the  diagnosis  was  made  before 
death  in  but  5  cases.  The  .v-rays  are  of  value  in  diagnosis,  especially  if  the 
stomach  is  in  the  hernia.  Strangulation  of  a  diaphragmatic  hernia  produces 
severe  y)ain  in  the  upper  abdomen,  violent  vomiting,  constipation,  boat-shaped 
abdomen,  great  thirst,  rapid  wasting,  and  the  excretion  of  a  very  small  amount 
of  urea  (Mackenzie  and  Battle,  "Lancet,"  Dec.  7,  1901).  Diaphragmatic 
hernia  may  be  confused  with  eventration  of  the  diaphragm,  an  unnaturally 
high  position  of  the  left  half  of  the  diaphragm,  with  ascent  of  the  viscera  of  th^ 
abdomen,  especially  the  stomach.  It  was  first  described  by  Petit  in  1790. 
Sailer  and  Rhein  reported  a  case  and  collected  12  others  ("'Am.  Jour.  ^led. 
Sciences,"  April,  1905).  The  physical  signs  of  eventration  are  practically 
identical  with  those  of  diaphragmatic  hernia,  except  that  in  the  former  the 
upper  border  of  the  tympany  moves  on  respiration. 

Treatment. — Open  the  belly  for  exploration.  If  a  hernia  is  found,  return  it 
to  the  abdomen;  open  the  chest  and  suture  the  diaphragm  from  above  (trans- 
pleural suturing).  Mackenzie  and  Battle,  MikuUcz,  Humbert,  and  others 
have  operated  for  this  condition. 

Hernia  of  the  Ovary. — The  ovary,  because  of  failure  of  descent,  may 
remain  in  the  lumbar  region.  It  may  pass  into  the  inguinal  canal  or  labium 
majus  (inguinal  hernia);  to  the  gluteal  region  (gluteal  hernia);  to  the  region 
of  the  obturator  foramen  (obturator  hernia);  or  to  the  front  of  the  abdo- 
men (ventral  hernia).  In  congenital  inguinal  hernia  there  may  be  ovary 
alone,  or  ovar}-,  tube,  omentum,  and  even  part  of  a  bicornate  uterus  (Gar- 
rigues).  It  is  impossible  to  restore  a  congenital  hernia.  Acquired  hernia  may 
follow  a  fall  and  sometimes  it  can  be  restored.  A  femoral  or  crural  ovarian 
hernia,  a  condition  in  which  the  ovary  passes  to  the  front  of  the  thigh  below 
Poupart's  ligament,  is  never  congenital.  In  some  cases  a  herniated  ovary 
can  be  returned  within  the  abdomen.     Any  herniated  ovary  may  inflame. 

Treatment. — If  it  can  be  restored,  a  truss  will  probably  retain  it.  If  it 
cannot  be  restored  or  if  it  is  painful  or  undesirable  to  wear  a  truss,  operate. 
Expose  the  ovar}%  return  it  to  the  belly  if  healthy,  and  do  a  radical  cure  of  the 
hernia.     In  some  conditions  of  disease  remove  the  ovary. 

Hernia  of  the  Uterus. — This  condition  is  a  surgical  curiosity,  but  a  few- 
cases  have  been  reported  (see  John  Howard  Jopson's  case  in  "Annals  of  Sur- 
gery," July,  1904).  The  hernia  may  be  umbihcal,  ventral,  inguinal,  or  fem- 
oral. Hernia  of  the  unimpregnated  womb  may  be  congenital  or  acquired; 
impregnation  may  occur  when  the  uterus  is  herniated,  or  an  impregnated 
uterus  may  pass  into  a  preexisting  hernia  sac.  If  a  herniated  uterus  becomes 
impregnated  or  if  an  impregnated  uterus  becomes  herniated,  pregnancy  may 
go  on  to  term.  Multiple  pregnancies  predispose  to  uterine  hernia.  Ovarian 
hernia  may  precede  uterine  hernia,  or  hernia  of  omentum  adherent  to  the 
uterus  may  pull  that  organ  into  the  sac.  In  many  cases  congenital  anom- 
alies have  been  found  to  exist  (bicornate  uterus,  rudimentery  uterus,  shortness 
of  the  round  ligament,  imperforate  vagina,  etc.).  A  hernia  of  the  uterus  en- 
larges and  becomes  painful  during  menstruation,  and  a  vaginal  examination 
shows  that  the  uterus  is  absent  from  its  normal  position  and  that  the  direction 


ii6o  Diseases  and  Injuries  of  the  Rectum  and  Anus 

of  the  cervix  and  vagina  are  abnormal  (Jopson).  A  uterine  sound  cannot  be 
passed  at  all  or  can  be  passed  with  great  difficulty.  The  hernia  is  hard  and 
probably  pyriform.  If  impregnation  occurs,  there  are  the  ordinar}-  signs  of 
pregnancy  and  progressive  enlargement  of  the  hernia. 

Treatment. — Expose  the  mass  by  incision.  If  conditions  justify  such  a 
course,  return  the  uterus  and  adnexa,  if  they  are  present  (one  or  both  ovaries 
and  tubes  may  be  present),  to  the  abdomen  and  do  a  radical  cure.  If  the 
uterus  is  infected,  remove  it.  Jopson  in  his  case  removed  the  uterus  and 
right  ovary  and  fastened  the  uterine  stump  into  the  wound. 


XXVril.   DISEASES  AND  INJURIES  OF  THE  RECTUM  AND  ANUS. 

Teratoids  and  Dermoids  Associated  with  the  Sacrococcygeal 
Region. — In  the  sacrococcygeal  region  there  are  many  opportunities  for  de- 
velopmental error.  In  this  region  the  caudal  end  of  the  primitive  streak  must 
undergo  evolution  and  involution,  the  neurenteric  canal  must  form  and  dis- 
appear, the  anus  must  be  formed,  the  posterior  fissure  must  close,  the  sacrum 
and  coccyx  must  develop,  and  various  other  processes  must  go  on  correctly 
and  uniformly  if  complete  development  is  to  be  obtained.  As  Cophn  puts 
it:  "Perfect  evolution  of  the  tissues  embraced  in  this  part  of  the  body  is 
beset  by  many  narrow  escapes"  (Pubhcation  from  the  laboratories  of 
"Jeff.  Med.  College  Hospital,"  vol.  iii,  1906).  Fissures  and  clefts  may  fail 
to  close,  fragments  from  one  blastodermic  layer  may  be  lodged  in  another 
layer,  groups  of  cells  may  be  sequestered,  closing  clefts  may  include  tissue 
elements,  and  parts  that  should  normally  atrophy  may  do  so  late  or  not  at  all. 

In  order  to  understand  teratomata  and  dermoids  arising  in  the  rectal  region 
we  must  recall  some  facts  of  development. 

Early  in  embryonic  life  the  central  canal  of  the  spinal  cord  and  the  ali- 
mentary canal  are  continuous  around  the  caudal  end  of  the  notochord  by 
a  communicating  path  called  the  neurenteric  canal. 

When  the  anal  pit  undergoes  invagination  it  meets  the  gut  considerably 
in  front  of  the  region  were  the  neurenteric  canal  joins  the  gut.  The  portion  of 
intestine  between  the  anus  and  the  opening  of  the  neurenteric  canal  is  called 
the  post-anal  gut.  The  post-anal  gut  disappears  during  normal  development. 
If  it  persists  it  causes  tumor  formation. 

The  congenital  tumors  of  the  sacrococcygeal  region  are:  (i)  Tumors  of  the 
post-anal  gut;  (2)  dermoids  back  of  the  rectum;  (3)  rectal  dermoids. 

According  to  Sutton,  tumors  of  the  post-anal  gut  "are  composed  of  closed 
vesicles  lined  with  glandular  epithehum  and  contain  glue-hke  fluid"  ("  Tumors, 
Innocent  and  Malignant,"  by  J.  Bland  Sutton,  F.R.C.S.).  These  tumors 
grow  to  a  large  size. 

Dermoids  back  of  the  rectum  often  contain  teeth,  may  attain  large  size, 
are  apt  to  mount  up  behind  the  peritoneum,  and  may  rupture  and  form  a  fistula. 
I  helped  Prof.  Keen  operate  on  such  a  case.  The  skin  over  the  mass  showed 
a  growth  of  hair,  there  was  a  gap  or  cleft  in  the  sacrum,  and  through  this  there 
was  a  clear  passage  from  the  rectum  to  the  skin.  This  sinus  closely  resembled 
the  trachea  in  structure. 


Examination  of  the  Anus  and  Rectum  1161 

Dermoids  occasionally  grow  from  the  mucous  membrane  of  the  rectum  and 
are  a])t  to  contain  an  abundant  growth  of  hair. 

Examination  of  the  Anus  and  Rectum.— There  are  four  positions  in 
which  we  may  place  the  patient  for  rectal  examination,  the  one  to  be  selected 
depending  upon  the  probable  local  difficulty.  These  posirions  are  the  left- 
lateral-prone,  the  knee-chest,  the  exaggerated  lithotomy,  and  the  squatting 
position.  That  most  commonly  employed  is  the  lefi-lateral-prone  position  oj 
Sims,  in  which  the  patient  Hes  on  the  left  side,  the  chest  on  the  table,  the  left 
arm  behind  the  back,  the  knees  drawn  up,  and  the  pelvis  elevated  on  a  hard 
pillow.  This  posirion  is  used  in  the  majority  of  cases  for  ocular,  digital,  or 
instrumental  examinations. 

\'ery  stout  people  must  \>e  placed  in  the  knee-chest  position  or  exaggerated 
lithotomy  position,  as  the  rectum  cannot  be  seen  when  they  lie  on  the  side. 

A  squatting  position,  when  the  patient  is  placed  as  though  on  a  commode, 
is  best  adapted  to  cases  of  prolapse  and  hemorrhoids.  It  is  also  used  to  bring 
within  the  range  of  the  finger  strictures  or  new  growths  that  in  the  other  atti- 
tudes would  be  beyond  digital  reach. 

In  some  patients  one  is  able  to  pass  a  sigmoidoscope  upon  a  patient  in  the 
exaggerated  lithotomy  position  when  it  has  been  found  impossible  to  carry  the 
instrument  high  enough  with  the  patient  in  any  other  position. 

While  making  a  rectal  examination  the  patient  should  have  no  constriction 
about  the  abdomen,  such  as  dress,  bandages,  or  any  tight  clothing. 

It  is  important  that  the  first  examination  be  made  when  no  cathartics  or 
enemata  have  been  administered,  so  that  the  condition  of  the  excretions  and 
secredons  may  be  noted.  After  these  obser\^ations  have  been  made  an  enema 
should  be  given  and  the  anus  and  rectum  be  well  cleansed.  By  such  first 
examination  pus,  blood,  mucus,  or  inspissated  fecal  matter  if  present  may  be 
seen,  and  from  their  var\ing  characteristics,  quantities  and  locations,  causal 
inferences  may  be  drawn.  When  the  parts  have  been  cleaned  and  the  bowel 
washed  out  the  anus  is  carefully  inspected,  the  anal  folds  being  opened  during 
the  process.  By  inspection  the  surgeon  can  notice  the  external  opening  of  a 
fistula,  external  piles,  protruding  internal  piles,  mixed  piles,  pruritus,  discharge 
from  the  rectum,  eczema,  fissure,  tumor,  ulcer,  condylomata,  abscess,  whether 
or  not  the  anus  is  retracted  and  funnel-shaped  or  protruding,  or  if  there  be 
parasites  on  the  anal  hairs. 

Next  the  thumbs  should  be  placed  on  either  side  of  the  anus  and  gently 
separated;  this  maneuver  aided  by  a  bearing  down  effort  on  the  part  of  the 
patient  will  often  cause  piles  to  protrude,  exhibit  fissures  and  polypi,  and  reveal 
the  condidon  of  the  mucocutaneous  border. 

Next,  a  digital  examination  of  the  rectum  is  made.  The  nail  of  the  index- 
finger  is  filled  \\ith  soap  and  the  finger  is  oiled  or,  better,  is  covered  with  a 
rubber  finger-tip  which  is  oiled.  The  digit  is  gently  inserted  through  the 
sphincter,  the  patient  being  asked  to  strain  lightly  while  it  is  passing.  The 
finger  is  inserted  with  a  gentle  boring  motion  and  is  pointed  toward  the  um- 
bilicus until  the  sphincter  is  passed.  A  digital  examination  enables  the  sur- 
geon to  detect  an  ulcer,  a  polypus,  a  tumor,  a  stricture,  and  to  determine 
certain  points  regarding  the  condidon  of  the  prostate  in  the  male  and  the 
uterus  in  the  female. 

Next,  in  some  cases  the  rectum  must  be  examined  with  a  speculum.     It 


1 1 62  Diseases  and  Injuries  of  the  Rectum  and  Anus 


Fig.  679. — Mathews'  self-retaining  rectal  speculum. 


Fig.  680. — Brinkerhofi's  speculum. 


Fig.  681. — Martin's  speculum. 


Examination  of  the  Anus  and  Rectum 


1 163 


is  not  often  necessary  to  give  ether.  Mathews'  speculum  (Fig.  679)  is  very 
serviceable.  Sims'  duck-bill  speculum  is  a  valuable  instrument.  The  specu- 
lum is  warmed,  oiled,  and  slowly  introduced.     It  is  first  directed  toward  the 


Fig.  682. — -Cook's  operating  speculum. 

umbilicus,  and  when  it  passes  the  sphincter,  its  direction  is  gradually  altered 
until  it  is  toward  the  promontory  of  the  sacrum.  Illumination  is  obtained 
by  direct  sunlight,  or  by  a  forehead  mirror  and  an  electric  light.  This  ex- 
amination will  extend,  confirm,  or  disprove  the  findings  of  the  digital  ex- 


Fig.  683. — Kelly's  rectal  specula. 


amination;  ulcers,  hemorrhoids,  and  mahgnant  growths  can  be  carefully 
examined,  and  the  condition  of  the  rectal  mucous  membrane  can  be  thor- 
oughly investigated. 

Marion  Sims  in  1845  demonstrated  the  ballooning  of  the  vagina  by  atmos- 


II64 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


pheric  pressure,  and  in  1870  Van  Buren  applied  this  method  to  the  rectum. 
Kelly  in  1895  put  forth  his  straight  tubes  and  described  in  detail  the  methods 
and  advantages  of  examination  by  them,  and  the  great  diagnostic  value  of 
ballooning  the  rectum.  Kelly's  method  of  examination  is  shown  in  Fig.  684. 
The  tubes  are  shown  in  Fig.  683.  It  is  not  necessary  to  give  ether.  The 
patient    is    placed    in    the   knee-chest    position.      A    tube    containing    an 


Fig.  684. — Examination  of  the  rectum  by  reflected  light  (Kelly). 


obturator  is  well  greased  with  vaselin.  "The  buttocks  are  drawn  apart, 
and  the  blunt  end  of  the  obturator  is  laid  on  the  anus,  which  is  also  coated 
with  vaselin.  The  direction  of  the  instrument  should  be  first  downward  and 
forward,  and,  when  the  sphincter  is  well  passed,  up  under  the  sacral  promon- 
tory. The  moment  the  speculum  clears  the  sphincter  ani  and  the  obturator 
is  withdrawn,  air  rushes  in  audibly  and  distends  the  bowel."  When  the  enter- 
ing instrument  is  pressed  gently  against  the  sphincter  a  sharp  muscular  con- 
traction ensues.  If  the  instrument  is  gently  and  slightly  withdrawn,  relaxation 
occurs,  and  the  moment  of  relaxation  may  be  seized  to  make  an  entry.  An 
entry  so  made  is  rapid  and  unresisted.  The  bowel  being  distended  with  air, 
the  mucous  membrane  is  plainly  seen  as  the  tube  is  slowly  withdrawn  and  the 
light  is  reflected  into  the  speculum.  The  normal  mucous  membrane  is  dull 
red,  hke  the  nasal  mucosa,  and  the  blood-vessels  are  plainly  distinguishable. 
The  Kelly  tube  must  be  used  with  great  care,  as  harm  may  be  done  by  it,  and 
the  longest  tube  should  be  used  only  in  exceptional  cases. 

I  use  with  the  greatest  satisfaction  Tuttle's  pneumatic  proctoscope  (Fig. 


Examination  of  the  Anus  and  Rectum 


1165 


685).  Dr.  Tuttlc  descril)es  it  as  follows  ("Diseases  of  the  Anus,  Rectum, 
and  Colon,"  by  James  P.  Tuttle):  "This  instrument  is  composed  of  a  large 
cylinder  (/) ,  into  one  part 
of  the  circumference  of 
which  is  fitted  a  small 
metalhc  tube  closed  by  a 
flint-glass  bulb  at  its  distal 
end.  The  electric  lamp 
(d)  is  fitted  upon  a  long 
metallic  stem,  and  carried 
through  the  small  cylinder 
to  the  end  of  the  instru- 
ment, as  shown  in  the  illus- 
tration. The  proctoscope 
is  introduced  through  the 
anus  with  the  obturator 
(a)  in  position.  As  soon  as 
the  internal  sphincter  is 
passed,  this  obturator  is 
withdrawn  and  the  bay- 
onet-fitting plug  (b),  which 
contains  either  a  plain  glass 
window  or  a  lens  focused  to 
the  length  of  the  instru- 
ment to  be  used,  is  inserted 
in  the  proximal  end  of  the 
instrument.  This  plug  is  ground  to  fit  air-tight  and  thus  closes  the  instru- 
ment perfectly.  The  plug  being  inserted  in  the  tube,  a  very  slight  pressure 
upon  the  hand-bulb  will  cause  inflation  of  the  rectal  ampulla  to  such  an  extent 
that  the  whole  rectum  can  be  observed  and  the  instrument  can  be  carried  up 
to  the  promontory  of  the  sacrum  without  coming  in  contact  with  the  rectal 
wall.  Further  dilatation  will  show  the  direction  of  the  canal  leading  into 
the  sigmoid,  and,  by  a  little  care  in  manipulating  the  instrument  and  keeping 
the  gut  well  dilated  in  advance,  it  can  be  carried  up  into  this  portion  of  the 
intestine  without  the  least  traumatism  of  the  parts.  If  any  fecal  matter  ob- 
scures the  light  by  being  massed  or  smeared  over  the  glass  bulb,  the  plug  can 
be  removed,  and  a  pledget  of  cotton,  introduced  wdth  a  long  dressing  forceps, 
will  wipe  this  off  so  that  the  plug  can  be  reintroduced  and  the  examination 
continued  with  very  slight  delay  or  inconvenience.  The  adjustable  handle 
(c)  fits  on  the  rim  of  the  instrument  and  thus  converts  it  into  a  Kelly  tube. 
This  instrument  is  operated  with  an  ordinary  dry  battery  of  four  cells.  It  is 
better,  how-ever,  to  have  a  battery  with  six  cells,  as  it  will  not  require  being 
recharged  so  frequently."  All  the  air  must  be  allowed  to  escape  before  the 
instrument  is  withdrawn,  otherwise  cohc  may  develop. 

If  an  anesthetized  patient  is  placed  in  the  knee-chest  position,  the  sphincter 
can  be  stretched  by  the  fingers,  and  the  rectum  \\all  distend  with  air  and 
can  be  easily  examined.  The  fingers  are  introduced  as  suggested  by  Mar- 
tin (Fig.  686)  and  the  rectum  becomes  visible  when  they  are  separated 
(Fig.  687). 


Fig.  685. — Tuttle's  pneumatic  proctoscope:  a,  Obturator; 
d,  plug  with  glass  window  closing  end  of  tube  ;  c,  handle  ;  d, 
cords  connecting  instrument  with  battery  ;  e,  inflating  appara- 
tus ;  y,  main  tube  of  proctoscope. 


ii66 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


Passage  of  Rectal  Tubes. — Some  have  asserted  that  soft  tubes  can  be 
passed  from  the  anus  through  the  sigmoid.  I  do  not  believe  this  can  be  done 
in  a  normal  rectum,  it  matters  not  in  what  position  the  patient  is  placed,  and 
whether  or  not  fluid  flows  from  the  tube  during  its  introduction.  A  soft  tube 
always  coils  up  after  it  has  ascended  6  or  7  inches.  In  several  laparotomies, 
desiring  to  locate  the  rectum,  I  have  had  an  assistant  pass  a  rubber  tube.  It 
would  never  ascend  above  the  rectal  dome  unless  I  aided  it  with  a  hand  in  the 
belly,  when  it  could  be  gotten  through  the  sigmoid.  Fortunately  it  is  not 
necessary  to  give  high  enemas,  as  fluid  introduced  into  the  rectum  is  carried 
back  to  the  sigmoid.  If  we  wish  fluid  retained,  attempts  to  pass  the  tube  high 
up  will  cause  irritation,  and  irritation  leads  to  expulsion. 

Foreign  Bodies  in  the  Rectum.— It  is  not  at  all  unusual  for  hard, 
undigested  articles  taken  with  the  food  to  lodge  in  the  rectum.     They  can 


Figs.  686,  687.— A  new  and  simple  method  of  proctoscopy  (.Thomas  C.  Martin) 


usually  be  lemoved  through  a  speculum  by  means  of  forceps.  In  some  cases 
ether  must  be  given  and  the  sphincter  stretched;  in  others,  the  sphincter  must 
be  divided.  Sometimes  large  bodies  are  voluntarily  inserted  and  the  indi- 
vidual is  imable  to  remove  them.  Lewis  H.  Adler  ("Am,  Med.,"  July  20, 
1901)  removed  the  valve  of  a  steam  radiator  pipe  from  the  rectum.  The 
small  end  was  one  and  one-half  inches  in  diameter;  the  large  end  was  two  and 
one-half  inches  in  diameter.  The  patient  had  been  in  the  habit  of  introducing 
it  frequently  and  removing  it  with  a  hook  of  galvanized  iron  wire.  Marma- 
duke  Shield  ("Lancet,"  Oct.  12,  1901)  reports  the  case  of  a  man  of  sixty 
years  of  age  who  forced  a  gallipot  into  the  rectum.  The  pot  was  two  and  one- 
half  inches  in  diameter  and  two  and  three-fourth  inches  in  height.  The 
patient  broke  it  trying  to  get  it  out.  Shield  incised  the  rectum  from  behind 
and  removed  the  article  by  means  of  obstetric  forceps. 

If  the  foreign  body  is  soft,  as  an  apple  or  a  potato,  a  hole  should  be  bored 
through  to  allow  the  air  to  pass  and  thus  reheve  the  suction.     It  can  then  be 


Inflammation  of  the  Rectum  and  Sigmoid  1167 

lifted  out.  If  the  body  is  of  wood,  screw  in  a  gimlet;  if  of  metal,  cut  with  strong 
forceps;  if  of  glass,  break  into  small  pieces.  If  the  arricle  is  rough  or  has 
sharp  edges,  pack  gauze  all  around  it  as  a  first  step  to  protect  the  rectal  walls. 
In  a  case  in  which  a  boar's  tail  had  been  introduced,  large  end  first,  the  holding 
back  of  the  bristles  was  overcome  by  sliding  over  it  a  large-sized  rubber  catheter. 

Foreign  bodies  may  escape  into  the  sigmoid  and  necessitate  a  laparotomy. 
They  may  also  cause  periproctic  inflammation. 

A  remarkable  series  of  cases  of  foreign  bodies  in  the  rectum  may  be  found 
in  "Anomalies  and  Curiosities  of  Medicine,"  by  George  M.  Gould  and  Wal- 
ter L.  Pyle. 

Wounds  and  Injuries  of  the  Rectum.— These  accidents  may  result 
from  fractures  of  the  pelvis,  most  often  from  fractures  of  the  sacrum,  from  the 
improper  use  of  enema  syringe  nozzles  or  tips,  from  gunshot-wounds,  stab 
wounds,  from  foreign  bodies  introduced  by  the  patient,  and,  rarely,  from  digital 
examinations.  The  important  points  to  consider  in  these  wounds  are  whether 
or  not  there  is  penetration  of  the  entire  rectal  wall,  involvement  of  the  perirectal 
tissues,  or  peritoneum.  Slight  wounds  involving  only  the  mucous  membrane 
are  frequently  very  grave  from  the  fact  that  the  hemorrhage  is  constant  into  the 
rectum,  filling  back  into  the  sigmoid,  often  followed  by  collapse  when  the  blood 
is  voided.  The  investigations  in  these  cases  should  always  be  thorough  and 
by  both  digital  and  Nisual  examination,  for  exact  diagnosis  is  of  the  utmost 
importance. 

If  the  peritoneum  has  been  lacerated,  laparotomy  should  be  performed  at 
once,  the  wound  in  the  bowel  repaired,  the  peritoneal  cavity  cleansed,  and  the 
Murphy  treatment  for  general  peritonitis  instituted.  If  the  laceration  in- 
volves the  perirectal  tissues  but  not  the  peritoneum,  cut  down  on  the  side  of  the 
bowel  that  is  injured  and  make  free  drainage.  In  the  event  of  vftr>'  extensive 
injuries  to  the  perirectal  tissues  the  question  of  inguinal  colostomy  should  be 
considered.  If  the  wound  involves  only  the  mucous  or  submucous  coats,  dilate 
the  sphincter,  arrest  hemorrhage  by  suture  or  ligature,  and  follow  by  irrigation. 

Inflammation  of  the  Rectum  and  Sigmoid  (Proctitis  and  Sig= 
moiditis). — These  conditions  may  be  acute  or  chronic,  simple  or  specific. 
The  simple  forms  are  acute  catarrhal,  atrophic  catarrhal,  and  h}^ertrophic 
catarrhal.  The  specific  forms  are  gonorrheal  catarrhal  diphtheritic  catarrhal, 
eresipelatous  catarrhal,  dysenteric  catarrhal,  and  syphilitic  catarrhal  (Tuttle). 

Acute  Inflammation. — Acute  catarrhal  inflammation  may  be  caused  by 
that  class  of  incidents  followed  by  ordinary  catarrh  of  the  respiratory  passages 
and,  in  addition,  errors  of  diet  or  sudden  change  of  temperature,  as  sitting  on 
a  cold  seat  when  overheated.  The  onset  is  sudden,  \rith  chill,  general  mal- 
aise, pain  and  discomfort  locally,  and  slight  fever.  There  is  a  sense  of  fulness 
and  weight,  vAith  often  a  burning  sensation  referred  to  the  rectum,  and  at  times 
tenesmus  with  frequent  desire  to  go  to  stool.  Pain  radiates  to  adjacent  parts 
and  there  is  bladder  irritabilit>\  Patients  usually  prefer  to  be  in  the  recumbent ' 
posture. 

There  will  be  at  first  a  thin  fecal  discharge  followed  by  mucus  tinged  with 
blood.  Ulceration  soon  supen-enes.  The  parts  are  hot,  dry,  and  swollen  in 
the  first  stages  and  digital  examination  is  very  painful.  Later  the  parts  are 
slimy  and  the  mucous  membrane  is  covered  with  tenacious  mucus  and  pus. 

Treatment. — First   remove   irritating   intestinal  contents  and  reduce  en- 


II 68  Diseases  and  Injuries  of  the  Rectum  and  Anus 

gorgement  by  lavage  and  saline  cathartics,  followed,  if  early  in  the  case,  by  irri- 
gations of  cold  water;  if  later,  by  hot  water.  A  useful  medicated  irrigation  is 
a  5  to  lo  per  cent,  solution  of  the  aqueous  extract  of  krameria. 

Chronic  Inflammation. — In  chronic  proctitis  and  sigmoiditis  the  symp- 
toms are  similar  to  those  present  in  the  acute  forms  of  the  inflammation,  but 
less  severe  in  character.  In  addition  there  is  increased  secretion  of  mucus, 
flatulence,  and  marked  general  intestinal  disturbance. 

The  mucous  membrane  is  soft,  doughy,  and  thickened,  which  condition 
palpably  reduces  the  caUber  of  the  gut.  Through  the  speculum  the  membrane 
is  seen  to  be  edematous,  pale,  and  covered  with  secretion.  It  bulges  into  the 
aperture  of  the  speculum  and  does  net  bleed  easily. 

Treatment  is  hygienic  and  dietetic,  with  antiseptic  and  astringent  irrigations. 

Atrophic  Inflammation. — The  atrophic  variet}-  of  these  inflammations 
is  characterized  by  long-continued  constipation,  dry  stools  covered  \\\i\\  blood 
and  mucus.  There  is  such  pain  on  expulsion  of  feces  as  to  simulate  in  many 
cases  tissure  of  the  anus.  The  mucous  membrane  of  the  anus  ruptures  easily 
when  stretched  during  examination.  It  is  bright  red  and  shiny,  does  not  fill 
the  aperture  of  the  speculum,  and  bleeds  readily.  Ulceration  is  common  and 
hemorrhoids  are  a  frequent  comphcation.  Treatment  is  local  and  general 
Locally  use  nitrate  of  silver,  hydrastis,  or  ichthyol,  appMed  after  the  rectum 
is  emptied.     General  treatment  is  hygienic  and  dietetic. 

Peri=anal  and  Perirectal  Inflammations.— These  are  of  two 
classes — circumscribed  inflammations  or  abscesses  and  difltuse  inflammations 
that  always  develop  pus.  The  circumscribed  variety  may  be  either  superficial 
or  deep.  The  superficial  variety  again  may  be  tegmentary,  subtegmentary, 
or  ischiorectal.  The  deep  variety  may  be  of  two  forms — retrorectal  or  superior 
pelvirectal.  It  is  important  to  note  that  right-sided  superior  pelvirectal 
abscess  may  be  confounded  with  appendicitis. 

The  diffuse  perirectal  inflammations  are  variously  classified,  but  the  par- 
ticular names  refer  only  to  the  degree  of  the  inflammator}'  process,  which  may 
vary  from  ordinary  suppuration  to  gangrene. 

These  inflammations  travel  in  the  fine  of  least  resistance,  which  is  upward, 
and  more  often  burst  into  the  bowel  than  externally.  They  may  follow  chilhng 
of  the  region  or  external  traumatisms,  may  be  caused  by  perforations  of  the 
rectum  by  hard  fecal  masses,  or  by  the  direct  passage  of  bacteria  into  the  fossa 
through  a  fissure,  an  ulcer,  or  an  ulcerated  pile.  They  may  be  either  acute  or 
tuberculous.  In  many  cases  the  process  is  at  first  tuberculous,  and  secondary 
infection  with  pyogenic  bacteria  takes  place. 

The  symptoms  are  the  same  as  those  of  abscess  anywhere,  the  swelling, 
however,  being  brawny,  and  it  being  difficult  or  impossible  to  detect  fluctua- 
tion. Pain  in  the  groins  is  often  complained  of,  and  there  may  be  enlarged 
glands  in  these  regions.  Abscesses  commonly  result  in  fistula,  and  a  patient 
should  be  warned  of  this  tendency  before  operation  is  performed.  Superior 
pelvirectal  abscesses  generally  follow  inflammation  of  some  pehic  organ,  \iz.: 
tubes,  urethra,  prostate,  and  the  symptoms  are  mainly  those  of  such  an  inflam- 
matory condition.  The  usual  tendency  of  the  pus  is  to  burrow  upward.  The 
presence  of  pus  is  indicated  by  the  symptoms  of  suppurative  toxemia,  which 
sometimes  simulate  t}'phoid  fever. 

The  treatment  is  instant  incision.     The  patient  is  placed  in  the  Uthotomy 


Fistula  in  Ano 


1 169 


position  after  having  been  anesthetized.  The  cut  should  be  parallel  to  the 
fibers  of  the  external  sphincter  and  well  outside  of  the  muscle  and  longer  than 
the  inflamed  area.  When  this  incision  is  made  the  finger  should  be  introduced 
to  break  down  the  necrotic  se[)ta  of  cellular  tissue.  Then  an  incision  should 
be  made  from  the  middle  of  the  first  cut  radiating  outward  and  opening  any 
pockets  external  to  the  original  focus.  Then  the  free  edges  of  the  cuts  are 
pared  away,  sacrificing  all  involved  tissue.  The  wound  is  irrigated,  the 
sphincter  dilated,  and  the  cavity  packed  with  iodoform  gauze.  If  a  fistula  is 
found  opening  into  the  rectum,  it  is  not  to  be  operated  on  until  after  the  wound 
is  nearly  healed,  only  a  small  fistulous  tract  remaining. 

In  cases  of  superior  pelvirectal  abscess  the  incision  should  be  made 
at  right  angles  to  the  fibers  of  the  levator  ani  muscle  to  facilitate  drainage.  In 
these  cases  tubal  drainage  is  used. 

Imperforate  Anus. — There  are  two  forms  of  this  condition.  In  one 
form  the  rectum  empties  into  the  bladder,  vagina,  or  urethra.  In  the  other 
form  there  is  no  rectal  opening  either  upon  the  surface  of  the  body  or  in  the 
urinar}'  organs.  The  diagnosis  is  usually  at  once  apparent,  except  in  cases 
where  the  anus  looks  normal,  when  the  diagnosis  will  often  not  be  made  until 
symptoms  of  obstruction  arise. 

Treatment. — If  the  rectum  bulges  when  the  child  cries,  open  into  it  with 
a  knife  and  keep  the  opening  patent  by  inserting  a  plug  of  iodoform  gauze. 
In  cases  in  which  the  rectum  is  more  deeply  seated,  a  catheter  is  introduced 
into  the  bladder,  an  incision  is  made  from  the  anus  to  the  coccyx,  the  rectum 
is  sought  for,  and  when  found,  is  sewed  to  the  anus  and  is  incised.     In  some 


Fig.  688.— Fistula  in  ano  :  a,  Blind  external ;  b,  blind  internal ;  c,  complete  (Esmarch  and  Kowalzig). 


cases  Keen  and  others  have  performed  Kraske's  sacral  resection,  pulling  down 
the  rectum  to  the  anal  margin,  sewing  it  there,  and  incising  the  occluded  anus. 
If  the  rectum  cannot  be  found  or  cannot  be  pulled  down,  an  artificial  anus 
must  be  made. 

Fistula  in  ano  is  the  track  of  an  unhealed  abscess.  An  abscess  in  the 
anal  region  is  apt  to  refuse  to  heal  because  of  the  constant  movement  of  the 
parts  (produced  by  respiration,  coughing,  the  passage  of  gas,  defecation,  etc.). 
The  passage  of  feces  will  keep  a  fistula  open.  If  a  tuberculous  ulcer  perforates, 
a  tuberculous  sinus  forms,  and  a  tuberculous  sinus  is  also  apt  to  follow  a 
cold  abscess  of  the  ischiorectal  fossa.  Fistula  is  often  associated  with  phthi- 
sis pulmonalis,  and  is  not  unusually  linked  with  piles,  cancer,  or  stricture. 

There  are  three  varieties  of  fistula — the  blind  external  (Fig.  688,  a),  the 
blind  internal  (Fig.  688,  b),  and  the  complete  (Fig.  688,  c).  The  external 
opening  is  usually  near  the  anus,  but  may  be  far  away,  and  there  may  be  only 
one  pathway  or  there  may  be  several  sinuses  and  openings.  In  a  healthy 
individual  the  external  orifice  is  small  and  a  mass  of  granulations  sprouts 
from  it.  In  a  tuberculous  fistula  the  external  orifice  is  large  and  irregular, 
74 


iiyo  Diseases  and  Injuries  of  the  Rectum  and  Anus 

with  thin  and  undermined  edges,  shows  no  granulations,  extrudes  small 
quandties  of  sanious  pus,  and  the  skin  about  it  is  purple  and  congested.  In  a 
fistula  following  an  anal  abscess  the  internal  opening  is  just  above  the  anus, 
between  the  two  sphincters.  In  fistula  following  an  ischiorectal  abscess  the 
internal  opening  is  usually  near  the  anus,  but  may  in  rare  cases  be  above  the 
internal  sphincter.  A  sinus  may  run  up  under  the  mucous  membrane  from  the 
internal  opening.  In  a  horseshoe  fistula  the  internal  opening  is  usually  upon  the 
posterior  wall  of  the  bowel,  "  and  from  this  a  tract  leads  into  the  ischiorectal 
fossa,  not  on  one  side  only,  but  upon  both.  Therefore  we  have  one  opening  into 
the  bowel  and  one  through  the  skin  on  either  side."*  In  some  cases  of  horse- 
shoe fistula  there  is  no  internal  opening;  in  other  cases  there  are  two  openings. 
In  an  old  fistula  the  track  becomes  fibrous  and  cannot  collapse.  Two  or  more 
fistulas  may  exist  in  the  same  patient.  In  dealing  with  a 
fistula  always  determine  if  the  condition  is  stationary  or 
progressive.  The  symptoms  of  a  complete  fistula  are 
the  passage  of  feces  and  gas  through  the  opening  and  the 
flow  of  a  discharge  which  stains  the  clothing.  In  a  com- 
plete fistula  a  probe  can  be  carried  from  the  external 
opening  into  the  bowel.  After  a  time  incontinence  of 
feces  is  apt  to  come  on,  repeated  attacks  of  inflammation 
thickening  the  rectum  and  destroying  its  sensibility. 
From  time  to  time  the  opening  will  block,  and  new  ab- 
fon  'for  ffstui  \n  ^^tfo  sccsscs  form.  In  examining  a  fistula  use  Brodie's  probe, 
(Esmarch  and  Kowai-  as  its  flat  handle  enables  one  to  locate  the  direction  the 
^■s)-  bent  instrument  has  taken,  and  its  slender   shaft  will 

find  its  way  through  a  very  small  channel. 
Treatment. — In  treating  a  fistula  cleanse  the  parts,  as  cleanly  work, 
though  it  will  not  prevent  pus,  will  limit  suppuration.  The  external  parts 
are  washed  with  soap  and  water.  The  rectum,  which  must  be  empty,  is  irri- 
gated with  hot  saline  solution.  Corrosive  sublimate  should  not  be  used  in 
the  rectum,  because  it  is  irritant,  causes  a  flow  of  serum,  and  hence  lessens 
tissue  resistance,  and  is  rendered  inert  as  an  antiseptic  by  being  converted 
into  sulphid  of  mercury.  Anesthetize  the  patient  with  ether  unless  the  fistula 
is  tuberculous,  in  which  case  use  local  anesthesia,  spinal  anesthesia,  or  nitrous 
oxid.  Ether  is  avoided  for  fear  of  the  existence  of  a  pulmonary  focus.  A 
tuberculous  focus  in  the  lung  may  disseminate  after  inhalation  anesthesia 
(page  1 191).  Place  the  patient  in  the  lithotomy  position.  If  operating  upon 
a  comj)lete  fistula,  pass  a  grooved  director  into  the  external  opening,  carry  it 
through  the  sinus,  make  it  enter  the  bowel,  bring  its  point  out  externally,  and 
Uft  the  tissue  between  the  sinus  and  the  surface.  Incise  the  bridge  of  tissue 
(Fig.  689).  If  the  director  ascends  above  the  internal  opening,  the  opening 
must  be  made  into  the  bowel  from  the  summit  of  the  sinus.  Cut  the  sphincter 
at  a  right  angle  to  its  fibers,  and  do  not  cut  it  more  than  once  at  one  operation. 
If  a  fistula  is  non-tuberculous,  cut  with  a  knife.  If  it  is  tuberculous,  divide  the 
tissues  with  a  Paquelin  cautery  in  order  to  lessen  the  danger  of  dissemination  of 
the  infection.  Push  the  finger  to  the  depth  of  the  wound,  to  determine  that 
the  sinus  does  not  ascend  above  the  internal  opening.  Search  with  a  small 
probe  for  branching  sinuses,  and  if  any  are  found,  sHt  them  open.  Examine 
*  "Diseases  of  the  Rectum,  Anus,  and  Sigmoid  Flexure,"  by  Joseph  M.  Mathews. 


Pruritus  of  the  Anus  1171 

carefully  to  see  if  there  is  a  sinus  beneath  the  mucous  membrane  of  the  bowel, 
and  if  such  a  sinus  is  found,  slit  it  up.  Curet  all  sinuses,  and  if  they  are  very 
fibrous,  clip  them  away  with  scissors.  Cut  away  diseased  skin;  irrigate  with  salt 
solution;  pack  firmly  with  iodoform  gauze  to  [)revent  oozing;  and  dress  with 
gauze  and  a  T-bandage.  The  packing  is  removed  in  twenty-four  hours  unless 
it  is  soiled  earlier,  in  which  case  it  is  promptly  removed.  After  twenty-four 
hours  the  wound  is  irrigated  and  packed  Hghtly  with  gauze  to  its  full  depth. 
This  dressing  should  be  repeated  eve^ry  day  and  any  bridging  of  the  tissues 
should  be  broken  down  with  a  probe.  If  the  wound  becomes  sluggish  it  is 
stimulated  with  nitrate  of  silver  and  sodium  iodid  is  given  in  small  doses 
three  times  daily. 

The  bowels  should  be  moved  after  forty-eight  hours  by  enema.  The  diet 
should  be  light  and  fluid  for  the  first  few  days  after  operation  and  the  bowels 
should  not  be  restrained  by  drugs.  Get  a  tuberculous  patient  out  of  bed  as 
soon  as  possible.  If  there  are  two  fistulae,  cut  one  through,  and  when  one 
wound  has  healed,  cut  the  other.  In  some  straight  sinuses  the  tract  can  be 
extirpated  and  the  parts  sutured,  primary  union  occasionally  resulting. 

If  a  blind  external  fistula  does  not  heal,  every  sinus  must  be  incised,  and 
thickened  walls  must  be  cut  away  or  scraped  away. 

In  a  blind  internal  fistula  an  external  incision  is  made  to  convert  the  case 
into  a  complete  fistula,  which  is  then  treated  as  is  directed  above. 

In  horseshoe  fistula,  more  than  one  operation  may  be  necessary  in  order 
to  avoid  cutting  the  sphincter  muscle  twice  in  one  operation,  a  proceeding 
which  would  probably  lead  to  fecal  incontinence.  One  side  alone  is  operated 
on  at  one  seance.  Sinuses  are  opened  and  scraped,  the  sphincter  is  divided, 
the  angles  and  edges  of  skin  are  trimmed  away,  and  the  wound  is  packed. 
When  the  wound  is  healed,  or  nearly  healed,  the  other  side  should  be  operated 
upon. 

If  fecal  incontinence  results  from  an  operation  for  fistula,  remove  the  scar 
tissue  and  endeavor  to  suture  the  separated  muscular  fibers.  A  modern 
scientific  operation  for  incontinence  is  that  of  A.  Mayo  Robson  ("The  Prac- 
titioner," Feb.,  1903).  A  crescentic  incision,  from  i  to  f  inch  in  depth  and 
taking  in  about  one-half  of  the  circumference  of  the  bowel,  is  made  at  the 
anterior  border  of  the  anus.  The  middle  borders  of  the  incision  are  then 
pulled  apart  until  the  ends  of  the  cut  approximate  in  the  middle  line,  when 
they  are  stitched  with  deep-  catgut  sutures  and  the  skin  is  sewed  with  silk- 
worm gut,  the  immediate  result  being  an  incision  apparently  radiating  from 
the  anus.  Should  an  operation  be  undertaken  for  fistula  if  phthisis  exists? 
Many  of  the  old  masters  said  no.  Mathews  sums  up  the  modern  view:  In 
incipient  phthisis  operate;  in  rapidly  progressive  fistula  operate  whether  cough 
exists  or  not;  if  much  cough  exists,  do  not  operate  unless  the  fistula  is  rapidly 
progressive;  in  the  last  stages  of  phthisis  do  not  operate. 

Pruritus  of  the  anus  is  a  symptom,  and  not  a  disease.  It  may  be 
due  to  piles,  fissure,  seat-worms,  eczema,  nerve-disturbance,  kidney  disease, 
gout,  jaundice,  constipation,  inebriety,  the  opium-habit,  torpid  liver,  dyspepsia, 
alcohol,  tea-drinking,  vesical  calculus,  tobacco-smoking,  urethral  stricture, 
uterine  disease,  diabetes,  ovarian  trouble,  and  mental  disorder.  In  some 
cases  it  seems  to  be  a  pure  neurosis  and  no  special  causative  factor  can  be 
recognized.     It  is  vastly  more  frequent  in  males  than  in  females,  and  is  espe- 


1 1 72  Diseases  and  Injuries  of  the  Rectum  and  Anus 

daily  common  in  fat  men  who  sweat  profusely.  It  is  seldom  seen  before  the 
age  of  thirty,  except  in  children  suffering  from  threadworms.  The  itching 
comes  on  gradually  and  usually  intermittently,  but  grows  progressively  worse 
and  worse  until  it  becomes  torturing.  In  many  cases  it  is  at  first  noticed  only 
when  warm  in  bed;  in  other  cases  it  exists  day  and  night.  A  violent  exacer- 
bation may  be  excited  by  worry,  anxiety,  overwork,  dietary  indiscretion,  a 
sudden  change  of  temperature,  and  many  other  things.  The  itching  finally 
becomes  an  unbearable  agony,  sleep,  except  in  snatches,  is  impossible,  the 
-appetite  disappears,  the  strength  fails,  and  the  sufferer  may  become  a  nervous 
"wreck.  In  some  cases  of  pruritus  the  anal  folds  are  edematous,  there  are 
abrasions  here  and  there  from  scratching,  the  area  is  white  and  moist  and 
gives  origin  to  a  fine  secretion;  in  other  cases  the  mucous  membrane  is  dry 
and  fissured. 

Treatment. — In  every  case  first  of  all  make  a  careful  examination  to 
find  a  probable  or  a  possible  cause,  local,  reflex,  or  constitutional,  and  en- 
deavor to  remove  this  supposed  cause.  Then  undertake  treatment  for  the 
pruritus.  It  is  very  important  to  prevent  constipation.  Kelsey  directs 
that  the  parts  be  cleansed  twice  a  day,  and  after  each  cleansing  that  the  fol- 
lowing ointment  be  applied:  menthol,  5j;  cerat.  simp.,  oiJ!  oil  of  sweet 
almonds,  f  oj;  acid.  carboHc,  5  J!  pulvis  zinc,  oxid.,  §ij.  Mathews  commends 
the  following  mixture:  chloral,  oj;  gum-camphor,  3ss;  glycerin  and  water, 
each,  §  j.*  In  this  disease  a  "scarf  skin"  forms,  which  must  be  made  to  peel 
off  by  the  application  of  iodin,  pure  carbolic  acid,  corrosive  sublimate  (gr. 
iv  to  5j  of  cosmolin),  calomel  (5ij  to  5j  of  cosmolin),  or  camphophenique. 
In  obstinate  cases  paint  the  parts,  night  and  morning,  with  a  mixture  of  60 
gr.  of  alum,  30  gr.  of  calomel,  and  300  gr.  of  glycerin;  or  smear  with  an  oint- 
anent  composed  of  ^  part  of  oleate  of  cocain,  3  parts  of  lanolin,  2  parts  of 
vaselin,  and  2  parts  of  olive  oil  (Morain).  In  very  severe  cases  in  which  the 
■skin  is  dry  and  cracked,  apply  a  5  per  cent,  solution  of  eucain  to  the  abraded 
portions  and  paint  the  entire  surface  with  a  concentrated  solution  of  silver 
nitrate.  It  may  be  necessary  to  repeat  this  treatment  several  times  at  inter- 
•vals  of  four  or  five  days.  Adler  advised  us  to  apply  to  the  parts  the  day  after 
the  silver  has  been  used  unguentum  hydrargyri  nitratis  in  full  strength,  only  dis- 
continuing on  the  day  a  fresh  application  of  silver  is  made  and  the  next  day 
resuming  the  applications  of  ointment.  If  during  treatment  the  skin  becomes 
sore,  use  calomel  ointment  until  soreness  disappears.  Violent  attacks  of 
itching  are  met  by  applying  hot  water  and  black  wash  or  calomel  ointment. 
This  plan  of  treatment  must  be  pursued  for  some  months  (Lewis  H.  Adler,  Jr., 
"New  York  and  Phil.  Med.  Jour.,"  July  29,  1905).  I  have  used  this  plan 
with  some  satisfaction.  In  severe  and  protracted  cases  we  may  employ  the 
x-rays  twice  a  week  (J.  R.  Pennington).  I  have  seen  their  application  pro- 
ductive of  great  benefit.  In  some  cases  we  employ  the  Paquelin  cautery,  in 
others  we  resect  the  mucous  membrane,  as  in  Whitehead's  operation  for  hem- 
orrhoids. Ball  divides  the  sensory  nerves  going  to  the  implicated  skin  and  has 
obtained  excellent  results. 

Fissure  of  the  anus  is  an  irritable  ulcer  at  the  anal  orifice  producing 
spasm  of  the  sphincter.    Pain  exists  because  twigs  of  nerves  are  exposed  upon 
the  floor  of  the  ulcer.    Fissure  is  caused  by  constipation  or  traumatism.    The 
*  "  Diseases  of  the  Rectum." 


Thrombotic  External  Hemorrhoids  1173 

symptom  is  violent,  burning  pain,  sometimes  beginning  during  defecation, 
but  usually  at  the  end  of  the  act,  and  lasting  for  some  hours.  Constipation 
exists,  and  often  pruritus.  Examination  discloses  a  fissure,  usually  at  the 
posterior  margin,  running  up  the  bowel  one-quarter  to  one-half  an  inch. 
Piles  often  exist  with  fissure. 

Treatment. — The  palliative  treatment  is  to  prevent  constipation,  to  wash 
out  the  rectum  with  cold  water,  and  apply  an  ointment  made  by  evaporating 
5ij  of  the  juice  of  conium  down  to  5ij>  ^^d  adding  it  to  §j  of  lanolin  and 
gr.  xij  of  persulphate  of  iron.  Pure  ichthyol  frequently  promotes  healing  unless 
the  edges  are  thick  or  the  base  indurated,  when  operation  must  be  done. 

Operative  Treatment. — Anesthetize  the  patient.  Thoroughly  cleanse  the 
parts.  Some  surgeons  advocate  operation  without  stretching  the  sphincter. 
The  fissure  is  incised  through  its  base  \  inch  deeper  than  the  deepest  part  of  the 
ulcer,  extending  -j  inch  above  and  below  the  diseased  tissues,  so  that  the 
healthy  muscular  fibers  at  either  end  are  divided.  In  cases  in  which  the 
ulcer  is  at  either  the  anterior  or  posterior  commissure  a  V-shaped  incision  is 
made,  the  apex  of  which  should  begin  \  inch  above  the  highest  point  of  the 
ulcer  and  the  diverging  Kne  running  close  to  the  sides  of  the  fissure,  but  in 
healthy  tissue. 

If  there  are  redundant  edges,  exuberant  granulations,  a  sentinel  pile,  or  a 
polypus,  they  should  be  curetted  or  excised.  The  wound  is  then  packed  Hghtly 
with  gauze  and  the  patient  kept  in  bed  for  twenty-four  hours.  A  large  per- 
centage of  these  operations  may  be  done  under  local  anesthesia. 

Many  cases  are  so  sensitive  and  painful  to  the  touch  that  medication  and 
examination  are  almost  impossible.  These  may  be  made  bearable  by  in- 
suffiationsof  orthoform.  It  has  always  been  my  custom  to  stretch  the  sphincter 
for  fissure.  Stretching  gives  us  room  in  which  to  work,  and,  by  thus  paralyz- 
ing the  muscular  fibers,  the  raw  surface  is  put  at  rest  and  paroxysms  of  pain 
cease  to  occur.  In  order  to  stretch  the  sphincter  the  patient  is  anesthetized, 
the  surgeon's  thumbs  are  inserted  into  the  rectum,  and  the  parts  are  stretched 
until  the  thumbs  touch  the  ischia.  After  stretching  the  sphincter  incise  the 
floor  of  the  fissure,  scrape  it  with  a  curet,  search  carefully  with  a  probe  to  be 
sure  no  pockets  exist,  and  touch  it  with  nitrate  of  silver  stick. 

Hemorrhoids,  or  Piles. — There  are  three  varieties  of  varicose  tumors 
of  the  rectum,  namely:  internal,  which  take  origin  within  the  external  sphinc- 
ter; external,  which  take  origin  without  the  external  sphincter;  and  mixed 
hemorrhoids,  which  are  a  combination  of  the  two. 

External  hemorrhoids  are  covered  with  skin.  Internal  hemorrhoids  are 
covered  with  mucous  membrane.  The  term  external  hemorrhoids  is  not 
strictly  accurate,  as  hemorrhage  does  not  occur  in  external  piles,  and  all  ex- 
ternal piles  are  not  related  to  the  external  hemorrhoidal  veins.  An  external 
pile  may  involve  the  veins  or  the  skin. 

External  Hemorrhoids. — External  hemorrhoids  are  classified  as  throm- 
botic, varicose,  inflammatory,  and  connective-tissue  external  hemorrhoids 
(Tuttle). 

Thrombotic  External  Hemorrhoids. — These  are  external  hemor- 
rhoidal veins  filled  with  clot.  When  an  external  hemorrhoidal  vein  inflames, 
the  parts  become  itchy,  painful,  and  swollen,  and  defecation  increases  the 
pain.     The  blood  clots  in  the  inflamed  vein  and  sometimes  the  vessel  ruptures. 


1 1 74  Diseases  and  Injuries  of  the  Rectum  and  Anus 

Sympioms  and  Treatment. — External  piles  of  this  variety  are  usually,  but 
not  always,  multiple.  Small  oval  tumors  appear  beneath  the  skin  or  the  junc- 
tion of  the  skin  and  mucous  membrane.  They  appear  suddenly.  The 
parts  itch  and  pain,  defecation  increases  the  pain,  and  each  pile  increases 
rapidly  in  size.  When  the  vein  ruptures,  a  livid,  soft  enlargement  rapidly 
forms.  External  piles  of  this  variety  may  be  absorbed,  may  become  organ- 
ized into  a  scar,  or  may  suppurate.  These  piles  do  not  bleed.  In  treating 
external  hemorrhoids  some  surgeons  merely  use  remedies  to  combat  the 
inflammation.  An  old  plan  of  treatment  is  to  incise  the  blood-tumor,  turn 
out  the  clot,  and  pack  with  a  bit  of  iodoform  gauze.  Mathews  freezes  the 
part  or  injects  cocain,  catches  up  the  blood-tumor  with  a  volsellum,  excises 
the  tumor  and  the  tabs  of  inflamed  skin,  dusts  the  part  with  iodoform,  and 
dresses  it  with  antiseptic  gauze.  The  bo\\els  should  not  be  allowed  to  move 
for  two  days.  Never  inject  external  piles  with  carbolic  acid;  it  causes  great 
inflammation,  violent  pain,  and  is  not  free  from  danger.  If  the  patient 
decHnes  operation,  order  rest,  a  non-stimulating  diet,  avoidance  of  tobacco 
(IMathews),  the  use  of  sahne  purgatives,  injections  into  the  rectum  of  cold 
water  several  times  a  day,  sponging  of  the  anus  frequently  with  hot  water, 
and  the  application  of  hot  poultices.  As  the  acute  symptoms  begin  to  disap- 
pear use  lead- water  and  laudanum;  when  they  have  nearly  subsided,  apply 
zinc  ointment.    Extract  of  hamamehs  is  a  valuable  apphcation  to  external  piles. 

Varicose  External  Hemorrhoids. — These  are  varicose  external  hemor- 
rhoidal veins  and  are  visible  at  the  anal  margin  when  the  patient  strains. 
They  rarely  produce  pain  or  discomfort,  and  it  is  seldom  that  operation  is 
necessary.  The  bowels  should  be  moved  daily,  but  not  with  violent  purga- 
tives, and  after  each  movement  cold  should  be  applied  to  the  anus,  while  the 
patient  is  recumbent.  Tuttle  advocates  the  use  at  night  of  an  ointment 
containing  5  ij  of  suprarenal  extract  and  5  vj  of  lanolin.  The  ointment  is 
spread  on  cotton-wool,  which  is  apphed  to  the  anus  and  held  in  place  by  a 
T-bandage. 

Inflammatory  Piles. — By  this  term  we  mean  edematous  inflammation 
of  the  anal  folds.  The  inflammation  may  be  due  to  a  traumatism,  the  pres- 
ence of  an  ulcer  or  fissure,  etc.  There  are  burning,  itching,  and  swelhng  of 
the  anus,  which  are  all  greatly  increased  by  defecation.  One  or  more  pear- 
shaped  swelUngs  can  be  seen  at  the  anal  margin. 

In  some  cases  medical  treatment  produces  cure.  This  treatment  consists, 
during  the  first  twenty-four  hours,  in  the  use  of  cold  and  of  rest  in  bed.  After 
this  period  heat  should  be  employed.  Tuttle  applies  gauze  soaked  in  a  25 
per  cent,  solution  of  boroglycerid  and  places  a  hot-water  bag  over  this.  He 
also  recommends  the  following  ointment  to  be  apphed  two  or  three  times  a 
day: 

I^.     Morphinse  sulph., gr.  v-x 

Ichthyol, 5  iv 

Ung.  belladonnae,    1^       •  aa    ^i 

Ung.  stramonii,        j 
Sig. — Apply  two  or  three  times  a  day. 

If  these  means  fail,  ether  is  given,  the  sphincter  is  stretched,  and  the 
tumors  are  cut  away. 

Comiective-tissue  External  Hemorrhoids  (Skin  Tabs).— They  are 
due  to  hypertrophy  of  mucocutaneous  tissue  at  the  anal  margin.     Usually 


Internal  Hemorrhoids  1175 

they  result  from  acute  inflammatory  external  piles;  sometimes  they  arise 
gradually  as  a  result  of  chronic  anal  or  rectal  inflammation  or  irritation,  and 
they  may  be  due  to  varicose  or  thrombotic  external  piles  (Tuttle).  They 
produce  no  trouble  when  not  inflamed.  The  treatment,  if  they  cause  serious 
annoyance,  is  extirpation. 

Internal  hemorrhoids  are  varicose  tumors  of  the  internal  hemorrhoidal 
plexus,  and  are  found  internal  to  the  external  sphincter,  just  within  the  anus, 
and  they  prolapse  easily.  They  are  not  simply  varicosities,  but  new  tissue 
has  been  formed,  and  they  are  in  reality  vascular  tumors.  They  are  covered 
with  mucous  membrane.  Capillary  piles  are  small,  sessile,  with  a  surface 
like  a  mulberry,  and  bleed  freely.  Children  are  not  very  Hable  to  develop 
piles,  excepting  the  capillary  form.  Venous  piles  are  the  most  common  va- 
riety. They  extend  from  just  above  the  anal  margin  of  the  rectum  for  an 
inch  or  more.  They  are  purple  in  color,  soft,  irregular  in  outline,  and  are 
usually  muhiple.  They  bleed  when  irritated  by  hard  fecal  masses,  but 
not  so  easily  as  the  capillary  piles.  Each  pile  is  composed  of  a  varicose 
vein,  some  fibrous  tissue,  and  a  few  arterial  twigs.  Arterial  piles  are  very 
unusual.  They  are  large,  smooth,  pedunculated,  bleed  easily  and  freely, 
and  contain,  besides  a  distended  vein,  arteries  of  some  size. 

Anything  producing  venous  congestion  in  the  rectum— constipation,  dis- 
eases of  the  rectum,  enlargement  of  the  prostate,  pregnancy,  tumors  of  the 
womb,  congestion  of  the  hver,  cirrhosis  of  the  liver,  certain  diseases  of  the  heart 
and  lungs,  sedentary  occupations,  relaxing  chmate,  and  stricture  of  the  urethra 
— will  cause  hemorrhoids. 

Symptoms  and  TrealmenL— inhere  is  neither  bleeding  nor  protrusion,  the 
piles  give  no  trouble.  The  first  symptom  is  usually  hemorrhage,  and  rectal 
examination  by  the  speculum  will  make  clear  the  condition.  After  a  time, 
during  defecation,  the  piles  protrude;  they  may  reduce  themselves  w^hen  the 
patient  stands  up,  or  it  may  be  necessary  to  push  them  in.  Pain  does  not 
exist  in  uncomplicated  cases,  and  pain  during  or  after  protrusion  means  "abra- 
sion, fissure,  or  ulceration"  (Mathews). 

Palliative  Treatment.— This  will  not  cure,  but  it  will  give  great  comfort. 
Some  people  only  sufi^er  at  rare  times  when  the  Hver  is  congested,  and  such 
subjects  will  not  submit  to  operation.  Remove,  if  possible,  the  cause  (alcohol, 
irritating  foods,  want  of  exercise,  etc.);  restrict  the  diet;  insist  on  regular  ex- 
ercise; give  a  course  of  Carlsbad  sah,  and  follow  this  by  the  administration  of 
bichlorid  of  mercury  (gr.  -^j  after  each  meal).  Prevent  constipation  by  a 
nightly  dose  of  extract  of  cascara.  After  each  bowel  movement  wash  the  parts 
with  a  soft  sponge  soaked  in  cold  water  and  syringe  out  the  rectum  with  cold 
water,  and  dry  outwardly  with  a  soft  rag.  If  the  hemorrhoids  prolapse, 
after  restoring  them  and  injecting  cold  water,  insert  a  suppository  containing 
gr.  V  of  the  extract  of  hamamelis,  and  use  another  suppository  at  bedtime. 
A  useful  suppository  for  prolapse  is  that  employed  by  Tuttle:  it  contams 
gr.  vof  ichthyol,  gr.  v  of  tannic  acid,  gr.  ^  of  ext.  of  stramonium,  gr.  ^of  ext.of 
belladonna,  and  gr.  x  of  ext.  of  hamamelis.  Bleeding  may  be  arrested  by 
suppositories,  each  containing  gr.  v  of  suprarenal  extract.  When  the  piles 
prolapse  and  inflame,  rub  Allingham's  ointment  on  the  parts  (5ij  each 
of  ext.  of  conium  and  ext.  of  hyoscyamus,  5  j  of  ext.  of  belladonna,  and  §  j 
of  cosmoHn).     Mathews  uses  gr.  xij  of  cocain,  5j  of  iodoform,  5ss  of  ext. 


II76 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


of  opium,  and  5j  of  cosmolin.  Grant  uses  an  ointment  containing  gr.  viij  of 
morphin,  gr.  xij  of  calomel,  and  oj  of  vaselin.  This  is  applied  after  bathing 
the  part  with  hot  water.  If  the  piles  are  protruding  and  reduction  cannot  be 
effected,  put  the  patient  to  bed,  give  a  hypodermatic  injection  of  morphin,  and 
apply  hot  poultices.  If  reduction  cannot  soon  be  effected,  dixoilsion  of  the 
sphincter  must  be  practised  or  radical  operation  must  be  resorted  to. 

Operative  Treatment. — Give  a  sahne  the  morning  before,  and  an  enema 
the  evening  before,  the  operation,  and  wash  out  the  rectum  well  the  morning 
of  the  operation.  In  treating  by  injection  of  carbolic  acid  the  sphincter  should 
be  divulsed  while  the  patient  is  under  the  influence  of  nitrous  oxid  gas  unless  the 
pile  is  thrombotic.  "Under  gas  muscular  relaxation  does  not  obtain  as  in  the  use 
of  ether.  Hence  dilatation  under  gas  can  be  more  rapidly  induced,  as  we  have 
the  sphincteric  rigidity  as  a  guide  in  knowing  exactly  how  much  force  may  be 
employed  in  the  indi\idual  case"  (Lewis  H.  Adler,  Jr.,  in  "Jour.  Am.  Med. 
Assoc,"  Jan.  21,  1905).  The  surgeon  must  be  careful  not  to  tear  the  parts. 
The  tumors  are  drawn  out  or,  if  gas  was  not  given,  the  patient  strains  them  out, 


Fig.  690. — Brick's  pile  clamp. 


an  injection  is  given  by  a  hypodermatic  s}Tinge  into  the  center  of  the  pile, 
and  as  each  pile  is  injected  it  is  pushed  into  the  rectum.  But  one  or  to'o  piles 
are  injected  at  each  seance,  and  the  operation  is  not  repeated  for  one  week  (Geo. 
W.  Gay,  in  "Boston  Med.  and  Surg.  Jour.,"  Dec.  5, 1901),  The  dose  for  each 
pile  is  y\\\  or  rr^ij  of  a  10  per  cent,  solution  of  pure  carbolic  acid.  The  injections 
relieve  the  condition,  but  are  rarely  absolutely  curative,  and  are  not  without 
danger,  and  may  produce,  it  has  been  said,  hemorrhage,  phlebitis,  pyemia, 
stricture,  and  even  death  (W.  T.  Bull).  Dr.  Collier  F.  IMartin  ("American 
Medicine,"  August  27,  1904)  maintains  that  the  method  is  safe  and  satis- 
factory. He  injects  equal  parts  of  phenol  boboeuf  and  distilled  water,  freshly 
mixed  and  filtered.  From  7  to  15  minims  are  injected  into  a  pile,  and  only  one 
pile  is  injected  at  a  seance.  In  from  five  days  to  one  week  another  injection 
may  be  given.  Before  beginning  a  course  of  injections  the  sphincter  is 
stretched  while  the  patient  is  under  nitrous  oxid  and  ox^^gen.  It  is  not  neces- 
sar}'  to  repeat  this  for  future  injections.  During  injection  a  special  speculum 
is  used.  The  pile  protrudes  into  the  speculum,  is  cleansed  with  a  i  per  cent, 
solution  of  creolin  and  the  injection  is  thrown  into  the  most  prominent  part  of  the 
pile.  The  speculum  is  withdrawn  before  pulling  out  the  needle.  This  man- 
euver prevents  escape  of  injection  and  bleeding.  The  clamp  and  cautery 
is,  in  the  great  majority  of  cases,  the  operation  of  choice.  It  requires  but  a  few 
minutes  to  do  it;  after  it  is  done  there  is  httle  or  no  postoperative  pain,  in 


Internal  Hemorrhoids 


1177 


Fig.  691. — Extirpa- 
tion of  hemorrhoids 
(Esmarch  and  Kowal- 
zig)- 


very  many  cases  retention  of  urine  does  not  occur,  and  the  patient  usually  is 
about  again  within  ten  days.  The  patient  is  anesthetized  and  the  sphincter 
is  carefully  and  thoroughly  stretched.  The  stretching  of  the  sphincter  is  very 
important.  It  gives  free  access  to  the  parts,  prevents  subsequent  spasm 
and  pain,  and  lessens  the  likelihood  of  venous  bleedingafteroperation.  The  pile 
is  caught  with  forceps  and  drawn  outside  of  the  sphincter.  Many  use  Smith's 
clamp.  It  is  applied  with  the  ivory  surface  against  the  mucous  membrane  of 
the  bowel.  I  use  the  clampdevised  by  Dr.  J.Coles  Brick  (Fig.  690).  From  the 
bite  of  Brick's  clamp  the  pile  cannot  slip  as  the  blades  come  evenly  and  firmly 
together.  The  pile  is  cut 
off,  and  the  stump  is  seared 
with  the  Paquelin  cautery 
at  a  dull-red  heat.  Pile 
after  pile  may  be  thus 
treated,  care  being  taken  to 
leave  some  mucous  mem- 
brane at  each  side  of  every 
pile.  If  this  precaution  is 
not  taken,  healing  will  be 
slow  and  stricture  will  re- 
sult. After  cauterization  is 
complete  a  speculum  is  in- 
serted and  the  blades  are 
widely  opened.  Any  bleeding  point  is  at  once 
ligated.  Packing  is  never  inserted.  I  formerly 
used  it  but  have  given  it  up.  It  is  of  no  service 
and  produces  severe  pain  and  edema.  The 
treatment  from  this  point  is  identical  with  that 
advised  below  after  the  use  of  the  ligature. 
Excision  is  preferred  by  Allingham.  He  stretches 
the  sphincter,  holds  it  open  with   a   retractor, 

catches  up  the  pile,  cuts  it  off,  and  twists  the  bleeding  vessels.  Some  prefer 
to  pass  a  silk  or  catgut  suture,  cut  off  the  tumor,  and  tie  the  thread  (Fig. 
691).  Whitehead's  operation  (Fig.  692)  is  only  to  be  performed  in  severe 
cases,  when  the  piles  are  extremely  large  and  form  a  protruding  circular 
mass.  Primary  union  is  rarely  secured.  When  first  introduced,  the  operation 
was  viewed  with  favor,  but  experience  shows  it  is  sometimes  followed  by  dis- 
astrous consequences.*  Stricture  not  infrequently  arises  after  its  performance; 
fecal  incontinence  occasionally  results,  and  anal  anesthesia  with  inability  to 
restrain  the  passage  of  gas  is  common.  After  this  operation  the  anus  is  per- 
manently more  or  less  moist.  The  entire  pile-bearing  area  of  mucous  mem- 
brane is  dissected  out,  and  the  cut  margin  of  mucous  membrane  is  pulled 
down  and  stitched  to  the  surface.  The  sphincter  may  be  dilated  as  a  pre- 
liminary measure. 

The  application  of  the  ligature  is  an  easy  and  useful  method.     It  is  not  so 

rapid  as  the  cautery,    is   followed   by   more  pain,  healing  requires  a  longer 

time,  and  stricture  is  more  common.     In  this  operation,  after  anesthetizing, 

stretch  the  sphincter  and  treat  each  hemorrhoid  separately.     Catch  a  pile 

*  Andrews,  in  Mathews'  Medical  Quarterly,  Oct.,  1895. 


Fig.  692. — S,  S,  The  lower  circu- 
lar incision  along  Hilton's  white 
line ;  M,  Tube  of  mucous  membrane 
dissected  from  the  sphincter  ;  B,  B, 
dotted  line  showing  the  place  for 
the  upper  circular  incision  (Ed- 
mund Andrews). 


II' 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


with  a  pair  of  forceps  or  a  volsellum,  pull  it  down,  and  cut  a  gutter  through 
the  skin-margin  if  the  pile  is  of  the  mixed  variety;  tie  the  small  piles  without 
transfixing,  but  transfix  the  large  piles;  tie  with  silk  (coarse  silk  for  the  large 
piles,  finer  silk  for  the  small  piles);  cut  off  each  tumor  beyond  the  thread,  and 
cut  the  ligatures  short.  Treat  the  other  piles  in  the  same  manner.  Irrigate  with 
hot  normal  salt  solution.  Do  not  insert  packing.  Apply  a  gauze  pad  and 
a  T-bandage.  Give  some  morphin  to  lock  up  the  bowels,  and  keep  the 
patient  on  a  light  diet  for  three  days,  at  the  end  of  which  time  a  saline  may  be 
given.  Just  before  the  bowels  act  remove  the  dressings  and  give  an  enema  of 
warm  water  or  of  glycerin.  After  the  movement  wash  out  the  rectum  first 
with  dilute  peroxid  of  hydrogen  and  next  with  hot  salt  solution,  dust 
with   iodoform,  and    apply   a    gauze    pad   over    the    anus.     Irrigate    daily 

I 


\ 


1^ 


Fig.  093. — Rectal  prolapse. 

until  healing  is  complete.  After  the  tenth  day  examine  with  a  speculum  to  see 
that  the  ligatures  have  come  away;  if  any  are  found  in  place,  remove  them. 
Prolapse  of  Anus  and  Rectum.— If  the  mucous  membrane  is  pro- 
lapsed, the  condition  is  called  "prolapsus  ani";  if  the  entire  thickness  of  the 
rectal  wall  is  prolapsed,  it  is  called  ''prolapsus  recti"  (Fig.  693).  The  com- 
monest form  is  due  to  relaxation  of  the  submucous  connective  tissue  per- 
mitting the  protrusion  of  a  ring  of  mucous  membrane.  Prolapse  is  apt  to 
occur  from  excessive  straining  at  stool  and  is  commonest  in  feeble,  ill- 
nourished  children.  A  polypus  may  be  causative.  Piles  and  worms  may  lead 
to  prolapse.  Straining  from  phimosis,  stone  in  the  bladder,  or  urethral  stric- 
ture may  be  causative.  Its  development  is  favored  by  the  use  of  articles  of  food 
which  cause  frequent  movements  of  the  bowels.  If  an  individual  sits  a  long 
time  on  the  seat  of  the  closet  or  on  the  chamber  the  development  of  prolapse 


Treatment  of  Prolapse  of  Anus  and  Rectum 


1179 


is  favored.  Prolapse  may  be  either  large  or  small,  but  tends  to  recur  again  and 
again,  and  eventually  the  mucous  membrane  inflames,  ulcerates,  or  sloughs. 
Strangulation  of  the  prolapsed  part  may  occur.  The  condition  is  sometimes 
confused  with  hemorrhoids,  but  in  prolapse  the  protruding  mass  is  circular  and 
has  a  depression  in  the  center  (Fig.  693),  whereas  hemorrhoids  are  distinct 
masses.     Further,  hemorrhoids  are  very  rare  in  children. 

Treatment. — Palliative  treatment  forbids  straining  at  stool  and  amends 
an  improper  diet.     Phimosis  must  be  corrected;  stone  in  the  bladder  must 


fig.  694. — Joseph  D.  Bryant's  method  of  colopexy  ;  A,  A,  Longitudinal  band,  with  sutures  passed 
behind  it,  including  peritoneal  and  muscular  coats  of  the  intestines,  drawn  forward ;  £,  B,  parietal 
peritoneum  quilted  to  sides  of  the  intestine,  showing  stitches  ;  C,  old  fecal  fistula. 

be  crushed  or  removed.  If  prolapse  occurs,  the  protrusion  must  be  bathed 
with  cold  water  and  restored.  Constipation  must  be  prevented  (enemata 
of  water  or  glycerin  may  be  used),  and  after  each  movement  several  ounces 
of  a  solution  of  white  oak  bark  should  be  injected.  If  a  prolapse  is  caught 
firmly,  place  the  patient  in  the  knee-chest  position,  wash  the  mass  with  cold 
water,  grease  it  with  cosmolin,  insert  a  finger  into  the  rectum,  and  apply  taxis 
•around  the  finger  (Mathews).  If  this  fails,  cover  a  finger  with  a  handker- 
chief and  insert  the  wrapped  digit  into  the  rectum;  if  this  proves  futile,  invert 
the  patient.  Severe  cases  require  ether  before  reduction  is  attempted.  After 
reduction  apply  a  compress,  direct  it  to  be  worn  except  when  at  stool,  and 
before  each  act  of  defecation  give  an  injection  of  cold  water  containing  an 
astringent  (tannin  or  fluid  ext.  hydrastis).  A  useful  treatment  in  many 
cases  is  to  paint  the  prolapse  with  fuming  nitric  acid,  grease  it  with  oUve  oil, 
and  restore  it.  Some  cases  require  excision  of  the  mucous  membrane,  the 
divided  edge  of  this  membrane  being  stitched  to  the  skin.     In  other  cases  the 


ii8o  Diseases  and  Injuries  of  the  Rectum  and  Anus 

protrusion  is  stroked  with  a  cauter)'  and  restored.  When  the  surgeon  comes  to 
operate  for  recurring  prolapse,  it  will  often  be  found  to  have  modestly  with- 
drawn and  he  may  be  obliged  to  stretch  the  sphincter  to  bring  it  into  view. 
In  persistent  cases  of  rectal  prolapse  open  the  abdomen  and  attach  the  colon 
to  the  belly-wall  {colopexy  or  sigmoidopexy,  Fig.  694),  or  excise  the  protruding 
mass  (Cunningham,  in  "Annals  of  Surgery,"  May,  1909). 

Ulcer  of  the  Rectum. — Ulcers  of  the  rectum  are  divided  into  the  simple 
traumatic,  the  syphilitic,  the  tuberculous,  the  dysenteric,  the  gonorrheal, 
and  the  malignant.  Simple  ulceration  is  due  to  abrasion  with  fecal  masses 
or  a  foreign  body,  the  abraded  area  ulcerating.  It  may  follow  an  operation 
for  piles  and  also  protracted  labor  (Alhngham),  and  is  apt  to  be  single.  The 
base  and  edges  of  a  simple  ulcer  are  neither  prominent  nor  hard,  and  stricture 
rarely  forms.  Syphilitic  ulceration  is  a  tertiary  lesion  commonest  in  women. 
There  are  numerous  small  ulcers  of  the  mucous  coat  or  submucous  tissue, 
but  little  indurated,  with  sharp-cut  edges  which  are  not  undermined.  These 
ulcers  fuse  and  constitute  one  large  irregular  ulcer;  fibrous  tissue  forms  in 
the  wall  of  the  bowel,  induration  becomes  noticeable,  and  stricture  follows. 
There  is  profuse  discharge,  and  fistulae  are  apt  to  form.  Such  ulcers  may 
be  stirrounded  by  nodules  of  a  bluish  color.  In  many  cases  the  first  con- 
dition is  stricture  due  to  the  formation  of  masses  of  fibrous  tissue  in  the 
rectal  walls,  and  ulceration  occurs  secondarily  (Fournier).  In  syphilis  there 
may  be  a  breaking  down  of  a  huge  gummy  mass  or  of  multiple  gummata. 
It  has  been  proved  by  the  microscope  that  tuberculous  ulceration  may  arise 
in  the  rectum.  Tuberculous  ulceration  presents  a  conical  ulcer  with  over- 
hanging edges  and  a  pale-red  base.  There  is  some  mucous  discharge,  some 
tenesmus,  and  a  little  pain,  but  a  stricture  rarely  forms.  Dysenter}',  catarrh, 
diabetes,  Bright's  disease,  neoplasms,  and  foreign  bodies  may  produce  ulcera- 
tion of  the  rectum. 

Symptoms. — There  may  be  merely  uneasiness  about  the  rectum,  but 
sometimes  there  is  severe  burning  pain  on  defecation,  and  perhaps  for  some 
time  after  the  act.  There  may  be  constipation  or  diarrhea,  the  patient  strains 
at  stool,  and  the  stools  may  contain  blood,  mucus,  or  pus.  As  a  rule,  there  is 
diarrhea  on  rising  in  the  morning,  the  first  movement  consisting  of  blood  and 
mucus,  and  the  next  movement  being  fecal.  The  history  should  be  carefully 
inquired  into;  tuberculosis  should  be  sought  for;  the  question  of  syphilis 
should  be  investigated.  A  digital  examination  enables  the  surgeon  to  feel  the 
ulcer,  and  an  examination  with  an  ordinar}-  speculum  or  an  electric  proctoscope 
brings  it  into  view. 

Treatment. — In  simple  ulcer  empty  the  bowel  by  the  administration  of 
a  saline  cathartic,  wash  out  the  rectum  with  hot  water  after  the  saline  has 
acted,  introduce  a  speculum,  touch  the  ulcer  with  pure  carboHc  acid  or  silver 
nitrate  (gr.  xl  to  5j))  place  the  patient  in  bed,  restrict  him  to  a  liquid  diet, 
and  every  day  inject  iodoform  and  olive  oil  or  insufflate  iodoform  into  the 
rectum.  If  this  fails,  give  ether,  stretch  the  sphincter,  incise  the  ulcer  through 
its  entire  thickness,  and  cauterize  with  fuming  nitric  acid,  caring  for  the 
case  subsequently  as  we  would  a  patient  who  had  had  piles  ligated.  In 
tiihercnlous  ulcer  improve  the  general  health,  send  the  patient  to  a  genial 
climate,  or  at  least  into  the  sunlight  and  fresh  air,  prevent  constipation, 
give  nutritious  food,  especially  fats,  wash  out  the  rectum  every  day  with 


Non-cancerous  Stricture  of  the  Rectum  1181 

hot  water,  and  insufflate  iodoform  or  inject  iodoform  emulsion.  Touch  the 
ulcer  once  a  week  with  silver  nitrate  (gr.  x  to  5j).  In  syphilitic  ulcer  give 
antisyphilitic  treatment  and  treat  the  ulcer  locally  as  is  done  in  tuberculous 
ulcer.  Dvscnteric  ulcer  requires  injections  of  hot  water,  the  touching  of  the 
ulcer  with  pure  carbohc  acid,  insufflations  of  iodoform,  and  special  treatment  of 
the  dysentery. 

Benign  Tumors  of  the  Rectum  and  Anus. — These  tumors  may  be  of 
the  connective,  epithelial,  or  muscular  tissue  type.  Of  the  first  there  are 
fibroma,  enchondroma,  lymphadenoma,  lipoma,  and  myxoma;  of  the  second, 
adenoma  and  papilloma;  of  the  third,  myoma  and  fibromyoma.  These 
tumors  usually  appear  in  polypoid  form.  A  polypus  is  a  tumor  with  a  pedicle. 
The  most  common  forms  of  tumor  are  the  myxoma,  hypertrophied  solitary 
follicles,  adenoma,  fibroma,  and  lipoma.  Myxoma  is  most  common  in  children. 
Fibroma  originates  in  the  connective  tissue  or  the  submucosa  and  is  very  rare. 

Symptoms  of  tumor  are  dull  aching  pain,  tenesmus,  frequent  defecation, 
and  sometimes  ulceration  of  the  mucous  membrane.  The  absence  of  hemor- 
rhages and  mucous  discharges  distinguish  fibroma  from  polypus. 

Treatment. — Remove  the  tumor  after  dilating  the  sphincter.  In  tying  or 
snaring  off  polypi  it  should  be  borne  in  mind  that  the  peritoneum  may  be  in- 
vaginated  in  the  pedicle  and,  therefore,  no  traction  on  it  should  be  made  when 
operating.  Sessile  growths  are  dissected  out.  The  postoperative  treatment  is 
practically  the  same  as  for  hemorrhoids. 

Cryptitis  {Inflammation  of  the  Crypts  of  Morgagni).—T\\eit  crypts, 
five  to  ten  in  number,  are  situated  in  the  mucous  membrane  of  the  rectum 
about  3  centimeters  from  the  anus.  They  occasionally  become  packed 
with  mucus  or  feces.  There  is  quite  severe  pain  referred  to  the  site,  especially 
after  defecation.  In  this  condition  the  examination  of  the  anus  by  the  finger 
is  extremely  painful.  The  inflamed  crypts  may  be  detected  by  examination 
with  the  speculum. 

Treatment.— Divide  the  affected  crypts,  curet  away  any  granulations,  and 
allow  the  parts  to  heal. 

Non=cancerous  stricture  of  the  rectum  may  be  congenital  or  ac- 
quired. There  are  two  forms  of  acquired  stricture:  first,  stricture  due  to  ex- 
ternal pressure;  second,  stricture  due  to  primary  narrowing  of  the  rectal  wall* 
Stricture  due  to  external  pressure  is  very  rarely  complete,  and  may  be  caused 
by  bands  of  adhesions  or  a  cancerous  growth.  The  second  form  may  be 
produced  by  syphilitic  tissue,  ordinary  inflammatory  tissue,  cicatrices  after 
operations,  sloughing,  tuberculous,  syphilitic,  or  dysenteric  ulceration,  rectal 
gonorrhea,  and  traumatism.  The  usual  seat  of  simple  stricture  is  from 
one  inch  to  one  and  a  half  inches  above  the  anus.  The  deposit  may  be 
limited  to  the  submucous  coat  or  all  the  coats  may  be  involved.  It  is  very 
seldom  that  stricture  arises  as  a  result  of  abrasion  from  fecal  masses  or  foreign 
bodies.  It  may  follow  an  operation  for  piles  if  considerable  tissue  is  re- 
moved, and  is  an  occasional  sequence  of  Whitehead's  operation.  Stricture 
due  to  dysentery  is  extremely  rare,  and  no  case  has  ever  been  reported  to 
the  United  States  Pension  Office  (Peterson).  The  existence  of  stricture  as 
a  result  of  rectal  gonorrhea  has  not  been  positively  proved.  A  majority 
of  sufferers  from  rectal  stricture  have  labored  under  syphilis,  but  it  is  not 
*  Reuben  Peterson,  in  Jour.  Amer.  Med.  Assoc,  Feb.  3,  1900. 


Ii82  Diseases  and  Injuries  of  the  Rectum  and  Anus 

probable  that  the  lesion  is  s}'philitic  in  all  or  even  in  most  of  them.  The 
stricture  may  be  due  to  the  formation  of  fibrous  tissue,  and  ulceration  may 
or  may  not  occur.  It  may  be  caused  by  the  contraction  and  heahng  of  a 
large  ulcer.  Some  maintain  that  tuberculous  stricture  does  occur.  Mathews 
dissents  from  this  view  and  points  out  that  the  disposition  of  tuberculous 
matter  is  to  break  dowoi,  and  before  the  rectum  can  be  strictured  from  tuber- 
culosis it  breaks  down  from  ulceration.  Peterson  *  says  a  large  proportion 
of  the  victims  of  rectal  stricture  die  of  phthisis,  and  also  that  one-third  of 
so-called  syphilitic  cases  are  tuberculous.  It  may  begin  as  an  ulcer  or  as 
an  infiltration  of  submucous  tissue.  Although  a  syphilitic  lesion  or  a  tuber- 
culous lesion  may  cause  rectal  stricture,  in  most  cases  such  lesions  simply 
expose  the  tissues  to  infection,  and  a  benign  rectal  stenosis  results  from  the 
infection.  Hence  tuberculosis  causes  stricture,  but  does  so  indirectly  rather 
than  directly. 

The  symptoms  of  rectal  stricture  are  consdpation,  pain  on  defecation,, 
straining  at  stool,  the  presence  of  blood  and  mucus  in  the  stools,  an  open 
anus,  and  the  passage  of  stools  flattened  out  into  ribbons  if  the  stricture  is  low 
down.  In  some  cases  there  is  fluid  diarrhea,  solid  fecal  matter  being  retained 
above  the  stricture.  The  stricture  is  found  by  the  finger  or  by  the  soft-rubber 
bougie,  used  with  the  utmost  gentleness  and  care.  A  stiff  instrument  or  the 
rough  use  of  any  instrument  would  be  dangerous  and  might  rupture  the  rectum. 
In  syphilitic  cases,  in  tuberculous  cases,  and  in  benign  cases  the  fibrous  thick- 
ening is  usually  in  the  submucous  coat,  and  in  syphilitic  and  tuberculous  cases 
the  mucous  membrane  is  apt  to  ulcerate.  It  is  said  that  complete  obstruction 
may  arise.  I  have  seen  obstructive  symptoms,  but  never  complete  obstruction, 
in  rectal  stricture.     Distention  of  the  abdomen  and  colic  are  very  usual. 

The  treatment  of  non-cancerous  stricture  is  rest,  non-stimulating  diet, 
warm-water  injections,  mild  laxatives,  and  hot  hip-baths.  Cocain  supposi- 
tories may  be  needed.  Any  existing  disease  is  treated.  Bougies  are  passed 
every  other  day.  Use  a  soft-rubber  bougie,  warmed  and  oiled,  and  introduce 
it  gently.  If  only  the  method  of  gradual  dilatation  is  employed,  the  patient 
must  for  the  remainder  of  his  life  pass  a  bougie  from  time  to  time.  For 
fibrous  strictures  forcible  dilatation  {divulsion)  by  a  special  instrument  is 
employed  or  incision  is  practised.  Incision  {proctotomy)  may  be  either 
external  or  internal.  In  internal  proctotomy  one  or  more  incisions  are  made 
from  the  rectum  through  the  stricture  down  to  healthy  tissue,  the  first  cut  being, 
in  the  middle  Hne  posteriorly.  External  proctotomy,  which  divides  the  sphinc- 
ters, is  apt  to  leave  incontinence  as  a  legacy.  Electrolysis  finds  some  advocates,, 
but  on  what  grounds  it  is  difficult  to  see.  In  some  cases  the  rectum  should  be 
removed.     In  incurable  cases  perform  inguinal  colostomy. 

Cancer  of  the  rectum  is  the  cancer  of  the  bowel  most  often  met  with^ 
It  may  be  primarily  malignant  or  may  arise  from  an  adenoma.  The  com- 
monest growths  are  composed  of  cyhndrical  cells,  and  may  be  soft  or  scirrhous. 
In  cases  secondary  to  epithelioma  of  the  anus  ordinary  epithelioma  arises. 

In  most  rectal  carcinomata  the  cells  present  a  tubular  arrangement  sur- 
rounded by  a  more  or  less  plentiful  stroma  of  connective  tissue.  In  soft 
tumors  the  connective  tissue  is  scanty;  in  hard  tumors  it  is  plentiful. 

Cancer  is  most  common  after  the  age  of  forty,  but  it  not  unusually  occurs  before 
the  thirty-fifth  year,  and  is  sometimes  seen  even  as  early  as  the  twenty-fourth 
*  Reuben  Peterson,  in  Jour.  Amer.  Med.  Assoc,  Feb.  3,  1900. 


Treatment  of  Cancer  of  the  Rectum  1183 

year.  Extensive  ulceration  occurs.  If  a  hard  ring  encircles  the  rectum,  the 
lumen  of  the  tube  is  greatly  and  progressively  diminished.  In  cases  of  diffuse 
infiltration  the  lumen  is  not  greatly  lessened.  In  growths  of  the  anus  the  in- 
guinal glands  are  involved  and  also  the  glands  in  the  hollow  of  the  sacrum. 
In  growths  of  the  rectum  proper  the  glands  back  of  the  peritoneum  in  the 
sacral  hollow  are  involved,  and  the  inguinal  glands  are  involved  late  or  not  at  all. 

Symptoms. — The  symptoms  of  rectal  cancer  are  like  those  of  non- 
malignant  stricture,  except  that  the  pain  is  usually  greater,  the  hemorrhage 
more  severe,  and  constipation  is  apt  to  alternate  with  diarrhea.  The  diarrhea 
is  usually  in  the  morning.  Unfortunately,  in  many  cases  symptoms  are 
long  trivial;  in  fact,  pain  maybe  absentuntil  the  disease  is  far  advanced.  Muco- 
purulent or  bloody  stools  are  often  thought  to  result  from  dysentery  or  hemor- 
rhoids, which  latter  condition,  however,  may  be  only  an  accompanying  con- 
dition of  rectal  cancer.  Or  the  above  symptoms  may,  on  the  patient's  say-so, 
have  been  accepted  by  the  physician  as  caused  by  hemorrhoids,  without  any 
local  examination.  The  patient  again  may  have  only  imagined  the  presence  of 
hemorrhoids,  since,  according  to  his  notion,  the  above  symptoms  must  result 
from  hemorrhoids,  w'ith  w^hich  condition  so  many  of  his  friends  with  like  com- 
plaints are  afflicted.  Loss  of  strength,  emaciation,  and  cachexia  are  generally 
noticeable  only  in  the  late  stages  of  rectal  cancer.  Only  in  the  ver}-  latest  stages 
the  characteristic  odor  is  perceptible,  the  patient  becomes  septic,  and  abscesses 
attended  by  gangrene  may  form  (Ernest  Jonas,  in  "  Interstate  Med.  Jour.," 
No.  4,  1906).  The  finger  and  the  speculum  make  the  diagnosis.  In  rectal 
cancer  metastasis  occurs  late.  The  most  favorable  cases  for  operation  are  those 
in  which  the  growth  is  small  and  movable.  Accurately  define  the  extent  of 
the  growth,  and  endeavor  to  make  out  if  it  has  invaded  the  cellular  tissue 
outside  of  the  rectum,  the  prostate,  the  bladder,  the  sacrum,  the  uterus,  etc. 

Treatment. — In  every  case  of  cancer  of  the  rectum  the  following  question 
must  be  considered:  Shall  we  perform  a  radical  operation  in  hope  of  pro- 
ducing cure  or  at  least  greatly  prolonging  life  ?  In  what  cases  should  a  radical 
operation  be  attempted  ?  It  is  the  proper  procedure  if  there  are  no  met- 
astatic deposits,  if  the  patient  is  in  fair  general  condition  and  free  from  serious 
organic  disease,  and  if  the  cancerous  bowel  is  movable  and  not  fixed  by  dis- 
semination to  adjacent  structures.  As  W.  Watson  Cheyne  says  ("Brit. 
Med.  Jour.,"  June  13,  1903),  a  slight  adhesion  to  the  vagina  is  not  a  contrain- 
dication because  this  portion  of  the  vagina  can  be  readily  removed  with  the 
diseased  rectum.  Some  surgeons  will  not  attempt  radical  operation  if  they 
cannot  pass  a  finger  through  the  growth.  I  do  not  regard  high  position  as 
forbidding  operation,  although,  of  course,  it  makes  it  more  dangerous  to  life 
and  less  promising  as  to  cure.  Cheyne  is  of  the  same  opinion.  When  the 
surgeon  is  first  called  to  a  case  of  cancer  of  the  rectum  it  is  usually  found  to 
be  so  far  advanced  as  to  be  inoperable.  In  at  least  75  per  cent,  of  rny  cases 
radical  extirpation  was  impossible  when  I  first  saw  the  case. 

If  a  radical  operation  is  determined  on,  the  next  question  to  answer 
is.  Shall  we,  or  shall  we  not,  do  a  preliminary  colostomy?  If  the  cancer 
is  very  low  down  and  is  to  be  removed  from  the  perineum,  prehminary  colos- 
tomy should  not  be  done.  If  the  cancer  is  high  up  and  we  propose  to  attack 
it  by  Weir's  method,  or  the  Quenu-Mayo  method,  preliminary  colostomy 
should  not  be  done.  If  Kraske's  operation  is  to  be  performed,  I  believe 
preliminary  colostomy  is  indicated.     It  enables  us  to  cleanse  the  area  upon 


ii84 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


which  operation  is  to  be  performed,  and  to  keep  the  wound  clean,  and 
gives  us  a  much  better  chance  of  obtaining  primary  union.  In  cases  in 
which  the  sphincter  is  retained  and  it  is  possible  to  anastomose  the  divided 
ends  of  the  rectum  together,  colostomy  is  not  necessary;  and  if  an 
artificial  anus  has  been  made  in  such  a  case,  another  operation  will  be 
required  to  close  it.  As  a  matter  of  fact,  I  have  found  it  always 
difficult  and  usually  impossible  to  suture  the  divided  ends  of  the  gut 
together  after  Kraske's  operation,  and  I  now  follow  the  advice  of  Keen, 
and  always  precede  it  by  a  colostomy.  If  radical  operation  is  rejected  (and 
about  three-fourths  of  the  cases,  when  first  seen  by  the  surgeon,  are  beyond 


Fig.  695 — Tying  off  the  tumor  through  an 
abdominal  incision  after  separating  peritoneum 
from  sacrum  and  bladder  (Weir). 


Fig.  696.— Lower  end  of  rectum  everted 
through  the  anus  and  the  upper  end  of  bowel 
drawn  out  of  the  abdominal  cavity  (Weir). 


Fig.  697 — a,  The  upper  bowel  drawn  out 
through  the  everted  lower  end  of  rectum  ;  b, 
the  ends  of  the  two  portions  of  the  rectum  sewn 
together  (Weir). 


Fig.  698. — The  united  bowel  replaced  with 
posterior  drainage  and  the  divided  peritoneum 
so  sewn  together  as  to  shut  off  the  general 
peritoneal   cavity  from  the  pelvis    (Weir). 


such  aid),  palliative  treatment  is  desirable.  One  plan  is  to  introduce  a  tube 
through  the  stricture  daily,  wash  out  the  rectum  with  warm  water,  and  after 
washing  inject  emulsion  of  iodoform  (gr.  x  to  ij  of  sweet  oil).  Injections 
of  chlorid  of  zinc  (gr.  j  to  oj  of  water)  lessen  the  foulness  of  the  discharge. 
The  bowels  are  opened  regularly  by  laxatives,  and  if  the  growth  causes 
obstructive  symptoms,  it  is  scraped  away  with  a  sharp  spoon.  Opium  is 
given  to  relieve  pain.  The  advantage  of  this  plan  is  that  the  patient  does  not 
suffer  from  the  unpleasantness  of  an  artificial  anus.     Sooner  or  later,  how- 


Treatment  of  Cancer  of  the  Rectum 


Il8: 


ever,  the  growth  gets  outside  of  the  bowel,  and  terrible  pain  will  arise  from 
involvement  of  the  sacral  plexus.  W.  Watson  Cheyne  ("Brit.  Med.  Jour.," 
June  13,  1903)  would  restrict  palliative  treatment  of  this  character  to  cases 
in  which  fungating  masses  grow  from  one  side  of  the  bowel. 

If  a  growth  encircles  the  bowel  and  produces  symptoms  of  obstruction, 
palliative  colostomy  should  be  performed.  This  operation  gives  great  com- 
fort to  the  patient,  and  allays  pain  by  intercepting  the  feces  before  they 
reach  the  cancer.  I  am  not  convinced  that  it  distinctly  retards  the 
growth  of  the  cancer  or  notably  prolongs  life.  Unfortunately,  colostomy 
does  not  do  away  with  pain  if  the  sacral  plexus  is  involved.  I 
have  had  no  experience  with  radium  in  inoperable  cancer  of  the  rectum  and 
have  never  seen  the  .\"-rays  produce  any  marked  or  lasting  improvement. 
Operative  treatment  includes  one  of  several  procedures.  Excision  of  the 
"rectum  from  below  (Cripps's  operation)  is  practised  if  not  more  than  three 
inches  require  removal,  if  the  peritoneum  is  not  invaded,  and  if  the  adjacent 
organs  are  free  from  disease.  The  peritoneum  must  not  be  opened  in  Cripps's 
operation.  After  the  growth  is  removed  the  divided  rectum  is  pulled  down 
and  sutured  to  the  skin.  Excision  of  the  rectum  after  excising  the  coccyx  and  a 
portion  of  the  sacrum  {Kraske's  operation,  Fig.  699)  is  a  procedure  which  permits 
removal  of  the  entire  tube,  portions  of  the  colon,  and  even  of  adjacent  parts. 
The  peritoneum  is  opened  deUberately  in  this  operation,  and  is  subsequently 
closed  with  sutures  before  the  gut  is  opened.  The  glands  from  the  meso- 
colon are  always  removed.  The  lower  end  of  the  upper  segment  of  bowel 
is  fastened  in  the  wound,  or,  if  colostomy  has  been  previously  performed, 
may  be  closed.  In  some  few  cases  in  which  it  is  not  necessary  to  remove  the 
lower  end  of  the  rectum,  the  two  portions  may  be  anastomosed  after  resection 
of  a  part  of  the  tube.  Kraske's  operation  may  be  done  by  an  osteoplastic 
method,  the  bone  not  being  removed.  It  is  well  to  precede  a  Kraske  operation 
two  weeks  by  an  inguinal 
colostomy,  which  permits 
of  cleansing  the  lower 
bowel  of  feces  and  lessens 
the  chance  of  severe 
wound-infection  and  de- 
layed healing  after  the 
removal  of  the  rectum. 
A  preliminary  colostomy 
may  make  the  operation 
of  extirpation  more  diffi- 
cult by  fixing  the  intes- 
tine, and  thus  interfering 
with  the  necessary  draw- 
ing down  of  the  gut  (E. 
H.  Taylor).  If  the 
growth  is  extensive  and 
the  mesocolon  short,  it 
may  be  best  to  perform 

a  right  inguinal  colostomy;  but  in  most  cases  left  inguinal  colostomy  is  pre- 
ferred (Gerster).     The  colostoniy  remains  open   during   the  patient's  Hfe, 
75 


Fig.  699. — Different  levels  of  resection  of  the  sacrum : 
AT  O,  Kocher's  line;  B,  O,  Kraske's;  B,  If,  Hochenegg's; 
B,  D,    Bardenheuer's  ;  J?,  S,  Rose's  (Mass.). 


ii86  Diseases  and  Injuries  of  the  Rectum  and  Anus 

except  in  those  rare  cases  of  Kraske's  operation  in  which  the  continuity  of  the 
rectum  can  be  reestabHshed  after  excision  of  the  growth.  In  such  cases  the 
artificial  anus  may  be  closed  some  time  after  the  resection  of  the  rectum. 

Robt.  F.  Weir  ("Med.  News,"  July  27,  1901)  has  been  so  much  impressed 
with  the  difficulties  and  dangers  of  Kraske's  operation  in  a  case  of  high 
carcinoma  that  he  now  employs  it  solely  in  cases  in  which  there  is  freedom 
from  disease  for  two  inches  immediately  above  the  anus  and  in  which  the 
cancer  does  not  extend  more  than  five  inches  above  the  anus.  In  other 
cases  he  does  the  following  operation:  Open  the  abdomen  above  the  pubes, 
separate  the  peritoneum  so  that  the  bowel  and  "contents  of  the  sacral  curve" 
are  liberated  behind  nearly  "to  the  tip  of  the  coccyx  and  in  front  of  the  edge 
of  the  prostate."  The  tumor  is  then  tied  off  with  tapes  (Fig.  695).  The 
portion  of  the  rectum  bearing  the  tumor  is  removed,  the  lower  end  of  the 
bowel  is  everted  through  the  anus,  and  the  upper  end  is  drawn  out  of  the 
abdominal  incision,  Fig.  696).  The  upper  end  is  then  caught  with  forceps 
and  drawn  through  the  everted  lower  end  of  the  rectum  (Fig.  697,  a).  The 
ends  of  the  two  everted  pordons  (Fig.  697,  h)  are  sewn  together,  the  everted 
bowel  is  replaced,  the  divided  peritoneum  is  sutured  to  shut  off  the  peritoneal 
cavity,  and  posterior  drainage  is  inserted  (Fig.  698).  In  the  Quenu-Mayo 
operation  the  object  is  to  remove  all  of  the  diseased  glands  as  well  as  the  cancer 
(W.  J.  Mayo  in  "  St.  Paul  ]Med.  Jour.,"  April,  1906.  J.  Coles  Brick  at  meeting 
of  American  Proctologic  Soc,  June,  1906.)  The  patient  is  placed  in  an  ex- 
aggerated Trendelenburg  position  and  the  belly  is  opened  by  a  median  incision. 
The  growth  is  studied  to  see  if  it  is  removable,  and  a  search  is  made  for  enlarged 
glands  which  might  cause  us,  and  for  secondary  growths  which  would  cause  us, 
to  abandon  the  operation.  If  we  conclude  to  attack  the  growth,  pack  away  all 
the  intestine  except  the  sigmoid,  catch  two  clamps  across  the  sigmoid,  one  of 
them  being  on  the  level  of  the  sacral  promontory.  Divide  the  gut  between  them. 
Free  the  mesosigmoid  by  lateral  cuts  and  bring  the  proximal  stump  out  of  the 
belly,  ligate  it,  and  apply  a  purse-string  suture  to  invert  it.  A  gridiron  incision  is 
then  made  on  the  left  side  and  the  proximal  stump  is  pulled  through  it  and  is 
sutured  there.  Incisions  are  now  made  in  the  sides  and  in  front  to  liberate  the 
rectum,  the  inferior  mesenteric  artery  is  tied  above  and  to  the  left  of  the  prom- 
ontory, the  fat  and  glands  are  thoroughly  removed  from  the  sacral  hollow, 
vessels  being  tied  as  cut,  except  the  middle  sacral  and  middle  hemorrhoidal 
vessels,  which  are  tied  before  division.  The  area  is  now  packed  with  gauze 
and  the  patient  is  put  in  the  lithotomy  position.  The  rectum  is  packed 
with  gauze,  the  anus  is  sutured,  and  the  rectum  is  separated  from  the  prostate 
and  urethra  or  from  the  vagina  from  below  upward  to  just  above  the  levator 
ani  muscle.  An  assistant  presses  the  fragment  carrying  glands  down  from  the 
abdomen  and  the  surgeon  removes  it  from  the  perineum.  The  peritoneum  is 
sutured  within  the  abdomen,  room  being  left  for  a  small  drain  which  protrudes 
from  the  perineum.  The  perineal  wound  is  narrowed  by  sutures  and  the 
wound  in  the  belly  is  closed.  In  twenty-four  hours  the  protruding  end  of  the 
sigmoid  is  opened  and  an  artificial  anus  is  thus  made. 

The  mortahty  of  Kraske's  operation  is  from  12  to  15  per  cent.  Twenty- 
eight  per  cent,  of  Kocher's  cases  of  extirpation  of  cancer  of  the  rectum  remain 
well  from  three  to  sixteen  years  after  operation  (W.  W.  Cheyne,  "Brit.  Med. 
Jour.,"  June  13,  1903). 


Preparation  of  the  Patient 


Hi 


XXIX.  ANESTHESIA  AND  ANESTHETICS. 

Anesthesia  is  a  condition  of  insensibility  or  loss  of  feelins:  artificially 
produced.  An  anesthetic  is  an  agent  which  produces  insensibility  or  loss 
of  feeling.  Anesthetics  are  divided  into — (i)  general  anesthetics,  as  amylene, 
chloroform,  chlorid  of  ethyl,  ether,  bromid  of  ethyl,  nitrous  oxid,  and  bichlorid 
of  methylene;  (2)  local  anesthetics,  as  alcohol,  bisulphid  of  carbon,  carbolic 
acid,  ether  spray,  cocain,  eucain,  stovain,  ice  and  salt,  rhigolene  spray, 
and  ethyl  chlorid  spray. 

Anesthesia  may  be  induced  by  a  general  anesthetic  to  abolish  the  usual 
pain  of  labor  and  of  surgical  procedures;  to  produce  muscular  relaxation 
in  tetanus,  hernice,  dislocations,  and  fractures;  and  to  aid  in  diagnosticating 
abdominal  tumors,  joint-diseases,  fractures,  and  malingering. 

Death=rate  from  Anesthetic  Agents. — Hewitt  combines  the  statis- 
tics of  Julliard  and  Ormsby,  with  the  following  result  ("Anesthetics  and  Their 
Administration  ") : 


Anesthetic. 

Total  Numbhr  of 
Administrations. 

Total  Number  of 
Deaths. 

Death-rate. 

Chloroform 

Ether  

676,767 

407,553 

214 
25 

I  in  3162 
I  in  16,302 

Hewitt  finds  that  during  the  last  forty  years  only  thirty  fatalities  are 
recorded  as  produced  by  nitrous  oxid,  and  he  thinks  several  of  these  should 
be  excluded.  It  is  practically  certain,  however,  that  many  deaths,  or  at 
least  some  deaths,  have  not  been  recorded. 

Seitz  collected  16,000  instances  of  anesthesia  by  chlorid  of  ethyl,  with  one 
death.  I  have  seen  anesthetics  (particularly  ether)  given  many  thousand  times. 
For  five  years  1  gave  ether  and  chloroform  for  Prof.  Keen.  I  have  witnessed 
three  deaths  that  at  the  time  were  thought  to  be  directly  due  to  anesthetics, 
and  two  of  them  were  so  caused.  One  death  resulted  from  pouring  a  quantity 
of  chloroform  upon  an  AUis  inhaler,  the  bandage  of  which  was  saturated  with 
ether.  At  the  time  the  chloroform  was  poured  in  the  inhaler  the  patient  had 
just  been  struggHng  and  consequently  was  breathing  deeply.  One  death 
resulted  from  giving  ether  on  a  thick  cone  made  of  several  towels  with  paper 
between  the  folds.  The  towels  were  saturated  with  ether,  the  patient  got  no 
air  at  all,  and  was  asphyxiated,  as  she  might  have  been  had  the  cone  only  been 
wet  with  water.  The  third  case  was  a  man  who  had  an  impacted  hip  fracture. 
He  became  cyanotic  under  ether  and  died.  The  death  was  supposed  to  be  due 
to  ether,  but  necropsy  discovered  fat  emboli  in  the  brain  and  lungs. 

Preparation  of  the  Patient. — WTienever  possible,  prepare  a  patient 
before  administering  a  general  anesthetic  and  prepare  him,  if  the  case  admits 
of  it,  during  two  or  more  days.  Heart  disease  is  not  a  positive  contraindica- 
tion to  surgical  anesthesia.  It  is  quite  true  that  anesthetics  are  dangerous 
to  people  with  fatty  hearts,  but  shock  is  also  dangerous,  and  the  surgeon 
stands  between  the  Scylla  of  anesthesia  and  the  Charybdis  of  shock.  Gallant 
truly  says  that  not  enough  attention  is  paid  to  the  "character  of  the  pulse 


1 1 88  Anesthesia  and  Anesthetics 

and  action  of  the  heart  before  operation,  by  which  to  compare  its  work  during 
anesthesia,  and  after  the  operation  is  over,  and  this  neglect  leads  to  unneces- 
sary stimulation  and  overdriving  a  heart  which  is  doing  its  average  best."* 
Always  examine  the  urine  if  the  nature  of  the  case  allows  time.  If  albumin 
is  found,  operation  is  not  contraindicated;  but  the  peril  of  anesthesia  is 
greater,  and  certain  dangers  are  to  be  watched  for  and  guarded  against. 
If  much  albumin  is  present,  postpone  operation  except  in  emergency  cases. 
If  sugar  is  found,  the  danger  is  considerable,  as  diabetic  coma  occasionally 
develops.  The  percentage  of  sugar  does  not  determine  the  amount  of  danger. 
Coma  may  arise  when  only  a  little  sugar  is  present,  and  may  not  arise  when 
there  is  a  considerable  amount.  The  presence  of  aceto-acetic  acid  is  more 
ominous  than  is  the  presence  of  sugar.  Empty  the  intestinal  canal  by 
purgation  a  number  of  hours  before  anesthetization.  It  is  well  to  give  the  bowel 
six  to  twelve  hours'  rest  before  operation.  The  usual  custom  is  to  give  a  saline 
cathartic  the  evening  before  operation  and  an  enema  early  on  the  morning  of 
the  operation.  Frequently  the  nature  of  the  case  or  the  necessit}^  for  haste 
does  not  permit  of  prehminar}^  emptpng  of  the  intestine  by  the  administration 
of  cathartics.  During  the  twenty-four  hours  preceding  operation  food  should 
be  taken  in  small  amounts  and  in  forms  easily  digestible.  During  the  day 
or  so  before  operation  there  is  usually  impaired  digestion,  and  no  undue  strain 
should  be  put  upon  the  stomach.  In  the  morning  allow  no  breakfast  if  the 
operation  is  to  be  performed  at  an  early  hour,  but  if  the  patient  is  ver}'  weak, 
order  a  htde  brandy  and  beef-tea.  If  the  operation  is  to  be  about  noon, 
give  a  breakfast  of  beef-tea  and  toast  or  a  httle  consomme;  never  give  any 
food  within  three  hours  of  the  operation,  but  brandy  is  admissible  if  it  is  re- 
quired. If  the  stomach  is  not  empty  at  the  time  of  operation,  vomiting  is  al- 
most inevitable,  and  portions  of  food  may  enter  the  windpipe;  if  the  stomach 
contains  no  food,  vomiting  is  far  less  likely  to  happen;  and  even  if  it  occurs  and 
vomited  matter  should  enter  the  windpipe,  it  may  do  little  harm,  as  it  consists 
chiefly  of  liquid  mucus.  In  cases  of  intestinal  obstruction  in  which  there  has 
been  stercoraceous  vomiting  there  is  much  danger  that  vomiting  will  occur  dur- 
ing anesthetization.  In  some  cases  of  intestinal  obstruction,  during  the  admin- 
istration of  the  anesthetic,  and  during  the  anesthetic  state,  a  stream  of  stinking 
brown  fluid  may  flow  without  effort  from  the  mouth.  Vomiting  or  regurgi- 
tation of  stercoraceous  material  is  profuse,  sudden,  and  dangerous.  It  may 
flood  the  bronchial  tubes  during  inspiration  and  cause  death  by  suffocation. 
In  a  case  in  which  stercoraceous  vomiting  has  occurred  wash  out  the  stomach 
before  administering  the  anesthetic.  If  a  patient  with  intestinal  obstruction 
is  too  weak  to  permit  lavage,  a  local  anesthetic  should  be  used  instead  of 
a  general  anesthetic.  Vomiting  while  the  patient  is  under  the  influence  of 
an  anesthetic  is  dangerous  in  any  case,  because  of  the  great  cardiac  weakness 
which  precedes  and  follows  it.  If  a  patient  sleeps  well  the  night  before 
an  operation,  he  will  probably  take  the  anesthetic  better  than  if  he  sleeps 
poorly.  Effort  should  be  made  to  obtain  a  night's  sleep.  An  excellent 
expedient  is  a  hot  ammonia  bath,  followed  by  a  rub-do \ati  with  weak  alcohol,  f 
It  may  be  necessary  to  administer  trional  or  bromid.  About  fifteen  minutes 
before  giving  the  anesthetic  let  the  patient  drink  a  glass  of  hot  water.     This 

*  Medical  Record,  February  2,  iSqg. 

t  A.  Ernest  Gallant,  Med.  Record,  Dec.  30,  1899. 


Preparation  of  the  Patient  1189 

material  protects  the  stomach  from  the  irritant  effects  of  any  anesthetic  which 
may  be  swallowed.  Before  giving  the  anesthetic  see  that  artiiicial  teeth  are 
removed  and  that  the  patient  does  not  have  a  piece  of  candy  or  a  chew  of 
tobacco  in  the  mouth.  Always  have  a  third  party  present  as  a  witness,  be- 
cause in  an  anesthetic  sleep  vivid  dreams  often  occur,  and  erotic  dreams  in 
women  may  lead  to  damaging  accusations  against  the  surgeon.  Place  the 
patient  recumbent.  The  effort  should  be  to  place  him  in  as  comfortable  a 
position  as  possible  if  this  position  is  consistent  with  operative  necessities. 
Put  a  small  pillow  under  him,  so  as  to  support  the  normal  lumbar  curve  and 
prevent  postoperative  backache  (page  1 201).  See  that  the  clothing  is  loose, 
particularly  that  there  is  no  constriction  about  the  neck  and  abdomen.  Do 
not  have  the  head  high  unless  this  position  is  demanded  by  the  exigencies 
of  the  operation.  The  anesthetist  must  have  a  mouth-gag  and  a  pair  of  tongue 
forceps.  It  is  very  wrong  to  say  that  a  mouth-gag  and  tongue  forceps  are  never 
necessary.  It  is  cjuite  true  they  are  often  used  when  not  needed,  but  this  does 
not  justify  us  in  being  without  them  when  they  are  needed,  and  they  may  be 
needed  very  badly.  The  anesthetist  should  also  have  a  pair  of  artery  forceps 
and  some  small  gauze  sponges  to  swab  out  the  mouth  and  throat.  A  hypoder- 
matic needle  in  working  order,  and  solutions  of  strychnin,  atropin,  and  brandy 
are  to  be  in  a  readily  accessible  place,  oxygen  must  be  ready  for  administration, 
and  it  is  well  to  have  an  electric  battery  at  hand.  Accidents,  it  is  true,  are  rare, 
but  they  may  happen  at  any  time,  and  hence  the  surgeon  should  always  be  pre- 
pared for  them.  Any  danger  which  arises  must  be  met  with  promptness  and 
decision,  or  action  will  be  of  no  avail.  Many  surgeons  give  a  hypodermatic  in- 
jection of  morphin  a  short  time  before  operation,  to  steady  the  heart,  to  prevent 
vomiting  during  anesthetization,  to  shorten  the  stage  of  excitement,  to  prevent 
rigidity,  and  to  aid  the  bringing  about  of  insensibility  with  very  httle  of  the  anes- 
thetic. This  method  has  been  tried  by  many  during  the  last  forty  odd  years.  It 
is  used  in  drunkards  (as  their  muscles  tend  to  remain  rigid) ,  in  those  whom  it 
is  difficult  to  make  completely  unconscious,  in  neurotic  individuals,  and  in 
badly  frightened  subjects.  Its  greatest  use  is  in  operations  about  the  mouth 
and  face,  for  in  these  procedures  an  anesthetic  is  usually  given  intermittently 
and  a  preliminary  dose  of  morphin  keeps  the  patients  from  rousing  during  the 
intervals.  There  are,  however,  objections  to  morphin  before  anesthesia,  and 
its  use  should  be  the  exception  and  not  the  rule.  It  should  not  be  used  in 
children,  in  cases  of  stupor,  or  in  cases  in  which  the  respiratory  center  is  dis- 
ordered. It  depresses  the  respiration,  lowers  temperature,  and  thus  perhaps 
increases  operative  shock,  interferes  with  the  pupillary  phenomena  of  anes- 
thesia, delays  awakening  from  the  anesthetic  sleep,  adds  to  subsequent  ab- 
dominal distention  and  headache,  and  actually  favors  post-anesthetic  vomiting. 
Hevdtt  ("  Anesthetics  and  Their  Administration  ")  says  that  several  recorded 
fatalities  were  due  to  the  combination.  If  the  surgeon  determines  to  give 
morphin,  he  gives  gr.  ^  to  |  twenty  minutes  before  the  anesthetist  begins 
to  give  the  anesthetic.  Hewitt  (Ibid.)  says:  "The  anesthetic  should  be 
given  until  the  usual  signs  of  anesthesia  commence  to  appear.  It  should 
then  be  discontinued  for  a  few  moments  and  only  reapplied  as  occasion  may 
require.  As  little  as  possible  of  the  ether  or  chloroform  should  be  subsequently 
administered;  the  conjunctival  reflex  should  be  retained."  In  the  clinic  of  the 
Jefferson  Hospital  the  elder  Gross  long  used  as  a  routine  the  prehminary 


1 190  Anesthesia  and  Anesthetics 

administration  of  opium,  but  during  his  later  years  he  used  it  exceptionally. 
His  successor,  the  younger  Gross,  used  morphin  hypodermatically  excei>tion- 
ally.  In  some  cases  we  may  anticipate  trouble  from  the  anesthetic.  Cyanosis 
may  occur  in  drunkards;  in  fat,  thick-necked  individuals  of  the  Major  Bagstock 
type,  who  are  short  of  breath  and  congested  in  appearance;  in  individuals  with 
some  disease  of  the  lungs,  bronchi,  pharynx,  larynx,  or  trachea  (empyema, 
emphysema,  chronic  bronchitis,  croup,  cancer  of  the  larynx,  etc.) ;  in  individ- 
uals suffering  from  fatty  heart  or  valvular  incompetence.  Buxton  points  out 
that  an  individual  without  teeth  and  with  stenosis  of  the  nares  is  apt  to  become 
cyanotic  under  an  anesthetic,  because  the  lips  and  pillars  of  the  fauces  are 
drawn  in  like  valves  during  inspiration. 

Ether  and  Chloroform. — The  two  favorite  anesthetics  are  ether  and 
chloroform.  Only  the  very  best  ether  or  chloroform  should  be  used.  It 
is  a  good  plan,  in  order  to  lessen  bronchitis,  to  mix  with  ether  turpentine 
of  Pinus  pumilio  in  the  proportion  of  20  drops  to  6^  oz.  (Becker,  in  "  Cen- 
tralbl.  f.  Chir.,"  June  i,  1901).  Chloroform  is  more  dangerous  than  ether 
in  general  cases,  though  it  is  more  agreeable,  less  irritant  to  the  lungs  and 
kidneys,  and  quicker  in  its  action.  Chloroform  is  a  safer  anesthetic  in  warm 
than  in  cold  countries.  In  fact,  in  the  tropics  it  is  a  matter  of  considerable 
difficulty  to  use  ether  because  of  its  great  volatility.  Chloroform  is  preferred 
in  campaigns,  because  less  is  required  and  transportation  is  easier.  Recovery 
from  chloroform  is  quicker  and  quieter  than  that  from  ether,  but  chloroform- 
vomiting  lasts  longer  than  ether-vomiting.  Chloroform  may  induce  sudden 
and  even  fatal  syncope.  Hare's  experiments  on  animals  indicate  that  chloro- 
form may  kill  by  respiratory  failure  occurring  secondarily  to  failure  of  the 
vasomotor  center;  but  certain  it  is  that  clinically  the  danger  of  chloroform 
is  paralysis  of  the  heart,  and  this  condition  may  come  on  so  rapidly  that 
death  may  occur  almost  before  an  attempt  can  be  made  to  save  life.  Leonard 
Hill  has  proved  that  most  chloroform-deaths  that  take  place  after  considerable 
■of  the  anesthetic  has  been  taken  arise  from  paralytic  distention  of  the  heart. 
Sudden  death,  when  inhalations  of  chloroform  have  just  commenced,  may 
be  due  to  the  irritant  vapor  acting  on  the  nasal  mucous  membrane,  exciting  a 
nasal  reflex  and  powerfully  stimulating  cardiac  inhibition.  If  ether  produces 
danger  it  does  so  usually  through  the  respiration,  and  not  the  heart,  and  there 
is  generally  time  to  undertake  means  of  resuscitation,  which  means  are  apt 
to  be  successful.  Chloroform  is  preferred  to  ether  by  many  surgeons  for 
children  under  ten  years  of  age,  in  whom  ether  causes  a  great  outflow  of 
bronchial  mucus,  which  may  asphyxiate;  for  people  over  sixty,  entirely  free 
from  myocardial  disease,  at  which  age  most  persons  have  some  bronchitis, 
and  ether  chokes  them  up  with  mucus.  Ether  also  irritates  the  kidneys, 
which  at  the  latter  age  are  apt  to  be  weak  or  diseased.  Personally  I  give  ether 
even  to  infants  (if  they  are  free  from  bronchitis)  and  to  old  subjects  without 
marked  respiratory  trouble.  Chloroform  is  given  if  the  actual  cautery  is  to 
be  used  about  the  face,  neck,  or  mouth,  because  ether  vapor  may  take  fire 
and  chloroform  vapor  will  not.  Chloroform  is  preferred  for  labor  cases, 
when  moderate  anesthesia  only  is  required,  and  for  operations  on  the  mouth 
and  nose.  In  cleft-palate  operations  chloroform  is  usually  preferred,  because 
it  causes  but  little  cough  and  salivary  flow.  In  ligation  of  a  large  artery 
which  is  overlaid  by  a  vein  ether  greatly  enlarges  the  vein,  but  this  is  no  real 


Ether  and  Chloroform  1191 

embarrassment  to  an  experienced  surgeon.  In  goiter  operations  ether  will 
decidedly  enlarge  the  veins.  In  fact,  most  goiters  should  he  removed  with 
the  aid  of  local  anesthesia  only.  Chloroform  is  particularly  dangerous  when 
there  is  myocardial  disease,  and  is  apt  to  produce  cyanosis  and  embarrassed 
respiration.  In  valvular  heart  disease  chloroform  is  more  dangerous  than 
ether,  and  even  in  functional  heart  trouble  it  is  an  undesirable  anesthetic.  It 
should  not  be  used  in  those  who  smoke  or  chew  tobacco  to  excess,  or  who 
overindulge  in  coffee  or  alcohol.  Chloroform  is  more  dangerous  in  shock  than 
ether.  A  patient  in  dangerous  shock  requiring  operation  should,  if  possible, 
have  the  nerves  coming  from  the  part  injected  with  cocain  so  as  to  prevent 
further  shock  by  introducing  a  "physiological  block" — Crile  (page  262). 
Chloroform  is  preferred  for  patients  with  difficult  respiration  from  any 
cause  other  than  heart  disease  (emphysema,  bronchitis,  or  pulmonary  tuber- 
culosis), and  for  patients  with  kidney  disease.  I  am  convinced  that  ether- 
ization is  sometimes  responsible  for  a  latent  area  of  pulmonary  tuberculosis 
becoming  active.  Some  surgeons  do  not  use  ether  in  abdominal  opera- 
tions because  they  believe  it  may  cause  persistent  oozing  of  blood,  but  this 
view  is  not  in  accord  with  the  author's  experience.  Ether  is  the  best  and  safest 
anesthetic  for  general  use.  It  is  much  safer  than  chloroform  in  valvular 
disease  and  functional  heart  trouble.  It  is  dangerous  in  myocardial  disease, 
but  not  nearly  so  dangerous  as  chloroform.  In  valvular  disease  without 
heightened  arterial  tension  it  is  reasonably  safe,  but  in  valvular  disease  with 
heightened  arterial  tension  it  is  dangerous.  Ether  is  dangerous  when  athe- 
roma exists.  Both  ether  and  chloroform  may  induce  changes  in  the  blood.* 
In  practically  all  cases  they  produce  a  diminution  of  hemoglobin  and  leuko- 
cytosis. In  some  cases  they  produce  alteration  in  the  shape  of  the  corpuscles. 
These  changes  are  especially  marked  in  anemic  blood.  Ether  produces 
distinct  leukocytosis,  probably  toxic  in  origin.  These  blood-changes  indicate 
that  prolonged  anesthesia  may  militate  against  recovery  from  a  severe  opera- 
tion. If  a  patient's  hemoglobin  is  below  30  per  cent.,  a  general  anesthetic 
should  not  be  given.  During  the  state  of  anesthesia  the  temperature  drops 
from  one  to  three  degrees  or  more,  hence  the  patient  should  be  carefully 
covered  during  the  operation.  The  question  as  to  the  effect  of  ether  on  the 
kidneys  is  much  disputed.  Most  surgeons  beheve  that  it  tends  to  cause  albu- 
minuria or  increase  existing  albuminuria.  Nitrous  oxid  is  very  dangerous 
when  there  is  vascular  degeneration,  and  it  may  induce  apoplexy.  It  is  also 
dangerous  if  the  air-passages  are  narrowed  as  by  a  goiter.  '  In  giving  ether 
or  chloroform  the  administrator  must  devote  his  undivided  attention  to 
the  task.  He  must  note  every  symptom,  must  order  or  carry  out  proper 
treatment  for  complications,  and  must  keep  the  operator  informed  as  to  the 
necessity  for  haste.  The  anesthetist  must  be  a  man  who  has  a  wholesome 
respect  for  ether  and  chloroform,  although  not  afraid  of  them. 

Can  an  anesthetic  be  administered  to  a  sleeping  person  without  waking 
him?  I  know  that  chloroform  can  be  so  given,  for  I  have  succeeded  in 
giving  it  to  a  child  without  breaking  the  slumber.  Probably,  in  most  cases, 
an  attempt  will  fail,  but  in  some  it  will  succeed.  Stone  ("Cleveland  Med. 
Jour.,"  Jan.,   1902)   reports  successful  administration  to  sleeping  children 

*  See  the  author  on  the  "  Blood-alterations  of  Ether-anesthesia,"  Medical  News, 
March  2,  1895,  and  also  the  author  and  Kalteyer  in  The  Proceedings  of  the  American 
Surgical  Assoc,  for  igoi. 


II92 


Anesthesia  and  Anesthetics 


and  also  the  chloroforming  of  a  resident  physician  while  asleep.  Paugh 
("Jour.  Amer.  Med.  Assoc,"  May  18,  1901)  reports  three  successes  with 
children.  Ether,  because  of  the  irritant  nature  of  its  vapor,  would  be  more 
apt  to  arouse  a  sleeper  than  would  chloroform. 

Administration  of  Cflloroform. — Chloroform  should  be  given  only 
by  a  trained  man.  In  fact,  safety  in  giving  chloroform  is  dependent  upon 
skill  and  experience  more  than  in  giving  ether.  The  most  dangerous  period 
is  when  the  patient  is  incompletely  anesthetized,  but  is  going  under.  Most 
deaths  happen  at  this  time.  In  administering  chloroform  have  at  hand 
a  mouth-gag,  tongue  forceps,  artery  forceps,  small  gauze  sponges,  a  clean 
towel,  a  hypodermatic  syringe,  solutions  of  strychnin,  atropin,  and  brandy. 
an  electric  battery,  and  a  can  of  oxygen.  Use  only  pure  chloroform. 
The  patient  must  be  recumbent.  No  special  inhaler  is  required,  but  the 
drug  may  be  given  upon  a  thin  towel,  a  napkin,  or  a  piece  of  lint.  The 
mask  of  Skinner  is  very  useful  (Fig.  701).  Junker's  inhaler  is  used  by  many 
anesthetists  (Fig.  700).  In  operations  about  the  face  Souchon's  instrument 
is  serviceable.     Souchon's  apparatus  is  so  arranged  that  chloroform  may 


Fig.  700. — Junker's  inhaler. 


Fig.  701. — Skinner's  mask. 


be  given  through  a  tube  which  is  introduced  through  the  nose,  the  instrument 
being  well  out  of  the  way  of  the  operator.  Some  surgeons  cocainize  the  nares 
before  giving  chloroform,  so  as  to  prevent  the  supposedly  dangerous  nasal  reflex 
(Rosenberg).  It  is  a  good  plan  to  smear  the  lips  and  face  with  cosmolin 
to  prevent  blistering.  The  chloroform-vapor  must  be  well  mixed  with  air. 
The  chloroform  is  sprinkled  on  the  fabric  with  a  drop-bottle.  Raise  the 
napkin  well  above  the  mouth,  add  five  drops  of  chloroform,  and  tell  the 
patient  to  take  deep  and  regular  breaths,  but  do  not  tell  him  to  breathe  for- 
cibly. Forcible  respiration  may  lead  to  cessation  of  respiration.  Add  a 
few  more  drops  of  chloroform,  and  when  the  patient  grows  so  accustomed  to 
it  that  it  does  not  choke,  turn  the  wet  part  of  the  fabric  toward  the  face  and 
place  it  near  the  mouth;  do  not  touch  the  mouth  with  the  wet  lint,  because 
it  Avill  blister.  If  the  drug  is  given  gradually,  struggling  is  not  usually  violent 
or  prolonged.  Never  pour  on  a  large  amount  at  one  time.  Keep  the  lower 
jaw  pushed  forward  during  the  time  the  chloroform  is  being  given.  Cough 
and  vomiting  at  this  time  mean  that  the  vapor  is  too  strong.  During  the 
stage  of  excitement  do  not  suspend  the  administration  of  chloroform  unless 
respiration  becomes  difl&cult,  in  which  case  suspend  it  until  the  patient  takes 


Administration  of  Ether 


"93 


one  or  two  respirations.  If  the  patient  struggles,  do  not  hold  him  and  push 
the  administration  of  the  drug.  He  holds  his  breath  while  struggling,  and 
as  struggling  ceases  takes  full,  deep  breaths.  If  the  inhaler  is  .saturated 
with  chloroform,  he  may  inhale  a  dangerous  amount  during  the  deep  respira- 
tion after  struggling.  Chloroform  given  in  considerable  amount  when  the 
patient  is  breathing  deeply  from  the  effects  of  ether  is  unsafe.  If  chloroform 
is  given  subsequent  to  anesthetization  by  ether,  it  should  be  given  gradually 
and  well  mixed  with  air.  When  the  patient  becomes  anesthetized,  give 
just  enough  of  the  drug  to  keep  him  so.  After  the  patient  has  been  anes- 
thetized, hiccough  usually  means  that  vomiting  is  going  to  occur.  If  vomiting 
occurs  at  this  time,  more  chloroform  must  be  given  to  abolish  the  reflexes. 
Deep  and  sighing  respiration  and  repeated  swallowing  indicate  that  more 
of  the  anesthetic  is  required.  Stop  the  administration  or  give  very  little 
when  shock  becomes  evident  or  when  there  is  profuse  hemorrhage.  Chloro- 
form-vapor is  not  inflammable,  hence  it  is  safer  than  ether  when  a  hot  iron 
is  to  be  used  about  the  face  and  when  there  is  a  lighted  lamp  or  a  stove  in 
a  small  room;  but  the  presence  of  a  naked  gas-flame  decomposes  chloroform 
into  irritant  products  of  chlorin,  which  sometimes  cause  the  patient  and  the 
surgeon  to  cough  (COCI3). 

Chloroform  and  Oxygen.— The  use  of  this  mixture  was  suggested 
by  Neudorfer.  Some  anesthetists  advocate  the  use  of  chloroform  and  oxygen, 
asserting  that  it  does  not  produce  spasm  of  the  glottis  or  muscles  of  respiration, 
that  it  does  not  produce  cyanosis  or  weakness  of  circulation,  that  it  does 
not  irritate  the  kidneys,  is  safer  to  life  than  pure  chloroform,  and  is  less 
often  productive  of  severe  and  prolonged  vomiting.  These  alleged  advan- 
tages are  probably  stated  with  rather  undue  em- 
phasis, although  I  do  believe  the  mixture  has 
less  tendency  to  produce  cyanosis  than  has  the 
pure  drug,  does  not  so  often  induce  vomiting, 
and  is  somewhat  safer.  Hewitt  does  not  think 
that  the  method  offers  any  "special  advantages"/ 
("Anesthetics  and  their  Administration,"  by 
Fred.  W.  Hewitt).  If  this  method  is  used,  a 
bag  containing  oxygen  is  attached  to  the  hand- 
bellows  attachment  of  a  Junker  inhaler,  and 
oxygen  is  forced  through  the  chloroform  and 
flows  to  the  face-piece. 

Administration  of  Ether.— The  admin- 
istration should  not  be  intrusted  to  a  novice. 
The  anesthetist  should  be  one  of  your  best  men. 
Ether  is  best  given  by  a  partially  open  inhaler. 
The  most  satisfactory  appliance  is  Allis's  inhaler  (Fig.  702).  This  inhaler  se- 
cures a  plentiful  supply  of  air.  Before  being  used,  the  metal  frame  is  scalded, 
dried,  and  threaded  with  a  clean  gauze  bandage.  The  end  of  the  frame 
which  is  to  be  toward  the  mouth  is  covered  with  one  layer  of  gauze.  The  frame 
is  then  inserted  in  a  clean  metal  case  and  the  case  is  wrapped  in  a  clean  towel. 
Probably  the  safest  way  to  administer  ether  and  the  most  comfortable  for  the 
patient,  is  to  take  a  piece  of  gauze  or  an  Esmarch  inhaler  and  give  the  drug 
drop  by  drop,  the  drops  following  each  other  in  regular  sequence.     This  is 


Fig.  702. — Allis's    ether-inhaler. 


1 194 


Anesthesia  and  Anesthetics 


known  as  the  drop  method.  Many  surgeons  prefer  closed  inhalers.  The  Clover 
inhaler  is  popular  in  England  (Fig.  703) .  F  is  the  face-piece;  C,  a  reservoir  of 
ether  through  whichtheair-currentpasses;  5isan  India-rubber  bag.  In  this  ap- 
paratus there  is  no  provision  for  the  entrance  of  fresh  air.  By  turning  the  reser- 
voir C  on  the  tube  /  the  amount  of  current  passing  over  the  ether  can  be  regu- 
lated. When  this  apparatus  is  used,  the  ether  vapor  breathed  into  the  lungs  is 
expired  into  the  bag  and  is  rebreathed.  This  inhaler,  if  used  by  a  skilful  man, 
is  very  useful;  but  any  lack  of  watchfulness  or  skill  will  permit  of  cyanosis, 
and  the  very  young,  the  senile,  the  anemic,  and  feeble  are  best  anesthetized 
by  the  AUis  inhaler. 

An  admirable  detailed  account  of  anesthetization  by  the  closed  method 
will  be  found  in  Mr.  Frederic  W.  Hewitt's  treatise  on  "Anesthetics  and  their 
Administration"  (page  272),  and  in  Mr.  Dudley  W.  Buxton's  treatise  on 
"Anesthetics,  their  Uses  and  Administration  "  (page  109).  When  giving  ether, 
have  at  hand  the  same  drugs  and  appliances  as  when  chloroform  is  given, 
and  keep  the  lower  jaw  pushed  forward  during  the  administration.     When 


Fig.  70J.— Clo\cr's  portable  regulating  ether-inhaler. 


anesthetizing  by  Allis's  inhaler,  take  every  care  that  none  of  the  drug  runs 
through  on  to  the  face  and  into  the  eyes.  If  it  does  it  will  bUster.  Even  the 
vapor  irritates  the  eyes  and  boracic  acid  solution  should  be  used  now  and  then 
during  the  administration  to  flush  out  the  conjunctival  sacs.  It  is  \vise 
to  grease  the  face  and  lips  with  cosmolin.  Place  the  dry  inhaler  over  the 
mouth  and  nose,  let  the  patient  take  several  breaths,  that  he  may  gain  confidence, 
pour  a  few  drops  of  ether  into  the  inhaler,  let  the  patient  take  several  more 
breaths,  and  so  on,  gradually  increasing  the  amount  of  ether.  If  he  tends  to 
struggle,  diminish  the  amount  of  ether  for  a  time,  but  do  not  hold  him.  Do  not 
tell  him  to  breathe  forcibly.  Forcible  breathing  is  liable  to  cause  cessation  of 
respiration.  Never  suddenly  add  a  large  amount  of  the  anesthedc:  it  causes 
coughing  and  often  vomiting.  When  the  patient  becomes  thoroughly  anesthet- 
ized, give  a  very  little  ether  as  often  as  is  required  to  maintain  unconsciousness. 


Rectal  Etherization  HQS 

When  bleeding  is  profuse  or  shock  is  marked,  suspend  the  administration  of 
ether  or  give  very  little  of  it.  If  a  hot  iron  is  to  be  used  aljout  the  face,  remove 
the  inhaler  and  fan  away  the  ether  before  bringing  the  cautery  near.  Have  any 
light  set  high  up,  as  ether  vapor  is  heavier  than  air,  and  no  explosion  is  possible 
until  it  reaches  the  level  of  the  flame.  If  the  vapor  takes  tire,  cover  the  patient's 
mouth  and  nose  with  a  towel.  If  he  rolls  his  eyes  from  side  to  side,  if  the  res- 
pirations are  deep  and  sighing,  if  there  are  repeated  movements  of  swallowing, 
more  anesthetic  should  be  given  (Tarnowsky).  Hiccough  is  often  preliminary 
to  vomiting,  and  always  means  that  the  reflexes  are  returning. 

The  patient  should  be  kept  in  a  condition  in  which  he  feels  no  pain,  makes 
no  movement,  and  is  not  rigid.  In  this  condition  the  cutaneous  reflexes  are 
abolished,  the  breathing  is  regular  and  quiet,  the  color  is  good  and  the  pupils 
react  to  light,  though  slowly.  Just  enough  anesthetic  must  be  given  to  cause 
the  patient  to  pass  into  this  condition  and  remain  in  it.  To  give  any  more 
is  to  poison  him.  The  amount  necessary  varies  with  the  individual  and  the 
operation,  and  requires  skill,  experience,  and  attention  on  the  part  of  the  anes- 
thetist. 

The  old  idea  that  we  must  poison  a  man  into  dangerous  coma  has  been 
abandoned.  When  the  breathing  becomes  louder,  more  rapid,  or  spasmodic, 
it  means  that  reflexes  are  returning  and  a  little  more  anesthetic  should  be 
given. 

Ether  and  Oxygen. — This  mixture  is  useful  in  certain  cases  in  which 
respiratory  diiiiculty  exists,  particularly  in  empyema.  If  during  the  adminis- 
tration of  ether  cyanosis  tends  to  occur,  it  is  often  advantageous  to  give  oxygen 
with  the  ether.  The  process  of  anesthetization  by  ether  and  oxygen  is  some- 
what slower  than  by  ether  vapor  mixed  with  air.  It  can  be  given  by  insert- 
ing beneath  the  Allis  inhaler  or  pushing  deep  down  into  it,  from  above,  a  tube 
attached  to  a  reservoir  of  oxygen  and  from  which  a  stream  of  oxygen  emerges. 

Rectal  Etherization. — Pirogoff  suggested  this  method  in  1847  and 
Roux  employed  it  the  same  year.  The  method  is  only  used  in  operations  about 
the  face,  tongue,  nasopharynx,  larynx,  mouth,  and  larynx;  in  other  words,  in 
cases  in  which,  were  the  ether  given  by  inhalation,  the  operator  and  anes- 
thetist would  interfere  with  each  other.  The  rectum  should  be  emptied 
by  a  purgative  enema  the  day  before  the  operation,  and  again  the  morning  of 
the  operation,  and  a  short  time  before  giving  the  ether  the  rectum  should  be 
irrigated  with  warm  salt  solution.  A  dose  of  laudanum  is  given  a  few  hours 
before.  We  should  employ  an  apparatus  of  the  type  of  Buxton's,  which  pre- 
vents liquid  ether  from  passing  into  the  rectum. 

A  tube  containing  ether  is  set  in  a  vessel  containing  water  at  a  temperature 
of  122°  F.  The  ether  tube  is  joined  by  a  glass  tube  and  rubber  pipe  to  a  glass 
globe,  and  the  globe  is  connected  by  a  rubber  pipe  to  the  tip,  which  is  inserted 
into  the  rectum.  If  ether  vapor  condenses  into  liquid  in  the  glass  globe  the 
globe  should  be  at  once  emptied.  During  the  administration  abdominal  dis- 
tention occurs  from  unabsorbed  ether,  and  from  time  to  time  the  administra- 
tion should  be  suspended  temporarily  to  permit  the  gas  to  escape,  otherwise 
too  much  will  be  given  and  prolonged  stupor  and  postoperative  coHc  may 
result.  It  takes  much  longer  to  obtain  unconsciousness  by  rectal  administra- 
tion than  by  inhalation.  The  method  must  never  be  used  if  the  intestines  are 
irritated  or  inflamed  (Dumont,  in  "Corr-Bl.  f.  Schweizer  Aerzte,"-Dec.  15, 


1 196  Anesthesia  and  Anesthetics 

1908).  The  method  has  never  come  into  general  use.  It  irritates  the  large 
intestine,  often  produces  coHc,  and  sometimes  is  said  to  lead  to  protracted  stupor 
("Anesthetics  and  Their  Administration,"  by  Fred.  W.  He\\-itt).  Dudley  \V. 
Buxton,  however,  has  employed  it  in  many  operations  about  the  face,  mouth, 
and  lar}Tix,  and  in  some  operations  for  empyema,  and  commends  it.  Rectal 
etherization  does  not  produce  a  sense  of  suffocation,  the  stage  of  excitement  is 
short,  and  strugghng  is  tri\-ial  or  absent. 

Anesthetic  State  from  Ether  or  Chloroform.— The  inhalation  of 
an  anesthetic  produces  irritation  of  the  fauces,  often  some  cough,  a  profuse 
secretion  of  mucus,  acts  of  swallowing,  dilatation  of  the  pupils,  flushed  face, 
and  sometimes  strugghng  (especially  in  children  and  in  drunkards).  If  the 
vapor  is  given  at  once  in  concentrated  form,  cough  will  be  violent  and  will 
cause  cyanosis.  If  the  anesthetic  is  given  carefully,  the  cough  soon  ceases, 
the  respirations  become  rapid  and  often  convulsive,  the  pulse  becomes  fre- 
quent, and  the  patient  passes  into  a  condition  of  active  intoxication  with 
presentation  of  sight  and  touch,  loss  of  hearing  and  smell,  diminution  of 
pain  and  sensibility,  and  often  with  illusions  or  hallucinations.  In  this 
stage  the  patient  may  struggle,  and  while  efforts  are  being  made  to  hold 
him,  cyanosis  may  occur.  From  the  stage  of  excitement  just  alluded  to, 
many  subjects  (strong  men  and  drunkards)  pass  into  a  stage  of  rigidity 
in  which  the  muscles  become  firmly  fixed,  the  breathing  impeded,  the  respira- 
tions stertorous,  and  the  face  bluish  and  congested.  Too  rapid  forcing  of 
the  anesthetic  tends  to  cause  rigidity,  and  a  skilled  anesthetist  endeavors 
to  avoid  its  production,  because  it  is  dangerous.  The  next  stage  is  one 
of  insensibility ;  the  pupils  are  contracted,  but  react  sluggishly  to  light.  If  anes- 
thesia is  deep,  the  contracted  pupils  \\-ill  not  react  to  hght;  if  anesthesia  is  pro- 
found, the  pupils  dilate,  but  will  not  react  to  Hght.  The  conjunctival  reflex 
is  gone;  the  lids  are  closed;  if  the  arm  is  lifted  and  allowed  to  fall,  it  drops 
as  a  dead  weight;  the  skin  is  cool  and  moist,  and  often  wet  with  sweat;  the 
respirations  are  easy  and  shallow;  the  pulse  is  slow;  and  there  is  complete 
unconsciousness  to  pain.  The  loss  of  conjunctival  reflex  is  the  usually 
accepted  sign  that  the  patient  is  unconscious.  In  a  young  child  this  reflex 
is  soon  exhausted  by  touching  the  eye,  and  the  sign  is  unreliable.  If  a  baby 
is  to  be  anesthetized,  the  administrator  places  his  finger  in  the  infant's  hand. 
The  child  grasps  the  finger,  and  relaxes  its  grasp  when  unconscious. 

Always  bear  in  mind  that  dilated  pupils  reacting  to  light  and  associated 
with  presented  conjunctival  reflex  mean  that  anesthesia  is  not  complete; 
that  contracted  pupils  reacting  to  light  and  \\ithout  conjunctival  reflex  m.ean 
moderate  anesthesia;  that  contracted  pupils  not  reacting  to  Hght  and  without 
conjunctival  reflex  mean  deep  anesthesia;  that  dilated  pupils  not  reacting 
to  light  and  associated  with  lost  conjunctival  reflex  mean  dangerously  pro- 
found anesthesia.  The  pupillary  phenomena  are  very  valuable  when  present, 
but  unfortunately  they  are  absent  at  some  stage  of  the  anesthesia  in  many  cases. 
Inequality  of  the  pupils  is  not  unusual  and  fixation  of  one  pupil  or  of  both  may 
occur.  A  preliminary  dose  of  morphin  interferes  with  the  pupillar\'  phenom- 
ena. Sudden  dilatation  with  fixation  is  always  very  ominous.  Weak  pulse 
and  pallor  may  be  due  to  nausea,  but  always  require  instant  attention.  Vom- 
iting may  be  due  to  forcing  strong  vapor  upon  the  patient,  but  may  also  be 
due  to  his  partially  emerging  from  a  state  of  insensibility. 


Treatment  of  Complications  1197 

Watch  the  pulse  carefully  to  see  if  it  becomes  very  weak,  irregular,  ab- 
normally slow,  or  abnormally  fast.  Syncope  may  be  due  to  nausea,  shock, 
hemorrhage,  or  the  gi\'ing  of  too  much  of  the  drug.  Watch  the  respiration, 
and  do  not  forget  that  the  chest-walls  and  belly  may  move  when  no  air  is 
entering  the  lungs;  hence  always  listen  to  the  breathing.  Cyanosis  is  a  dusky 
or  bluish  discoloration  of  the  skin.  This  condition  indicates  want  of  oxy- 
gen in  the  blood.  The  individual  may  have  been  cyanotic  or  predisposed 
to  cyanosis  to  start  with;  cyanosis  may  be  due  to  pressure;  to  cough  early 
in  the  administration;  to  struggling  during  the  stage  of  excitement;  to  gather- 
ing of  mucus  in  the  respiratory  tract;  or  to  rigid  fixation  of  the  respiratory 
muscles.  It  may  also  be  due  to  obstruction  of  the  air-passages  by  some  foreign 
matter,  as  blood  or  vomit,  lodging  in  the  bronchial  tubes,  windpipe,  larynx, 
or  pharynx;  falling  back  of  the  tongue  {swallowing  of  the  tongue);  closure  of 
the  epiglottis;  or  to  the  glottis  being  pushed  against  the  pharyngeal  wall  by 
bending  the  head  forward.  Some  patients  with  occluded  nostrils  may  fail 
to  get  enough  air  because  of  closure  of  the  lips.  A  patient  may,  while  taking 
an  anesthetic,  lie  perfectly  quiet  and  appear  to  "forget  to  breathe."  Ether 
and  chloroform  can  certainly  cause  shock.  Neither  drug  keeps  nerves  from 
conveying  stimuli  and  each  produces  a  fall  of  blood-pressure,  chloroform  di- 
rectly by  its  action  on  the  vasomotor  center,  ether  by  overstimulation  of  the 
vasomotor  center  (Buxton,  in  "Proceedings  of  the  Royal  Soc.  of  Med.," 
April,  1909).  Each  produces  a  fall  of  temperature.  Buxton  heartily  con- 
demns the  once  common  behef  "that  evidences  of  shock  during  a  surgical 
operation  are  a  proof  that  an  insufficient  quantity  of  the  anesthetic  has  been 
given  and  that  the  symptoms  of  shock  can  be  abrogated  by  increasing  the  depth 
of  the  narcosis"  (Ibid.).  Shock  is  manifested  by  deathly  pallor,  weak, 
rapid,  and  irregular  pulse,  slow  respiration,  cold  extremities,  and  a  drench- 
ing sweat.  Edema  of  the  lungs  occasionally  arises  during  or  after  anesthesia. 
Treatment  of  Complications. — Vomiting  due  to  too  much  anes- 
thetic is  corrected  by  giving  a  few  breaths  of  air;  vomiting  due  to  incomplete 
anesthesia  is  amended  by  giving  more  of  the  vapor.  WTien  the  patient 
vomits,  hold  the  head  over  the  edge  of  the  bed,  separate  the  jaws  with  the 
gag,  and  wipe  out  the  vomited  matter,  mucus,  and  saliva.  Shock  is  treated 
by  diminishing  the  amount  of  the  anesthetic  given,  by  the  h}'podermatic 
injection  of  atropin  (atropin  is  very  useful  when  there  is  a  profuse  sweat), 
by  the  administration  of  hot  saline  fluid  by  the  rectum,  by  surrounding  the 
patient  with  hot-water  bottles,  or  by  wrapping  him  in  hot  blankets,  and  by 
lowering  the  head  of  the  bed.  Syncope  is  sudden  cerebral  anemia  usually 
due  to  a  reflex  cause.  A  tendency  to  syncope  requires  lowering  of  the  head 
of  the  bed,  suspension  of  the  anesthetic,  and  hypodermatic  injection  of  strych- 
nin. In  extreme  syncope,  which  is  most  apt  to  occur  from  chloroform,  do 
not  wait  for  breathing  to  cease,  but  suspend  the  anesthetic,  lower  the  head 
of  the  bed,  open  the  mouth  with  the  gag,  catch  the  tongue,  and  make  rhyth- 
mical traction  while  an  assistant  is  making  slow  artificial  respiration.  If  the 
patient  does  not  at  once  improve,  invert  him  completely,  holding  him  by  the 
legs  and  continuing  artificial  respiration  by  compressing  the  sternum  (Nel- 
aton).  By  continuing  artificial  respiration  the  blood  is  urged  on  through 
the  heart.  Give  hypodermatic  injections  of  atropin,  ether,  or  even  of 
ammonia.     Put   mustard  over   the  heart  and  spine.     Employ  faradism  to 


1 198  Anesthesia  and  Anesthetics 

the  phrenic  nerve  (one  pole  to  the  epigastric  region,  the  other  to  the  right 
side  of  the  root  of  the  neck).  Let  fresh  air  into  the  room,  put  hot-water 
bottles  around  the  legs,  apply  friction  to  the  extremities,  wrap  the  patient 
in  hot  blankets,  give  an  enema  of  hot  salt  solution,  and  hold  ammonia  to 
the  nose.  In  some  cases  of  chloroform  poisoning  direct  heart  massage  has- 
been  successfully  employed.  In  Sencert's  successful  case  an  operation 
was  being  done  for  gall-stones  when  collapse  occurred,  and  the  surgeon 
stroked  and  kneaded  the  heart  through  the  diaphragm.  In  a  case  recorded 
in  the  "Brit.  Med.  Jour.,"  Nov.  18,  1905,  respiration  and  pulse  had  ceased 
three  minutes  when  the  abdomen  was  opened  and  the  heart  was  kneaded. 
Recovery  ensued.  Miiller,  of  Hamburg,  advocates  exposing  and  opening, 
the  pericardium  to  perform  massage,  introducing  oxygenated  salt  solution  into^ 
a  vein,  opening  the  trachea,  and  performing  artificial  respiration.  Leonard 
Hill  holds  that  in  the  failure  which  arises  soon  after  administration  of  chloro- 
form is  begun  the  trouble  is  due  to  vasomotor  paralysis  with  starvation  of 
the  nerve-centers.  In  such  a  case  he  applies  abdominal  compression  and 
inverts  the  patient,  making  artificial  respiration  at  the  same  time.  In  the 
failure  which  occurs  after  considerable  chloroform  has  been  taken  there  are 
paralytic  distention  of  the  heart,  fulness  of  the  venous  system,  and  loss 
of  the  compensations  for  the  hydrostatic  effects  of  gravity.  In  such  a  con- 
dition empty  the  distended  heart  of  venous  blood  by  raising  the  patient 
into  an  erect  position;  and  after  a  moment  place  him  recumbent  and  make 
artificial  respiration. 

"Forgetting  to  breathe''  is  met  by  removing  the  inhaler  and  waiting  a 
moment;  a  breath  will  usually  be  taken  soon;  but  if  it  is  not  taken,  somewhat 
forcibly  knead  the  structures  in  the  arm-pit.  If  this  fails,  open  the  mouth  and 
pull  forward  the  tongue;  this  causes  a  reflex  inspiration.  Cyanosis  is  prac- 
tically not  encountered  when  oxygen  is  given  with  ether  or  chloroform.  Cyano- 
sis, if  slight,  and  due  to  cough  or  struggling,  is  met  by  removing  the  inhaler 
while  the  patient  takes  a  breath  or  two  of  air.  If  position  is  responsible  for 
cyanosis,  correct  it.  In  empyema,  lying  upon  the  sound  side  may  produce  it, 
and  obstruction  to  breathing  may  be  due  to  bending  down  the  head.  If  due 
to  stenosis  of  the  nares  in  a  person  without  teeth,  hold  the  lips  apart  with  a 
finger.  If  due  to  collection  of  mucus,  wipe  the  mucus  out  of  the  mouth  by 
means  of  bits  of  gauze  firmly  clamped  in  forceps;  raise  the  shoulders,  extend  the 
head  and  place  it  on  its  side  in  order  that  mucus  may  run  out  of  the  angle  of 
the  mouth;  and  give  a  dose  of  atropin.  If  the  amount  is  large  and  the  secre- 
tion persistent,  it  may  be  necessary,  especially  in  children,  to  empty  the  respira- 
tory passages  by  inverting  the  patient.  In  cases  of  excessive  bronchial  secre- 
tion we  fear  the  development  of  pulmonary  edema  or  postoperative  broncho- 
pneumonia. 

Dudley  W.  Buxton  points  out  that  duskiness  will  often  pass  away  if 
ether  is  removed,  one  or  two  inhalations  of  chloroform  given,  and  ether 
then  continued.  If  in  any  case  cyanosis  is  severe  or  grows  worse,  suspend 
the  drug,  dash  cold  water  in  the  face,  force  open  the  jaws,  pull  forward  the 
tongue,  make  artificial  respiration  until  a  breath  is  taken,  and  then  give 
oxygen  for  a  time.  If  these  means  fail,  stretch  the  sphincter  ani  and  bleed 
from  the  external  jugular  vein.  If  a  breath  is  not  now  taken,  do  trache- 
otomy.    In  respiratory  or  heart  failure  forced  artificial  respiration  by  Fell's 


Artificial  Respiration 


1199 


method  is  of  great  value  (page  894).  In  Fell's  method  a  tracheal  tube  is  in- 
serted, and  by  means  of  a  foot-bellows  air  is  forced  into  the  lungs,  after  first 
passing  through  a  warming  chamber.  Instead  of  a  tracheal  tube,  we  may  use 
a  face-mask  and  an  intubation-tube.  "Swallowing  the  tongue"  is  corrected 
by  pulling  the  tongue  forward.  If  it  tends  to  recur,  lay  the  head  upon  its 
side  or  keep  the  tongue  anchored  with  forceps.  Closure  of  the  epiglottis 
is  corrected  by  pulling  the  patient's  head  over  the  edge  of  the  table  and 
pushing  strongly  back  upon  his  forehead.  This  maneuver  lifts  the  hyoid 
bone,  and  with  it  the  epiglottis.  The  epiglottis  can  be  Hfted  by  passing  a  spoon- 
handle  or  the  index-finger  over  the  dorsum  to  the  base  of  the  tongue  and  press- 


Fig.  704.— Artificial  respiration,  first  movement. 

ing  forward.  If,  in  obstruction  to  respiration,  the  above  means  fail,  make 
artificial  respiration  at  once;  if  obstruction  continues,  perform  tracheotomy. 
Edema  of  the  lungs  is  treated  by  instant  venesection,  the  inhalation  of 
nitrite  of  amyl,  and  the  administration  of  stimulants  and  nitroglycerin  hypo- 
dermatically.  Sometimes,  duing  the  anesthetic  state,  the  muscles  of  the  belly 
become  very  rigid,  a  condition  which  greatly  interferes  with  an  abdominal 
operation.  It  may  arise  during  cyanosis,  and  if  so  caused,  is  amended,  as 
cyanosis  abates,  under  proper  treatment.  In  some  cases  it  is  due  to  the 
fact  that  sufficient  anesthetic  has  not  been  given.     If  the  air-passages  are 


tig.  705.— Artificial  respiration,  second  movement. 


obstructed,  abdominal  rigidity  is  apt  to  arise.  In  some  cases  it  seems  im- 
possible to  overcome  it  with  ether.  In  such  a  case,  if  the  anesthetist  is  a 
trusted  man,  anesthetize  the  patient  with  gas  and  ether  and  then  give  chloro- 
form (Blumfield,  in  "Lancet,"  May  31,  1902). 

Artificial  Respiration. — Laborde's  Method. — Place  the  patient  on 
his  back  with  the  head  lower  than  the  body,  all  the  clothing  loosened,  and 
the  jaws  wedged  apart,  and  wipe  the  mucus  from  the  throat  and  mouth. 
Grasp  the  tongue  with  forceps,  and  once  in  every  four  seconds  pull  it  quickly 


I200  Anesthesia  and  Anesthetics 

and  strongly  forward  and  then  permit  it  to  go  l)a  -k.  It  may  be  necessary 
to  keep  up  this  proceeding  for  thirty  minutes  or  eveu  more. 

Laborde's  method  should  be  associated  with  "concentric  thoracic  and 
upward  abdominal  pressure  applied  in  a  rhythmic  manner  by  two  assistants 
at  the  time  of  relaxation  of  the  tongue."*  Laborde  beheves  that  tongue- 
traction  causes  contractions  of  the  diaphragm. 

Sylvester's  Method  (Figs.  704,  705).— The  patient  is  placed  recumbent 
with  the  foot  of  the  bed  raised.  The  surgeon  grasps  the  arms  just  above 
the  elbows,  and  draws  them  outward  and  upward  until  they  are  nearly  per- 
pendicular (Fig.  704) ;  they  are  held  perpendicular  for  two  seconds,  while  air 
is  entering  the  lungs;  the  arms  are  then  lowered  and  pressed  against  the 
sides  of  the  chest  (Fig.  705)  for  two  seconds,  during  which  time  the  chest  is 
emptied  as  in  expiration.  These  movements  of  elevation  and  depression  are 
made  twelve  or  fifteen  times  a  minute. 

The  Reaction  from  Anesthesia.— When  ether  or  chloroform  is 
given,  a  considerable  quantity  is  swallowed  and  either  drug  irritates  the 
stomach  and  creates  nausea  and  often  vomiting.  The  longer  the  operation, 
the  more  of  the  anesthetic  enters  the  stomach,  and  the  greater  the  hability  to 
subsequent  vomiting.  At  the  termination  of  a  prolonged  operation  upon  an 
adult,  if  the  patient's  condition  admits  of  it,  and  if  the  nature  of  the  operation 
does  not  forbid  it,  I  like  to  have  a  stomach-tube  passed  and  the  stomach 
well  washed  out  with  warm  water.  The  washings  smell  strongly  of  the 
anesthetic,  and  the  procedure  greatly  lessens  the  severity  and  frequency  of 
post-operative  vomiting  (Geo.  S.  Brown,  in  "Surgery,  Gynecology,  and 
Obstetrics,"  August,  1905).  After  the  administration  of  the  anesthetic  has 
been  suspended  and  the  operation  has  been  completed,  the  temperature  is 
usually  subnormal.  The  patient  must  be  watched  until  consciousness  retiurns. 
If  he  is  left  alone,  a  change  of  posture  may  lead  to  arrest  of  feeble  respiration, 
the  assumption  of  the  erect  position  may  cause  fatal  syncope,  or  mucus  or 
vomited  matter  may  block  the  air-passages  and  cause  suffocation.  The  best 
position  to  place  him  in  is  the  recumbent,  the  head  being  level  with  the  body 
or  somewhat  lower,  and  the  side  of  the  face  resting  on  the  pillow.  Shock  is 
treated  by  ordinary  methods.  The  inhalation  of  oxygen  is  of  great  value  in 
rousing  a  patient  from  the  state  of  anesthesia,  and  will  often  prevent  vomiting. 
If  vomiting  occurs,  the  head  should  be  upon  its  side  or  should  be  held  over 
the  edge  of  the  bed,  and  after  the  spell  of  vomiting  the  mouth  must  be  wiped 
clean.  The  face  should  be  washed  with  cold  water  and  be  fanned  rather 
actively.  It  is  the  routine  practice  of  some  surgeons  to  administer  vinegar  by 
inhalation  during  the  reaction  from  an  anesthetic.  This  proceeding  some- 
times seems  to  prevent  vomiting.  Some  patients  awake  from  anesthesia  as 
from  a  quiet  sleep;  others  are  noisy,  tur]:)ulent,  and  violent.  The  duration  of 
the  period  of  reaction  varies  with  the  anesthetic  used,  the  amount  given,  and  the 
personal  tendencies  of  the  patient.  The  patient  must  not  be  allowed  to  sit  up 
for  several  hours  at  least.  No  food  is  to  be  allowed  for  at  least  six  hours. 
Unless  the  operation  was  upon  the  stomach,  I  do  not  forbid  water,  but  allow  the 
patient  to  drink  freely  of  hot  water.  This  dilutes  any  irritant  material  in  the 
stomach  and  dissolves  mucus,  and  if  vomiting  does  occur,  it  serves  to  wash  the 
stomach  out.  All  fat  patients,  all  patients  with  respiratory  difficulties,  or  in 
*  Joseph  D.  Bryant's  "Operative  Surgery." 


Respiratory  Disorders  1201 

whom  we  api)r(>hcncl  respiratory  complications,  should  be  placed  in  a  sitting 
or,  at  least,  a  semi-erect  posture  as  soon  as  reaction  from  anesthesia  is  obtained. 
If  this  plan  is  followed,  ether-pneumonia  and  other  respiratory  troubles  will 
very  seldom  develoj). 

After=effects  of  Anesthetics. — Vomiting. — Vomiting  *  may  occur 
in  spite  of  all  we  can  do,  and  may  persist  for  hours,  greatly  exhausting  the 
patient  and  doing  infinite  harm,  it  may  be,  if  the  operation  were  upon  the 
brain  or  an  intra-abdominal  structure.  If  vomiting  continues,  forbid  food. 
Very  hot  water  in  doses  of  a  teaspoonful  should  be  given  at  frequent  intervals. 
A  draught  of  hot  water  may  relieve  the  condition  by  washing  out  the  mucus 
from  the  stomach.  Other  remedies  which  may  succeed  are:  inhalations  of 
vinegar,  hot  black  coffee  by  the  mouth,  a  mustard  plaster  over  the  stomach, 
fresh  air  in  the  room,  small  pieces  of  ice  placed  in  the  mouth  and  sucked,  small 
doses  of  iced  champagne,  and  drop  doses  of  a  3  per  cent,  solution  of  cocain  or 
3-drop  doses  of  a  5  per  cent,  solution  of  eucain.  The  best  remedy  for  persistent 
vomiting  is  lavage  of  the  stomach.  Some  persons,  as  Dudley  W.  Buxton  points 
out,  suffer  greatly  from  nausea,  although  there  is  little  or  no  vomiting.  In  such 
cases  Buxton  uses  v\j  of  tincture  of  nux  vomica  in  a  teaspoonful  of  hot  water 
every  ten  minutes  until  six  doses  are  taken.  If  this  plan  fails,  he  gives  drop 
doses  of  wine  of  ipecac  or  minim  doses  of  dilute  hydrocyanic  acid.* 

Vomiting  jroni  chloroform  is  usually  more  difficult  to  check  than  vomit- 
ing from  ether. 

Backache. — This  is  a  very  common  and  often  a  very  distressing  conse- 
quence of  anesthesia.  It  is  often  complained  of  soon  after  consciousness  is 
regained,  it  may  persist  for  several  days,  and  it  is  a  not  uncommon  cause  of 
wakefulness.  It  is  usually  greatly  aggravated  by  turning  and  twisting,  and 
by  attempting  to  rise  up.  The  pain  is  located  in  the  lumbar  and  sacral  regions 
and  is  often  accompanied  by  rigidity  of  the  lumbar  muscles.  Various  ex- 
planations have  been  given  of  it.  One  view  is  that  it  is  due  to  renal  congestion. 
Another,  that  it  results  from  congestion  of  the  spinal  cord.  I  believe  that  the 
real  explanation  is  that  of  John  Dunlop  ("N.  Y.  Med.  Jour.,"  July  10,  1909), 
viz. :  "  The  patient  during  the  operation  lay  upon  a  flat  table  without  support 
to  the  lumbar  curve,  consequently  the  sacro-iliac  synchondroses  were  strained. 
The  backache  may  be  largely  prevented  by  placing  a  small  pillow  so  that  it  will 
support  the  lumbar  curve  during  anesthesia." 

Respiratory  disorders  are  more  often  noted  after  ether  than  after  chloro- 
form. Bronchitis  may  follow  or  bronchopneumonia  (eiher-pneumonia). 
Respiratory  difficulties  may  be  due  to  chilling  the  patient  by  bringing  him 
from  a  warm  operating-room  through  a  cold  hall  and  into  a  cool  bedroom. 
Bronchopneumonia  is  especially  common  in  septic  patients,  and  may  be 
due  in  some  cases  to  septic  emboli  and  in  others  to  aspiration  of  septic  material 
into  the  bronchi  (cases  of  cancer  of  tongue  and  pharynx,  and  cases  with  ster- 
coraceous  vomiting).  They  are  treated  by  ordinary  methods.  If  chloro- 
form is  given  when  a  gas-light  is  in  the  room,  the  vapor  is  decomposed 
and  certain  highly  irritant  products  are  formed,  which,  when  inhaled, 
produce  laryngeal  spasm  and  possibly  bronchitis.  The  irritant  material 
is  probably  CO  CI  3.  The  treatment  is  freely  to  admit  fresh  air  into  the 
room,  and  to  have  the  patient  inhale  oxygen  or  vinegar.     Ether-pneumonia 

*  "Anesthetics,"  by  Dudley  W.  Buxton. 
76 


I202  Anesthesia  and  Anesthetics 

must  not  be  confounded  with  postoperative  pneumonia,  described  by  Wm.  H. 
Bennett.*  This  latter  condition  may  arise  from  seven  to  fourteen  days  after 
operation  in  robust,  gouty  people,  and  is  usually  unilateral.  If  the  patient  is 
placed  in  a  sitting  position,  or  at  least,  semi-erect  in  bed,  as  soon  as  he  reacts  from 
the  anesthetic  the  danger  of  serious  respiratory  disorder  will  be  at  a  minimum. 

Renal  Complications. — After  the  administration  of  an  anesthetic, 
blood,  albumin,  or  sugar  may  appear  in  the  urine,  and  the  secretion  may 
become  scanty  or  even  be  suppressed.  It  is  usually  maintained  that  chloro- 
form is  less  apt  to  irritate  the  kidney  epithelium  than  is  ether,  but  there 
has  been  much  dispute  on  this  point.  If  casts  and  albvimin  are  present 
before  anesthetization,  the  condition  may  be  rendered  worse  when  ether  or 
chloroform  is  given.  If  neither  casts  nor  albumin  are  present,  they  will  not 
be  so  apt  to  appear  after  taking  chloroform  as  after  taking  ether,  but  if  they 
do  appear  after  chloroform,  they  remain  longer  than  after  ether  (Legrain). 
The  truth  of  the  matter  probably  is  that  if  the  kidneys  are  healthy,  a  small  or 
moderate  amount  of  either  drug  is  not  particularly  irritant ;  but  if  the  kidneys 
are  diseased,  a  small  amount,  and  even  if  they  are  healthy,  a  large  amount, 
of  either  drug  produces  decided  renal  irritation.  Chloroform  is  less  irritant 
because  less  chloroform  than  ether  is  given  to  secure  and  maintain  anesthesia. 
Scantiness  or  suppression  of  urine  may  be  due  to  operative  shock  rather 
than  to  ether  or  chloroform.  If  the  urine  becomes  somewhat  scanty  or 
if  albumin  appears  in  it,  give  non-irritant  diuretics,  diaphoretics,  and  cathar- 
tics, and  employ  enteroclysis.  If  the  urine  becomes  very  scanty,  use  hypo- 
dermoclysis.  If  post-operative  suppression  arises,  it  is  the  usual  custom  to 
give  intravenous  infusion  of  hot  saline  fluid,  but  I  am  doubtful  of  its  value. 
Exposure  of  each  kidney  in  the  loin  and  incision  of  its  capsule  to  relieve  tension 
is  justifiable  and  may  do  good. 

Acid  Intoxication. — This  condition  has  been  called  ^^ delayed  poisoning," 
aceionuria,  and  acidosis.  It  is  known  that  even  in  healthy  urine  there  may 
be  a  trace,  but  a  bare  trace,  of  acetone.  In  certain  cases  in  which  dangerous 
symptoms  arise  after  anesthesia,  the  urine  contains  albumin,  casts,  and  either 
diacetic  acid  or  acetone  or  both  of  these  substances.  Acid  intoxication  is  very 
much  commoner  after  the  administratin  of  chloroform  than  of  ether,  but 
may  follow  the  giving  of  any  general  anesthetic.  It  may  occur  in  individuals 
whose  tissues  contain  areas  of  fatty  degeneration,  but  it  also  occurs  in  those 
entirely  free  from  degeneration;  in  fact,  children  particularly  suffer  in  this 
way  after  the  use  of  chloroform.  The  actual  operation  has  nothing  to  do 
with  the  trouble,  and  sepsis  is  not  causative.  The  drug  used  as  an  anesthetic 
causes  acute  fatty  degeneration  of  the  hver,  quantities  of  toxins  are  formed,  and 
these  toxins  cause  the  symptoms.  Acetone,  diacetic  acid,  and  beta-oxybutyric 
acid  are  by-products  of  the  process  and  are  antecedents  or  precursors  of  acetone. 
The  symptoms  arise  after  the  patient  has  emerged  from  anesthesia  and  reacted 
from  shock.  There  is  persistent  vomiting  of  thin  and  foul  fluid,  the  patient  is 
extremely  restless  and  much  excited,  there  may  be  delirium,  but  dulness  and 
heaviness  may  take  the  place  of  restlessness  and  excitement  and  coma  may  arise 
(J.  A.  Kelly,  in  "Annals  of  Surg.,"  Feb.,  1905).  Usually  the  temperature  is 
subnormal,  but  sometimes  there  is  elevated  temperature.  In  many  cases 
jaundice  arises.     There  is  an  odor  of  acetone  on  the  breath.     The  urine  con- 

*  Practitioner,  Dec,  1896. 


Postanesthetic  Paralysis  or  Narcosis  Palsy  1203 

tains  albumin  and  casts,  and  either  diacetic  acid  or  acetone  or  both.  Some 
cases  recover,  but  most  of  them  die  in  from  one  to  five  days.  A  knowledge  of 
this  condition  explains  some  othervi^ise  inexplicable  deaths,  and  also  some  cases 
of  retarded  convalescence.  In  acid  intoxication  there  is  fatty  degeneration 
of  the  kidneys,  of  the  liver,  of  the  suprarenal  glands,  and  of  the  gastric  mucosa. 
The  occurrence  of  such  a  condition  is  an  impressive  admonition  that  a  surgeon 
should  operate  quickly,  that  as  Uttle  of  the  anesthetic  should  be  given  as 
possible,  that  the  urine  should  be  carefully  examined  each  day  after  operation 
for  certainly  several  days,  and  that  chloroform  should  not  be  used  for  prolonged 
administration.  Severe  acid  intoxication  is  treated  as  follows:  Encourage 
skin  activity  by  wrapping  the  patient  in  blankets  and  surrounding  him  with 
hot-water  bags.  Give  salt  solution  with  bicarbonate  of  sodium  by  hypoder- 
moclysis  and  by  the  rectum.  In  mild  cases  of  acetonuria  simply  give  sodium 
bicarbonate  by  the  stomach.  Bevan  and  Farill  ("Jour.  Am.  Aled.  Assoc," 
Sept.  20,  1905)  reported  one  case  and  collected  27  from  hterature.  In  this 
series  there  were  2  recoveries.  (On  this  subject  see  Lewis  Beesly,  in  "Brit. 
Med.  Jour.,"  May  19,  1906;  J.  A.  Kelly,  in  "Annals  of  Surgery,"  Feb.,  1905; 
A.  D.  Bevan  and  H.  B.  Farill,  in  "Jour.  Am.  Med.  Assoc,"  Sept.  20,  1905; 
Geo.  E.  Brewer,  in  "Transactions  Am.  Surg.  Assoc,"  vol.  xx,  1902.) 

Postanesthetic  Paralysis  or  Narcosis  Palsy. — Paralysis  may  arise 
during  anesthesia  as  a  result  of  cerebral  hemorrhage  or  embolism. 

It  sometimes  happens  that  when  a  person  has  come  out  of  anesthesia  a 
palsy  of  some  part  is  found  to  exist,  the  condition  being  peripheral  and  not 
central  in  origin.  Peripheral  narcosis  palsies  are  pressure  palsies,  although  it  is 
held  by  some  that  the  anesthetic  has  a  toxic  influence  which  distinctly  lowers 
the  capacity  of  the  nerves  to  sustain  pressure.  Certain  it  is  that  palsy  some- 
times follows  what  seems  a  degree  of  pressure  inadequate  to  cause  such  a 
result.  Narcosis  palsies  may  be  due  to  pressure  of  an  extremity  upon  a  table- 
edge  or  to  pressure  upon  nerves  by  placing  the  patient  in  certain  positions.* 
When  the  Trendelenburg  position  has  been  employed,  the  flexures  of  the  knees 
are  in  contact  vdth  the  edge  of  the  table,  and  paralysis  of  one  or  both  external 
popliteal  nerves  may  be  induced.  When  the  patient  hes  upon  the  side  any 
nerve  of  the  arm  or  forearm  may  suffer,  but  the  circumflex  and  radial  are  most 
Hable.  When  the  arm  is  elevated  to  the  side  of  the  head  or  when  it  is  drawn 
out  strongly  from  the  body  the  brachial  plexus  may  be  compressed  by  the  head 
of  the  humerus  (Braun,  in  "Deutsche  Med.  Woch.,"  1894).  When  the 
arm  is  in  external  rotation  and  is  drawn  backward  and  outward,  the 
median  nerve  is  stretched,  and  when  the  forearm  is  flexed  and  supinated, 
the  ulnar  nerve  is  stretched  (Braun,  Ibid.).  In  most  cases  the  paralysis 
involves  muscles  supplied  by  the  brachial  plexuses  and  is  due  to  drawing  the 
arm  upward  and  backward  over  the  head,  a  position  which  may  squeeze  the 
cords  of  the  plexus  between  the  collar-bone  and  the  first  rib.  Garrigues  shows 
that  the  plexus  is  particularly  apt  to  be  squeezed  when  it  is  stretched  by  the 
head  being  drawn  to  the  opposite  side  or  being  allowed  to  fall  back.f  Ac- 
cording to  Biidinger  the  mounting  up  of  the  clavicle  squeezes  the  plexus  as 
its  cords  cross  the  first  rib.  This  surgeon  thinks  that  extreme  abduction  of  the 
arm  may  squeeze  the  cords. 

*  H.  J.  Garrigues,  in  Amer.  Jour.  Med.  Sciences,  Jan.,  1897. 
t  Amer.  Jour.  Med.  Sciences,  Jan.,  1897. 


I204  Anesthesia  and  Anesthetics 

Postanesthetic  paralysis  is  most  common  in  the  arm,  but  may  occur 
in  the  leg  or  face.  The  prognosis  is  good  as  a  rule.  Slight  cases  are  soon 
recovered  from;  more  serious  cases,  in  which  degeneration  occurs,  may  not  be 
recovered  from  for  months.     The  treatment  is  that  of  any  pressure  palsy. 

Primary  .Anesthesia. — Instruct  the  patient  to  count  aloud  and  hold 
one  arm  above  his  head.  Give  the  ether  rapidly.  In  a  short  time  he  be- 
comes mixed  in  his  count  and  his  arm  sways  or  drops  to  the  side.  There 
is  now  a  period  of  insensibility  to  pain  lasting  only  about  half  a  minute, 
and  during  this  period  a  minor  operation  can  be  performed.  The  patient 
quickly  reacts  from  primary  anesthesia  without  vomiting  (Packard). 

Mixtures. — Mixture  of  Ether  and  Chloroform. — This  may  be  used 
in  varying  proportions.  Hewitt  employs  2  parts  of  chloroform  to  3  parts 
of  ether. 

Mixture  of  Alcohol  and  Chloroform. — All  the  chloroform  mixtures 
produce  the  effects  of  chloroform,  but  we  are  giving  the  drug  in  an  unknown 
amount.  It  was  believed  by  Sansom,  who  devised  this  mixture,  that  the 
alcohol  prevents  concentration  of  chloroform-vapor  by  retarding  evaporation. 
When  used,  i  part  of  alcohol  is  added  to  4  parts  of  chloroform. 

Nitrous  Oxid  and  Oxygen. — (See  page  1206.) 

A.  C.  E.  Mixture. — This  mixture  is  often  valuable  in  cases  in  which 
ether  cannot  be  given.  It  is  composed  of  i  part  of  alcohol,  2  parts  of  chloro- 
form, and  3  parts  of  ether.  Its  action  is  supposed  to  be  between  that  of 
chloroform  and  ether.  The  objection  to  the  A.  C.  E.  mixture,  as  to  any 
mixture,  is  that  the  materials  do  not  evaporate  in  the  ratio  in  which  they 
are  mixed,  hence  an  uncertain  amount  of  chloroform-vapor  is  being  inhaled 
(Buxton).  This  mixture  is  given  by  some  in  a  Junker  and  by  others  in  an  open 
inhaler.  Plenty  of  air  should  be  given  with  it.  The  anesthetic  acts  similarly 
to  chloroform. 

Schleich's  Mixture  for  General  Anesthesia. — Schleich  has  recently 
introduced  a  new  anesthetic  agent  which  he  claims  is  safer  than  chloroform. 
This  surgeon  maintains  that  a  material  is  safe  as  an  anesthetic  only  when 
almost  all  of  the  amount  taken  in  at  an  inspiration  is  expelled  on  expira- 
tion. The  anesthetic  is  unsafe  in  direct  proportion  to  the  amount  absorbed; 
and  the  lower  the  boiling-point  of  an  anesthetic,  the  less  is  absorbed,  hence 
an  anesthetic  agent,  to  be  safe,  should  have  a  low  boiling-point.  Schleich 
makes  three  solutions.  The  first  contains  (by  volume)  i|  oz.  of  chloroform, 
J  oz.  of  petroleum  ether,  and  6  oz.  of  sulphuric  ether.  The  second  contains 
i^  oz.  of  chloroform,  J  oz.  of  petroleum  ether,  and  5  oz.  of  sulphuric  ether. 
The  third  contains  i  oz.  of  chloroform,  J  oz.  of  petroleum  ether,  and  2f  oz. 
of  sulphuric  ether.  The  anesthetic  can  be  given  on  an  open  inhaler  or  a 
towel.  The  anesthetic  state  is  quiet,  reaction  is  rapid,  and  vomiting  occurs 
in  but  half  the  cases.  The  superiority  of  this  new  anesthetic  has  not  been 
proved.  It  sometimes  causes  dangerous  symptoms,  and  has  produced  death. 
Some  surgeons  who  formerly  approved  of  it,  have  abandoned  it.  It  will 
certainly  not  displace  ether  or  chloroform.  Petroleum  ether  has  no  anesthetic 
power  and  Meltzer  shows  that  it  is  dangerous  and  tends  to  paralyze  the  res- 
piratory muscles.  Willy  Meyer  ("Med.  Record,"  August  15,  1908)  believes 
in  the  Schleich  principle,  but  substitutes  ethyl  chlorid  with  a  boiling-point  of 
59°  F.  for  the  petroleum  ether.  He  uses  17  per  cent,  volume  of  ethyl  chlorid 
with  83  per  cent,  volume  of  the  molecular  mixture  of  ether  and  chloroform. 


Chloric!  of  Ethyl  1205 

Ethyl  bromid  is  sometimes  used  for  short  operations.  It  is  given  while 
the  patient  is  recumbent.  The  unconsciousness  is  obtained  in  from  one  to 
three  minutes  and  is  rapidly  recovered  from,  and  there  is  no  after-sickness. 
The  unconsciousness  lasts  about  three  minutes.  Three  drams  are  given  to  a 
child,  and  six  drams  to  an  adult.  A  towel  is  put  over  the  face,  and  the  entire 
amount  to  be  given  is  poured  on  at  once,  and  as  soon  as  the  patient  is  uncon- 
scious the  towel  is  taken  away  and  no  more  of  the  drug  is  given  (Cumston). 
Even  if  consciousness  is  regained  too  quickly  to  suit  the  purposes  of  thesurgeon, 
it  is  not  safe  to  give  more  of  the  drug,  a  notable  objection  which  chlorid  of 
ethyl  does  not  possess.  Cases  have  been  reported  in  which  sudden  death 
has  followed  the  administration  of  this  drug,  and  it  should  not  be  given  if 
there  is  disease  of  the  heart,  lungs,  or  kidneys.*  Twenty-four  deaths  from 
bromid  of  ethyl  are  on  record  (Gaudiana).  If  it  kills,  it  acts  like  chloroform. 
It  may  be  given  before  ether  to  prevent  unpleasant  effects,  but  it  is  usually  not 
considered  proper  to  give  it  before  chloroform.  Zematski,  however,  has  used 
it  before  chloroform  in  2000  cases  ("  Vratch,"  August  25,  1901).  There  were 
recently  two  deaths  from  it  in  Philadelphia,  neither  of  which  was  pubHshed. 
I  never  use  it  and  regard  it  as  unsafe. 

Chlorid  of  ethyl  is  a  rapid  anesthetic  and  statistics  imply  that  it  is  a 
safe  one.  My  faith  in  it  has  been  greatly  shaken  by  knowledge  of  three  un- 
published deaths  in  Philadelphia.  It  was  first  used  by  Heyfelder  in  1848. 
A  committee  of  the  British  Medical  Association  condemned  it  in  1880.  Carlson 
and  Thiesing  reintroduced  it  in  1895  (McCardie,  in  "Lancet,"  April  4,  1903). 
It  may  be  sprayed  upon  a  mask  covered  by  six  to  eight  layers  of  gauze,  so  that 
the  drug  does  not  evaporate  too  quickly  in  the  air.  Many  anesthetists  give  it 
in  a  closed  apparatus,  the  patient  respiring  into  and  from  a  rubber  bag.  The 
odor  of  the  drug  is  agreeable.  From  5  to  10  gm.  of  ethyl  chlorid  are  given  for  a 
short  operation  if  the  mask  is  used.  The  patient  must  always  be  recumbent 
when  taking  it.  The  anesthetic  state  is  induced,  when  the  mask  is  used,  in 
from  two  to  three  minutes,  and  as  soon  as  it  is  obtained  the  patient  is  allowed 
to  get  air.  If  the  closed  inhaler  is  used  unconsciousness  is  obtained  more 
rapidly.  The  anesthetic  condition  lasts  from  one  to  three  minutes,  and  it  is 
recovered  from  rapidly,  usually  without  vomiting  or  unpleasant  after-effects. 
If  the  patient  recovers  too  rapidly  for  the  surgeon's  purpose,  more  ethyl 
chlorid  can  be  given.  It  is  to  be  noted  that  complete  muscular  relaxation  does 
not  occur,  in  many  cases  the  conjunctival  reflex  is  not  completely  abohshed, 
and  often  the  pupils  do  not  dilate.  It  has  no  superiority  over  nitrous  oxid, 
except  as  to  cost  and  portabiUty,  and  sometimes  it  fails  to  produce  complete 
unconsciousness.  A  large  dose  rapidly  given  is  dangerous,  as  it  may  cause 
cessation  of  respiration  and  spasm  of  the  diaphragm.  A  contraindication  to 
its  use  is  any  respiratory  obstruction.  In  many  cases  there  is  spasm  of  the 
masseters.  Concentrated  vapor  administered  for  a  considerable  time  lowers 
the  blood-pressure,  induces  cyanosis  and  asphyxia,  and  would  eventually 
cause  death  by  respiratory  failure  (McCardie,  in  "Lancet,"  April  4,  1903). 
Lotheisser,  in  a  study  of  2500  cases  of  anesthesia  by  this  agent,  reports  i  death. 
Ware  collected  12,436  cases  with  i  death  ("Jour.  Am.  Med.  Assoc,"  Nov.  8, 
1902).  Seitz,  of  Konstanz,  collected  16,000  cases  vrith  i  death.  It  is  perhaps 
safer  than  chloroform,  not  nearly  so  safe  as  nitrous  oxid,  and  not  so  safe  as 
*  See  Cumston,  in  Boston  Med.  and  Surg.  Jour.,  Dec.  20,  1894. 


I206 


Anesthesia  and  Anesthetics 


ether.  The  drug  is  used  only  for  a  brief  operation  or  examination.  It  can 
be  given  to  infants  a  few  days  old  with  reasonable  safety  and  it  has  been  ad- 
ministered many  times  to  the  aged.  When  it  kills,  it  acts  in  a  similar  manner 
to  chloroform.  I  have  often  given  it  before  ether  to  prevent  unf)leasant 
symptoms  and  to  hasten  the  advent  of  anesthesia,  but  it  must  never  be  given 
before  chloroform.     Of  late  I  have  practically  ceased  to  use  it. 

Nitrous  oxid  gas  may  be  used  to  obtain  anesthesia  for  brief  operations. 
It  is  contraindicated  when  vascular  degeneration  exists,  because  apoplexy 
may  follow  its  administration.  It  should  never  be  given  when  the  air- 
channel  is  narrowed,  as  in  Ludwig's  angina,  abscess  in  or  below  the  tongue, 
^nd    thyroid    enlargement   (F.  W.  Hewitt,  in   "Lancet,"  July  20,  27,  and 

August  10,  1907).  This  gas  is 
stored  in  steel  cylinders,  in  which 
it  is  liquefied.  The  gas  is  passed 
into  a  rubber  bag  (Fig.  706),  and  is 
given  to  the  patient  by  means  of  a 
tube  and  a  mouth-mask,  a  wedge 
being  placed  between  the  patient's 
molar  teeth,  and  the  nostrils  being 
closed  by  the  anesthetist's  fingers. 
The  wedge  must  be  held  by  a  string, 
so  that  it  cannot  be  swallowed. 
The  patient  becomes  unconscious  in 
about  one  minute,  and  we  know  the 
patient  is  anesthetized  by  the  stertor 
and  cyanosis  and  the  insensitiveness 
of  the  conjunctivae.  Watch  the 
pulse,  and  if  it  flags,  at  once  suspend 
the  administration.  The  phenom- 
ena are  asphyxial,  stertorous  res- 
piration, cyanosis,  and  even  con- 
vulsions, dilatation  of  the  pupils, 
rapidity  of  the  heart,  and  swelling 
of  the  tongue.*  It  is  sometimes 
useful  to  give  nitrous  oxid  first  and 
follow  this  with  ether  (page  1208). 
By  this  method  the  patient  is  anes- 
thetized rapidly  and  pleasantly  with 
the  nitrous  oxid,  and  the  anesthesia 
is  maintained  by  the  ether. 

It  was  formerly  taught  that  nitrous 
oxid  necessarily  produces  cyanosis, 
because  the  gas  can  only  cause  anes- 
thesia by  partially  asphyxiating  the 
patient.     \\'e  know  this  is  untrue, 
because  if  nitrous  oxid  is  mixed  with  oxygen  or  atmospheric  air  anesthesia  is 
obtained  without  cyanosis.     Nitrous  oxid  is  a  genuine  anesthetic  agent.     If  a 
prolonged  administration  of  nitrous  oxid  is  desired,  pure  nitrous  oxid  can  be 
*  See  He\\-itt,  Brit.  Med.  Jour.,  Feb.  18,  1899. 


Fig.  706.— Hewitt's  nitrous  oxid  apparatus. 


Nitrous  Oxid  Gas 


1207 


given,  a  breath  of  fresh  air  being  allowed  from  time  to  time.  By  this  method 
Preston  has  anesthetized  many  patients,  the  duration  of  the  anesthesia  being 
from  ten  to  tifty  minutes.  A  better  plan  is  to  give  nitrous  oxid  and  oxygen. 
I  am  satisfied  that  this  combination  does  not  occupy  the  place  in  surgeiy  its 
merits  entitle  it  to.  One  reason  is  the  absolute  necessity  of  ha\ing  a  specially 
skilled  administrator.  A  trouble  frequently  encountered  is  persistent  rigidity. 
This  can  often  be  prevented  by  a  preliminary  dose  of  morj)hin.     Postanes- 


Fig.  707. —Hewitt's  nitrous  oxid  and  oxygen  apparatus. 


thetic  vomiting  is  rare  (Teter,  in  Thirteen  Thousand  Administrations  of  Nitrous 
Oj.id  with  Oxygen,  "Jour.  Am.  Med.  Assoc,"  August  7,  1909).  He\\itt 
formulates  the  following  views  as  to  the  use  of  oxygen  and  nitrous  oxid.* 

"In  order  to  obtain  the  best  form  of  anesthesia  oxygen  should  be  admin- 
istered with  nitrous  oxid  by  means  of  a  regulating  apparatus  (Fig.  707), 
the  percentage  of  the  former  gas  being  progressively  increased  from  2  to 
3  per  cent,  at  the  commencement  of  the  administration  to  7,  8,  9,  or  10  per 

*  Brit.  Med.  Jour.,  Feb.  18,  1899. 


i2o8  Anesthesia  and  Anesthetics 

cent.,  according  to  the  circumstances  of  the  case.     The  longer  the  adminis- 
tration lasts,  the  greater  may  be  the  percentage  of  oxygen  admitted. 

"The  next  best  results  to  those  obtainable  by  means  of  a  regulating 
apparatus  for  nitrous  oxid  and  oxygen  are  to  be  secured  by  administering 
certain  constant  mixtures  of  these  two  gases.  Mixtures  containing  5,  6,  or 
7  per  cent,  of  oxg3'en  are  best  for  adult  males;  and  mixtures  containing  7, 
8,  or  9  per  cent,  are  best  for  females  and  children.  The  next  best  results 
to  those  last  mentioned  are  to  be  obtained  by  means  of  mixtures  of  nitrous 
oxid  and  air,  from  14  to  18  per  cent,  of  the  latter  being  advisable  in 
anesthetizing  men,  and  from  18  to  22  per  cent,  in  anesthetizing  women  and 
children." 

Bichlorid  of  Methylene.— The  composition  of  the  so-called  bichlorid 
of  methylene  is  a  matter  of  dispute.  Some  high  authorities  believe  it  to  be 
a  mixture  of  methyl  alcohol  and  chloroform.  It  rapidly  produces  uncon- 
sciousness, and  the  patient  returns  quickly  to  consciousness  when  the  ad- 
ministration is  suspended.  Some  surgeons  have  thought  highly  of  it,  and 
claim  that  it  is  pleasant,  safe,  and  is  not  followed  by  vomiting  as  often  as 
is  chloroform.  The  weight  of  opinion  is  that  it  is  dangerous,  death  being 
similar  to  death  from  chloroform.  It  is  given  by  means  of  a  Junker  appa- 
ratus. 

Anesthetic  Successions.— Bromid  of  Ethyl  Followed  by  Chloro- 
form or  Ether. — (See  page  1205.) 

Chlorid  of  Ethyl  Followed  by  Ether. — (See  page  1205.) 

Chloroform  Followed  by  Ether. — Chloroform  is  sometimes  given  until 
the  sensation  becomes  more  or  less  obtunded,  when  ether  is  substituted. 
This  is  done  to  save  the  patient  from  the  unpleasant  sensations  of  etheri- 
zation. It  is  a  practice  not  to  be  commended,  because  it  is  precisely  in  the 
beginning  that  chloroformization  is  most  dangerous. 

Ether  Followed  by  Chloroform. — When  the  patient  cannot  be  relaxed 
or  rendered  unconscious  by  ether,  or  when  some  other  complication  develops, 
it  is  common  practice  to  suspend  ether  and  substitute  chloroform.  If  the 
change  is  made,  chloroform  should  be  given  cautiously.  A  large  quantity 
should  never  be  poured  upon  the  inhaler  at  one  time.  The  change  should 
never  be  made  when  the  patient  is  struggling,  because  the  deep  respirations 
which  attend  or  follow  struggling  may  lead  to  the  rapid  inhalation  of  a  dan- 
gerous dose  of  chloroform-vapor.  Further,  as  Hewitt  points  out,  when  the 
patient  is  deeply  under  the  influence  of  ether,  the  change  should  not  be  made 
unless  it  is  imperatively  necessary. 

Nitrous  Oxid  Gas  Followed  by  Ether  (Gas  and  Ether). — This  very 
valuable  method  was  suggested  by  Clover.  I  have  used  it  repeatedly  with 
great  satisfaction.  The  patient  is  made  unconscious  by  nitrous  oxid  and  is 
kept  unconscious  by  ether.  Thus  are  avoided  excitement,  struggling,  choking, 
and  the  very  unpleasant  sensadons  induced  by  ether.  It  lessens  the  amount 
of  time  requisite  to  obtain  anesthesia  and  lessens  the  amount  of  ether  used. 
More  important  even  than  this,  the  method  is  safe.  It  is  more  satisfactory 
in  women  and  children  than  in  men.  In  very  muscular  men  and  in  very 
stout  elderly  men  it  should  not  be  used.  In  many  cases  nitrous  oxid  causes  a 
flow  of  mucus  from  the  respiratory  tract.  Because  of  the  frequency  of  this 
happening  it  is  wise  to  precede  gas  and  ether  anesthesia  twenty  minutes  by  a 


Nitrous  Oxid  Gas  Followed  by  Ether 


1209 


hypodermatic  injection  of  morphin  and  atropin  (Van  Kaathoven,  in  "Annals 
of  Surgery,"  Sept.,  1908),  or,  as  I  usually  prefer,  of  atropin  alone.  Many 
operators  first  anesthetize  with  nitrous  oxid,  using  an  ordinary  dental  appara- 
tus, and  then  give  ether  on  an  ordinary  inhaler.  The  anesthetist  must  bear 
in  mind  that  ether  must  be  given  gradually,  not  suddenly  poured  on  in  large 
amount.  Others  prefer  to  use  a  combined  gas-and-ether  inhaler.  Hewitt 
thus  describes  the  administration  by  means  of  Clover's  portable  ether-inhaler 
fitted  with  a  stop-cock  and  a  detachable  gas-bag  ("Anesthetics  and  their 
Administration") : 

"If  the  patient  be  lying  upon  his  back,  his  head  should  be  turned  to 
one  side.  The  face-piece  with  the  charged  ether  chamber  is  then  applied 
during  an  expiration.  Air  will  be  breathed  backward  and  forward.  When 
the  respiration  is  seen  to  be  proceeding  freely,  and  the  face-piece  fits  well, 
the  charged  gas-bag  is  attached  to  the  ether  chamber.  Air  will  still  be 
breathed,  but  not  through  the  valves  of  the  special  stop-cock.  When  the 
valves  are  heard  to  be  working  properly,  *gas'  is  turned  on,  and  is  likewise 
breathed  through  the  valves.  Three  or  four  respirations  (or  about  one-half 
of  the  contents  of  the  bag)  are  allowed  to  escape.  The  valve  action  is  now 
stopped  by  turning  the  tap  at  the  upper  part  of  the  stop-cock.  At  the  same 
moment  at  which  the  patient  begins  to  breathe  'gas'  backward  and  for- 
ward, the  rotation  of  the  ether  chambers,  for  the  addition  of  ether-vapor 
should  be  commenced.  The  administrator  will,  in  fact,  find  that  he  can, 
in  a  few  seconds  from  the  commencement  of  the  administration,  rotate  the 
ether  chamber  as  far  as  'i'  or  'i^. '  Should  swallowing  or  coughing 
arise,  he  must  rotate  more  slowly.  Respiration 
soon  becomes  deep  and  regular,  and  more  and  more 
ether  may  be  admitted.  At  about  this  juncture,  if 
the  apparatus  has  been  fitting  the  face  well,  signs  of 
nitrous  oxid  narcosis  may  appear,  especially  in  those 
who  are  quickly  affected  by  this  gas.  Should  jerky 
breathing  or  'jactitation'  arise,  one  full  inspiration 
of  air  may  be  admitted  at  the  air-tap.  It  should  be 
remembered,  however,  that  in  giving  '  gas  and  ether  ' 
by  this  method,  the  object  is  to  just  steer  clear  of  the 
clonus  and  'stertor  '  of  nitrous  oxid  narcosis,  and  to 
gradually  but  increasingly  mix  ether  with  the  gas. 

"  In  muscular  and  vigorous  subjects,  the  quantity 
of  gas  above  mentioned  will  be  found  to  be,  as  a 
general  rule,  insufficient  to  lead  to  the  usual  signs  of 
deep  nitrous  oxid  anesthesia.  The  rotation  of  the 
ether  chamber  should  be  continued  till  the  indicator 
points  to  '2,'  '3,'  or  'F.' 

"The  mistake  that  is  most  commonly  made  is 
that  of  admitting  air  too  soon.  Should  air  be  given 
during  the  first  half  or  three-quarters  of  a  minute,  the 
patient  will  partially  come  round,  hold  his  breath,  set 
his  teeth,  and  give  a  good  deal  of  trouble.     Duskiness 

of  the  features  must  be  expected.  Speaking  generally,  air  should  not  be 
allowed  until  the  patient  is  stertorous,  when  one  breath  may  be  given.     In 


Fig.  708.— Gebauer's  ethyV 
chlorid  tube. 


I2IO  Anesthesia  and  Anesthetics 

this  manner  the  patient  will  continue  breathing  a  mixture  of  nitrous  oxid, 
ether,  and  air,  till  the  usual  signs  of  deep  ether  anesthesia  appear,  when  the 
gas-bag  may  be  detached,  and  the  little  bag  ordinarily  used  with  Clover's 
inhaler  substituted." 

Hewitt  prefers  to  use  a  modified  Clover's  inhaler,  which  permits  of  the 
introduction  of  ether  after  the  inhalation  of  nitrous  oxid  has  begun. 

Scopolamin-morphin  Anesthesia. — This  method  has  been  enthusias- 
tically praised  and  I  used  it  with  satisfaction  in  a  number  of  cases,  but  I  have 
grown  afraid  of  it.  In  a  patient  in  the  Jefferson  Hospital  dangerous  symptoms 
arose  after  a  dose  of  gr.  yi-q  of  scopolamin.  Ely  records  a  death  from  respira- 
tory failure  two  hours  after  the  administration  of  gr.  J  of  morphin  and  gr.  y^  of 
scopolamin  ("New  York  Med.  Jour.,"  Oct.  20,  1906).  Fifteen  deaths  have 
been  reported  as  following  its  use  and  there  are  beyond  doubt  unreported  cases. 
Four  deaths  in  2400  cases  were  certainly  directly  due  to  it  (H.  J.  Whitacre, 
in  "New  York  Med.  Jour.,"  March  31,  igo6).  It  has  even  been  stated  that 
the  death-rate  is  i  in  100  ("Semaine  Medicale, "  Jan.  11,  1905).  Scopolamin 
is  chemically  identical  with  hyoscin  and  must  never  be  used  unless  fresh,  as 
it  decomposes  in  air  and  light.  If  given  without  morphin,  it  is  inefficient. 
Large  doses  are  certainly  dangerous,  and  the  combination  should  never  be 
given  in  sufficient  amount  to  induce  anesthesia  unaided.  If  used  at  all,  it 
should  only  be  as  an  aid  to  local  anesthesia  or  to  general  anesthesia  by  ether  or 
chloroform.  I  have  used  it  as  an  aid  to  local  anesthesia  in  6  goiter  operations, 
and  in  2  cases  of  removal  of  the  Gasserian  ganglion.  It  should  not  be  used 
in  heart  disease  (Hayem);  in  persons  under  sixteen  or  over  sixty  (Korff); 
in  any  one  with  a  tendency  to  pulmonary  edema  or  with  any  acute  condition 
of  the  throat  which  interferes  with  respiration  (A.  C.  Wood,  in  "American 
Medicine,"  Nov.  11,  1905). 

It  produces  a  drowsy,  heavy  state  or  actual  sleep,  and  the  patient  can  be 
kept  unconscious  with  an  extremely  small  quantity  of  ether  or  chloroform. 
For  five  or  six  hours  after  the  operation  the  sleep  continues,  and  in  most  cases 
there  is  not  post-operative  vomiting. 

If  it  is  used,  a  mixture  is  freshly  made  containing  gr.  -j-^q-  of  scopolamin 
and  gr.  -g-  of  morphin,  and  this  is  given  hypodermatically  one-half  an  hour 
before  the  operation.  During  the  operation  the  sleep  may  be  maintained 
by  ether  or  chloroform.  If  symptoms  of  poisoning  occur,  artificial  respiration 
and  oxygen  inhalations  may  be  required,  external  heat  is  needed,  and  nitro- 
glycerin, strychnin,  or  caffein  are  given. 

I  agree  with  Kochmann  that  we  are  not  as  yet  justified  in  recommending 
this  method  of  anesthesia  ("Miinchener  medizinische  Wochenschrift, " 
1905,  No.  17). 

Local  Anesthesia. — In  every  case  requiring  operation  we  should 
inquire  whether  local  anesthesia  can  be  used  instead  of  general  anesthesia. 
Many  really  extensive  operations  can  be  done  under  it  and  its  field  has  been 
greatly  broadened  by  the  knowledge  that  viscera  innervated  by  purely  visceral 
nerves  are  insensitive  and  sensation  exists  only  in  those  which  receive  branches 
from  the  somatic  nerves  (K.  G.  Lennander,  in  "  Mittheilungen  aus  dem  Grenz- 
gebieten  der  Medicin  und  Chirurgie, "  Bd.  x.  Heft  i  and  2,  1902).  Len- 
nander shows  that  the  parietal  peritoneum  is  sensitive  to  pain,  but  not  to 
touch — that  the  intestine,  stomach,  edge  of  liver,  mesentery,  gall-bladder. 


Hypodermatic  Injection  of  Cocain  Hydrochlorate  1211 

urinary  bladder,  kidney  parenchyma,  lung,  anterior  wall  of  the  trachea,  tes- 
ticle, and  epididymis  are  insensitive,  though  the  coverings  of  the  testicle  and 
epididymis  are  sensitive.  My  experience  is  that  the  viscera  may  be  cut, 
sutured,  and  handled  without  any  severe  pain  if  they  are  not  pulled  upon.  In 
removing  an  appendix  the  only  pain  felt  will  be  when  the  meso-apj)endix 
is  pulled  upon  or  adhesions  to  the  parietal  peritoneum  are  separated.  Baldy 
recently  affirmed  Lennander's  views  ("Surg.,  Gynecol.,  and  Obstet.,"  May, 
1909).  The  advantages  of  operation  under  local  anesthesia  are  freedom 
from  the  danger  of  anesthetic  accidents,  blood  changes,  and  postanesthetic 
discomforts  and  dangers.  The  disadvantage  is  the  knowledge  of  the  patient 
as  to  what  is  taking  place.  He  may  become  alarmed  and  turbulent  and 
may  thus  interfere  with  a  necessary  procedure  at  a  vital  moment.  I  have 
operated  under  local  anesthesia  with  satisfaction  in  the  following  cases: 
Tracheotomy,  rib  resection,  goiter,  iliac  colostomy,  typhoid  perforation, 
abscess  of  the  lung,  gangrenous  appendicitis,  radical  cure  of  hernia,  strangu- 
lated hernia,  suprapubic  cystotomy,  extirpation  of  the  external  carotid  artery 
(Dawbarn's  operation),  and  ligation  of  the  femoral  artery.  There  are  many 
methods  of  local  anesthesia. 

Freezing. — Ice  and  salt  may  be  used.  Take  one-quarter  of  a  pound  of 
ice,  wrap  it  in  a  towel,  and  break  it  into  fine  bits;  add  one-eighth  of  a  pound  of 
salt;  then  place  the  mixture  in  a  gauze  bag  and  lay  it  upon  the  part.  The 
surface  becomes  pallid  and  numb,  and  in  about  fifteen  minutes  decidedly 
analgesic.  A  spray  of  rhigolene  freezes  a  part  in  about  ten  seconds.  It  is 
highly  inflammable.  Ether-spray  anesthesia  was  suggested  by  Benjamin 
Ward  Richardson.  Chlorid  of  etliyl  comes  in  glass  or  metal  tubes  (Fig.  70S). 
Remove  the  cap  from  the  tip  of  the  tube  and  hold  the  bulb  in  the  palm:  the 
warmth  of  the  hand  causes  the  fluid  to  spray  out.  Hold  the  tube  some  little 
distance  from  the  part,  and  let  the  fine  spray  strike  the  surface.  The  skin 
blanches  and  whitens,  and  is  ready  for  the  operation  in  about  thirty  seconds. 

Hypodermatic  Injection  of  Cocain  Hydrochlorate. — Always  bear  in 
mind  that  cocain  is  sometimes  a  decidedly  dangerous  agent.  There  are  on 
record  fourteen  deaths  from  cocain  (Reclus).  The  urethra  is  a  particularly 
dangerous  region,  and  so  is  the  face.  Never  use  more  than  two- thirds  of  a 
grain  upon  a  mucous  surface,  and  never  inject  hypodermatically  more  than  one- 
third  of  a  grain,  and  be  sure  never  to  inject  the  drug  into  a  vein.  Mild  cases  of 
cocain-poisoning  are  characterized  by  great  tremor,  restlessness,  pallor,  dry 
mouth,  talkativeness,  and  weak  pulse.  In  severe  cases  there  is  syncope  or 
delirium.  Death  may  arise  from  paralysis  or  from  fixation  of  the  respiratory 
muscles  (Mosso).  Cases  with  a  tendency  to  respiratory  failure  require  the 
hypodermatic  injection  of  strychnin.  In  cases  with  tetanic  rigidity  of  muscles 
give  hypodermatic  injections  of  nitroglycerin,  or  inhalations  of  the  nitrite  of 
amyl.  In  cases  marked  by  delirium,  if  the  circulation  is  good,  give  hyoscin. 
In  any  case  give  stimulants,  employ  a  catheter,  and  favor  diuresis.  Cocain- 
poisoning  is  always  followed  by  a  wakeful  night.  Cocain  should  not  be  used  if 
the  kidneys  are  inefficient.  In  using  cocain  try  to  prevent  poisoning.  Because 
of  the  dangers  inherent  in  cocain,  have  the  patient  recumbent.  One  minute  be- 
fore giving  the  cocain  administer  hypodermatically  one  drop  of  a  i  per  cent,  solu- 
tion of  nitroglycerin  and  repeat  the  dose  once  during  the  operation.  In  operat- 
ing on  a  finger,  after  making  the  part  anemic,  tie  a  tube  around  the  root  of  the 


12 1 2  Anesthesia  and  Anesthetics 

digit  before  injecting  cocain,  and  after  the  operation  gradually  loosen  the  tube. 
A  hot  solution  of  cocain  is  more  efficient  than  a  cold  solution  (T.  Costa);  hence 
hot  solutions  can  be  used  in  much  less  strength  and  are  safer.  The  method  of 
injection  is  as  follows:  A  sharp  needle  is  held  at  an  angle  of  forty-five  degrees 
to  the  surface,  and  is  pushed  into  the  Malpighian  layer.  One  or  two  minims  of 
a  2  per  cent,  solution  are  forced  into  the  Malpighian  layer,  and  a  whitened 
elevation  forms.  The  needle  is  withdrawn,  at  the  margin  of  the  wheal  is 
reinserted,  and  more  fluid  is  introduced,  and  so  on  until  the  region  to  be 
operated  upon  has  been  injected.  After  waiting  five  minutes  the  operation 
is  begun.  If,  after  cutting  the  skin,  it  is  necessary  to  cut  the  subcutaneous 
tissue,  pour  a  few  drops  of  a  i  per  cent,  solution  into  the  wound  from  time 
to  time.  After  the  completion  of  the  operation,  if  a  rubber  band  was  used, 
it  is  loosened  for  a  few  seconds,  tightened  for  a  few  minutes,  again  loosened 
and  readjusted,  and  so  on  several  times  (Wyeth).  In  this  way  only  a  small 
quantity  of  cocain  is  admitted  into  the  circulation  at  one  time,  and  toxic 
symptoms  are  prevented.  For  operations  upon  the  eye  a  i  to  4  per  cent, 
solution  is  employed;  a  drop  of  fluid  is  instilled  every  ten  minutes  until  three 
drops  have  been  given.  Rarely  use  over  a  10  per  cent,  solution  on 
mucous  membrane,  although  in  laryngeal  operations  a  20  per  cent,  solution 
may  be  required.  For  the  nasal  mucous  membrane  a  bit  of  wool  soaked  in  a 
5  per  cent,  solution  is  inserted  or  a  spray  of  4  per  cent,  solution  is  thrown 
from  an  atomizer  into  the  nostrils.  In  the  rectum,  vulva,  vagina,  and  uterus 
use  a  5  per  cent,  solution;  in  the  urethra,  a  4  per  cent,  solution, and  in  the  blad- 
der, a  2  per  cent,  solution. 

Cocainization  of  a  Nerve-trunk. — Krogius  has  pointed  out  that  if 
cocain  is  injected  into  the  tissue  about  a  nerve-trunk  anesthesia  will  follow 
in  the  area  supplied  by  the  nerve.  The  anesthesia  will  be  produced  in  five 
minutes,  and  will  last  fifteen  minutes.  If  cocain  is  injected  about  the  root 
of  the  finger,  all  of  the  tissues  of  the  digit  will  become  insensitive.  Injection 
over  both  supra-orbital  notches  renders  the  middle  of  the  forehead  insensitive. 
Injection  over  the  ulnar  nerve  causes  complete  anesthesia  of  its  trajectory. 
This  plan  is  extensively  used  in  Helsingfors. 

It  has  been  demonstrated  by  Crile  ("Jour.  Amer.  Med.  Assoc,"  Feb. 
22,  1902)  that  the  injection  of  cocain  into  a  nerve-trunk  interposes  an  absolute 
block  to  the  transmission  of  afferent  and  efferent  impulses  and  greatly  lessens 
operative  shock.  In  5  cases  he  employed  this  method  to  secure  anesthesia 
for  amputation  of  the  leg,  and  4  of  the  patients  did  not  know  that  any  opera- 
tion was  being  performed. 

Eucain  hydrochlorate  (/5-eucain)  is  far  safer  than  cocain,  and  in  most 
cases  is  to  be  preferred  to  it.  It  is  injected  in  the  strength  of  from  2  to  5  per 
cent.  It  can  be  boiled  without  destroying  its  properties,  and  hence  can  be 
readily  rendered  sterile.  It  occasionally,  though  rarely,  happens  that  the 
injection  of  eucain  causes  sloughing,  especially  at  the  extremities,  in  fatty  tis- 
sue, in  tendon-sheaths,  and  in  bursas.     It  can  be  used  on  mucous  membranes. 

Stovain. — This  agent  is  a  new  local  anesthetic  introduced  by  Fourneau. 
It  is  as  powerfully  analgesic  as  cocain,  is  only  one-third  as  toxic,  and  is  slightly 
germicidal.  It  is  dissolved  in  cold  water,  or  salt  solution  and  a  solution  used 
of  the  strength  of  0.5  per  cent.  Adrenalin  can  be  given  with  it  (see  Sonnen- 
burg,  in  "Deutsche  medicinische  Wochenschrift, "  March,  1905). 


Bier's  Intravenous  Method  of  Local  Anesthesia  12 13 

Infiltration-anesthesia  was  devised  by  Schleich,  of  Leipsic,  who  was 
dissatisfied  with  cocain,  because  it  is  not  safe  and  sometimes  fails  to  produce 
complete  local  anesthesia,  owing  to  want  of  thorough  diffusion.  He  found 
that  salt  solution  (0.2  per  cent.),  if  injected  into  uninflamed  parts,  produced 
anesthesia.  To  obtain  this  anesthesia  the  part  must  be  distended  by  wide 
infiltration.  If  minute  quantities  of  cocain,  morphin,  and  carbolic  acid 
are  added  to  the  solution,  the  anesthesia  becomes  more  thorough  and  more 
prolonged,  and  can  be  obtained  even  in  inflamed  areas. 

Schleich  uses  three  solutions: 

No.  I,  a  strong  solution,  which  is  used  in  inflamed  areas:  cocain  hydro- 
chlorate,  gr.  iij;  morphin  hydrochlorate,  gr.  |-;  sodium  chlorid,  gr.  iij;  dis- 
tilled sterile  water,  5iijf ;  phenol  (5  per  cent.),  2  drops. 

No.  2,  medium  solution,  which  is  employed  in  most  cases:  cocain  hydro- 
■chlorate,  gr.  iss;  morphin  hydrochlorate,  gr.  f;  sodium  chlorid,  gr.  iij;  dis- 
;tilled  sterile  water,  §iij|-;  phenol  (5  per  cent.),  2  drops. 

No.  3  is  the  weak  solution  used  to  infiltrate  extensive  areas :  cocain  hydro- 
-chlorate,  gr.  -g-;  morphin  hydrochlorate,  gr.  |-;  sodium  chlorid,  gr.  iij;  dis- 
tilled sterile  water,  §iijf ;  phenol  (5  per  cent.),  2  drops. 

The  injections  are  begun  in  the  skin,  not  under  it  (Fig.  709),  and  are 
made  one  after  another  until  the  area  to  be  operated  upon  is  surrounded 
above,  below,  and  on  all  sides  with  Schleich's  solution.  At  each  infiltrated 
area  a  wheal  forms  in  the  skin.  This  infiltration  can  be  made  painlessly  by 
touching  with  pure  carbolic  acid  the  point  where  the  needle  is  to  be  inserted, 
or  by  freezing  this  spot  with  ethyl  chlorid.  After  infiltration  of  the  skin  the 
surgeon  waits  ten  or  fifteen  minutes  and  then  operates,  incision  is  made, 
and  when  deeper  tissues  are  reached,  they  are  infiltrated  before  incising  them. 
If  a  nerve  comes  in  sight,  touch  it  with  a  drop  of  pure  carbolic  acid.  Van 
Hook  says  that  the  anesthesia  obtained  by  this  method  is  due  to  artificial 
ischemia,  pressure  upon  the  tissues,  the  direct  action  of  the  drugs,  and  the 
lowered  temperature.*  The  method  is  very  efficient,  and  can  be  used  for 
operations  of  considerable  magnitude.  Matas  uses  a  special  apparatus  to 
infiltrate  the  tissues.  The  fluid  is  driven  by  compressed  air,  and  wide-spread 
or  "massive"  infiltration  is  produced.  The  addition  of  adrenalin  chlorid 
to  the  cocain  solution  is  an  advantage,  as  it  retards  the  circulation  and  hence 
favors  analgesia  and  lessens  bleeding  during  the  operation.  I  do  not  beheve 
that  adrenahn  in  any  way  modifies  the  toxic  action  of  cocain — in  fact.  Berry 
("Am.  Jour.  Med.  Sciences,"  Nov.,  1905)  seems  to  prove  that  it  actually 
increases  it.  A  satisfactory  fluid  for  infiltration  is  i  part  of  a  i :  1000  solution 
of  adrenalin  chlorid  and  9  parts  of  a  0.5  per  cent,  solution  of  cocain  (Gangitans, 
in  "Riforma  Medica,"  Sept.  9,  1903).  Eucain  and  adrenahn  are  preferred 
by  some.  Barker  uses  distilled  water,  100  gm.;  pure  sodium  chlorid,  0.8 
gm.;  /5-eucain,  0.2  gm.;  chlorid  of  adrenalin,  o.ooi  gm.  After  injecting 
this  fluid  the  surgeon  waits  for  twenty  minutes  before  operating. 

Bier's  Intravenous  Method  of  Local  Anesthesia. — This  plan  was 
described  by  Bier  at  the  German  Surgical  Congress  of  1908.  It  permits  of 
serious  operations  upon  the  limbs,  operations  for  which  ordinary  methods  of 
local  anesthesia  would  prove  quite  inefficient.     Suppose  the  surgeon  intended 

*Med.  News,  Nov.  16,  1895. 


1 2 14  Anesthesia  and  Anesthetics 

to  resect  an  elbow-joint.  The  Esmarch  bandage  is  used  to  make  tlie  limb 
bloodless.  A  thin  soft-rubber  band  is  applied  many  times  abound  the  arm  above 
the  elbow,  and  a  like  band  is  applied  below  the  elbow.  The  anesthetic  is 
injected  into  a  superficial  vein  (basilic  or  the  cephalic).  The  vein  is  exposed, 
the  syringe  of  the  canula  is  introduced,  and  ligatures  are  used  as  though  we 
were  going  to  give  an  ordinary  intravenous  injection  of  salt  solution,  except 
that  the  canula  is  pointed  to  the  periphery.  The  fluid  used  is  a  .25  or  .5  i)er 
cent,  solution  of  novocain.  The  syringe,  containing  50  cc.  of  fluid,  forces  the 
solution  downward  into  the  veins  and  the  limb  swells. 

If  the  stronger  solution  is  used,  50  cc.  are  enough;  if  the  weaker  solution  is 
used,  100  cc.  will  be  required.  If  resecting  the  knee  the  injection  should  be 
made  into  the  internal  saphenous  vein  and  twice  the  amount  would  be  necessary 
as  advised  for  the  elbow. 

After  injecting  the  strong  solution  operation  may  be  begun  at  once. 
After  injecting  the  weak  solution  we  should  wait  ten  minutes.  The  analgesia 
is  entirely  satisfactory  and  passes  away  as  soon  as  the  band  is  removed.  Some- 
times motor  palsy  occurs  as  well  as  sensory  paralysis.  When  the  operation  has 
been  completed,  wash  out  the  vein  with  salt  solution  in  order  to  prevent  toxic 
effects. 

Anesthesia  by  Infiltration  with  Sterile  Water. — When  the  tissues 
are  well  infiltrated  with  warm  or  cold  sterile  water,  anesthesia  ensues  promptly. 
I  have  not  found  it  as  complete  as  when  cocain  or  eucain  is  employed,  even 
when  a  considerable  amount  of  fluid  is  introduced.  Gant  uses  it  in  rectal 
operations  and  commends  it  strongly  ("New  York  and  Phila.  I\Ied.  Jour.," 
Jan.  28,  1904). 

Spinal  Analgesia. — J.  Leonard  Corning  in  1885  discovered  that  cocain 
injected  between  the  spines  of  the  eleventh  and  twelfth  dorsal  verte- 
brae produces  analgesia  of  the  lower  hmbs  ("  N.  Y.  Med.  Jour.,"  Oct.  31, 
1885).  From  this  observation  spinal  anesthesia  springs.  Bier  produced  com- 
plete anesthesia  of  the  entire  body  except  the  head  by  the  injection  of  a  small 
amount  of  cocain  into  the  subarachnoid  space  of  the  spinal  cord.  A  solution  of 
cocain  of  a  strength  of  from  0.5  per  cent,  to  i  per  cent,  is  used  by  some,  but 
cocain  cannot  be  boiled  without  impairment  of  its  anesthetic  power,  and 
carboHc  acid  must  be  added  to  it  in  small  amount.  Hence  cocain  so  pre- 
pared is  not  certainly  sterile,  and  the  carboHc  acid  added  may  induce  harmful 
symptoms.  (See  Neugebauer,  in  "Wien.  khn.  Woch.,"  1901,  Nos.  50,  51, 
52.)  Some  surgeons  use  a  solution  of  eucain  which  can  be  boiled,  but  it 
is  not  so  rapid  and  certain  as  cocain.  Some  use  tropacocain  (Illwicz).  A 
solution  of  this  drug  can  be  boiled,  is  less  poisonous  than  cocain,  and  some- 
what slower  in  action.  Experimenters  tell  us  that  gr.  ss  to  gr,  iss  may  be 
given,  but  it  is  not  wise  to  give  over  0.5  grain.  I  have  used  stovain  in  a 
number  of  cases.  It  may  be  combined  with  adrenahn  if  this  is  desired.  The 
dose  is  5  to  10  gm.  The  analgesia  lasts  from  one-half  an  hour  to  an  hour  or 
more,  and  was  followed  in  my  cases  by  retention  of  urine.  Some  have  used 
novocain,  alone  or  combined  with  adrenalin. 

The  best  plan  is  that  of  A.  W.  Morton.  He  takes  chemically  pure  crystal- 
line hydrochlorate  of  cocain,  places  it  for  fifteen  minutes  in  a  dry  temperature 
of  300°  F.,  and  puts  it  in  sterile  tubes  until  wanted.  The  dose  depends  upon 
the  locality  in  which  we  wish  to  induce  analgesia,  and  varies  between  0.3 


Spinal  Analgesia  1215 

and  0.5  gr.  The  required  dose  is  placed  in  the  barrel  of  the  sterile  syringe 
and  is  dissolved  in  cerebrospinal  lluid  drawn  into  the  syringe  for  that  purpose. 
The  syringe  should  be  of  glass,  so  that  it  can  be  boiled.  The  concave  portion 
of  the  needle  should  be  dull,  so  that  a  plug  of  skin  will  not  be  cut  out  and 
obstruct  the  needle  (A.  W.  Morton,  in  "Jour.  Amer.  Med.  Assoc,"  Nov.  8, 
1902).  The  patient  lies  upon  his  side  with  the  back  curved.  The  back 
has  been  previously  sterilized.  The  dressings  are  removed  and  the  region 
to  be  punctured  is  resterilized.  The  spines  of  the  third  and  fourth  lumbar 
vertebrae  are  located,  and  the  needle  is  entered  in  the  mid-line  beneath  the 
spine  of  the  third  or  fourth  lumbar  vertebra  and  is  pointed  upward  and  forward. 
The  surgeon  determines  that  he  has  punctured  the  subarachnoid  space  by 
lessened  resistance  and  the  appearance  of  fluid  at  the  needle-opening.  The 
syringe,  with  a  closed  piston,  contains  0.3  gr.  of  sterile  cocain.  It  is  attached 
to  the  needle;  the  piston  is  withdrawn  until  the  syringe  is  half  full  of  cere- 
brospinal fluid.  When  the  cocain  is  dissolved,  the  solution  is  slowly  injected, 
the  needle  is  withdrawn,  and  the  puncture  is  sealed  with  collodion. 

The  anal  region  becomes  anesthetic  in  from  one  to  two  minutes,  the 
lower  extremities  in  from  three  to  six  minutes,  and  the  upper  extremities 
in  from  fifteen  to  thirty  minutes.  The  anesthetic  condition  lasts  from  one 
to  three  hours,  or  even  longer,  and  is  due  to  the  contact  of  cocain  with  the 
nerve-roots  (A.  W.  Morton,  "Jour.  Amer.  Med.  Assoc,"  Nov.  8,  1902). 

In  performing  the  operation  care  must  be  taken  to  prevent  the  escape  of 
cerebrospinal  fluid. 


r^,M/^toS^=^ 


Fig.  709.— The  syringe-point  stops  at  the  papillary  layer,  and  the  fluid  lodges  in  the  skin  itself  (Van 

Hook). 


After  cocainization  of  the  spinal  cord  surgical  operations  can  be  per- 
formed on  many  regions  without  causing  pain.  Among  the  operations  which 
have  been  performed  are  resection  of  the  knee,  resection  of  the  ankle,  osteotomy 
(Bier),  amputation  of  the  leg  (Lower),  and  hysterectomy  (Tufi&er). 

Spinal  analgesia  is  not  growing  in  popularity.  It  is  regarded  by  most 
surgeons  as  a  method  to  be  used  in  exceptional  cases.  It  should  never  be 
used  as  a  routine  procedure,  and  it  will  not  displace  ether  or  chloroform. 
By  it  analgesia  can  usually  be  secured.  A.  W.  Morton  ("Jour.  Amer.  Med. 
Assoc,"  Nov.  8,  1902)  has  used  it  673  times  without  a  failure,  and  60  of  these 
operations  were  above  the  diaphragm.  If  we  desire  to  obtain  analgesia  of 
the  upper  portion  of  the  body  the  patient  must  be  placed  in  the  Trendelenburg 
position  after  the  fluid  has  been  injected.  Most  operators  have  had  failures, 
especially  above  the  diaphragm.     In  Sonnenburg's  1117  cases  there  were  78 


I2i6  Anesthesia  and  Anesthetics 

utter  failures  ("Jour,  de  Chir.,"  Oct.,  1908).  Bier  says  that  failures  occur 
in  4  per  cent,  of  cases;  Moynihan  says  in  14  per  cent.;  Leguen  says  in  one- 
seventh  of  the  cases.  In  Barker's  last  100  cases  it  failed  3  times.  No  one 
should  attempt  it  who  is  not  well  trained  in  aseptic  methods,  because  infection 
of  the  cord  or  its  membranes  will  prove  fatal.  Untoward  effects  are  common, 
and  they  may  arise  during  or  after  the  operation. 

Sonnenburg  had  them  in  193  out  of  11 17  cases.  Among  the  untoward 
effects  reported  are  grave  collapse,  temporary  paralysis  of  the  abducens  ner\'e, 
of  the  facial  nen-e,  of  the  hypoglossal  nerve,  meningitis,  retention  of  urine, 
chills,  elevation  of  temperature,  incontinence  of  urine,  persistent  paraplegia, 
pain  in  the  back  and  legs,  perhaps  lasting  for  months,  nausea  and  vomiting 
during  and  after  the  operation,  sweating,  overaction  of  the  heart,  dimness  of 
vision,  cramps  in  the  limbs,  dyspnea,  \'iolent  headache,  involuntar}-  evacuation 
of  feces,  and  cardiac  overaction.  Many  of  the  immediate  symptoms  are 
probably  due  to  the  absorption  of  the  drug  injected.  The  headache  is  due  to 
tension  and  is  relieved  when  some  cerebrospinal  t3uid  is  ^^■ithdra■v^^l  by  lumbar 
puncture. 

Whether  or  not  permanent  harm  ever  comes  to  the  cord  is  not  certain. 
Bristow  ("Brooklyn  Med.  Jour.,"  1902,  x\-i,  page  410)  reports  the  case  of  a 
man,  fifty-five  years  of  age,  on  whom  he  operated  for  hemorrhoids  after 
spinal  cocainization.  An  examination  one  month  later  indicated  degenera- 
tion of  the  posterior  and  lateral  columns  of  the  cord  (spastic  lower  extremities, 
ataxic  gait,  increased  knee-jerks,  ankle-clonus,  and  inability  to  retain  urine). 
Marx  ("New  York  Med.  Record,"  Dec.  22,  1900)  states  that  one  case  in  his 
experience,  after  cocainization  of  the  spinal  cord,  developed  t}'pical  loco- 
motor ataxia.  Dandois  ("Jour,  de  Chir.  Brux.,"  April-May,  1901)  reports 
a  case  upon  which  he  had  operated  for  traumatic  rupture  of  the  urethra. 
Spinal  cocainization  was  employed.  Paraplegia  developed  and  lasted  tAvo 
months.  Several  cases  of  hemorrhage  into  the  subarachnoid  space  are  on 
record.  Leguen  states  that  persistent  paraplegia  and  persistent  incontinence 
of  urine  may  arise  ("Rev.  de  Chir.,"  Oct.,  1908). 

Is  there  any  danger  of  death  from  spinal  analgesia?  If  the  operation 
is  not  performed  with  scrupulous  aseptic  care  it  is  ver)'  dangerous.  Even 
when  performed  by  the  best  surgeons  death  may  occur.  Tuffier  places 
the  mortahty  at  3  in  2000,  but  excludes  from  consideration  3  deaths  ("La 
Presse  Medicale,"  vol.  Iv,  1901,  page  190).  Reclus  finds  6  deaths  in  less 
than  2000  cases  (Address  before  the  Paris  Academie  de  ^Medicine,  March  19, 
1901).  Hahn,  in  1708  cases  collected  from  literature,  found  8  deaths  ("Mitt, 
a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,"  1900,  iii,  337).  The  mortalit}'  is  usually 
supposed  to  be  about  3  in  every  1000  cases.  Wm.  N.  Perkins  ("New  Orleans 
Med.  Jour.,"  Jan.-Sept.,  1902)  collected  2345  cases  with  16  deaths  or  i  death 
in  146  administrations.  Strauss's  table  shows  46  deaths  in  22,717  cases  (quoted 
by  Hardonin,  in  "Archiv.  Generale  de  Chir.,"  August,  1908). 

Cocain  seems  to  act  like  a  toxin  on  the  pia  and  arachnoid.  Examination 
of  fluid  withdrawn  after  the  performance  of  cocainization  shows  that  it  con- 
tains poh-morphic  leukocytes  (Ravant  and  Aubourg,  in  "Gaz.  Hebd.  de  Med. 
et  de  Chir.,"  June  27,  1901). 

In  a  case  in  which,  because  of  heart  disease,  pulmonan,-  disease,  kidney 
disease,  or  some  other  condition  in  which  a  general  anesthetic  is  inadmissible. 


Symptoms  of  Burns  1217 

spinal  cocainization  is  justifiable.  It  should  be  reserved  exclusively  for  cases 
in  which  other  forms  of  anesthesia  are  positively  contraindicated.  The  method 
should  not  be  em])loyed  on  those  under  fifteen  or  on  the  subjects  of  central 
nervous  disease. 

A  solution  of  Epsom  salts  has  been  used  by  Blake,  Haubold,  and  Willy 
Meyer.  It  was  discovered  (Meltzer  and  Auer,  ''Am.  Med.,"  Nov.  25, 
1905)  that  subcutaneous  injections  of  salts  of  magnesium  produce  local 
anesthesia.  The  same  investigators  later  pointed  out  (S.  J.  Meltzer,  "Med. 
Record,"  Dec.  16,  1905)  that  subarachnoid  spinal  injections  produce  wide- 
spread and  complete  anesthesia.  A  25  per  cent,  solution  is  used  and  r 
cc.  of  this  is  given  for  every  25  pounds  of  body  weight.  After  a  wait  of 
three  or  four  hours  the  drug  causes  paralysis  and  analgesia  of  the  legs  and 
pelvic  region.  Sensation  and  motion  do  not  return  for  eight  to  fourteen 
hours.  Retention  of  urine  may  last  two  days.  The  pulse  and  blood-pressure 
are  unaffected,  but  the  respiration  is  slowed.  Large  doses  would  endanger 
life  by  respiratory  arrest.  In  view  of  the  fact  that  in  some  cases  the  effect  of 
the  drug  is  inordinately  prolonged,  it  is  wise,  when  the  operation  is  completed,  to 
puncture  the  theca  of  the  cord  again  and  wash  it  out  with  salt  solution. 


XXX.  BURNS  AND  SCALDS. 

Burns  and  scalds  are  injuries  due  to  the  action  of  caloric.  Scalds  are 
due  to  heated  fluids  or  vapors.  There  is  no  true  pathological  difference 
between  burns  and  scalds.  Dupuytren  classifies  burns  into  six  degrees,  as 
follows:  (i)  Characterized  by  erythema;  (2)  characterized  by  dermatitis  with 
the  formation  of  vesicles;  (3)  characterized  by  partial  destruction  of  the  skin, 
which  structure  is  not,  however,  entirely  burned  through;  (4)  characterized 
by  destruction  of  the  skin  to  the  subcutaneous  tissue;  (5)  characterized  by 
destruction  of  all  superficial  structures  and  of  part  of  the  muscular  layer; 
(6)  characterized  by  "carbonization"  of  the  whole  thickness  of  the  muscles. 

The  symptoms  of  a  severe  burn  are  local  and  constitutional.  Local 
symptoms  are  pain  and  inflammation,  which  very  in  nature,  in  intensity, 
or  in  degree  according  to  the  extent  of  tissue-damage.  Constitutional  symp- 
toms are  very  weak  pulse,  shallow  respiration,  and  subnormal  temperature 
— in  other  words,  the  condition  of  shock  exists.  The  patient  may  die  without 
reacting  from  shock,  but  in  most  cases  there  is  reaction,  followed  by  a  severe 
reactionary  fever,  with  a  strong  tendency  to  congestion  of  internal  parts. 
During  the  existence  of  fever  there  may  be  vomiting,  diarrhea,  hemoglobinuria, 
albuminuria,  and  enlargement  of  the  liver,  spleen,  lymph-glands,  and  tonsils. 
Marked  blood  changes  follow  burns  (see  "Clinical  Hematology,"  by  J.  C. 
DaCosta,  Jr.).  There  is  a  marked  and  rapid  increase  in  red  blood-cells  (poly- 
cythemia). This  is  due  in  part  to  venous  stasis  and  in  part  to  loss  of  blood 
plasma.  Leukocytosis  is  rapid  and  pronounced  and  there  is  a  notable  increase 
in  blood  plaques. 

The  blood  has  a  marked  disposition  to  clot,  and  clots  may  damage  various 

structures  or  organs.     Further,  the  altered  blood  damages  the  organs  of 

excretion,  and  the  liver  and  kidneys  may  cease  to  perform  their  functions 

properly.    After  a  severe  burn  there  are  imperfect  oxygenation  and  a   ten- 

77 


12 18  Burns  and  Scalds 

dency  to  universal  fatty  degeneration.  The  symptomatic  stages  are  often 
designated  as  prostration,  reaction,  and  suppuration.  During  the  first  forty- 
eight  hours  after  a  burn  there  are  congestion  in  and  about  the  burned  area, 
severe  pain,  and  possibly  internal  congestions.  There  may  be  shock  and 
possibly  toxic  delirium  or  convulsions.  From  the  end  of  the  second  to  the 
end  of  the  eighth  or  ninth  day  there  are  severe  inflammation  of  the  burned  area, 
formation  of  sloughs,  and  a  strong  tendency  to  inflammation  of  the  brain  in 
head  burns,  of  the  lungs  in  chest  burns,  of  the  abdominal  organs  in  abdominal 
burns,  and  of  duodenal  inflammation  in  any  burns.  HyaHne  emboli  in  very 
unusual  cases  cause  Curling's  ulcer  of  the  duodenum.  Duodenitis  and 
Curling's  ulcer  are  possibly  due,  as  Wm.  Hunter  suggested,  to  the  bile  having 
become  irritant  by  the  excretion  in  it  of  toxic  matter  ("A  Manual  of  Surgical 
Treatment,"  by  W.  Watson  Cheyne  and  F.  F.  Burghard).  After  the  eighth 
or  ninth  day  the  sloughs  separate  from  the  burned  area  and  healing  begins. 
The  raw  svirface  is  slow  to  heal,  hemorrhages  may  occur,  the  granulations  are 
apt  to  be  exuberant  and  edematous,  and  the  scars  are  very  contractile  and 
often  produce  hideous  or  disabling  deformity.  If  over  one-half  of  the  body- 
surface  is  badly  burned,  death  will  almost  certainly  occur,  and  probably  within 
two  days.  The  danger  of  a  burn  depends  upon  its  extent,  its  depth,  and  its 
situation.  Burning  of  a  large  area  superficially  is  much  more  dangerous 
than  burning  a  small  area  deeply.  Burns  of  the  extremities  are  not  so  danger- 
ous as  are  burns  of  the  head,  chest,  or  abdomen.  Death  after  severe  burns  is 
positively  not  due  to  loss  of  body-heat  in  the  burned  area.  Some  think  it  is 
produced  by  autointoxication  with  retained  body-secretions.  High  tempera- 
ture produces  blood-changes — viz.,  disintegration  of  red  corpuscles.  Throm- 
bosis may  occur,  and  irritation  of  the  kidneys  and  other  organs  is  produced  by 
"products  of  corpuscular  degeneration."* 

The  blood  of  burned  animals  contains  toxins  (Kijanitzen),  and  so  does 
the  urine  (Reis).  It  seems  probable  that  the  constitutional  symptoms  and 
death,  if  it  occurs,  are  due  partly  to  corpuscular  disorganization,  and  partly 
to  the  absorption  of  toxic  matter  from  the  seat  of  injiu-y,  this  matter  having 
been  formed  by  the  action  of  heat  on  the  body-cells  and  fluids.  Sepsis  is 
not  infrequent.  Death  may  be  directly  due  to  shock,  to  sepsis,  to  exhaustion, 
to  embolism  or  thrombosis,  to  congestion  of  the  brain,  lungs,  or  kidneys, 
or  to  CurHng's  ulcer  of  the  duodenum. 

Treatment. — The  local  treatment  of  slight  burns  is  to  moisten  the 
parts  frequently  with  a  saturated  solution  of  bicarbonate  of  sodium,  or 
a  I  :  8  solution  of  phenol  sodique.  In  burns  of  moderate  degree  a  mixture 
of  zinc  ointment  with  iodoform,  though  not  antiseptic,  is  a  comfortable 
dressing. 

If  a  large  surface  is  burned,  remove  the  clothing  with  great  care,  and  before 
applying  dressings,  give  a  hypodermatic  injection  of  morphin,  administer 
stimulants,  and  if  the  patient  has  a  chill,  place  him  in  a  warm  bath.  Use  all 
ordinary  means  to  secure  reaction  from  shock.  If  we  desire  to  dress  a  large 
burn  aseptically,  anesthetize  the  patient,  spray  the  burnt  area  with  per- 
oxid  of  hydrogen,  irrigate  it  with  a  solution  of  boric  acid,  dry  with  sterile 
cotton,  dust  with  Senn's  powder  (three  parts  of  boric  acid  and  one  part  of 
salicylic  acid),  and  dress  with  sahcylated  cotton.  Senn's  powder  is  better 
*  Bardeen,  in  Johns  Hopkins  Hospital  Bulletin,  April,  1897. 


Treatment  of  Burns  12 19 

than  iodoform.  Iodoform  may  allay  pain,  but  is  apt  to  produce  dermatitis. 
Change  the  dressing  no  oftener  than  is  required,  and  at  each  change  proceed 
as  above  described,  although  it  will  not  be  necessary  to  anesthetize.  Per- 
oxid  of  hydrogen  softens  and  loosens  the  dressings,  and  they  can  be  readily 
removed.  The  custom  in  the  Jefferson  Medical  College  Hospital  is  to  give 
morphin  and  stimulants,  to  cut  away  the  clothing,  to  wrap  the  unburned  parts 
with  blankets,  and  place  about  them  cans  or  bags  of  hot  water.  The  burned 
region  is  sprayed  with  peroxid  of  hydrogen  contained  in  an  atomizer,  and 
irrigated  with  salt  solution.  Portions  of  epidermis  which  remain  are  re- 
tained. Any  blisters  are  opened  with  a  sterile  needle,  and  the  part  is  dressed 
with  several  layers  of  sterile  lint  or  tarlatan  soaked  in  normal  salt  solution, 
and  the  dressing  is  kept  moist.  During  the  second  or  inflammatory  stage 
use  stimulants  and  concentrated  food,  allay  pain  by  opium  or  morphin, 
favor  elimination  by  the  skin,  bowels,  and  kidneys,  and  combat  any  tendency 
to  internal  congestion  or  inflammation.  In  very  extensive  burns  complete 
and  continuous  immersion  of  the  part  in  warm  salt  solution  is  an  excellent 
treatment. 

The  picric  acid  treatment,  first  suggested  by  Thiery,  has  many  advocates. 
It  greatly  mitigates  the  pain.  It  is  used  early  only  in  limited  burns  of  the 
first  and  second  degrees,  but  it  can  be  employed  in  late  stages  of  deep  burns 
to  stimulate  the  formation  of  epidermis.  If  used  early  in  a  large  or  a  deep 
burn,  it  may  poison  the  patient.  It  may  poison  a  child  when  used  upon  a 
burn  of  the  second  degree.  A  case  was  reported  by  Dr.  J.  Stuart  Rose 
("Scottish  Med.  and  Surg.  Jour.,"  Dec,  1903),  occurring  in  a  boy  of  nine, 
who  was  treated  with  picric  acid  for  a  scald  of  the  first  degree,  there  being 
only  one  or  two  small  blisters  in  addition  to  the  redness .  Ointment  of  picric  acid 
was  used  (5ss  to  an  ounce  of  vaseHn).  Symptoms  were  noted  three  days 
after  beginning  the  treatment.  The  symptoms  are  dark-colored  urine 
(carboluria) ,  albuminuria,  marked  yellowness  of  the  skin,  yellowness  perhaps 
of  hair  at  the  scalp  margins,  diarrhea,  and  elevated  temperature.  Rose  considers 
a  I  per  cent,  solution  safe.  It  is  appHed  as  follows :  The  part  should  be  dis- 
infected, gauze  saturated  with  a  i  per  cent,  watery  solution  of  picric  acid 
should  be  laid  upon  the  burned  area,  and  be  covered  with  absorbent  cotton 
and  a  bandage.  This  dressing  is  not  changed  for  three  to  five  days,  and  the 
next  dressing  can  be  left  in  place  until  the  burn  is  healed.  D'Arcy  Power 
has  carefully  studied  the  real  status  of  picric  acid  as  a  remedy  for  burns,  and 
some  of  his  conclusions  have  been  set  forth  above. 

Perier  dresses  a  burn  with  a  tarlatan  compress,  folded  six  times  and 
soaked  in  the  following  solution:  boric  acid,  5iiss;  antipyrin,  5iss;  sterile 
water,  Bviij.  The  following  ointment  is  used  by  Reclus:  iodoform,  gr.  xv; 
antipyrin,  gr.  Ixxv;  boric  acid,  gr.  Ixxv;  vaselin,  §iss. 

Carron  oil  consists  of  equal  parts  of  Hnseed  oil  and  lime-water.  It  allays 
the  pain  of  a  burn,  but  it  is  a  filthy  preparation,  and  its  use  is  followed  by 
much  pus-formation.  Cosmolin  gives  comfort  as  a  dressing,  but  should 
not  be  used  on  the  face,  lest  it  cause  pigmentation.  The  elder  Gross  used 
lead  paint.  A  solution  of  nitrate  of  potassium  allays  the  pain.  In  every  burn 
of  the  fingers  and  toes  keep  the  burnt  digits  separated  by  gauze,  lint,  or  rubber 
tissue  during  healing,  otherwise  adjacent  fingers  will  adhere  and  ^^ webbing'* 
will  result.     Where  extensive  destruction  of  tissue    has    taken   place    and 


I2  20  Burns  and  Scalds 

healing  has  begun,  use  splints  and  extension  to  limit  contractures,  and  skin- 
graft  as  soon  as  possible.  If  granulation  is  slow,  stimulate  with  copper  sul' 
phate  or  mild  silver-nitrate  solutions.  Exuberant  granulations  require  burning 
down.  Flabby  granulations  require  pressure.  If  healing  is  slow,  or  if  the  bum 
is  extensive,  skin-graft.  Skin-grafting  should  be  done  early  in  an  extensive 
burn.  If  performed  before  much  cicatricial  tissue  has  formed,  the  graft 
will  be  more  apt  to  adhere,  and  if  the  graft  does  grow  fast,  further  formation 
of  scar  tissue  will  be  greatly  limited.  When  an  extremity  has  been  carbonized, 
amputation  must  be  performed.  The  constitutional  treatment  of  a  severe 
burn  is  to  bring  about  reaction;  combat  pain  with  opium;  and  keep  the  bowels 
and  kidneys  active.  If  suppuration  occurs,  give  tonics,  stimulants,  and  con- 
centrated foods.     Complications  are  treated  according  to  general  rules. 

Burns  and  Scalds  of  the  Tongue,  Pharynx,  Glottis,  and 
Epiglottis. — A  child  or  lunatic  may  drink  boiling  fluid  or  inhale  steam  from  a 
tea-kettle.  Firemen  occasionally  suffer  from  scalds  of  the  tongue  and  phar- 
ynx after  being  suddenly  enveloped  in  a  cloud  of  hot  steam,  and  from  burns 
by  the  inhalation  of  hot  vapor  or  flame.  Caustic  may  be  taken  into  the  mouth 
or  swallowed.  The  tongue  and  pharyngeal  mucous  membrane  swell  greatly, 
large  vesicles  form,  there  are  shock,  severe  pain,  dysphagia,  and  dyspnea. 
Edema  of  the  glottis  may  arise. 

Treatment. — Combat  shock;  give  morphin  for  pain;  puncture  vesicles, 
and  have  the  patient  almost  constantly  suck  bits  of  ice.  If  great  swelling 
occurs,  make  multiple  longitudinal  incisions  through  the  mucous  membrane 
of  the  dorsum  of  the  tongue.  If  edema  of  the  glottis  begins,  scarify  it.  If 
this  fails,  perform  intubation  or  tracheotomy. 

Burns  of  the  Esophagus. — The  esophagus  is  seldom  scalded,  as  a 
boiling  fluid  rarely  gets  below  the  pharynx.  The  swallowing  of  an  acid  or 
alkali  produces  severe  burns  at  the  constricted  portions  of  the  gullet  (page 
■926).  Such  an  accident  produces  shock,  dyspnea,  violent  pain,  vomiting 
of  blood,  and  thirst.  Death  may  occur  from  shock  or  perforation  of  the 
stomach.  In  many  cases  severe  gastritis  follows  a  burn  of  the  esophagus. 
As  the  acute  symptoms  of  a  burn  of  the  gullet  gradually  abate,  sloughs  are 
•cast  off,  ulcers  form,  cicatrization  begins,  and  the  signs  of  stricture  develop 
(page  926). 

Treatment. — Give  a  remedy  to  neutralize  the  caustic.  Administer 
several  large  draughts  of  water  and  wash  out  the  stomach.  Combat  shock. 
Give  morphin  for  pain.  Feed  by  the  rectum  as  long  as  the  patient's  strength 
does  not  begin  to  fail.  On  beginning  mouth-feeding,  use  at  first  milk  and 
then  beef-juice,  jelly,  and  ice-cream.  In  from  two  to  four  weeks  after  the 
infliction  of  the  burn  begin  the  use  of  bougies  to  limit  contraction. 

Effects  of  Cold. — Local  Effects. — Cold  produces  numbness,  pricking, 
a  feeling  of  weight,  redness  of  the  surface  followed  by  stiffness,  local  insensi- 
bility, and  mottling  or  pallor.  Sudden  intense  cold  causes  the  formation 
of  blebs,  the  coagulation  of  blood  in  the  superficial  veins,  and  violent  pain 
in  the  part.      Cold  locally  produces  frost-bite  (page  191). 

The  constitutional  effects  of  cold  are  at  first  stimulating,  then  depressing, 
and  are  exhibited  by  uneasiness,  pain,  and  an  intense  drowsiness  which,  if 
yielded  to,  is  the  road  to  death  by  way  of  internal  congestion.  Death  from 
prolonged  cold  resembles  in  appearance  death  from  apoplexy.     Death  from 


Chilblain  or  Pernio  1221 

sudden  and  overwhelming  cold  is  caused  by  anemia  of  the  brain  from  weak 
circulation  and  capillary  embolism.  To  bring  a  partly  frozen  person  into 
a  warm  room  may  cause  death  by  embolism. 

Treatment. — Frost-bite  is  treated  as  outlined  on  page  192.  When  a 
person  is  nearly  frozen  to  death  place  him  in  a  cool  room,  but  under  no  cir- 
cumstance, in  a  cold  bath;  make  artificial  respiration,  rub  him  briskly  with 
flannel  soaked  in  alcohol  or  in  whisky,  and  follow  this  by  rubbing  with 
dry  hands.  After  a  time  wrap  the  patient  in  warm  blankets  and  give  an 
enema  of  brandy.  Mustard  plasters  are  to  be  applied  over  the  heart  and 
spine.  As  soon  as  swallowing  is  possible  brandy,  is  administered  by  the 
mouth.  As  the  condition  improves  gradually  raise  the  temperature  of  the 
room  and  give  hot  drinks. 

Chilblain  or  pernio  is  a  secondary  effect  of  cold.  It  is  really  an  area 
of  local  asphyxia  (page  188) .  It  usually  appears  as  a  local  congestion  upon  the 
toes,  the  ears,  the  fingers,  or  the  nose,  and  now  and  then  inflames  and  ulcerates. 
A  chilblain  is  apt  to  become  congested  on  approaching  a  fire  or  on  taking  ex- 
ercise, and  when  congested,  it  itches,  tingles,  and  stings.  Frequent  attacks  of 
congestion  produce  crops  of  vesicles;  these  vesicles  rupture  and  expose  an 
ulcer,  which  in  rare  instances  sloughs. 

Treatment. — If  chilblain  affects  the  toes,  prevent  congestion  of  the  legs 
and  feet.  Order  large  shoes  and  woollen  stockings,  and  forbid  tight  garters. 
The  patient  with  pernio  must  take  regular  outdoor  exercise  and  must  not 
loiter  around  a  hot  fire.  Every  morning  and  evening  he  should  take  a  general 
cold  sponge-bath,  following  by  rubbing  with  alcohol  and  frictions  with  a 
coarse  towel,  and  in  winter  he  should  sleep  with  warm  stockings  on  or  with 
his  feet  upon  a  warm-water  bag.  When  a  chilblain  is  only  a  congested  spot, 
it  should  be  washed  twice  a  day  in  cold  salt  water,  rubbed  dry  with  flannel, 
and  subjected  to  applications  of  tincture  of  iodin  and  soap  liniment  (i :  2), 
tincture  of  cantharides  and  soap  liniment  (i :  6),  or  equal  parts  of  turpentine 
and  olive  oil  (W.  H.  A.  Jacobson).  Jacobson  says  itching  is  relieved  by 
painting  belladonna  liniment  upon  the  part  and  allowing  it  to  dry.  Tincture 
of  iodin  may  relieve  it,  and  so  may  a  mustard  foot-bath.  A  valuable  prepara- 
tion for  itching  is  composed  of  5j  of  powdered  camphor  and  5iv  of  cosmolin. 
A  Httle  of  this  ointment  is  rubbed  in  twice  a  day.  The  following  prescription, 
the  source  of  which  I  do  not  remember,  is  very  valuable  for  itching:  5j  of 
powdered  camphor;  oiss  of  ichthyol;  5ss  of  lanolin,  and  oiv  of  cosmolin, 
rubbed  into  the  part  and  covered  with  cotton-wool.  If  vesicles  form,  paint 
with  contractile  collodion;  if  ulcers  form,  dress  antiseptically.  If  ulcers  are 
sluggish,  use  equal  parts  of  resin  cerate  and  spirits  of  turpentine.  A  good 
antiseptic  and  protective  is  the  following:  oxid  of  zinc,  gr.  vj;  chlorid  of  zinc, 
gr.  xx;  gelatin,   §ij;  distilled  water,  5j- 


1222  Diseases  of  the  Skin  and  Nails 


XXXI.    DISEASES  OF  THE  SKIN  AND  NAILS. 

Dermatitis  venenata  is  a  dermatitis  resulting  from  irritants.  It  may 
be  caused  by  wearing  garments  containing  arsenic,  but  is  generally  due  to 
rhus-poisoning.  Rhus-poisoning  arises  from  the  poison-oak,  the  poison-ash, 
the  poison-ivy,  and  some  species  of  sumach.  Actual  touching  of  the  plants 
is  usually,  but  not  always,  necessary.  Some  suffer  if  they  simply  come  near 
them.  Some  people  are  immune  to  rhus-poisoning,  some  are  slightly  suscep- 
tible, some  are  strongly  predisposed.  It  is  believed  that  toxicodendric  acid 
is  the  irritant  agent.  The  condition  is  most  apt  to  arise  when  the  skin  is 
moist  from  perspiration. 

The  symptoms  are  burning  and  itching,  redness  and  edema  of  the  affected 
parts.  The  hands  and  forearms  are  most  apt  to  suffer,  but  any  part  may  be 
attacked.  If  the  penis  and  scrotum  suffer  from  rhus-f)oisoning  there  is  great 
swelling  from  edema.  An  eruption  on  the  hands  may  inoculate  the  penis 
when  that  organ  is  handled.  A  vesicular  eruption  begins  between  the  fingers, 
and  the  eruption  and  the  fierce  red  edematous  inflammation  spread  widely 
over  the  body.  There  may  be  slight  fever.  The  condition  begins  to  abate 
in  two  or  three  days,  as  a  rule,  and  desquamation  follows. 

When  one,  knowing  from  experience  that  he  is  predisposed,  feels  the 
inaugural  itching,  he  should  at  once  apply  to  the  parts  a  i  per  cent,  solution  of 
lactic  acid  in  95  per  cent,  alcohol  (R.  F.  Ward,  in  "N.  Y.  Med.  Jour.,"  Dec. 
26,  1908). 

The  treatment,  when  a  moderate  area  is  involved,  comprises  the  appHca- 
tion  of  cloths  wet  with  black  wash  or  lead-water  and  laudanum,  or  a  saturated 
solution  of  acetate  of  aluminium  (R.  F.  Ward,  Ibid.).  If  an  extensive  area 
is  involved,  apply  grindelia  robusta  (3iv  to  Oj  of  water)  or  moisten  the  surface 
frequently  with  sweet  spirits  of  niter.  Oxid  of  zinc  ointment,  containing 
10  gr.  of  carboUc  acid  to  ,?j,  gives  great  relief.  A  i :  8  solution  of  phenol 
sodique  allays  pain  and  itching. 

Furuncle,  or  boil,  is  an  acute  and  circumscribed  inflammation  of  the 
deep  layer  of  the  true  skin  and  the  subcutaneous  cellular  tissue  following  on 
bacterial  infection  of  a  hair-follicle  or  a  sebaceous  gland.  A  boil  is  caused  by 
infection  of  a  hair-folHcle  through  a  slight  wound  (by  scratching,  shaving,  etc.) 
with  the  staphylococcus  pyogenes  aureus.  Boils  are  very  common  in  indi- 
viduals with  Bright's  disease,  diabetes,  gout,  lithemia,  tuberculosis,  and 
disorders  of  menstruation  and  digestion;  and  crops  of  boils  are  apt  to  appear 
during  convalescence  from  typhoid  fever.  Boils  are  commonest  in  the 
spring,  and  sometimes  an  epidemic  of  furunculosis  appears  in  a  hospital,  a 
jail,  or  an  asylum. 

The  symptoms  of  a  boil  are  as  follows:  a  red  elevation  appears,  which 
stings  and  itches;  this  elevation  enlarges  and  becomes  dusky  in  color;  a 
pustule  forms,  that  ruptures  and  gives  exit  to  a  very  little  discharge  which 
forms  a  crust.  Inflammatory  infiltration  of  adjacent  connective  tissue 
advances  rapidly,  and  the  boil  in  about  three  days  consists  of  a  large,  red, 
tender,  and  painful  base  capped  by  a  pustule  and  a  little  crusted  discharge. 


Carbuncle  1223 

In  rare  instances,  at  this  stage,  absorption  occurs,  but  in  most  cases  the 
sweUing  increases,  the  discoloration  becomes  darker,  the  skin  becomes  edem- 
atous, the  pain  becomes  severe  and  pulsatile,  and  the  center  of  the  boil  becomes 
raised.  About  the  seventh  day  rupture  occurs,  pus  flows  out,  and  a  "co^-e" 
of  necrosed  tissue  is  found  in  the  center  of  a  ragged  opening.  This  core  con- 
sists of  the  sebaceous  gland  and  hair-follicle,  which  have  undergone  coagula- 
tion necrosis  (Warren).  In  a  day  or  two  more  the  core  will  be  discharged, 
and  healing  by  granulation  will  begin.  A  blind  boil  lasts  only  three  or  four 
days  and  has  no  core.  The  constitution  often  shows  reaction  during  the 
progress  of  a  boil.  Boils  may  be  either  single  or  multiple.  The  development 
of  one  boil  after  another,  or  the  formation  of  several  boils  a*:  once,  is  known 
as  "  jurimculosis.''     Boils  are  commonest  upon  the  neck  and  the  back. 

The  treatment  consists  of  crucial  incision,  removal  of  necrotic  tissue, 
irrigation  with  peroxid  of  hydrogen,  touching  with  pure  carbolic  acid,  and 
the  application  of  hot  antiseptic  fomentations. 

Aleppo  boils  (endemic  bolls  of  the  tropics)  are  papules  appearing  upon 
the  exposed  parts  of  the  body.  These  papules,  which  ulcerate  and  do  not 
cicatrize  for  at  least  a  year,  are  due  to  a  pathogenic  bacterium  and  leave 
ineradicable  scars. 

Carbuncle  (benign  anthrax)  is  a  circumscribed  infectious  inflammation 
of  the  deeper  layer  of  the  true  skin  and  of  the  subcutaneous  tissue,  with 
fibrinous  exudation,  multiple  foci  of  necrosis  arising,  and  the  tissue  adjacent 
to  each  necrotic  plug  becoming  gangrenous.  The  infection  takes  place 
through  a  hair-follicle.  It  is  really  a  boil  with  extensive  infiltration  of  adjacent 
tissues.  A  boil  may  become  a  carbuncle,  and  pus  from  a  carbuncle  inoculated 
into  a  healthy  person  may  cause  either  a  boil  or  a  carbuncle.  The  causative 
organism  seems  to  be  the  staphylococcus  pyogenes  aureus.  Carbuncle  is 
most  common  in  the  upper  part  of  the  back  and  on  the  back  of  the  neck. 
In  this  region  the  skin  is  very  thick;  each  hair-follicle  holds  only  a  downy  hair, 
is  shallow,  and  projects  but  a  short  distance  into  the  cutis  vera.  Columns 
of  fatty  tissue  run  from  the  subcutaneous  tissue  in  an  oblique  direction 
to  join  the  point  and  sides  of  the  hair-follicle.  These  columns  are  known  as 
columncB  adipose,  and  each  one  contains  a  sweat-gland  (Fig.  710).  When 
pus  runs  down  one  of  these  columns,  it  seeks  an  outlet;  it  cannot  spread 
easily  to  the  sides,  so  it  slowly  works  its  way  to  deeper  tissue  and  from 
one  to  another  interspace  and  finds  its  way  to  the  surface  through 
other  fatty  columns  (Warren's  "Surgical  Pathology")  (Fig.  711).  When 
pus  finds  its  way  to  the  surface,  an  opening  forms,  hence  the  numerous 
foci  of  pointing;  finally  a  large  opening  forms  (Fig.  712).  Carbuncles  are 
most  common  in  the  spring  of  the  year.  In  persons  with  diabetes  and 
Bright 's  disease  carbuncles  not  unusually  occur. 

The  local  S5miptoms  in  the  beginning  resemble  those  of  a  boil,  but  the 
constitution  sympathizes  from  the  very  start  (perhaps  a  chill  and  always  a 
septic  fever)  and  the  pain  is  usually  severe.  The  inflammatory  area  beginsJ 
as  a  papule  with  an  indurated  base,  it  enlarges  enormously,  is  boggy  to  the 
touch,  is  dusky  in  color,  is  edematous,  and  the  skin  is  not  freely  movable 
over  the  deeper  parts.  In  a  few  days  many  pustules  appear,  each  pustule 
marking  the  site  of  a  focus  of  necrosis.  Large  vesicles  filled  with  bloody 
serum  very  frequently  form.     In  some  cases,  about  the  tenth  day,  the  pustules 


1224 


Diseases     of  the  Skin  and  Nails 


rupture,  the  narcotic  plugs  are  discharged,  and  the  case  slowly  progresses 

toward  cure;  but  in  many  cases  the 
carbuncle  spreads  at  the  periphery 
while  pustules  are  rupturing  near  the 
center  of  intlammation,  and  pus  forms 
in  the  deeper  tissues,  reaching  the 
surface  through  many  small  open- 
ings, each  of  which  is  partly  blocked 
by  a  plug  of  dead  tissue.  A  car- 
buncle in  this  stage  resembles  a 
honeycomb  (Fig.  712),  discharges 
bloody  pus,  and  large  masses  of  skin 
and  subcutaneous  tissue  are  destroyed. 
The  entire  carbuncular  mass  may 
become  gangrenous,  and  a  sudden 
and  almost  complete  cessation  of 
pain  points  to  this  compHcation.  An 
ordinary  carbuncle  remains  acute  for 
about  three  wrecks,  but  healing  re- 
quires a  month  or  more.  The  most 
dangerous  situations  in  which  to  have 
a  carbuncle  are  the  face  and  neck 
(tends  to  produce  septic  phlebitis,  septic  clots  in  the  facial,  jugular,  or 
ophthalmic  veins,  or  in  the  cerebral  sinuses,  or  infective  emboh).     The  mor- 


Fig.  710. — Columna  adiposa  (Warren). 


Fig.  711. — Infiltration  of  columna  adiposa  and  subcutaneous  tissue  with  pus  in  carbuncle  (Warren). 

tality  of  facial  carbuncle  is  at  least  50  per  cent.     The  most  usual  positions 
for  carbuncle  are  the  neck,  the  back,  and  the  buttocks.     The  diagnosis  of 


Clavus  or  Corn  1225 

carbuncle  is  made  by  noting  the  multiple  foci  of  necrosis  and  the  profound 
constitutional  involvement.  A  carbuncle  may  produce  death  by  causing 
septicemia,  pyemia,  or  profuse  hemorrhage. 

Treatment. — Some  have  suggested  the  treatment  of  a  carbuncle  in  an 
early  stage  by  injecting  from  five  to  thirty  drops  of  carbolic  acid  (80  per  cent.) 
into  and  around  the  inflammatory  mass.  Such  a  method  does  not  promise  suc- 
cess and  necessitates  dangerous  delay.  The  best  treatment  if  the  case  is  seen  suffi- 
ciently early  is  thorough  extirpation  while  the  patient  is  anesthetized.  The  entire 
area  of  the  infection  is  thus  removed,  and  the  large  wound  heals  by  granulation 
and  is  subsequently  skin-grafted.  When  the  condition  is  too  far  advanced  to 
admit  of  complete  extirpation,  the  following  useful  plan  should  be  employed: 

Give  ether,  make  free  crucial  incisions,  remove  dead  and  necrosing  tissue 
and  also  the  points  of  the  skin-flaps  with  the  scissors  and  forceps,  curet  pockets, 
arrest  hemorrhage  by  pressure  and  hot  water,  cauterize  with  pure  carbolic  acid, 
dust  with  iodoform,  pack  with  iodoform  gauze,  and  dress  with  hot  antiseptic 
fomentations.  Cover  the  gauze  with  a  piece  of  some  impermeable  material 
and  lay  a  hot-water  bag  upon  the  dressing.  Every  day,  or  several  times  a  day, 
remove  the  dressings,  wash  with  peroxid  of  hydrogen,  irrigate  with  corrosive 


Fig.  7  12. — Diagram  of  a  carbuncle  (Warren). 

sublimate  solution,  dust  with  iodoform,  and  reapply  the  iodoform  gauze  and 
antiseptic  fomentation.  Keep  up  this  treatment  until  sloughs  are  separated, 
then  dress  with  dry  antiseptic  gauze.  Secure  sleep  by  morphin,  give  quinin, 
milk-punch,  and  nourishing  diet,  and  maintain  the  action  of  the  bowels  and 
kidneys. 

Erysipelas.— (See  page  215.) 

Clavus  or  Corn. — A  corn  is  a  tender,  painful,  and  circumscribed 
thickening  of  the  epidermis,  and  is  commonest  over  one  of  the  joints  of  the 
toes.  Hard  corns  are  situated  on  exposed  parts  of  the  digits;  soft  corns 
appear  between  the  digits,  where  the  parts  are  kept  constantly  moist.  Corns 
are  caused  by  pressure. 

Treatment. — The  wearing  of  well-fitting  boots  will  usually  cause  a  corn . 
upon  the  toe  to  disappear.  Soak  the  feet  often  in  water  containing  bicarbonate 
of  sodium,  dry  them,  and  apply  a  circular  corn-plaster  to  the  corn  to  take  off 
the  pressure  of  the  boot.  Another  method  is  to  touch  the  corn  with  iodin 
every  night  and  pare  away  the  hard  tissue  every  morning.  An  old  and 
valuable  plan  is  to  paint  the  corn  every  night  and  morning  for  several  days 
with  a  mixture  composed  of  salicylic  acid,  gr.  xl;  extract  of  cannabis  indica, 
gr.  x;  and  collodion  and  flexible  collodion,  of  each,  5ij;  then  soak  the  parts 
in  hot  water  and  scrape  away  the  mass.  Soft  corns  are  treated  by  wash- 
ing the  feet  often  with  ethereal  soap,  drying,  gently  removing  the  sodden 


12  26  Diseases  and  Injuries  of  the  Thyroid  Gland 

epithelium,  dusting  the  toes  and  between  them  with  borated  talc,  and  plac- 
ing absorbent  cotton  between  the  digits.  Incurable  soft  corns  require  the 
removal  of  the  skin  from  the  adjacent  sides  of  the  two  toes  and  suturing 
them  together  (thus  converting  two  toes  into  one).  In  inflamed  corns  em- 
ploy rest  and  lead-water  and  laudanum,  and  let  out  pus  when  it  forms. 
Remember  that  in  old  persons  the  cutting  of  a  corn  may  cause  senile  gangrene. 
In  the  inflamed  and  painful  feet  of  a  person  who  has  corns  nothing  gives  so 
much  relief  as  washing  the  feet  with  ethereal  soap,  soaking  in  hot  water, 
and  wrapping  the  feet  for  half  an  hour  in  cloths  wet  with  a  mixture  com- 
posed of  linseed  oil  and  lime-water,  each,  §ij,  and  spirits  of  camphor,  5j- 

Warts.— (See  page  375.) 

Onychia  is  inflammation  of  the  matrix  of  the  nail.  Syphilis  often  causes 
severe  onychia  which  requires  specific  treatment  (page  322).  A  " run-around'* 
or  paronychia  is  suppuration  of  the  matrix  at  the  root  of  the  nail,  and  of  the 
skin  about  it,  of  traumatic  origin.  It  requires  incision,  trimming  away  of  the 
buried  edge  of  the  nail,  and  packing  with  iodoform  gauze.  Syphilitic  parony- 
chia is  referred  to  in  page  322 . 

Malignant  onychia,  which  is  inflammation  and  ulceration  of  the  entire 
matrix,  occurs  only  in  a  person  of  dilapidated  constitution.  This  condition 
requires  removal  of  the  entire  nail,  cauterization  of  the  matrix,  dressing  with 
iodoform  gauze,  and  the  internal  use  of  stimulants,  tonics,  and  nourishing  diet. 

Ingrowing  toe-nail  (page  173)  is  sometimes  due  to  lateral  hypertrophy  of  the 
edge  of  the  nail,  but  usually  to  forcing  of  the  soft  tissue  over  the  margin  of  the 
nail.  An  irritable  ulcer  arises.  The  condition  is  treated  by  spHtting  the  nail, 
removing  the  ingrown  piece,  the  soft  tissue  at  the  margin,  and  the  adjacent 
matrix,  and  dressing  antiseptically. 

XXXII.  DISEASES  AND  INJURIES  OF  THE   THYROID   GLAND. 

The  thyroid  gland  possesses  important  nutritive  functions.  Kocher 
pointed  out  that  its  complete  removal  in  a  young  or  middle-aged  person  usually 
causes  operative  myxedema  (cachexia  strumipriva)  and  perhaps  tetany.  Re- 
moval of  the  gland  in  an  elderly  person  does  not  cause  these  curious  conditions. 
Later  knowledge  indicates  that  removal  of  the  thyroid  with  the  parathyroids 
certainly  produces  myxedema  or  tetany,  unless  aberrant  thyroids  exist  and  com- 
pensate. Removal  of  the  thyroid  without  the  parathyroids  may  not  induce 
permanent  grave  consequence,  even  when  there  are  no  aberrant  thyroids.  The 
thyroid  furnishes  an  internal  secretion  which  destroys  certain  toxic  products 
of  metabolism.  It  is  thought  that  the  parathyroids  furnish  an  antitoxin  to 
poisons  formed  during  digestion. 

Wounds  cause  violent  hemorrhage  which  is  difficult  to  arrest.  Ligatures 
may  cut  out  and  forceps  will  not  hold.  The  hemorrhage  is  arrested  by 
suture  Hgatures,  purse-string  sutures,  the  actual  cautery,  or  removal  of  the 
bulk  of  the  gland. 

The  thyroid  gland  may  be  absent  at  birth.  Congenital  atrophy  or 
congenital  hypertrophy  may  exist. 

Acquired  atrophy  leads  to  myxedema,  a  condition  characterized  by  the 
presence  of  a  firm  subcutaneous  sweUing  in  the  face,  neck,  and  Hmbs;  slow 


Tumors  1227 

speech ;  mental  dulness ;  and  subnormal  temperature.  The  condition  is 
identical  with  that  jjroduced  by  removal  of  the  entire  gland. 

Cretinism  is  a  form  of  infantilism  and  idiocy  due  to  atrophy  of  glandular 
elements  in  the  thyroid,  although  the  size  of  the  gland  is  often  increased.  The 
body  is  dwarfed ;  bone  development  is  very  defective,  the  face,  neck,  and  extrem- 
ities resemble  those  parts  in  myxedema,  and  a  low  grade  of  idiocy  exists. 
Myxedema  and  cretinism  are  treated  by  the  internal  administration  of  thyroid 
extract. 

Thyroid  Grafting. — Many  experiments  have  been  made  and  are  being 
made  on  thyroid  grafting  in  the  treatment  of  cretinism  and  myxedema.  Grafts 
have  been  placed  under  the  skin,  in  bone  at  the  junction  of  the  epiphysis  with 
the  diaphysis,  in  the  spleen,  and  in  other  regions.  Very  encouraging  cases 
have  been  reported. 

Congestion  of  the  thyroid  may  be  caused  by  violent  exertion,  prolonged 
effort,  febrile  maladies,  and  venous  obstruction.  It  is  treated  by  removing 
the  cause  and  applying  heat  locally.     Tracheotomy  may  be  required. 

Inflammation  of  the  thyroid  (acute  or  inflammatory  goiter)  may  be 
induced  by  a  septic  or  febrile  malady,  rheumatism,  muscular  strain  causing 
vascular  rupture,  a  wound  or  contusion  of  the  thyroid.  But  one  lobe  is 
affected.  The  ordinary  symptoms  of  inflammation  are  present.  In  addition 
there  are  dysphagia,  dyspnea,  venous  congestion  of  the  face,  epistaxis,  nausea 
and  vomiting,  and  possibly  delirium.  It  may  terminate  in  resolution,  suppu- 
ration, or  fibrous  induration. 

Tuberculosis  of  the  Thyroid.— Is  usually  a  part  of  general  miliary 
tuberculosis.  It  is  very  seldom  that  a  local  caseating  focus  occurs,  but  such 
cases  have  been  reported. 

Syphilis  of  the  Thyroid — Early  in  the  secondary  stage  there  is  apt 
to  be  slight  and  painless  thyroid  enlargement.  In  the  tertiary  stage  gummata 
may  form. 

Tumors  of  the  thyroid  are  of  various  sorts.  Among  them  are  adenomata, 
cystic  adenomata,  sarcomata,  and  carcinomata.  Eight  cases  of  teratoma  are 
on  record  (Isabella  C.  Herb,  "Am.  Jour.  Med.  Sciences,"  June,  1906).  Malig- 
nant disease  is  unusual.  I  have  operated  on  but  two  cases :  one  of  cystic  car- 
cinoma in  which  operation  was  rapidly  fatal,  and  one  of  round-celled  sarcoma, 
which  is  living  and  apparently  well  four  years  after  partial  thyroidectomy. 
Malignant  disease  may  arise  in  the  normal,  but  is  more  apt  to  arise  in  a  goitrous 
thyroid.  In  over  50  per  cent,  of  the  reported  cases  there  is  a  history  of  a,ntece- 
dent  goiter.  Malignant  disease  is  more  common  in  women  than  in  men  and 
is  very  seldom  met  with  before  the  age  of  thirt}^  It  is  most  common  between 
forty  and  sixty.  One  should  always  suspect  malignant  disease  of  the  th}Toid 
gland  when  the  growth  appears  rather  suddenly  in  a  patient  over  forty  years 
of  age.  If  the  growth  is  irregular  in  outUne  and  is  accompanied  with  pain 
and  difficulty  in  swallowing,  the  diagnosis  becomes  reasonably  certain.  Later 
in  the  case  there  are  symptoms  due  to  pressure  upon  and  infiltration  of  the 
nerves;  the  growth  becomes  firmly  anchored  and  the  lymph-glands  adjacent 
to  the  thyroid  become  involved;  there  may  be  tracheal  bleeding,  and  perhaps 
fever,  and  eventually  cachexia  develops.  Sarcoma  or  carcinoma  may  occur 
and  it  is  seldom  possible  to  determine  clinically  with  which  we  are  dealing.  The 
cancer  may  be  a  scirrhus  or  an  epitheUoma,  but  is  usually  an  adenocarcinoma. 


1228 


Diseases  and  Injuries  of  the  Thyroid  Gland 


Fig.  7131 — Sarcoma  of  thyroiii  Rlaiid. 


A  sarcoma  may  be  either  round  cell  or  spindle  cell  in  type.     In  malignant 

disease  of  the  thyroid,  metas- 
tasis occurs  early  in  a  great 
majority  of  cases,  the  lungs 
being  first  involved,  and  then 
the  bones  and  other  structures; 
though  it  has  been  stated  that 
in  adenocarcinoma  the  lungs 
are  likely  to  escape  and  that 
soHtary  bone-metastasis  is  not 
infrequently  noted.  Sarcoma 
(Fig.  7 1 3 )  may  involve  one  lobe, 
but  carcinoma  (Fig.  714),  even 
at  an  early  stage,  is  apt  to  in- 
volve both  lobes  (Berry,  "  Dis- 
eases of  the  Thyroid  Gland"). 
Tliese  growths  soon  penetrate 
the  gland  capsule,  become  an- 
chored to  surrounding  parts, 
and  involve  the  vocal  cords, 
trachea ,  and  even  the  great  ves- 
sels of  the  neck.  It  is  after  the 
fortieth  year  that  malignant 
growths  may  be  met  with :  they 
are  hard  and  nodular  and  grow  rapidly.  At  first  the  gland  moves  with  degluti- 
tion, but  later  becomes  anchored  to  surrounding  parts.  In  malignant  disease  of 
the  thyroid  it  is  usual  to  find 
difficulty  of  swallowing  and 
paralysis  of  the  vocal  cord 
on  the  side  of  the  growth. 
Malignant  disease  is  rap- 
idly fatal.  Many  die  within 
six  months  and  few  sur- 
vive over  eighteen  months. 
Radical  operation  is  proper 
only  before  the  growth 
breaks  through  the  capsule, 
although  at  any  stage  it 
may  be  necessary  to  operate 
in  order  to  prevent  sufi'oca- 
tion. 

Goiter.  —  A  goiter  is 
an  enlargement  of  the 
thyroid  gland  not  due  to 
a  malignant  tumor  or  to 
inflammation.  The  en- 
largement may  affect  a 
small  portion  of  the  gland, 

one  lobe,  both  lobes,  or  both  lobes  and  the  isthmus,  and  it  may  occur  eithei 
sporadically  or  endemically. 


Fig.  714.— Cystic  carcinoma  of  thyroid  gland. 


Goiter 


1229 


Fig.  715  -—Adenomatous  goiter. 


There  are  a  number  of  forms  of  ordinary  goiter.     The  most  common  is 
what  is  called  parenchymatous  goiter  (Fig.  716).     In  this  condition  all  por- 
tions of  the  gland  enlarge,  and  the  goiter  is  consequently  bilateral.     It  does 
not  appear  first  in  one  lobe  and  at  a 
considerably  later  period  in  the  other, 
but  each  lobe  is  enlarged  equally  or 
nearly     equally.        Parenchymatous 
goiter  is  often  spoken  of  as  simple 
goiter,  and  is  sometimes,  though   not 
with  entire  accuracy,  designated  hy- 
pertrophy of  the  thyroid  gland. 

Adenomatous  goiter  (F\g.  715)  is  a 
condition  due  to  the  growth  of  encap- 
suled  adenomata  in  the  thyroid  gland. 
It  may  be  a  single  adenoma,  but 
frequently  there  are  multiple  growths. 
One  or  both  lobes  may  be  involved. 
The  goiter,  however,  seems  to  begin 
in  one  lobe;  and  if  both  lobes  en- 
large, one  does  so  at  a  period  dis- 
tinctly subsequent  to  the  enlarging 
of  the  other.  xA.denoma  may  develop 
in  a  healthy  thyroid  gland,  but  adenomatous  growth  is  usually  associated 
with  some  parenchymatous  growth. 

Cystic  goiter,  or  broncJiocele,  is  a  condition  in  which  the  chief  mass  of  the 
enlargement  is  composed  of  a  cyst  or  of  multiple  cysts.     When  cysts  form, 

the  thyroid  gland  is  usually 
hypertrophied  or  adenomatous; 
occasionally,  however,  cysts 
form  in  a  non-hypertrophied 
thyroid.  The  great  majority 
of  cysts  are  due  to  cystic  de- 
generation of  adenomata;  some 
are  formed  by  the  running  to- 
gether of  overdistended  thyroid 
vesicles,  and  some  few  follow 
blood-extravasation  into  the 
thyroid  tissue.  The  liquefaction 
is  due  to  mucoid  or  colloid 
degeneration,  and  the  fluid  of 
the  cyst  is  sometimes  clear 
and  thin,  sometimes  viscid,  and 
often  coffee-ground  in  appear- 
ance. 

A  fibrous  goiter  is  a  fibrous  in- 
duration.    It  is  likely  to  arise  in 
old  bronchoceles,  which  may  actually  pass  into  a  calcareous  condition.      By 
the  term  malignant  goiter  is  meant  malignant  disease  of  the  thyroid  gland,  either 
carcinoma  or  sarcoma.     As  stated  above,  such  cases  are  not  really  goiters. 


Fig.  716. — Parenchymatous  goiter. 


1230  Diseases  and  Injuries  of  the  Thyroid  Gland 

When  hemorrhage  takes  place  into  a  goiter,  the  condition  is  often  spoken  of  as  a 
hemorrhagic  goiter.  A  colloid  goiter  is  a  form  of  parenchymatous  goiter  in  which 
there  is  an  extremely  large  amount  of  colloid  material.  Exophthalmic  goiter  is 
discussed  on  page  1234.  Occasionally  an  ordinary  goiter  becomes  exophthalmic. 
This  evolution  gives  rise  to  what  the  French  call  a  Basedoniped  goiter  (see  Mores- 
tin,  in  "  Rev.  de  Chir.,"  Nov.  10,  1899).  A  goiter  that  develops  with  great  rapid- 
ity is  sometimes  called  an  acide  goiter,  and  one  that  induces  marked  dyspnea 
is  designated  a  suffocating  goiter.  Syphilitic,  tuberculous,  and  amyloid  enlarge- 
ments are  extremely  rare,  but  occasionally  occur.  Further,  a  goiter  may  be 
back  of  the  sternum,  that  is  siihsternal  or  retrosternal.  A  very  movable  goiter, 
which  is  now  above  and  now  below  the  sternal  notch,  is  called  a  wandering  or 
diver  goiter.  A  goiter  within  the  thorax  is  called  intrathoracic;  and  such  a 
goiter  may  be  retrosternal ,  retrotracheal ,  or  retro-esophageal.  When  a  number 
of  persons  in  the  same  region  are  attacked  with  goiter,  the  condition  is  frequently 
referred  to  as  epidemic  goiter.  When  the  condition  is  common  in  a  certain  dis- 
trict, it  is  called  endemic  goiter.  When  a  person  h\'ing  in  a  district  in  which  the 
disease  is  rare  develops  goiter,  we  speak  of  the  condition  as  sporadic  goiter.  It 
has  long  been  known  that  accessory  or  aberrant  thyroids  exist.  The  term  aber- 
rant is  better  than  accessory  because  in  some  reported  cases  the  thyroid  proper 
was  absent  (V.  L.  Schrager,  in  "Surgery,  Gynecology,  and  Obstetrics,"  Oct., 
1906) .  Aberrant  thyroids  are  masses  of  tissue  composed  of  structure  identical 
with  the  thyroid  gland,  and  distinct  and  separate  from  the  thyroid  gland  proper. 
Median  accessory  thyroids  are  found  about  the  hyoid  bone  and  are  formed  from 
remnants  of  the  thyroglossal  duct.  Lateral  accessory  thyroids  are  found  and 
develop  from  the  remains  of  the  lateral  anlages  of  the  thyroid  (Schrager). 
Aberrant  thyroids  var}'  in  number:  there  may  he  none,  one,  several,  or  chains  of 
them.  An  aberrant  thyroid  may  enlarge  with  the  thyroid,  may  not  enlarge  even 
though  the  th\Toid  does,  or  may  enlarge  when  the  thyroid  proper  remains 
normal.  When  cachexia  strumipriva  does  not  develop  after  complete  thy- 
roidectomy, including  the  parathyroids,  the  patient  has  been  saved  by  enlarge- 
ment and  functionation  of  accessory  thyroids. 

Causes  of  Goiter. — It  is  known  that  goiter  is  extremely  common  in  the 
valleys  at  the  foot  of  certain  mountain  ranges  in  Switzerland,  southeastern 
France,  northern  Italy,  the  Austrian  Tyrol,  and  in  the  Himalayas  and  the 
Andes.  In  a  portion  of  England  it  is  so  common  that  it  is  referred  to  as 
the  Derbyshire  neck.  It  seems  evident  that  the  disease  is  due  to  the  intro- 
duction of  some  poisonous  element  into  the  system;  but  what  this  element 
is,  is  not  positively  known.  Some  writers  maintain  that  individual  hability 
is  developed  by  habits  of  life;  others  think  that  susceptibility  depends  upon 
hygienic  surroundings;  and  some  attach  great  importance  to  hereditary 
influence.  The  probability  is,  however,  that  the  disease  is  due  to  the  existence 
of  some  poisonous  substance  in  the  drinking-water.  Some  observers  have 
blamed  snow-water;  many  have  laid  the  cause  of  the  trouble  at  the  door  of 
water  impregnated  with  salts  of  lime;  but  the  real  cause  has  not  been  positively 
demonstrated. 

An  ordinary'  parenchymatous  goiter  seems  to  be  a  species  of  hypertrophy. 
A  number  of  years  ago  I  suggested  the  view  that  the  gland  has  undergone 
such  an  enlargement  and  has  become  distended  with  colloid  material  because 
the  human  body  has  demanded  more  of  the  secretion  of  the  gland  than  the 


Symptoms  of  Goiter  1231 

normal  gland  has  been  able  to  supply;  as  a  consequence,  the  normal  gland 
has  enlarged  its  capacity  and  increased  its  output. 

Symptoms  of  Goiter.— One  may  determine  that  a  growth  is  in  the 
thyroid  gland  or  is  connected  with  it  by  studying  a  number  of  facts.  A 
goiter,  as  a  rule,  follows  the  movements  of  the  larynx  and  the  trachea  during 
deglutition,  and  this  sign  may  be  obtained  in  the  great  majority  of  instances. 
There  are,  however,  rare  conditions,  such  as  hyoid  cyst,  in  which  a  movement 
of  the  mass  takes  place  during  the  act  of  swallowing,  although  the  thyroid 
gland  is  not  involved.  Then,  again,  a  malignant  or  an  inflammatory  growth 
of  the  thyroid  usually  becomes  anchored  to  the  surrounding  tissues  and  does 
not  show  this  mobility.  Certainly,  however,  in  the  greater  number  of  the 
cases  the  goiter  moves  with  the  larynx  and  the  trachea  during  swallowing. 

Goiters  vary  greatly  in  size.  Cases  in  which  the  goiter  was  as  large  as 
an  adult's  head,  and  some  cases  in  which  the  goiter  hung  in  front  of  the  breast- 
bone and  reached  to  below  the  level  of  the  ensiform  cartilage,  have  been 
described.     A  very  large  goiter  may  have  a  stalk. 

When  the  entire  gland,  as  well  as  the  isthmus,  is  enlarged,  or  when  the 
isthmus  alone  is  involved,  the  swelling  may  appear  to  be  in  the  median  line 
of  the  neck.  If  the  condition  begins  in  one  lobe,  the  growth  will,  for  a  time 
at  least,  be  distinctly  one-sided;  though  when  such  a  growth  has  attained  a 
large  size,  it  may  displace  the  windpipe  and  come  itself  to  the  middle  line  of 
the  neck. 

A  goiter  of  any  considerable  size  pushes  the  sternocleidomastoid  muscle 
externally  and  anteriorly,  and  the  muscles  that  run  from  the  sternum  to  the 
hyoid  bone  and  to  the  thyroid  cartilage  overlie  the  front  of  the  growth.  The 
carotid  artery  is  displaced  externally  and  posteriorly.  The  relation  of  the 
jugular  vein  to  the  carotid  artery  is  usually  profoundly  altered.  The  artery, 
as  already  stated,  goes  externally  and  posteriorly,  while  the  vein  is  actually 
pulled  anteriorly  and  is  flattened  out  upon  the  side  or  the  anterior  surface 
of  the  goiter;  hence  the  vein  comes  to  lie  to  the  inner  side  of  the  artery.  This 
curious  alteration  in  relationship  is  due  to  the  fact  that  the  common  carotid 
artery  has  no  branches,  and  therefore  is  pushed  externally  with  ease;  but 
the  internal  jugular  vein  receives  branches  that  lie  in  the  tumor,  pull  upon 
the  vein,  and  prevent  its  displacement  with  the  artery  (Liicke). 

Berry  alludes  to  the  fact  that  the  tumor,  unless  it  is  very  small,  usually 
reaches  the  upper  level  of  the  sternum,  and  frequently  passes  below  this 
level;  and  that  only  extremely  large  goiters  hang  in  front  of  the  sternum,  but 
that  It  is  not  at  all  unusual  for  prolongations  from  a  goiter  to  extend  for 
quite  a  distance  into  the  mediastinum.  A  substernal  goiter  is  productive 
of  very  dangerous  symptoms  and  offers  many  difficulties  in  diagnosis.  A 
goiter  will  occasionally  wander,  now  appearing  in  the  neck  and  again  dis- 
appearing behind  the  sternum. 

Some  goiters  are  said  to  pulsate.  This  takes  place  in  exophthalmic 
goiter,  the  vessels  of  the  goiter  pulsating  as  do  the  other  vessels  of  the  body; 
but  in  the  ordinary  simple  goiter,  what  is  called  pulsation  of  the  goiter  is 
usually  the  transmitted  pulsation  from  the  carotid  artery. 

Some  of  the  most  important  symptoms  of  goiter  are  due  to  pressure  and 
to  the  displacing  of  anatomical  structures.  Pressure  upon  the  veins  at  the 
root  of  the  neck  causes  great  enlargement  of  the  veins  above  the  goiter  and 


1232  Diseases  and  Injuries  of  the  Thyroid  Gland 

in  it.  Pressure  upon  the  recurrent  laryngeal  nerve  may  induce  characteristic 
symptoms  (spasm  of  the  glottis  or  paralysis  of  a  vocal  cord),  hut  the  dyspnea 
of  goiter  is  due  to  pressure  upon  the  trachea  and  not  to  interference  v^ith  the 
recurrent  laryngeal.  Paralysis  of  a  vocal  cord  is  rare  in  non-malignant,  com- 
mon in  mahgnant,  goiter.  Pressure  upon  the  cervical  sympathetic  may  cause 
contraction  of  the  pupil  and  narrowing  of  the  palpebral  fissure  (Berry).  Pres- 
sure upon  the  cervical  plexus  or  the  brachial  plexus  causes  paresthesia,  anesthe- 
sia, or  paralysis  in  the  parts  supplied  by  nerves  from  the  compressed  plexus. 
Pressure  upon  the  larynx  and  the  trachea  may  cause  very  great  displacement, 
and  any  such  displacement  is  productive  of  marked  dyspnea.  This  displace- 
ment is  usually  to  the  side;  and  it  may  cause  such  a  flattening  out  of  the  tra- 
cheal rings  that  when  the  tumor  is  removed,  the  trachea  collapses  and  the 
patient  perishes  of  suffocation. 

A  parenchymatous  goiter  usually  begins  insidiously  and  grows  slowly. 
It  occasionally  ceases  to  grow  for  a  considerable  period  of  time,  and  may 
even  shrink.  It  frequently  enlarges  temporarily  during  menstruation  or 
pregnancy,  and  occasionally  attains  an  enormous  size  by  changing  into  the 
cystic  form.  Alterations  in  its  consistency  and  outline  may  be  due  to  the 
developing  of  adenomatous  masses. 

In  making  a  diagnosis  between  the  different  forms  of  goiter,  one  should 
remember  that  a  fairly  symmetrical,  bilateral  growth  is  probably  parenchy- 
matous; that  sudden  enlargements  are  produced  by  hemorrhage;  that  cyst- 
formation  may  lead  to  very  great  enlargement,  and  possibly  to  fluctuation; 
that  if  a  non-malignant  goiter  induces  dyspnea,  it  almost  invariably  does  so 
by  pressing  upon  the  larynx  and  the  trachea,  whereas  a  malignant  goiter 
may  do  so  by  interfering  with  the  nerves  of  the  part;  that  a  non-malignant 
goiter  very  rarely  produces  difficulty  in  swallowing,  but  that  a  malignant 
goiter  frequently  does  so;  and  that  cough  often  exists  if  there  is  pressure 
upon  the  larynx  or  the  trachea,  such  a  cough  being  metallic  in  nature  and 
unassociated  with  impairment  of  the  voice. 

In  any  goiter  there  may  be  cerebral  symptoms,  such  as  anemia,  syncope, 
or  even  convulsions.  Rapidly  growing  goiters  are  often  fatal,  and  slowly 
growing  goiters  are  very  rarely  so.  A  malignant  goiter  grows  with  great 
rapidity,  becomes  adherent,  infiltrates,  and  quickly  produces  metastases,  and 
both  sarcoma  and  carcinoma  produce  metastases  by  way  of  the  venous  system. 

Metastasis  of  Non-malignant  Goiter. — An  ordinary  goiter  which 
presents  no  sign  of  being  malignant  may  suddenly  be  disseminated.  The 
deposits  are  apt  to  take  place  in  the  bones  and  in  the  lungs.  Tumors' have 
been  removed  without  any  thought  of  thyroid  trouble  being  responsible,  and 
examination  has  shown  thyroid  structure.  Patel  collected  18  cases  of  thyroid 
metastasis  ("Tumeurs  benignes  du  corps  thyroide  donnant  des  metastases," 
"Revue  de  Chirurgie,"29,  1904).  The  bones  most  apt  to  receive  metastases 
are  the  bones  of  the  cranium,  the  lower  jaw,  the  vertebras,  the  pelvis,  and  the 
long  bones.  In  4  of  these  18  cases  the  spine  was  affected.  Dercum  has 
reported  a  case  of  thyroid  metastasis  to  the  spine  ("Journalof  Nervous  and 
Mental  Diseases,"  March,  1906).  Colloid  goiters  are  particularly  prone  to 
metastasis.  Some  surgeons  maintain  that  if  a  metastatic  deposit  grows  and 
destroys  bone,  the  primary  tumor  should  be  regarded  as  malignant  no  matter 
what  histological  studies  indicate. 


Endotracheal  Goiter  1233 

Treatment  of  Goiter. — lodid  of  potassium  and  arsenic  internally  have 
been  advised;  ointment  of  red  oxid  of  mercury  locally  is  advocated  by  some 
writers.  The  administration  of  thyroid  extract  may  do  much  good  in  a  case  of 
parenchymatous  goiter,  but  it  is  useless  in  other  forms  of  the  disease.  It 
should  be  associated  vi^ith  the  local  use  of  tincture  of  iodin  or  ointment  of  red 
iodid  of  mercury.  In  times  past  it  was  customary  to  treat  cystic  goiters  by 
aspiration  and  injection  with  a  solution  of  iodin.  Electrolysis  may  benefit  a 
soft  goiter,  the  negative  pole  being  pushed  into  the  growth,  the  positive  pole 
being  applied  to  its  surface.  In  some  cases  the  .T-rays  may  prove  of  benefit. 
In  considering  the  propriety  of  operation  remember  that  a  goiter  which  begins 
at  puberty  may  pass  away.  We  should  operate  on  every  non-malignant  goiter 
which  is  increasing  in  size  steadily  or  rapidly.  Operation  is  justifiable  even 
if  there  is  not  pressure  because  the  mortaHty  is  very  small,  and  it  saves  the 
patient  from  the  possibility  of  malignant  change,  of  hemorrhage,  and  of  inflam- 
mation. If  enucleation  or  extraglandular  extirpation  is  performed,  ether  is 
seldom  given.  General  anesthetics  increase  bleeding  and  are  to  that  extent 
dangerous.  Do  the  operation  with  the  aid  of  local  anesthesia  (cocain,  eucain, 
or  Schleich's  fluid).  It  is  a  great  advantage  to  have  the  patient  conscious, 
because  by  asking  him  to  speak  during  the  operation  the  surgeon  can  tell  if  the 
recurrent  laryngeal  nerve  is  being  approached  or  touched.  In  many  cases 
intraglandular  enucleation  is  performed,  in  other  cases  extirpation.  Occa- 
sionally these  two  methods  are  combined  (Bergeat).  Some  surgeons  advise 
simple  division  of  the  isthmus.  Ligation  of  the  thyroid  arteries  bas  been 
recommended.  Exothyropexy  is  the  operation  of  exposing  the  thyroid  gland, 
dislocating  it  through  the 
wound,  and  leaving  it  in 
this  situation.  Exothyro- 
pexy is  now  almost  never 
performed,  on  account  of 
the  safety  of  the  operation 

of      thyroidectomy.        Atro-  Fig.  717.— Koenig's  tracheotomy  tube. 

phy   of   the    gland    follows 

the  operation.  Enucleation,  if  possible,  is  the  desirable  operation.  It 
may  easily  be  employed  for  the  removal  of  a  single  adenomatous,  col- 
loidal, or  cystic  area.  Thyroidectomy  or  extirpation  is  employed  when 
enucleation  is  impossible.  The  entire  thyroid  is  not  removed  for  an 
innocent  growth:  a  portion  of  the  gland  is  left  behind,  otherwise  operative 
myxedema  will  probably  arise.  Unilateral  extirpation  is  the  method  usually 
chosen.  In  sarcoma  or  cancer  of  the  thyroid  complete  extirpation  may  be 
attempted.  The  operation  in  malignant  disease  will  occasionally  prolong  life, 
but  it  will  rarely  effect  a  cure.  In  malignant  disease  tracheotomy  may  be 
rendered  necessary  by  urgent  dyspnea.  The  operation  is  often  very  difficult 
because  the  growth  may  cover  the  trachea,  the  trachea  may  be  deviated  a  con- 
siderable distance  from  its  proper  position,  and  the  veins  are  very  large.  After 
the  performance  of  the  operation  it  is  usually  impossible  to  use  an  ordinary 
tracheotomy  tube,  and  in  such  a  case  Koenig's  long,  flexible  tube  is  employed 
(Fig.  717). 

Endotrac Ileal  Goiter. — Such  a  goiter  may  be  due  to  misplaced  thyroid 
tissue,  or  may  be  a  prolongation  from  the  thyroid  gland.     Occasionally  the 
78 


1234 


Diseases  and  Injuries  of  the  Thyroid  Gland 


growth  is  situated  in  front;  but,  as  a  rule,  it  is  attached  to  the  y)osterior  sur- 
face of  the  larynx  or  trachea.  The  first  symptom  is  dyspnea,  which  increases 
and  becomes  very  severe.  An  examination  with  a  laryngoscope  makes  the 
condidon  evident.  Endotracheal  goiter  is  much  more  common  in  the  female 
than  in  the  male.  It  is  beheved  to  begin  usually  at  about  the  age  of  puberty, 
though  it  may  exist  for  a  long  time  unnoticed.  In  some  reported  cases  the 
patients  were  forty  years  of  age  before  being  seen.  The  proper  treatment  for 
an  endotracheal  goiter  is  the  performance  of  a  preliminary  tracheotomy  and 
then  extirpation. 

Exophthalmic  Goiter  {Graves'  Disease,  Basedow's  Disease;  Pulsating 
Goiter). — This  condition  was  first  described  by  Graves,  of  Dublin,  in  1835. 
It  is  vastly  more  common  in  women  than  in  men,  and  is  most  common  be- 
tween the  ages  of  twenty 
and  forty.  It  may  arise  at 
puberty.  It  has  been  stated 
that  child-bearing  has  Httle 
influence  in  its  causation, 
but  I  have  seen  the  devel- 
opment of  it  in  a  woman 
three  times  in  three  different 
pregnancies.  There  is  not 
proof  of  heredity,  but  it  is 
not  unusual  to  find  more 
than  one  member  of  a 
family  with  it.  It  is  not 
particularly  prone  to  appear 
in  ordinary  goitrous  fami- 
lies, although  a  person  with 
an  ordinary  goiter  some- 
times develops  it.  It  may 
arise  after  emotional  excite- 
ment or  depression,  fright, 
shock,  hemorrhage,  or  an 
acute  illness.  It  may  de- 
velop during  the  existence 
of  locomotor  ataxia,  paresis, 
epilepsy,  neurasthenia,  hys- 
teria, and  other  nervous 
troubles,  and  abdominal  and  pelvic  diseases.  Digestive  toxemia  may  be  re- 
sponsible in  some  cases.  It  is  frequently  associated  with  marked  anemia,  the 
result  of  excessive  vomiting.  Many  believe  that  the  disease  is  a  toxemia  and 
that  the  real  cause  is  hypertrophy  of  the  thyroid  and  excessive  secretion  of 
the  gland  {hyperthyroidism) .  This  view  is  rendered  more  probable  when  we 
recall  that  a  condition  known  as  myxedema  possesses  many  symptoms  directly 
opposite  to  those  of  Graves'  disease  and  that  myxedema  is  due  to  deteriora- 
tion, great  diminution  or  absence  of  thyroid  secretion,  and  the  unopposed 
action  of  adrenal  secretion.  The  administration  of  thyroid  extract  to  an 
individual  may  produce  some  symptoms  observed  in  exophthalmic  goiter  and 
partial  thyroidectomy  may  improve  or  cure  the  disease.  Thyreoglobulin  is 
probably  the  poisonous  element. 


Fig.  718. — Exophthalmic  goiter  and  total  blindness  from 
protrusion  of  eyes  (Hansell). 


Exophthalmic  Goiter  1235 

An  apparent  objection  to  this  view  is  that  Graves'  disease  may  exist  with- 
out detectable  thyroid  enlargement,  but  this  objection  loses  force  when  we 
recall  that  the  thyroid  may  be  somewhat  enlarged,  though  we  cannot  detect 
the  increase.  It  is  probable  in  exophthalmic  goiter  that  whether  or  not  there 
is  an  excess  of  thyroid  products  passing  into  the  circulation,  toxic  materials  of 
some  sort  are  formed  in  the  gland  and  are  taken  into  the  lymph  and  blood.  The 
real  cause  of  exophthalmic  goiter  is  not  positively  proved,  but  it  seems  probable 
that  the  disease  is  due  to  the  action  on  the  sympathetic  system  of  large  amount:^ 
of  thyroid  material  or  of  some  poisonous  product  of  thyroid  acti\aty. 

In  exophthalmic  goiter  the  vessels  of  the  gland  are  not  dilated — in  fact 
they  are  "usually  smaller  and  less  numerous  than  in  a  parenchymatous  goiter 
of  the  corresponding  size "  (Berry  on  "Diseases  of  the  Thyroid  Gland  ") .  The 
surface  of  the  gland  is  smooth.  On  section,  the  cut  surfaces  seem  sohd  and 
very  Uttle  colloid  is  visible.  The  enlargement  is  due  to  growth  of  the  glandu- 
lar epithehum,  and  this  epithelial  proliferation  may  be  induced  by  the  different 
exciting  causes  previously  mentioned. 

In  exophthalmic  goiter  the  lymphatics  v^thin  the  lobules  are  usually  ob- 
literated, and  the  lymphatics  around  the  lobules  are  present  in  increased 
number  and  are  of  exaggerated  size.  Sometimes  the  thyroid  becomes  fibrous, 
and  in  such  cases  myxedema  is  apt  to  arise.  In  a  typical  case  there  are  rapid 
pulse  or  tachycardia,  protrusion  of  the  eyeballs  or  exophthalmus  (due  to  a  col- 
lection of  fat  back  of  each  eye),  and  enlargement  of  the  thyroid  gland  or  goiter. 
Either  thyroid  enlargement  or  exophthalmus  may  be  absent — in  fact,  in  some 
rare  cases  both  are  absent.  The  pulse-rate  in  most  cases  is  from  90  to  140. 
Exophthalmus  is  present  in  at  least  80  per  cent,  of  cases.  The  enlargement  of 
the  thyroid  is  bilateral.  Supposed  unilateral  enlargements  are  instances  of  Base- 
do  wified  goiter — that  is,  are  cases  in  which  hyperthyroidism  arises  in  the  course 
of  an  ordinary  goiter.  A  systolic  bruit  is  usually  audible  over  the  thyroid  region, 
and  the  large  vessels  at  the  root  of  the  neck  pulsate  strongly  because  of  arterial 
dilatation.  The  cardiac  symptoms  are  of  great  importance.  Cardiac  dilatation 
occurs  during  tachycardia,  and  for  a  time,  at  least,  disappears  as  tachycardia 
abates.  Even  tri\ial  fatigue  brings  on  temporary  dilatation.  Dilatation  may 
become  permanent,  valvular  insufficiency  may  arise,  or  cardiac  hypertrophy 
may  occur  (see  Grocco,  in  "Riv.  Crit.  di  Clin.  Med.,"  Jan.  2,  1904).  Von 
Gracfe's  sign  may  be  present;  this  is  inability  of  the  lids  to  follow  the  eyes 
in  looking  down.  Stellwag's  sign  is  retraction  of  the  upper  lids.  The  lids  in 
some  cases  cannot  be  completely  closed,  and  when  the  eyeball  is  suddenly 
turned  up,  the  lid  and  brow  may  fail  to  act  together.  Moehiush  sign  is  in- 
ability to  maintain  the  eyes  in  convergence.  In  some  cases  ocular  palsies 
exist,  in  others  there  is  photophobia  or  nystagmus.  Patients  may  suft"er  from 
neuralgia,  coUc,  choreic  movements,  tremor,  flushes  of  heat,  and  gastric  crises. 
Tremor  is  practically  always  present  when  the  arms  and  forearms  are  extended, 
the  palms  of  the  hand  are  turned  down,  and  the  fingers  are  spread  apart. 
Widespread  tremor  is  apt  to  arise  from  any  excitement,  shock,  or  surprise. 
Dyspnea  often  exists  and  albuminuria  and  polyuria  are  not  uncommon. 
Hemoptysis,  hematemesis,  or  mental  disturbance  is  sometimes  noted.  The 
patient  is  usually  greatly  depressed  mentally,  sometimes  is  excited,  and 
may  have  outbreaks  of  violent  hysteric  excitement  or  even  of  mania.  The 
usual  expression  is  one  of  fright.     There  may  be  insomnia,  elevated  tempera- 


1236  Diseases  and  Injuries  of  the  Thyroid  Gland 

ture,  excessive  sweating,  or  sudden  attacks  of  diarrhea.  All  symptoms  are 
increased  by  fear  or  fright.  Exophthalmic  goiter  is  sometimes  associated 
with  osteomalacia.  This  fact  is  important  in  connection  with  MacCallum's 
observations  on  the  action  of  the  parathyroids  in  controlling  calcium  meta- 
bolism. The  duration  of  a  case  is  entirely  uncertain.  It  is  usually  very 
chronic,  \\ath  remissions  or  actual  intermissions.  Sometimes  the  patient  gets 
entirely  well,  but  this  result  is  rare.  There  is  often  a  partial  cure,  which  may 
at  any  time  be  followed  by  a  renewed  outbreak.  Sometimes  the  condition 
})asses  away  rapidly,  but  abatement  is  usually  gradual.  Some  cases  get  pro- 
gressively worse  and  die.  Certain  cases  are  acute  and  these  are  apt  to  result 
fatally.  A  man  in  the  Jefferson  Hospital  died  in  five  weeks  after  the  first 
symptoms  were  noted.     He  was  delirious  for  several  weeks. 

Treatment. — Thyroid  extract  does  harm.  Medical  treatment  in  a  se- 
vere case  should  comprise  rest  in  bed,  the  use  of  an  ice-bag  over  the  heart, 
and  the  administration  of  adrenalin.  When  the  patient  gets  about  again, 
he  must  avoid  alcohol  and  all  forms  of  excitement.  Gentle  exercise  is  de- 
sirable, but  never  violent  exercise.  Diet  is  to  be  nutritious,  but  non-stimulat- 
ing. Electricity  is  said  to  be  of  benefit.  Thymus  extract  has  been  used. 
Experiments  in  organotherapy  are  being  tried  in  this  disease.  Ballet  and 
Enriquez  assumed  that  the  thyroid  gland  furnishes  an  antitoxin  to  certain 
body  poisons,  that  an  excess  of  thyroid  secretion  over  the  amount  required  to 
neutralize  toxin  causes  the  condition  known  as  Graves's  disease,  and  that  the 
symptoms  of  Graves's  disease  should  disappear  if  sufficient  toxin  is  adminis- 
tered to  antidote  the  excess  of  thyroid  secretion  (Hubert  Richardson,  in  "Am. 
Medicine,"  August,  1906).  The  two  observers  mentioned  above  obtained 
blood-serum  fromthyroidectomized  dogs  and  injected  it  into  individuals  suffer- 
ing from  Graves's  disease  and  claim  that  they  noted  improvement.  In  two 
of  their  patients,  however,  tetany  developed.  Lanz  has  used  the  milk  of 
thyroidectomized  goats  instead  of  the  serum  of  thyroidectomized  dogs.  The 
serum  of  thyroidectomized  sheep,  powder  made  from  the  dried  goiter  of  a 
cretin,  and  the  powdered  flesh  of  thyroidectomized  sheep  have  been  used 
(Hubert  Richardson,  "Am.  Med.,"  August,  1906).  What  is  known  as 
thyroidectin  is  the  dried  serum  of  an  animal  from  which  the  thyroid  gland  has 
been  removed.  John  W.  Rogers  and  S.  P.  Beebe  have  made  some  extremely 
interesting  studies  on  the  production  and  application  of  a  serum.  Rogers 
makes  two  sera,  using  one  or  the  other,  according  to  the  needs  of  the  case. 
One  serum,  called  the  normal  serum,  is  obtained  from  sheep  or  rabbits  after 
injecting  them  with  the  combined  nucleoproteids  and  thyreoglobulin  of  healthy 
thyroids;  the  other,  called  the  pathological  serum,  is  obtained  from  the  animals 
after  injecting  them  with  combined  nucleoproteids  and  thyreoglobulin  obtained 
from  the  thyroids  of  Graves's  disease.  In  one  severe  case  I  have  seen  rapid 
improvement  and  apparent  cure  follow  the  use  of  Rogers's  serum.  The  value 
of  serum  treatment  is  as  yet  undetermined.  It  is  certainly  not  free  from  danger 
and  some  deatlis  have  followed  its  use.  One  cause  of  diverse  results  after  the 
use  of  goat  serum  may  be  found  in  the  fact  that  some  of  the  animals  were 
probably  incompletely  thyroidectomized.  The  goat  possesses  aberrant  thy- 
roids and  these  must  be  removed  as  well  as  the  gland  proper.  Bilateral  extir- 
pation of  the  cervical  ganglia  of  the  sympathetic,  and  division  of  the  nerve  be- 
low the  ganglion,  have  been  employed,  and  it  is  alleged  with  benefit  (Jaboulay). 


Treatment  of  Exophthalmic  Goiter 


1237 


I  have  not  employed  the  operation  for  this  disease.  Ligation  of  the  thyroid 
arteries  may  do  good.  Partial  thyroidectomy  is  the  operation  commonly  em- 
ployed in  severe  cases;  it  cures  within  six  months  50  per  cent,  of  the  cases  oper- 
ated upon.  Some  cases  do  not  improve;  others  improve  slow^ly  and  relief 
is  only  partial.  It  is  the  operation  vi^hich  I  prefer.  The  Mayos  have  ob- 
tained a  splendid  series  of  results  from  this  operation.  They  have  ojjerated 
on  no  cases  with  9  deaths,  but  in  the  last  64  cases  there  were  but  2  deaths 
(C.  H.  Mayo,  "Jour.  Am.  Med.  Assoc,"  Jan.  26,  1907);  50  per  cent,  of  the 
survivors  were  cured;  25  per  cent,  showed  lasting  improvement  in  the  main 
symptoms;  20  per  cent,  were  greatly  improved,  but  have  temporary  relapses 
of  tachycardia  and  tremor.  The  Mayos  had  but  one  case  of  tetany  (and  that 
slight)  in  375  operations  on  the  thyroid  gland.  It  is  their  custom  to  apply  the 
x-ray  daily  for  several  weeks  and  then  to  operate.  The  rays  produce  decided 
but  temporary  improvement.  The 
operation  is  intracapsular  extirpa- 
tion of  one  lojje.  Ether  is  given  to 
most  cases.  In  some  cases  thyroid 
intoxication  follows  operation.  In 
other  cases  very  rapid  growth  fol- 
lows incomplete  removal,  and  the 
operation  seems  actually  to  have 
done  harm.  Sudden  death  occa- 
.sionally  follows  the  operation.  The 
removal  of  an  exophthalmic  goiter 
is  difficult;  the  capsule  and  blood- 
vessels rupture  from  slight  force. 
All  cases  should  not  be  operated 
upon;  in  fact,  only  those  cases 
should  be  operated  upon  in  which 
medical  treatment  has  proved 
futile,  or  in  which  there  is  profound 
toxemia  or  excessive  dyspnea.  If 
extraglandular  extirpation  is  per- 
formed, neither  ether  nor  chloroform  should  be  given.  Such  an  operation  is 
to  be  done  under  local  anesthesia  (eucain,  cocain,  or  Schleich's  fluid).  The 
younger  Kocher  reports  the  experience  of  the  Berne  Clinic  ("Mittheilungen 
aus  den  Grenzgebieten  der  Medicin  und  Chirurgie,"  Bd.  ix).  He  reports  74 
cases  of  true  exophthalmic  goiter,  59  of  which  were  operated  upon.  Every 
operation  was  done  with  the  aid  of  local  anesthesia  (i  per  cent,  cocain). 
In  some  cases  partial  thyroidectomy  was  performed;  in  some  the  thyroid 
arteries  were  ligated;  in  3  cases  not  only  were  the  arteries  tied,  but  the  sym- 
pathetic ganglia  were  resected.  In  these  59  cases  were  4  deaths  within  ten  days 
from  tetany,  and  in  39  of  the  cases  there  were  marked  disturbances  (tremor, 
irregularity  and  palpitation  of  the  heart,  vomiting,  sweating,  and  elevated 
temperature).  These  abnormahties  were  possibly  due  to  forcing  diseased 
thyroid  secretion  into  the  circulation;  45  of  the  59  cases  were  cured  and  8 
were  greatly  improved.  In  3  of  the  fatal  cases  autopsy  was  made,  but  did  not 
disclose  the  cause  of  death.  Kocher  beheves  in  operation.  He  thinks, 
however,  it  removes  but  one  element  of  the  disease,  and  that  medical  treatment 


719. — Enucleation  of  cystic  goiter;   capsule 
opened  (C.  H.  Mayo). 


1238  Diseases  and  Injuries  of  the  Thyroid  Gland 

may  remove  the  others.  He  advises  strongly  against  operation  during  an 
exacerbation,  unless  rehef  has  been  sought,  but  not  obtained,  by  medical  means. 
That  Kocher  had  4  cases  of  tetany  in  59  operations  and  the  Mayo's  none  in 
1 10  operations  seems  a  complete  confirmation  of  the  value  of  the  retention  of 
the  posterior  portion  of  the  capsule.  The  :x:-rays  frequently  have  a  very  bene- 
ficial effect  upon  the  symptoms  of  exophthalmic  goiter.  They  probably  de- 
stroy some  of  the  secreting  glandular  epitheUum,  and  thus  diminish  the  amount 
of  the  thyroid  secretion  and  alter  its  character.  Occasionally,  though  seldom, 
they  will  produce  a  cure.  It  is  my  custom  to  use  the  rays  prehminary  to  opera- 
tion, in  order  to  decrease  the  vascularity  of  the  part,  to  lessen  the  amount  and 
diminish  the  toxic  quality  of  the  thyroid  secretion,  and  to  modify  the  various 
symptoms. 

Operations  on  the  Thyroid  Gland. — The  removal  of  a  goiter  is  a  major 
operation  and  one  beset  with  difficuldes  and  dangers.  Nevertheless  it  is  a  very 
successful  operation.  I  have  operated  on  54  cases  of  non-malignant  and  i  case 
of  sarcoma  of  the  thyroid  goiter  without  a  death.  I  lost  a  case  of  carcinoma  of  the 
thyroid  and  a  case  of  adenoma  of  the  inferior  right  parathyroid  (but  neither  of 
these  cases  is  considered  a  goiter).  In  200  cases  of  ordinary  goiter  the  Mayos 
had  a  mortahty  of  i  per  cent,  following  extirpation.  Kocher's  rnortahty  is 
.4  per  cent.  Certain  anatomic  points  are  to  be  borne  in  mind.  The  internal 
jugular  vein  is  frequently  found  internal  to  the  carotid  artery  and  lying  on  the 
goiter  (because  the  vein  has  branches  which  run  to  the  goiter  and  hold  the 
vessel  against  the  thyroid) .  The  recurrent  laryngeal  nerve  ascends  along  the 
side  of  the  trachea  back  of  the  gland,  and  is  against  the  esophagus  before  it 
passes  through  the  cricothyroid  membrane.  On  the  right  side  the  nerve  is 
very  close  to  the  inferior  thyroid  artery,  sometimes  passing  over  it,  sometimes 
under  it.  On  the  left  side  it  is  deeper  and  not  so  near  the  artery.  The  para- 
thyroids are  behind  the  thyroid  and  usually  behind  the  capsule. 

In  view  of  the  fact  that  one  or  both  recurrent  laryngeal  nerves  may  be 
paretic  from  pressure,  all  cases  should  be  examined  vdth  the  laryngeal  mirror 
before  the  operation  to  determine  this  point,  as,  if  the  paresis  is  on  one  side 
only,  the  sound  vocal  cord  may  possibly  compensate  by  advancing  across  the 
midline.  Othervdse  in  such  condidons  the  paresis  may  be  first  observed 
following  operation,  leading  the  operator  to  think  that  he  has  injured  a  nerve 
(C.  H.  Mayo,  in  "Surg.,  Gynecol.,  and  Obstet.,"  July,  1907). 

Intra  glandular  Enucleation  {Socin^s  Operation). — By  this  operation  an 
adenoma  or  cyst  of  the  thyroid  gland  is  removed,  the  encompassing  glandular 
tissue  being  left  in  place.  The  capsule  of  such  a  growth  is  glandular  tissue. 
The  operation  of  enucleation  is  not  suited  to  the  removal  of  multiple  tumors 
and  it  cannot  be  performed  for  parenchymatous  goiter  or  exophthalmic  goiter. 
Intraglandular  enucleation  is  performed  as  follows:  The  thyroid  is  exposed 
by  an  oblique  or  by  a  horseshoe-shaped  incision.  An  incision  is  made  through 
the  capsule  of  the  thyroid  gland  and  through  the  glandular  tissue  until  the  cyst 
or  solid  tumor  is  reached.  As  a  rule,  the  tumor  can  be  recognized  from  the 
fact  that  its  color  differs  from  the  color  of  the  thyroid  tissue.  The  tumor  is 
turned  out  by  the  fingers,  a  special  scoop,  the  knife  handle,  or  a  dry  dissector. 
In  some  cases  a  cyst  can  be  most  easily  evacuated  if,  after  exposure,  it  is  in- 
cised and  emptied  and  its  wall  is  then  grasped  with  strong  forceps.  A  soUd 
tumor  should,  if  possible,  be  removed  intact.     The  wound  is  packed  tempor- 


Operations  on  the  Thyroid  Gland 


1239 


arily  with  gauze,  the  edges  of  the  cavity  are  grasped  with  forceps,  the  gauze  is 
removed,  and  e\-ery  bleeding  point  is  carefully  Ugated.  The  wound  is  closed 
by  three  layers  of  sutures — "one  in  the  gland,  one  in  the  muscles,  and  a  third 
in  the  skin"  ( James  Berr}^  on  "  Diseases  of  the  Thyroid  Gland").  If  the  tumor 
is  large,  drain  for  twenty-four  hours;  otherwise,  do  not  drain. 

Enucleation  is  a  very  successful  operation  if  performed  upon  jiroperly 


Fig.  720. — Kocher's  transverse  incision 
exposing  the  muscles  and  median  veins  of 
the  neck  (Kociierj. 


Fig.  721. — Isolating     the     accesson.-    veins 
(Kocher). 


selected  cases,  and  can  be  performed  rapidly,  but  the  arrest  of  bleeding  is 
often  tedious  and  troublesome. 

Extirpation. — This  term  means  removal  of  the  entire  gland  {complete 
thyroidectomy)  or  a  portion  of  the  gland  {partial  thyroidectomy)  with  the 
glandular  capsule,  the  operation  being  an  extracapsular  procedure.  Usually 
but  one  lobe  is  extirpated.  This  method  enables  the  operator  to  tie  the 
chief  vessels  before  he  cuts  them,  and  as  his  vision  is  not  obscured  by  bleeding, 


Fig.  722. — Exposure  of  veins   at  lower  end       Fig.  723.— Dislocation  of   the   goiter   toward 
before  ligation  (Kocher).  the  right  (Kocher), 

he  can  avoid  cutting  the  glandular  capsule,  which  would  be  sure  to  provoke 
copious  bleeding,  and  he  keeps  a  safe  distance  away  from  the  recurrent 
laryngeal  nerve. 

If  the  patient  suffers  from  dyspnea,  a  general  anesthetic  is  contraindicated. 
It  is  best  in  an}-  case  not  to  use  one.     Local  anesthesia  is  reasonably  satis- 


1 240 


Diseases  and  Injuries  of  the  Thyroid  Gland 


factory  and  is  far  safer.  The  patient  is  placed  recumbent,  with  the  shoulders 
a  little  raised  and  the  neck  laid  upon  a  sand-pillow  so  as  to  throw  the  head 
back  as  far  as  is  consistent  with  comfortable  respiration. 

An  obHque  incision,  a  horseshoe-shaped  incision,  or  a  transverse  collar 
incision  (Fig.  720)  may  be  made.     I  usually  employ  an  incision  shaped  Hke  an 


A.carotis 


_^L,  N  recurreas 

'ilvjMmalhureo- 
^^^VideoLinJenor 


Fig.  724.— Isolation  of  the  superior  thyroid 
artery  and  vein  (Kocher). 


Fig.  725. —Ligation  of  the  inferior  thyroid 
artery  (Kocher). 


incomplete  horseshoe,  the  convexity  being  downward.  Layer  by  layer  the 
tissues  are  divided,  each  layer  being  infiltrated  with  the  local  anesthetic 
before  it  is  cut.  Vessels  are  carefully  tied  as  divided  or  before  division. 
The  muscles  which  run  from  the  sternum  to  the  hyoid  bone  may  in  some 
cases  be  separated,  but  the  extirpation  of  a  large  goiter  requires  transverse 
division  of  the  muscles  high  up.     The  capsule  of  the  lobe  is  exposed,  and 


Fig.  726. — Isolation  of  the  venae  thyreoidese 
imse  (Kocher). 


Fig.  727. — Isolation  and  clamping  of  the 
isthmus  (Kocher). 


is  separated  from  external  parts  (Figs.  721,  722,  and  723).  The  upper  jwr- 
tion  of  the  gland  is  cleared.  The  superior  thyroid  vessels  are  found,  tied 
with  two  Hgatures  each,  and  dixnded  between  the  Hgatures  (Fig.  724).  The 
clearing  of  the  gland  is  carried  on  toward  the  median  line  and  some  rather 
large  veins  are  encountered  and  tied  (Fig.  726).  The  lower  portion  of  the 
lobe  is  cleared  and  the  inferior  thyroid  vessels  are  found.  Near  this  point 
the  recurrent  laryngeal  nerve  can  be  located.     If  it  is  pressed  upon  or  touched 


Acute  Thyroidism  1241 

with  a  blunt  instrument,  the  patient's  voice  becomes  metallic.  A  deliber- 
ate attempt  is  made  to  locate  it  and  the  patient  is  encfaged  in  a  conversa- 
tion requiring  answers  while  the  surgeon  is  investigating.  The  lobe  is  lifted 
from  its  bed  and  dislocated  from  the  wound  and  the  inferior  thyroid  ves- 
sels are  tied  close  to  the  border  of  the  gland  in  order  to  avoid  the  recurrent 
laryngeal  nerve  (Fig.  725).  The  vessels  are  tied  and  cut  across  as  were  the 
superior  thyroid  vessels.  The  isthmus  is  next  exposed,  clamped,  ligated,  and 
cut  across,  every  care  being  taken  to  prevent  colloid  from  being  squeezed  into 
the  wound  (Fig.  727).  After  dividing  the  isthmus,  any  bleeding  point  is 
ligated  and  the  stump  is  cauterized.  The  divided  muscles  are  sutured  with 
catgut,  a  drainage-tube  is  inserted,  and  the  superficial  wound  is  closed  with 
sutures  of  silkworm-gut. 

Intracapsular  Extirpation. — This  operation  is  warmly  advocated  by  the 
Mayos.  I  have  employed  it  in  my  last  10  cases.  The  preservation  of  the 
posterior  portion  of  the  capsule  protects  the  recurrent  laryngeal  nerve  and 
greatly  lessens  the  risk  of  injuring  the  parathyroids.  Ether  is  given  unless 
there  is  grave  respiratory  difficulty  with  myocardial  degeneration,  and  one-half 
an  hour  before  administering  the  ether  the  patient  is  given  a  hypodermatic 
injection  of  gr.  \  of  morphin  and  gr.  y^  of  atropin.  When  anesthetized, 
the  patient  is  placed  in  the  reversed  Trendelenburg  position  and  the  shoulders 
are  elevated  (C.  H.  Mayo,  in  "Surg.,  Gynecol.,  and  Obstet.,"  June,  1907). 
Kocher's  transverse  collar  incision  is  made.  Muscles  are  separated  or  divided 
as  in  ordinary  extraglandular  extirpation.  If  the  ribbon  muscles  are  divided 
the  cut  is  made  near  their  upper  insertion  to  save  their  nerve  supply  and  pre- 
vent the  muscle  scar  from  being  in  line  with  the  skin  scar.  The  gland  is 
elevated.  The  vessels  entering  and  leaving  the  raised  lobe  are  double  clamped 
and  tied.  The  capsule  is  incised  along  the  outer  side  of  the  gland,  is  pushed 
back  with  gauze,  and  the  lobe  is  drawn  toward  the  midHne,  and  vessels  are 
caught  by  forceps,  the  tissues  being  grasped  in  line  with  the  midline  of  the 
body  (C.  H.  Mayo,  Ibid.). 

Every  structure  bearing  any  resemblance  to  a  parath}Toid  is  allowed  to 
remain.  The  isthmus  is  clamped,  divided,  and  closed  by  suture.  The 
muscles  and  skin  are  sutured.  Drainage  is  required  after  removal  of  large 
growths,  a  separate  incision  being  made  to  permit  of  it. 

Dangers  in  Goiter  Operations. — During  any  operation  for  goiter  sudden 
death  may  occur.  In  some  cases  a  general  anesthetic  is  responsible.  In 
others  suffocation  arises  from  pressure  upon  or  bending  of  the  trachea  or 
collapse  of  the  trachea  as  the  goiter  is  Hfted  from  its  bed.  In  rare  cases 
dangerous  dyspnea  arises  from  irritation  of  the  laryngeal  nerves,  and  cardiac 
inhibition  may  be  induced  in  the  same  manner.  The  parathyroids  may 
be  injured  or  removed  and  myxedema  may  result.  Rough  handling  and 
flooding  the  wound  vAih.  colloid  may  be  followed  by  great  and  even  fatal  hyper- 
thyroidism. The  trachea  or  esophagus  may  be  opened.  The  recurrent  laryn- 
geal nerve  may  be  injured.  Air  embolism  seldom  occurs.  Reactionary  or 
secondary  hemorrhage  i§  usually  due  to  slipping  of  the  Kgature  on  the  superior 
thyroid  artery  "caused  by  including  a  piece  of  muscle"  (C.  H.  Mayo,  Ibid.). 

Acute  Thyroidism  (Hyperthyroidism). — When  colloid  from  the  thjToid 
is  squeezed  into  the  wound  during  the  operation  or  leaks  into  it  later,  it  is 
absorbed  and  may  produce  serious  symptoms  or  even  death.     This  is  most 


1242  Diseases  and  Injuries  of  the  Thyroid  Gland 

apt  to  happen  in  exophthalmic  goiter.  The  symptoms  always  appear 
within  forty-eight  hours  and  usually  within  twenty-four  hours.  Sometimes 
they  arise  quickly  after  operation.  In  some  cases  in  which  this  happens  the 
patient  never  reacts  from  the  operative  shock,  but  develops  a  very  rapid  pulse 
and  intense  dyspnea,  and  dies  in  a  few  hours.  In  less  severe  cases  there  is  a 
period  of  circulatory  excitement,  dyspnea,  and  elevated  temperature  {thyroid 
fever).  The  surgeon  seeks  to  prevent  acute  thyroidism  by  limiting  leaking  of 
colloid,  by  cauterizing  the  stump,  by  washing  the  wound  with  adrenaUn  solution, 
suturing  the  capsule  over  the  raw  stump  of  the  gland,  and  inserting  drainage. 

The  Parathyroid  Glands. — These  glands  were  discovered  by  Sand- 
strom  in  1880;  and  their  ntal  functions  were  pointed  out  by  Gley.  He 
showed  that  removal  of  the  parathyroids  causes  tetany. 

The  parathyroids  are  brownish  red  and  are  larger  in  adults  than  in  infants. 
They  are  constant  in  man,  never  being  congenitally  absent. 

They  are  usually  four  in  number  and  are  usually  placed  external  to  the 
thyroid  capsule.  In  some  cases,  however,  one  or  more  of  them  may  be  found 
embedded  in  the  thyroid  gland,  but  even  when  they  appear  to  He  within  the 
thyroid  they  are  always  separated  from  it  by  a  capsule  of  connective  tissue. 

While  there  are  usually  four  parathyroids,  there  may  be  only  three, 
or  there  may  be  six,  seven,  or  eight.  Accessory  parathyroids  may  be  found 
over  wide  areas.  One  was  discovered  by  Rogers  and  Ferguson  in  the  middle 
of  the  posterior  portion  of  the  pharynx;  and  there  was  found  in  the  thorax  by 
Ogle  a  gland  that  was  partly  parathyroid. 

From  their  situation  the  parathyroids  are  divided  into  superior,  or  external, 
and  inferior,  or  internal.  Walsh  describes  these  glands  in  adults  as  being 
each  from  6  to  7  mm.  in  length,  3  to  4  mm.  in  breadth,  and  i^  to  2  mm.  in 
thickness.  Each  of  these  glands  is  suppHed  by  a  terminal  artery,  and  the  arte- 
rial supply  is  very  largely  obtained  from  the  inferior  thyroid  artery  or  from  the 
branch  of  anastomosis  between  the  superior  and  inferior  thyroid  vessels. 

If  the  parathyroid  glands  are  extirpated  from  an  animal,  tetany  develops. 
This  is  positively  the  case  in  dogs.  These  glands  certainly  have  most  import- 
ant functions  in  the  metaboHsm  of  the  body.  MacCallum  and  Voegtlin 
("Johns  Hosp.  Bull.,"  March,  1908)  believe  that  damage  or  removal  of  them 
causes  great  changes  in  calcium  metabolism. 

Very  little  is  known  of  diseases  of  the  parathyroid  glands.  A  few  cases  of 
tumor  have  been  reported,  each  being  an  example  of  work-hypertrophy  or  an 
adenoma.  One  of  these  cases  was  reported  by  the  author  in  "  Surgery,  Gyne- 
cology, and  Obstetrics,"  Jan.,  1909.  In  this  case  the  tumor  was  removed  under 
the  impression  that  it  was  an  adenoma  of  the  right  lobe  of  the  thyroid  gland. 
The  pathologic  report,  however,  showed  it  to  be  a  parathyroid.  No  trouble 
of  any  kind  followed  the  operation;  though  at  a  later  period  enlargement  of  the 
opposite  side  of  the  neck  occurred.  This  has  been  let  alone  through  fear  that 
it  may  be  a  left  parathyroid. 

Some  persons  have  maintained  that  deficiency  of  parathyroid  secretion 
is  the  cause  of  paralysis  agitans,  but  this  idea  has  been  warmly  combated  and 
lacks  evidence.  Several  observers  believe  that  there  is  a  deficiency  of  parathy- 
roid secretion  in  exophthalmic  goiter. 

In  \aew  of  the  well-known  fact  that  removal  or  damage  of  the  parathyroids 
will  result  in  tetany,  provided  that  several  of  these  glands  or  all  of  them  are 


The  Parathyroid  Gland  1243 

damaged  or  removed,  it  becomes  the  duty  of  the  surgeon,  when  operating  for 
goiter,  to  exercise  the  utmost  care  that  he  does  not  remove  any  of  these  bodies. 
The  safest  way  to  avoid  them  is  to  retain  the  posterior  portion  of  the  capsule 
of  the  thyroid  gland.  If,  during  an  operadon,  any  small  body  that  resembles 
a  parathyroid  is  detected,  it  should  be  let  alone;  or  if  such  a  body  has  been 
accidentally  removed,  it  should  immediately  be  implanted  into  the  capsule  of 
the  lobe  of  the  thyroid  gland  that  has  been  left  undisturbed.  It  is  highly 
improbable  that  the  removal  of  even  both  parathyroids  on  one  side  will  cause 
tetany  if  there  are  two  normal  parathyroids  on  the  opposite  side. 

On  account  of  the  possibiHty  of  the  development  of  tetany,  the  question  of 
the  transplantation  of  parathyroids  from  animals  becomes  extremely  important. 
Halsted  has  made  some  very  valuable  experiments  upon  the  auto-  and  iso- 
transplantation  of  the  parathyroid  glands  in  dogs  ("Annals  of  Surgery," 
Oct.,  1907;  "Jour,  of  Experimental  Med.,"  vol.  xi.  No.  i,  1909).  He  has 
shown  that  if  the  parathyroid  be  transplanted  into  an  animal  with  normal 
parathyroids  failure  will  follow,  and  the  transplanted  glandule  will  disappear. 
If,  however,  there  is  parathyroid  deficiency  in  the  animal  into  which  the  trans- 
plantation is  made,  the  glandule  will  attach  itself  and  grow.  He  obtained  the 
best  results  by  placing  the  parathyroid  beneath  the  posterior  sheath  of  the 
rectus  muscle  of  the  abdomen.  Some  observers  have  placed  it  in  the  spleen; 
others,  within  the  peritoneum  and  in  various  other  regions. 

If  tetany  follows  an  operation,  it  may  be  treated  by  the  intravenous,  rectal, 
or  stomach  administration  of  a  5  per  cent,  solution  of  lactate  of  calcium 
(Mac Galium  and  Voegtlin,  Ibid.).  Beebe  and  Berkeley  have  prepared  a 
parathyroid  serum  that  they  claim  to  be  efficient.  Charles  H.  Mayo  maintains 
that  in  tetany  either  the  serum  or  the  calcium  lactate  should  be  used,  in  the 
hope  of  dding  the  patient  over  until  parathyroid  glands  can  be  secured 
and  implanted  ("Annals  of  Surgery,"  July,  1909).  Joseph  H.  Branham  ("An- 
nals of  Surgery,"  August,  1908)  has  reported  tetany  following  thyroidectomy 
cured  by  the  subcutaneous  injection  of  parathyroid  emulsion.  The  emulsion 
was  made  by  grinding  up  fresh  glands  of  beeves  in  a  mortar,  and  then  pouring 
400  cc.  of  sterile  salt  solution  into  the  mortar.  The  preparation  was  filtered 
through  sterile  gauze  and  was  administered  beneath  the  patient's  breast. 

When  tetany  begins  to  develop  in  a  patient  there  are  usually  headache, 
dizziness,  and  pain  in  the  extremities.  The  muscles  in  one  or  both  forearms 
and  hands  are  liable  to  be  affected.  The  hand  flexes  at  the  wrist,  while  the 
fingers  are  extended,  and  in  some  cases  the  forearm  flexes  at  the  elbow.  Now 
and  then  the  fingers  will  flex  at  the  metacarpophalangeal  joints,  but  the  distal 
phalanges  will  remain  extended.  These  spasms  are  painful.  Similar  spasms 
may  occur  in  the  feet  and  toes.  In  the  most  severe  cases  the  trunk  muscles 
and  those  of  the  chest,  throat,  and  eye  may  be  involved. 

Trousseau,  years  ago,  showed  that  a  spasm  may  be  brought  on  in  the 
affected  limb  by  pressing  upon  the  nerve- trunks  and  blood-vessels;  this  is 
called  the  Trousseau  sign.  Pressure  upon  the  facial  nerve  may  induce  the 
spasms,  and  it  is  called  Chvostek's  sign.  Erb's  sign  is  a  great  increase  in  the 
galvanic  irritability  at  the  motor  nerves.  Hoffmann^s  sign  is  excessive  sensi- 
tiveness of  the  sensory  nerves. 

Tetany  due  to  absence  of  the  parathyroids  will  inevitably  prove  fatal  with- 
out active  treatment. 


1244  Diseases  and  Injuries  of  the  Lymphatics 

XXXIII.  DISEASES  AND  INJURIES  OF  THE  LYMPHATICS. 

Wounds,  Ruptures,  and  Occlusions  of  the  Left  Thoracic  Ducts. 

— It  was  long  believed  that  wounds  of  any  part  of  the  thoracic  duct  were 
almost  certainly  fatal.  It  is  now  known  that  wounds  of  the  duct  at  the 
root  of  the  neck  are  rarely  very  dangerous  unless  the  duct  is  divided  close 
to  the  vein.  A  wound  of  the  duct  is  rarely  seen  as  the  result  of  an  accident 
because  the  adjacent  vital  structures  are  apt  to  be  injured  at  the  same  time 
and  death  rapidly  ensues.  Wounds  of  the  duct  or  of  its  large  branches 
occasionally,  but  very  rarely,  are  inflicted  during  surgical  operations.  Bene- 
tau  speaks  of  12  cases  thus  inflicted;  in  8  cases  the  operation  was  for  tuber- 
culous glands,  in  3  for  mahgnant  glands,  and  in  i  for  ligation  of  the  sub- 
clavian artery.  One  alleged  danger  of  wound  of  the  duct  is  entrance  of  air 
into  the  adjacent  vein.  This  is  said  to  have  happened  in  one  case.  As  a  rule, 
the  short  end  of  the  cut  duct  does  not  bleed,  the  duct  valves  preventing  hem- 
orrhage. In  Fullerton's  case,  when  a  grooved  director  was  passed  along 
the  stump  of  the  duct  and  by  way  of  a  terminal  into  the  vein,  blood  at  once 
appeared.  In  most  cases  the  injury  is  not  recognized  at  the  time,  but  later, 
when  white  fluid  escapes  from  the  wound.  The  discharge  may  continue 
or  may  cease  spontaneously.  If  it  continues,  there  is  rapid  loss  of  flesh  and 
strength.  I  assisted  Dr.  Keen  in  the  case  in  which  he  did  recognize  the  wound 
at  the  time  it  was  inflicted.  A  thin  fluid  was  observed  flowing  rhythmically 
from  a  tear  in  the  duct.  It  is  to  be  remembered  that  the  course  of  the  cervical 
part  of  the  duct  is  very  variable  and  sometimes  the  duct  lies  very  high  above 
the  clavicle.  There  was  i  death  in  17  recorded  cases  (Dudley  P.  Allen  and 
C.  E.  Briggs,  in  "Amer.  Med.,"   Sept.    21,    1901). 

The  discharge  from  a  cut  duct  may  continue  to  leak — perhaps  a  pint  or 
more  flows  out  during  twenty-four  hours.  If  leakage  continues,  constitu- 
tional effects  will  sooner  or  later  become  evident.  In  Schoff's  case  ("  Wien. 
klin.  Woch.,"  Nov.  28,  1901)  it  was  not  known  that  the  duct  had  been  injured 
until  the  stitches  were  removed  from  the  wound  in  the  neck.  The  wound  was 
found  distended  with  chyle  and  Schoff  packed  it  with  iodoform  gauze.  Fifteen 
days  later  the  patient  died  from  chylothorax  and  pulmonary  compression. 

Rupture  of  the  thoracic  duct  or  of  the  receptaculum  chyli  may  occur  from 
traumatism  or  be  a  secondary  consequence  of  tuberculosis  or  carcinoma. 
Rupture  leads  to  death  by  starvation,  or  to  fatal  compression  by  the  exuded 
fluid  (Harvey  W.  Gushing,  in  ''Annals  of  Surgery,"  June,  1898).  Occlusion 
of  the  main  duct  may  be  followed  by  rupture  of  the  receptaculum  chyli. 
Gradual  occlusion  by  a  tuberculous  or  inflammatory  growth  may  not  produce 
any  serious  symptoms.  Gushing  assumes  that  in  such  a  case  the  lymph- 
current  is  reversed  and  is  taken  up  by  the  right  thoracic  duct.  In  gradual 
obstruction  masses  of  dilated  lymph- vessels  may  be  found,  particularly  in 
the  thorax  and  abdomen.  If  lymph-vessels  rupture,  chyle  flows  out  and, 
according  to  the  situation,  there  arises  "chylous  ascites,  chylothorax,  chyluria, 
or  chylous  diarrhea"  (Harvey  W.  Gushing,  "Annals  of  Surgery,"  June,  1898). 

Treatment  of  Wounds. — If  the  wound  in  the  neck  does  not  completely 
divide  the  duct,  and  if  the  duct  wound  is  discovered  at  the  time  of  operation, 


Acute  Lymphadenitis  1245 

suture  the  duct.  Alien  sutured  the  duct  and  had  no  further  leakage.  Keen 
sutured  the  duct  and  recovery  followed.  If  the  duct  is  completely  divided,  fol- 
low Cushing's  advice:  "  It  would  seem  advisable  to  place  a  provisional  ligature 
about  the  duct  on  the  proximal  side  of  the  wound,  and  to  control  the  leakage, 
if  possible,  by  a  gauze' tampon.  This  would  act  as  a  safety-valve,  and  allow 
chyle  to  escape,  if  the  pressure  in  the  duct  became  too  great  and  there  was 
difficulty  in  establishing  a  collateral  lymphatic  circulation.  The  patient 
meanwhile  should  be  given  a  meager  diet.  If  the  leakage  should  become 
uncontrollable  and  threaten  starvation,  the  provisional  ligature  should  be  tied, 
with  the  hope  of  a  final  readjustment  of  collateral  circulation  or  trusting  in  the 
presence  of  some  anomalous  anastomotic  branch  which  might  suffice  to  carry 
the  lymph  into  the  venous  circulation"  ("Annals  of  Surgery,"  June,  1898). 
Fullerlon  tied  both  ends  of  a  divided  duct  and  the  patient  recovered  ("  Brit. 
Med.  Jour.,"  June  16,  1906).  Deanesley  ("Lancet,"  Dec.  26,  1903)  inserted 
the  divided  duct  into  the  internal  jugular  vein  and  sutured  it  in  place.  There 
was  some  leakage,  but  recovery  ensued.  After  ligation  the  duct  on  the  proxi- 
mal side  of  the  ligature  may  distend  greatly  and  may  actually  rupture.  When 
a  wounded  duct  is  leaking,  the  patient  should  be  fed  exclusively  on  proteids. 
The  diet  should  be  scanty  and  the  patient  must  be  kept  absolutely  quiet  in 
order  to  keep  pressure  in  the  duct  at  as  low  a  level  as  possible  during  the  es- 
tablishment of  a  collateral  lymphatic  circulation  (FuUerton). 

Lymphangitis  is  inflammation  of  lymphatic  vessels.  Reticular  or  capil- 
lary lymphangitis,  which  is  inflammation  of  lymphatic  radicles,  is  seen  in 
some  circumscribed  inflammation  of  the  skin.  It  is  apt  to  attack  the  hands, 
causing  redness  and  swelling,  fading  at  the  point  of  initial  trouble  while  it 
spreads  at  the  periphery;  it  is  caused  by  micro-organisms  derived  from  de- 
composing animal  matter  (Rosenbach).  Erysipelas  also  causes  it  (see 
Erysipelas).  Tubular  lymphangitis,  which  is  due  to  the  entry  into  the 
lymphatic  ducts  of  virulent  micro-organisms  or  toxic  materials,  is  seen  after 
the  infliction  of  dissecting-wounds,  septic  wounds,  snake-bites,  etc.  It  is 
announced  by  edema  and  by  minute,  hard,  red  streaks  running  from  the 
wound  up  the  extremity.     Suppuration  may  occur. 

Septic  or  infective  lymphadenitis,  or  inflammation  of  the  glands, 
may  follow  lymphangitis  or  may  be  due  to  the  deposition  of  infective  material, 
the  lymph -vessels  not  being  inflamed.  In  this  form  of  lymphadenitis  there 
are  pain,  tenderness,  and  swelling;  in  severe  cases  there  are  a  chill  and  a 
septic  fever.  Suppuration  way  arise.  The  treatment  is  to  drain  and  asepticize 
the  wound,  to  apply  iodin,  blue  ointment,  or  ichthyol  over  the  glands  and  ves- 
sels, and  to  employ  rest,  heat,  and  compression.  Internally,  milk-punch,  quinin, 
and  nourishing  diet  are  required.  If  the  glands  do  not  rapidly  diminish  in 
size  after  disinfection  of  a  wound,  and  if  they  are  in  an  accessible  region,  ex- 
tirpate them.     If  suppuration  of  the  glands  occurs,  incise  and  drain. 

Acute  lymphadenitis,  or  acute  inflammation  of  the  lymphatic  glands, 
may  be  due  to  tubercle,  syphilis,  glanders,  cold,  or  traumatism.  Suppura- 
tion may  or  may  not  occur.  In  inflammatory  lymphadenitis  there  are  pain, 
heat,  and  nodular  swelling.     In  severe  cases  there  is  fever. 

The  treatment  is  to  asepticize  any  area  of  infection,  place  the  glands  at 
rest,  apply  heat  and  ichthyol  ointment,  or  inject  into  the  gland  every  day  5 


1246 


Diseases  and  Injuries  of  the  Lymphatics 


minims  of  a  3  per  cent,  solution  of  carbolic  acid  to  prevent  suppuration.  If 
the  glands  do  not  rapidly  shrink,  extirpate  them.  If  pus  forms,  evacuate 
it,  drain,  and  asepticize. 

Chronic  lymphadenitis  is  almost  invariably  syphilitic  or  tuberculous. 
It  requires  constitutional  treatment  and  the  local  use  of  ichthyol,  iodin,  or 
blue  ointment.  If  these  remedies  are  not  rapidly  successful,  tuberculous 
glands  should  be  removed,  but  syphilitic  glands  will  rarely  require  such 
radical  treatment. 

Lymphangiectasis  (varicose  lymphatics),  or  dilatation  of  the  lymphatic 
vessels,  is  due  to  obstruction.  Many  external  causes  may  produce  obstruc- 
tion; for  instance,  the  removal 
or  suppurative  annihilation  of 
a  considerable  group  of  lym- 
phatics; pressure  of  a  scar 
or  of  a  new-growth  upon 
lymph -vessels ;  tuberculosis  or 
neoplasm  of  a  group  of  glands. 
In  many  cases  of  external 
pressure  upon  lymphatics 
there  is  no  lymphangiectasis 
because  the  lymph  finds  other 
channels.  In  fact,  it  has  been 
proved  that  ligation  of  a 
large  lymphatic  trunk  is  not 
of  necessity  followed  by  lym- 
phangiectasis. Even  when 
the  condition  arises  from  ex- 
ternal pressure,  it  is  usually 
temporary,  although,  particu- 
larly if  glandular  tumors  exist, 
it  may  be  permanent. 

The  persistent  cases  are 
usually  due  to  obstruction 
within  the  ducts,  for  instance, 
endothelial  proliferation  as  a 
result  of  chronic  lymphangitis, 
or  recurrent  attacks  of  acute  capillary  lymphangitis  (erysipelas)  or  ordinary 
acute  lymphangitis;  or  tuberculosis  and  other  chronic  infections.  There 
may  be  such  a  condition  as  primary  intralymphatic  endothelial  prolifera- 
tion ("Med.  Record,"  Sept.  6,  1902).  Blocking  with  filarial  worms  may 
occur,  and  if  it  does,  the  lymphangiectasis  is  usually  situated  in  the  pubic, 
the  inguinal,  or  the  scrotal  region,  or  on  the  inner  side  of  the  thigh.  There 
are  two  forms:  the  varicose,  in  which  the  vessels  have  a  tortuous  outline, 
like  varicose  veins,  but  are  covered  only  with  surface  epithelium;  and  lym- 
phatic warts  (lymphangioma  circumscriptum),  in  which  wart-like  masses  spring 
up,  these  masses  being  covered  with  epithelium  and  filled  with  lymph.  In 
most  cases  of  lymphangiectasis  there  is  considerable  hard  edema.  Periodic 
attacks  of  pain  and  redness  occur  in  the  area  of  disease,  and  usually  at  such 


Fig.  728. 


-Spurious  elephantiasis.     No  filarise  found. 
Born  and  ilved  in  Philadelphia. 


Lymphadcnoma 


1247 


times  fever  develops.  Rupture  of  the  dilated  vessels  causes  a  flow  of  lymph 
{lymphorrhea).  Infection  and  erysipelas  are  apt  to  occur;  it  may  be  over 
and  over  again.  It  is  uncertain  whether  these  repeated  attacks  of  erysipelas 
cause  and  maintain  or  are  predisposed  to  by  lymphangiectasis. 

Treatment. — If  the  entire  area  can  be  removed,  it  should  be  extirpated. 
Maitland  ("Brit.  Med.  Jour.,"  Jan.  25,  1902)  shows  that  many  varices  are 
local  and  can  be  removed.  If  the  varices  are  only  partially  removed,  lymphor- 
rhea will  probably  develop. 

Lymphangioma  is  an  advanced  stage  of  lymphangiectasis  (page  362). 

The  treatment  in  mild  cases  is  to  pierce  each  vesicle  with  the  negative 
pole  of  a  galvanic  battery  and  pass  a  current.  In  severe  cases  destroy  the 
mass  with  the  Paquelin  cautery  or  excise  it  with  a  knife  or  with  scissors. 

Elephantiasis.  — 
True  elephantiasis  (ele- 
phantiasis arabum)  is 
chronic  hypertrophy  of 
the  skin  and  subcutan- 
eous tissues  following 
upon  a  lymphangiecta- 
sis produced  by  a  nema- 
tode worm  (the  filaria 
sanguinis  hominis). 

Spurious  elephan- 
tiasis (Fig.  ^2^)  is  hyper- 
trophy of  the  skin  and 
subcutaneous  tissue  due 
to  chronic  inflammation 
(for  instance,  in  a  leg 
which  possesses  an 
ancient  ulcer,  or  in  the 
scrotum  of  a  man  with 
iirinary  fistula). 

The  treatment  is 
massage  and  bandag- 
ing, sometimes  ligation 
of  the  artery  of  supply, 
extirpation,  or  amputa- 
tion. 

Tuberculous  Glands.— (See  page  253.) 

Lymphadenoma  {Malignant  Lymphoma;  Hodgkin's  Disease;  Pseudo- 
leukemia).— The  term  lymphoma  is  used  loosely  to  designate  any  persistent 
swelling  of  a  lymphatic  gland  or  glands.  Lymphadenoma  means  a  swelhng 
of  lymph-glands  or  lymphadenoid  tissue,  which  swelling  is  progressive  in 
character,  involves  group  after  group  of  glands,  is  associated  with  anemia, 
and  often  accompanied  by  secondary  growths  in  the  abdominal  viscera. 
Fig.  729  exhibits  a  case  of  Hodgkin's  disease. 

This  disease  is  most  common  in  those  under  forty,  and  affects  males  far 
more  frequently  than  females.  In  many  cases  the  disease  arises  slowly  in 
apparently  healthy  glands,  and  exists  for  some  time  before  it  takes  on  signs 


Fig.  729. — Hodgkin's  disease  (Patterson). 


1248  Diseases  and  Injuries  of  the  Lymphatics 

of  malignancy  and  invades  distant  glands.  In  some  cases  the  disease  has  a 
tendency  to  generalization  from  the  start;  in  others  it  appears  to  remain  local- 
ized for  many  months.  A  gland  enlarged  from  irritation  or  from  tuberculous 
disease  may  become  lymphadenomatous,  and  .tubercle  bacilli  can  sometimes 
be  found  in  lymphadenomatous  glands.  Lazarus  asserts  that  the  disease  is 
lymphosarcoma  and  the  tuberculosis  accidental.  Musser,  Sternberg,  and 
others  beheve  that  tuberculosis  is  the  disease.  Some  few  believe  that  lymph- 
adenoma  is  really  tuberculosis,  but  this  view  seems  to  have  been  definitely 
disproved. 

That  the  disease  is  at  least  similar  to  sarcoma  seems  certain.  That  it  is 
a  variety  of  sarcoma  is  highly  probable.  There  is  a  form  of  tuberculosis 
strongly  resembling  Hodgkin's  disease,  but  I  do  not  beheve  that  the  two 
])rocesses  are  identical.  The  glandular  and  splenic  enlargements  are  neoplastic 
and  not  hyperplasdc.  The  new  dssue  formed  is  called  iymphadenoid  dssue 
and,  according  to  Banti,  it  is  often  atypic,  tends  to  invade  glandular  trabeculae 
and  capsules,  sometimes  adjacent  tissue,  and  gives  origin  to  metastases. 

Leukemia  and  pseudoleukemia  are  closely  related,  and  both,  according 
to  Banti,  are  sarcoma.  In  leukemia  the  influence  that  stimulates  prohferation 
falls  chiefly  upon  the  bone-marrow;  in  Hodgkin's  disease,  upon  the  lymph- 
nodes  (Neumann,  quoted  by  Coley,  in  a  forceful  ardcle  maintaining  that  Hodg- 
kin's disease  isatype  of  sarcoma,  "Transactions American  Surg.  Assoc,"  1908). 

Symptoms. — The  glands  in  the  neck  are  usually  involved  first,  but  the 
disease  may  begin  in  the  axillary  glands,  the  thoracic  glands,  or  the  intra- 
abdominal glands. 

Two  or  more  regions  are  sometimes  involved  simultaneously  or  almost 
simultaneously. 

When  the  disease  begins  in  the  neck  it  affects  at  first  one  side,  and  after 
many  weeks  or  months  the  other  side  becomes  involved.  The  glands  are  at 
first  hard,  separated  from  each  other,  movable,  and  the  skin  moves  freely  over 
them.  Later  the  large  glands  weld  together  and  form  great  masses  upon  both 
sides  of  the  neck  and  in  the  axillae,  which  may  obstruct  respiradon. 

After  a  time  a  very  large  mass  may  break  through  its  capsule  and  infiltrate 
adjacent  structures,  and  in  very  rare  cases  the  skin  becomes  adherent  and 
finally  breaks.  Intrathoracic  symptoms  point  to  involvement  of  the  thoracic 
glands.     It  may  be  possible  to  palpate  enlarged  abdominal  glands. 

The  leukocytes  may  be  increased  to  20,000  or  more,  but  in  many  cases 
the  count  is  normal  and  the  relative  proportion  of  the  varieties  remains 
normal.  In  a  certain  percentage  of  cases,  without  any  increase  in  the  num- 
ber of  leukocytes,  there  is  great  relative  lymphocytosis.  Early  in  the  case 
the  number  of  red  cells  may  be  unaffected,  but  after  a  time  anemia  develops. 
A  fall  in  hemoglobin  is  noted  early  and  this  fall  is  somewhat  more  rapid  than 
the  decrease  of  erythrocytes  ("Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.). 

The  spleen  is  enlarged;  the  thyroid  may  be  enlarged.  When  anemia 
becomes  marked  there  are  the  ordinary  symptoms  which  go  with  it,  viz., 
palpation,  breath lessness,  indigestion,  vertigo,  headache,  pallor,  and  sometimes 
epistaxis.  Occasionally,  without  obvious  reason,  the  glands  suddenly  increase 
in  size  or  rapidly  undergo  a  notable  but  temporary  diminution. 

Slight  fever  exists  at  times  in  many  cases,  and  ague-Hke  paroxysms  may 
occur.    During  the  existence  of  fever  the  glands  usually  increase  rajndly  in  size 


Lymphadenoma  1249 

Diagnosis. — In  a  wide-spread  case  the  diagnosis  is  easy;  in  a  localized 
case  it  is  difficult.  True  tuberculous  glands  are  most  apt  to  first  appear  in 
the  submaxillary  triangle;  lymphadenomatous  glands,  in  the  root  of  the 
neck  or  in  the  occipital  triangle.  Tuberculous  adenitis  is  most  common  in 
children.  As  a  rule,  tuberculous  glands  caseate,  but  they  may  remain 
localized  for  years  if  caseation  does  not  occur.  The  tuberculous  glands 
usually  soon  become  adherent  and  immovable.  Lymphadenoma  is  most 
common  after  twenty,  rarely  remains  localized  for  more  than  a  few  months, 
rarely  softens  unless  very  large,  and  the  glands  are  separated  and  movable 
until  a  huge  mass  forms.  Early  softening,  prolonged  limitation  to  one 
region,  and  absence  of  pronounced  anemia  in  a  person  under  twenty  point  to 
tubercle.  In  doubtful  cases  a  gland  should  be  removed  for  microscopical 
and  bacteriological  study. 

In  widespread  tuberculous  lymphatic  involvement,  simulating  Hodgkin's 
disease,  fever  is  far  more  likely  to  be  present  than  in  Hodgkin's  disease.  La- 
Roy  ("Archives  Internat.  de  Chir.,"  1907,  vol.  iii)  points  out  that  tuberculous 
glands  are  but  Httle  improved  by  the  x-rays,  whereas,  enlargements  in  Hodg- 
kin's disease  may  be  greatly  benefited,  and  that  in  tuberculous  conditions 
there  is  no  particular  tendency  to  hemorrhage  and  there  often  is  in  Hodg- 
kin's disease.  Coley  shows  (Ibid.)  that  the  patients  with  Hodgkin's  disease 
react  strongly  to  the  toxins  of  erysipelas. 

Prognosis. — The  disease  is  almost  always,  if  not  invariably,  fatal.  Most 
cases  die  within  three  years,  some  die  within  six  months,  some  few  live  four 
or  five  years  or  more. 

Treatment. — If  the  glands  are  locahzed  to  one  side  of  the  neck,  or  even 
to  both  sides  of  the  neck,  remove  them.  Early  removal  before  dissemination 
has  occurred  may  possibly  save  the  patient.  If  early  or  radical  removal  is 
not  possible,  do  not  operate,  but  treat  the  patient  with  nutritious  food,  tonics, 
course  of  arsenic,  the  mixed  toxins  of  erysipelas  and  the  bacillus  prodigiosus, 
and  applications  of  the  x-rays.  Coley  treated  a  case  with  the  mixed  toxins 
and  after  two  months  the  lymphatic  and  splenic  enlargements  entirely  disap- 
peared. Seven  months  later  the  patient  was  still  well  ("Transactions  of  Am. 
Surg.  Assoc,"  1908) .  Efforts  are  now  being  made  to  obtain  a  curative  serum. 
Beck  makes  nucleoproteid  serum  from  the  glands  of  cases  of  Hodgkin's  dis- 
ease. 

79 


1250  Bandages 


XXXIV.  BANDAGES. 

A  BANDAGE  is  a  fibrous  material  which  is  rolled  up  and  is  then  employed 
to  retain  dressings,  applications,  or  appliances  to  a  part,  to  make  pressure, 
or  to  correct  deformity.  It  may  be  composed  of  flannel,  of  calico,  of  un- 
bleached muslin,  of  plain  gauze,  of  gauze  infiltrated  with  plaster-of-Paris  or 
soaked  in  silicate  of  sodium,  or  of  gauze  wet  with  corrosive  sublimate  solu- 
tion. Unbleached  muslin,  which  is  the  best  material  for  general  use,  is 
washed  to  remove  the  sizing,  is  torn  into  strips,  and  the  edges  are  stripped 
of  selvage.  One  end  is  folded  to  the  extent  of  six  inches,  this  is  folded  upon 
itself  again  and  again  until  a  firm  center  is  formed,  and  over  this  center  the 
bandage  is  rolled.  In  a  well-rolled  bandage  the  center  cannot  be  pushed  out 
of  the  roll.  A  roller  bandage  is  divided  into  the  initial  end,  which  is  within  the 
roll,  the  body  or  rolled  part,  and  the  terminal  end,  which  is  free.  In  applying 
a  bandage  the  outer  surface  of  the  terminal  end  is  first  laid  upon  the  part. 

A  cylindrical  part  of  the  body  may  be  covered  by  a  circular  bandage, 
each  turn  exactly  covering  the  previous  turns.  A  conical  part  may  be  covered 
by  a  spiral  bandage,  each  turn  ascending  a  little  higher  than  the  previous 
turn.  As  each  turn  of  a  spiral  bandage  is  tight  at  its  upper  and  loose  at 
its  lower  edge,  the  reverse  was  devised  to  correct  this  inequality;  hence  a 
conical  part  should  be  covered  by  a  spiral  reversed  bandage.  To  make  a 
reverse,  hold  the  roller  in  the  right  hand,  start  the  bandage  obliquely  upward 
(do  not  have  more  than  six  inches  of  slack),  place  the  thumb  across  the  fresh 
turn,  fold  the  bandage  down  without  traction,  and  do  not  make  traction 
until  the  turn  has  been  carried  well  around  the  limb.  A  projecting  point 
is  covered  with  -figure-of-eight  turns.  The  groin,  shoulder,  breast,  or  axilla 
can  be  covered  by  figure-of-eight  turns,  each  succeeding  turn  ascending  and 
covering  two-thirds  of  the  previous  turn  and  forming  a  figure  like  "the  leaves 
on  an  ear  of  corn."  Such  a  figure  is  called  a  "spica."  In  bandaging  an 
extremity  the  peripheral  turns  should  be  tighter  than  the  turns  nearer  the 
body.  Never  apply  a  tight  bandage  to  the  leg  or  the  arm  without  including 
the  foot  or  the  hand.  In  firm  dressings  of  the  forearm  and  arm  it  is  well  to 
leave  the  ends  of  the  fingers  exposed,  and  use  them  as  an  index  of  the  con- 
dition of  the  circulation  in  the  part.  In  firm  dressings  of  the  leg  and  thigh 
leave  the  toes  exposed. 

Spiral  Reversed  Bandage  of  the  Upper  Extremity.— To  apply 
this  form  of  bandage  use  a  roller  two  and  a  half  inches  wide  and  eight  yards 

long.  Take  a  circular  turn  about 
'f''''''^'~fYTn7T/97'7i''jp»r^^  the  wrist,  and  a  second  turn  to 

hold  the  first;  pass  obliquely 
across  the  back  of  the  hand  to 
the    extremities    of    the    fingers; 

Fig.  73o.^Spiral  reversed^bandage  of  the  upper  ex-  ^^r^^^    the    hand    tO    the    rOOt    of 

the  thumb  by  several  spiral  turns; 
cover  the  wrist  by  ascending  figure-of-eight  turns;  ascend  the  forearm  by 
spiral  reversed  turns;  cover  the  elbow  by  a  figure-of-eight,  and  the  arm  by 
spiral  reversed  turns;  end  the  bandage  by  two  circular  turns,  and  pin  them 
together  (Fig.  730). 


Selva's  Thumb  Bandage 


1251 


Spiral  Bandage  of  All  the  Fingers  (Gauntlet). — The  gauntlet  bandage 
requires  a  roller  one  inch  wide  and  three  yards  long.  Take  two  circular 
turns  around   the  wrist,  pass  obliquely  across  the  wrist  to  the  root  of  the 


Fig.  731. — Gauntlet  bandage. 


Fig.  732. — Demi-gauntlet  bandage. 


Fig.  733. — Spica  of  the  thumb. 


thumb,  and  descend  to  its  tip  by  spiral  turns;  cover  in  the  thumb  by  ascending 
spiral  turns,  and  return  to  the  wrist.     Cover  successively  each  finger  in  the 
same  manner,  and  terminate  by  two  circular  turns  around  the  wrist  (Fig.  731). 
Spiral  Bandage  of  the  Palm  or  Dorsum  of  the  Hand  (Demi-gaunt 
let). — The  demi-gauntlet  requires  a  roller  one  inch  wide  and  three  yards  long. 

This  bandage  has  only  a  limited  value; 
it  must  not  be  applied  tightly,  as  it  makes 
much  pressure  at  the  finger-roots,  but 
leaves  the  fingers  free.  If  it  is  desired  to 
cover  the  palm,  supinate  the  hand;  if  to 
cover  the  dorsum,  pronate  the  "hand. 
Take  two  circular  turns  around  the  wrist,  sweep  around  the  root  of  the 
thumb,  and  return  to  the  point  of  origin.  Treat  each  finger  in  the  same 
way.     End  by  circular  turns  around  the  wrist  (Fig.  732). 

Spica  of  the  Thumb. — For  this  bandage  use  a  roller  one  inch  wide 
and  three  yards  long.  Start  at  the  wrist,  and  reach  the  tip  of  the  thumb  as 
in  applying  a  spiral  bandage  of  a  finger.  Make  a  series  of  ascending  figure- 
of-eight  turns  between  thumb  and  wrist,  each  ascending  turn  overlying  two- 
thirds  of  the  previous  turn;  terminate  with  a  circular  of  the  wrist  (Fig.  733). 

Selva's  Thumb  Ban= 
dage  (Fig.  734).— Lay  the 
terminal  end  of  the  bandage 
on  the  outer  side  of  the  sec- 
ond phalanx  of  the  thumb, 
near  the  base  of  the  pha- 
lanx. Carry  it  over  the 
palmar  side  of  the  pulp  of 
the  last  phalanx  to  the  inner  side  of  the  second  phalanx.  The  surgeon  holds  this 
turn  in  place  with  his  left  thumb  and  index  finger.  The  roller  is  returned  in  a 
recurrent  manner  to  its  placeof  origin,  overlaps  the  preceding  turn, and  is  placed 
as  much  as  possible  on  the  dorsum.     The  roller  is  carried  over  the  dorsum 


Selva's  thumb-bandage  applied. 


1252 


Bandages 


of  the  terminal  phalanx  and  is  turned  around  the  tip,  the  loop  crossing  over 
the  center  of  the  nail.  Figure-of-eight  turns  are  now  made  over  the  dorsum 
of  the  hand,  over  the  palm,  and  returning  to  the  ter- 
minal phalanx,  and  an  ascending  spica  is  made.* 
Spiral  Reversed  Bandage  of  the  Lower 

Extremity. — Take  a  roller  two  and  a  half  inches 
wide  and  seven  yards  long,  and  make  two  circular 
turns  just  above  the  malleoli,  and  an  oblique  turn 
across  the  dorsum  of  the  foot  to  the  metatarsopha- 
langeal articulation;  make  a  circular  turn,  and 
cover  the  foot  with  ascending  spiral  reversed  turns; 
return  to  the  ankle  by  a  figure-of-eight ;  ascend  the 
leg  by  spiral  reverses;  cover  the  knee  by  a  figure- 
of-eight,  and  the  thigh  by  spiral  reverses;  termi- 
nate by  two  circular  turns  (Fig.  735). 

Bandage  of  the  Foot  Covering  the  Heel 
(American  Bandage  of  the  Foot). — Take  a  roller 
two  and  a  half  inches  wide  and  seven  yards  long. 
The  bandage  is  begun  as  is  a  spiral  reversed  ban- 
dage of  the  lower  extremity.  After  the  foot  is 
well  covered  by  ascending  spiral  reversed  turns 

carry  the  bandage  directly  around  the 
point  of  the  heel  and  return  to  the  in- 
step; from  this  point  carry  it  around 
the  back  of  the  ankle,  down  the  side 
of  the  heel,  under  the  heel,  up  to  the 
instep,  around  the  ankle  in  the  opposite 
direction,  down  the  opposite  side  of  the 
heel,  and  under  the  heel  and  up  to  the 
instep ;  take  the  roller  to  above  the  mal- 
leoli, and  end  by  a  circular  turn  (Fig. 
736). 

Bandage  of  the  Foot  Not  Covering  the  Heel  (French  Method).— 
Take  a  roller  two  and  a  half  inches  wide  and  six  yards  long.  Make  a  spiral  re- 
versed bandage  of  the  foot  and  a  figure-of-eight  of  the  ankle-joint  (Fig.  737). 


Fig.  735.— Spiral  reversed 
bandage  of  the  lower  extrem- 
ity. 


Fig.  736.— Method  of  covering  the  heel. 


•Fig.  737. — Figure-of-eight  bandage  of  the  ankle. 


Fig.  738. — Spica  of  the  instep. 


Spiral  Bandage  of  the  Foot  Covering  the  Heel  (Ribbail's  Bandage; 
Spica  of  the  Instep). — Take  a  roller  two  and  a  half  inches  wide  and  six  yards 
*  Medical  News,  Sept.  28,  1895. 


Gibson's  Bandage 


1253 


long.  Apply  as  a  spiral  reversed  bandage  of  the  lower  extremity  until  the 
metatarsus  is  well  covered.  Carry  the  bandage,  parallel  with  the  margin  of 
the  foot  (the  inner  or  outer  margin,  according  as  to  whether  it  is  the  left 
foot  or  the  right),  around  the  posterior  aspect  of  the  heel,  along  the  opposite 
margin  of  the  foot  to  cross  the  original  turn  at  the  median  line  of  the  dorsum. 
Make  a  number  of  these  ascending  turns,  each  turn  covering  in  three-fourths 
of  the  i)revious  turn;  terminate  by  circular  turns  above  the  ankle  (Fig.  738). 

Crossed  Bandage  of  Both  Eyes  (Figure-of-eight  of  Both  Eyes). — 
Take  a  roller  two  inches  wide  and  six  yards  long.  Make  a  circular  turn 
around  the  forehead  from  right  to  left,  a  second  turn  to  hold  the  first,  a  turn 
downward  over  the  left  eye,  under  the  left  ear,  around  the  back  of  the  neck, 
and  upward  under  the  right  ear  and  over  the  right  eye ;  repeat  these  turns, 
and  terminate  by  a  circular  turn  of  the  forehead  (Fig.   739)- 

Barton's  Bandage  (Figure-of-eight  of  the  Jaw  and  Occiput).— Take  a 
roller  two  inches  wide  and  five  yards  long.  Place  the  initial  extremity  of 
the  bandage  behind  the  inion;  pass  over  the  right  parietal  bone,  across  the 


Fig.  739. — Crossed  figure-of-eight  bandage  of 
both  eyes. 


Fig.  74Q, — Barton's  bandage  or  figure-of-eight 
of  the  jaw. 


vertex,  down  the  left  side  in  front  of  the  ear,  under  the  chin,  up  the  right 
side  in  front  of  the  ear,  across  the  vertex,  and  across  the  left  parietal  bone 
to  the  point  of  origin.  A  turn  is  now  taken  forward  along  the  right  side  of 
the  jaw  to  the  chin,  and  backward  along  the  left  side  of  the  jaw  from  the 
chin  to  the  nape  of  the  neck;  repeat  these  turns,  and  pin  the  points  of  junction 
(Fig.  740) •  In  Barton's  bandage  the  ear  lies  in  an  uncovered  triangle.  The 
bandage  may  be  finished  by  circular  turns  around  the  forehead.  Barton's 
bandage  is  used  for  fracture  of  the  lower  jaw. 

Borsch's  eye=bandage  is  convenient  and  useful  (Fig.  741).  A  narrow 
bandage  is  laid  along  the  head  and  permitted  to  hang  down  the  face  in  front 
of  the  sound  eye.  A  circular  bandage  is  apphed  around  both  eyes  and  over 
the  narrow  bandage  (a).  The  narrow  strip  is  lifted  and  pinned,  and  the 
sound  eye  is  thus  uncovered.  Of  course,  the  posterior  end  of  A  should  first 
be  pinned  to  the  circular  turn. 

Gibson's  Bandage. — Take  a  roller  two  inches  wide  and  six  yards  long. 
Make  three  vertical  turns  around  the  head  and  the  jaw  in  front  of  the  ear; 


1254 


Bandages 


reverse  the  bandage  above  the  level  of  the  ear,  and  carry  it  horizontally 
around  the  forehead  and  head  three  times;  drop  the  bandage  to  the  nape 
of  the  neck,  and  take  three  turns  around  the  neck  and  jaw;  terminate  by 
taking  from  the  nape  of  the  neck  a  half  turn  upward,  carrying  the  bandage 
forward  to  the  forehead,  and  pinning  it  over  the  neck  and  over  the  forehead. 


Fig.  741.— Borsch's  eye-bandage:  A,  First  step;  b,  second  step. 

Pin  each  point  of  junction  (Fig.  742).     Gibson's  bandage  is  used  for  fracture 
of  the  lower  jaw. 

Crossed  Bandage  of  the  Angle  of  the  Jaw  (Obhque  Bandage  of  the 
Jaw). — Take  a  roller  two  inches  wide  and  six  yards  long.  Make  a  circular 
turn  around  the  forehead  toward  the  affected  side,  and  a  second  turn  to 
hold  the  first;  take  the  turn  to  the  back  of  the  neck;  carry  it  forward  on  the 
sound  side,  under  the  ear  and  chin;  now  make  a  series  of  turns  around  the 
head  and  jaw,  in  front  of  the  ear  on  the  injured  side,  but  back  of  the  ear 


Fig.  743.— Oblique  or  crossed  bandage  of  the 
angle  of  the  jaw. 


on  the  sound  side:  these  turns  successively  advance  on  the  injured  side  only; 
terminate  by  going  backward  under  the  ear  of  the  sound  side  to  the  nape 
of  the  neck,  and  then  by  taking  two  circular  turns  around  the  forehead  (Fig. 
743).  This  bandage  is  used  for  fractures  of  the  ramus  of  the  jaw  and  for 
holding  dressings  upon  the  face  and  the  cranium. 


Velpeau's  Bandage 


iz'^S 


Spica  of  the  Groin  (Figure-of-eight  of  the  Thigh  and  Pelvis). — For 
one  groin  the  roller  is  three  inches  wide  and  seven  yards  long;  for  both  groins, 
three  inches  wide  and  ten  yards  long.  Take  two  circular  turns,  from  right 
to  left,  around  the  waist,  then  down  over  the  front  of  the  right  groin,  around 
the  back  of  the  thigh,  up  over  the  front  of  the  right  groin,  around  the  waist, 
down  over  the  front  of  the  left  groin,  round  the  back  of  the  thigh,  up  over 
the  left  groin,  and  around  the  waist.     The  map  being  thus  laid  out,  the 


Fig.  744.— Spica  of  the  groin. 


Fig.  745.— Spica  of  the  shoulder. 


turns  are  continued  and  ascended,  each  turn  overlying  one-third  of  the  pre- 
vious turn,  and  the  bandage  is  completed  by  a  circular  turn  around  the  waist 
(Fig.  744)-    Pin  the  crossed  pieces. 

Spica  of  the  Shoulder. — Take  a  roller  two  and  a  half  inches  wide 
and  seven  yards  long.  Make  a  circular  turn  and  several  spiral  reversed 
turns  around  the  upper  arm;  then,  coming  from  behind  forward,  carry  the 
bandage  over  the  shoulder,  across  the  front 

of  the  chest,  through  the  opposite  arm-pit,  and  .  .^> 

return  across  the  back  to  the  shoulder.    Make  IriJ, 

successive  and  advancing  turns  (Fig.  745) .  HlVi! 


Fig.  746.— Figure-of-eight  bandage  of  the 

elbow. 


Fig.  747. — Posterior  figure-of-eight  of  both 
shoulders. 


Figure-of-eight  bandages  of  the  elbow,  both  shoulders  (posterior  figure- 
of-eight),  the  neck  and  axilla  are  shown  in  Figs.  746,  747,  and  748.  A  figure;- 
of-eight  of  the  breast  is  shoMOi  in  Fig.  753. 

Velpeau's  Bandage.— Take  a  roller  two  and  a  half  inches  wide  and 


1256 


Bandages 


ten  yards  long.  Place  the  palm  of  the  hand  of  the  injured  side  upon  the 
shoulder  of  the  sound  side,  interposing  cotton  between  the  arm  and  the 
side.  Start  the  bandage  at  the  axilla  of  the  sound  side  posteriorly,  carry 
it  across  the  back  to  the  shoulder  of  the  injured  side,  down  the  front  of  the 
arm  and  under  the  arm  just  above  the  elbow,  returning  to  the  point  of  origin; 
repeat  this  turn,  but,  on  reaching  the  axilla  the  second  time,  cross  the  back 
and  pass  around  the  chest,  including  the  arm;  keep  on  with  these  turns. 


Fig.  748. — Figure-of-eight  of  neck  and  axilla. 


Fig.  749. — Velpeau's  bandage. 


each  alternate  turn  going  over  the  injured  clavicle,  each  alternate  turn  en- 
circling the  arm  and  the  body,  the  first  turns  advancing  and  the  second  turns 
ascending  (Fig.  749).  Pin  the  crossed  pieces.  This  bandage  is  used  for 
fracture  of  the  clavicle. 

Desault's  Apparatus. — This  apparatus  consists  of  three  rollers,  a  pad, 
and  a  sling.     Each  roller  is  two  and  a  half  inches  wide  and  seven  yards  long. 


Fig.  750.— Desault's  bandage,  first  roller. 


\  ^         1  ^; 

Fig.  751.— Desault's  bandage,  second  roller. 


The  pad,  which  is  wedge-shaped,  is  inserted  into  the  axilla  with  the  base 
up.  The  first  roller  is  used  to  hold  the  pad  (Fig.  750).  The  second  roller 
binds  the  arm  to  the  side  over  the  pad.  This  pad  is  a  fulcrum,  the  shoulder 
is  the  weight,  the  arm  is  the  lever,  and  the  second  roller  of  Desault  corrects 
the  inward  deformity  of  a  fractured  clavicle  (Fig.  751).  The  third  roller 
corrects  the  downward  and  forward  displacement.  It  starts  in  the  axilla 
of  the  sound  side  anteriorly,  crosses  the  chest  to  the  shoulder  of  the  injured 


Handkerchief  Bandages 


1257 


side,  runs  down  the  back  of  the  arm,  around  the  elbow,  and  crosses  the  chest 
to  the  point  of  origin,  forming  the  anterior  triangle;  it  is  now  carried  through 
the  axilla  of  the  sound  side  to  the  back,  crosses  the  back  to  the  shoulder 
of  the  injured  side,  runs  down  the  front  of  the  arm,  around  the  elbow,  and 
across  the  back  to  the  axilla  of  the  sound  side,  forming  the  posterior  triangle 
(Fig.  752).  The  formula  for  the  Desault  bandage  is:  start  in  the  axilla  of 
the  sound  side  anteriorly,  run  from  the  axilla  to  the  shoulder,  from  the 
shoulder  to  the  elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  back; 
from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the  elbow,  from  the 
elbow  to  the  axilla,  and  pass  to  the  front.  Pin  the  crossed  pieces  and  hang 
the  hand  in  a  sling  (Fig.  752). 

Recurrent  Bandage  of  the  Head.— Take  a  roller  two  inches  wide 
and  six  yards  long.  Make  two  circular  turns  horizontally  around  the  fore- 
head and  head;  when  the  middle  of  the  forehead  is  reached,  catch  the  bandage, 
take  a  half  turn,  carry  the  bandage  to  the  occiput,  let  an  assistant  catch  it, 
take  a  half  turn,  bring  the  roller  forward  to  the  forehead,  covering  a  portion 
of  the  preceding  turn;  continue  this  process  until  the  scalp  is  well  covered; 


Fig.  752. — Desault's  bandage,  third  roller. 


Fig.  753. — Figure-of-eight  bandage  of  the  breast. 


terminate  with  two  circular  turns  around  the  forehead  and  head  (Fig.  754). 
It  is  often  advisable  to  take  a  turn  around  the  head  and  chin.  Pin  the  crossed 
pieces. 

Recurrent  Bandage  of  a  Stump.— Take  a  roller  two  inches  wide  and 
six  yards  long.  Make  two  light  circular  turns  around  the  root  of  the  stump ; 
make  recurrent  turns  covering  the  stump  as  is  done  in  covering  the  head; 
take  a  circular  turn  around  the  root  of  the  stump,  oblique  turns  to  the  top 
of  the  stump,  circular  turns  around  the  tip,  and  apply  an  ascending  spiral 
reversed  bandage  (Fig.  755). 

T=Bandage  of  the  Perineum.— Pass  the  transverse  part  around  the 
body  above  the  iliac  crests,  and  pin  it  in  front:  bring  one  of  the  tails  over 
the  dressing  and  up  between  the  thigh  and  the  genitals  of  one  side,  and  the 
other  tail  over  the  dressing  and  up  between  the  thigh  and  the  genitals  of 
the  opposite  side:  secure  these  tails  to  the  horizontal  band. 

Handkerchief  Bandages.— Take  unbleached  mushn  one  yard  square. 
The  muslin  folded  once  makes  an  oblong  bandage;  bringing  its  diagonal 
angles  together  makes  a  triangle  bandage;  a  cravat  is  formed  by  folding  a 


1258 


Bandages 


triangle  bandage  from  summit  to  base;  a  cord  is  a  twisted  cravat.     The 
triangle  makes  an  admirable  sling. 

Fixed  Dressings.— Plaster-of-Paris  Bandage.— Cover  the  extremity 
with  a  cotton  or  flannel  bandage  or  with  a  woolen  stocking.  Take  a  gauze 
roller  infiltrated  with  plaster  and  place  it  endwise  in  a  basin  of  tepid  water, 
the  water  covering  the  plaster.  When  bubbles  cease  to  arise,  squeeze  the 
bandage  and  apply  it  without  much  tension,  smoothing  out  each  turn  with 
a  moistened  hand.  As  each  bandage  is  taken  from  the  basin  drop  a  fresh 
one  into  the  water.  Apply  four  thicknesses  of  bandage,  and  finish  the  dress- 
ing by  sprinkling  dry  plaster  over  the  bandage  and  smoothing  it  with  wet 
hands.  The  ordinary  plaster  will  set  in  from  fifteen  to  thirty  minutes.  If 
it  is  desired  to  have  it  set  more  rapidly,  put  a  tablespoonful  of  salt  in  each 
pint  of  water  used;  if  to  have  it  set  more  slowly,  pour  stale  beer  into  the  water. 
The  plaster  bandage  is  removed  by  sawing  it  down  the  front  or  by  moisten- 
ing with  dilute  hydrochloric  acid  and  then  cutting  through  the  moistened 
line  with  a  strong  knife.     Gigli  has  devised  a  mode  of  application  which 


Fig.  754.— Recurrent  bandage  of  the  head. 


Fig.  755. — Recurrent  bandage  of  a  stump. 


enables  us  to  remove  the  dressing  with  ease.  A  layer  of  cotton  is  placed 
around  the  limb.  A  piece  of  parchment  paper  which  has  been  wet  and 
shaken  out  is  placed  over  the  cotton.  A  cord  greased  with  vaselin  is  laid 
upon  the  paper  in  a  position  corresponding  to  the  line  we  will  wish  to  saw 
through  the  plaster.  Apply  the  plaster  bandage  and  see  that  the  ends  of 
the  cord  project  beyond  the  bandage.  When  desiring  to  remove  the  bandage 
take  a  steel  wire,  make  nicks  on  one  side  of  it  by  means  of  a  file,  and  attach 
the  string  to  the  wire.  Pull  the  wire  under  the  bandage.  Attach  each  end 
of  the  wire  to  a  wooden  handle  and  saw  through  the  plaster.* 

Silicate  of  Sodium  Dressing. — Protect  the  part  as  is  done  for  a  plaster 
bandage.  Bandage  the  limb  loosely  with  an  ordinary  gauze  bandage,  paint 
this  bandage  with  silicate  of  sodium,  apply  another  bandage  and  paint  it, 
and  so  on  until  six  layers  are  applied.  Gauze  bandages  are  better  than 
ordinary  bandages  to  take  up  silicate  of  sodium.  SiHcate  dressings  require 
from  twelve  to  eighteen  hours  to  dry,  and  they  are  removed  by  softening 
with  warm  water  and  then  cutting. 

*  La  Semaine  Med.,  Nov.  3,  1895. 


Plastic  Surgery 


1259 


XXXV.  PLASTIC  SURGERY. 

Plastic  surgery  includes  operations  for  the  repair  of  deficiencies,  for 
the  replacement  of  lost  parts,  for  the  restoration  of  function  in  parts  tied 
down  by  scars,  and  for  the  correction  of  disfiguring  projections.  Many 
reparative  operations  have  been  devised.  Among  them  are:  cheiloplasty, 
or  the  construction  of  a  new  lip;  the  closure  of  a  cleft  in  the  palate,  the 
lip,  or  the  penis;  the  making  of  a  new  nose;  skin-grafting;  grafting  of  muscle 
or  tendon;  nerve-grafting ;  the  introduction  of  celluloid  or  metal  into  the  tissues 
to  act  as  supports;  the  injection  of  paraffin  into  the  tissues  to  amend  a  de- 


Fig.  756.— Injury  caused  by  crush  and  burn.  Healed  by  granulation  in  eight  months.  Showing  a 
condition  after  removal  of  scar  of  the  palm,  which  has  been  repaired  by  stitching  in  an  autoplastic 
graft  (.free  flap)  from  the  thigh  (Geo.  S.  Brown). 


pression;  the  diminution  in  the  size  of  a  lip  or  a  nose;  the  amendment  of 
protuberant  ears;  the  correction  of  distortion  due  to  cicatrices;  excision  of 
scars;  closure  of  congenital  sinuses  and  of  fistulae;  removal  of  disfiguring 
growths. 

The  subject  of  plastic  surgery  is  very  e.xtensive,  and  a  treatise  upon  it 
should  be  consulted  if  one  wishes  to  obtain  detailed  and  comprehensive 
information. 

A  plastic  operation  can  be  successful  after  lupus  only  when  the  disease 
has  been  cured.     It  is  useless  to  do  a  plastic  operation  during  active  syphilis, 


I26o 


Plastic  Surgery 


and  a  plastic  operation  for  a  syphilitic  loss  of  substance  is  to  be  performed 
only  after  the  patient  has  Ijeen  thoroughly  treated  and  the  disease  has  been 
apparently  cured.  The  first  step  of  a  plastic  operation  consists  in  making 
the  surfaces  which  are  to  be  brought  together  raw;  the  second  step  is  the 
complete  arrest  of  bleeding;  the  third  step  is  the  approximation  of  the  surfaces 
without  tension;  the  fourth  step  is  to  close  any  gap  from  which  tissue  may 

have  been  transplanted ;. 
and  the  final  step  is  the  ap- 
plication of  the  dressings.* 
The  following  are  the 
methods  u.sed :  f 

Dis placement  is  the 
method  of  stretching  or  of 
sliding:  (i)  approximation 
after  freshening  the  edges 
(as  in  hareli]));  (2)  sliding 
into  position  after  trans- 
ferring tension  to  other  lo- 
calities (linear  incisions  ta 
allow  of  stretching  of  the 
skin  over  large  wounds). 
Interpolation  is  the  method 
of  borrowing  material  from, 
an  adjacent  or  a  distant  re- 
gion or  from  another  per- 
son: (i)  trans /erring  a  flap 
■with  a  pedicle,  which  flap 
is  put  in  place  at  once  or 
is  gradually  gotten  into 
place  by  a  series  of  partial 
operations  (as  in  rhino- 
plasty, when  a  flap  is  taken 
from  the  forehead) ;  (2) 
transplanting  without  a  pedicle,  which  is  performed  by  placing  in  position  and 
by  fixing  there  portions  of  tissue  recently  removed  from  the  part,  from  another 
part  of  the  same  individual,  or  from  a  lower  animal  (as  replacement  of  the 
button  of  bone  after  trephining,  transplanting  a  piece  of  bone  from  a  lower 
animal  to  remedy  a  bone-defect  in  a  human  being,  or  the  grafting  of  a  piece 
of  nerve  from  a  lower  animal  or  an  amputated  human  limb  to  remedy  a  loss 
of  nerve  in  a  human  being  in  nerve-grafting,  or  skin-grafting).  Retrench- 
ment is  the  removal  of  redundant  material  and  the  production  of  cicatricial 
contraction. 

Skin=grafting. — As  long  ago  as  1847  Dr.  Frank  Hamilton  partly  covered 
an  ulcer  with  a  pediculated  flap,  and  trusted  that  the  uncovered  portion  would 
be  healed  by  new  skin  from  the  flap.  We  may  graft  small  pieces  of  epi- 
thelium taken  from  the  patient,  or  another  person,  or  one  of  the  lower  animals, 
or  we  may  graft  large  pieces  of  epithelium.  The  grafts  should,  if  possible, 
come  from  the  person  to  be  grafted.     The  epidermic  scales  may  be  scraped 

*  "American  Text-book  of  Surgery."  \  Ibid. 


Fig.  757.— Claw-hand    from  hurn.     A  flap  witli  a  peilicli;  was 
taken  from  the  chest.     The  pedicle  was  cut  on  ninth  day. 


Ollier-Thiersch's  Method  of  Skin-grafting  1261 

ofiF  the  sound  skin  and  grafted.  Lusk  has  blistered  the  skin  with  cantharides 
and  grafted  portions  of  the  epidermis.  The  shavings  of  a  corn  have  been 
used.     The  best  plan  is  to  cut  off  and  transplant  small  bits  of  epidermis. 

Grafts  may  come  from  another  person  or  from  a  lower  animal,  but  such 
grafts  are  not  so  apt  to  grow  as  grafts  obtained  from  the  individual,  and  even 
when  they  do  grow,  fail  to  furnish  a  secure  cicatrix.  Frog-skin  furnishes 
unsatisfactory  grafts.  Some  surgeons  have  used  bits  of  sponge;  others  the 
skin  of  rabbits,  guinea-pigs,  or  pups.  Arnot  has  employed  the  lining  mem- 
brane of  a  hen's  egg,  cut  in  strips  and  applied  upon  the  wound  with  the  shell- 
surface  uppermost.  Small  bits  of  epidermis  taken  from  a  recently  ampu- 
tated foreskin  or  leg  may  be  used. 

Reverdin's  Method. — This  operation  was  devised  by  Reverdin  in  1869. 
Small  bits  of  epithelium  are  used  and  they  are  taken  preferably  from  the 
person  himself.  The  surface  to  be  grafted  should  possess  healthy  granula- 
tions level  with  the  skin.  Cleanse  the  skin  from  which  the  grafts  are  to 
come,  the  ulcer,  and  the  skin  about  it,  and,  if  corrosive  subHmate  is  used, 
wash  it  away  with  a  stream  of  warm  normal  salt  solution.  Thrust  a  sewing- 
needle  under  the  epidermis  to  raise  it,  cut  off  the  graft  with  a  pair  of  scissors, 
and  place  the  raw  surface  of  the  graft  upon  the  ulcer.  After  applying  a 
number  of  grafts,  place  thin  pieces  of  gutta-percha  tissue  over  them  and 
extending  on  each  side  of  the  ulcer,  and  so  placed  as  to  have  distinct  inter- 
vals between  them,  the  gaps  permitting  drainage.  This  tissue,  after  being 
asepticized,  is  moistened  with  warm  normal  salt  solution.  Dress  with  a 
pad  of  aseptic  gauze  moistened  with  salt  solution;  place  over  this  gauze 
a  rubber-dam,  and  over  the  latter  absorbent  cotton  and  a  bandage.  In 
the  case  of  children  apply  a  light  silicate  bandage.  Put  the  patient  in  bed. 
In  forty-eight  hours  remove  all  the  dressings  except  the  gutta-percha  tis- 
sue, irrigate  with  normal  salt  solution,  and  reapply  the  dressings.  All  signs 
of  the  grafts  will  often  have  disappeared.  In  a  day  or  two,  at  the  site  of 
grafting,  bluish-white  spots  should  appear,  which  are  islands  of  epider- 
mis. Each  graft  is  capable  of  forming  about  half  an  inch  of  cicatrix.  Graft- 
ing also  stimulates  the  edges  of  the  ulcer  to  cicatrize  and  contract.  At  the 
end  of  seven  days  the  special  dressings  can  be  dispensed  with.  The  spot 
from  which  the  grafts  are  taken  is  dressed  antiseptically.  Reverdin's  method 
does  not  limit  cicatricial  contraction  to  any  great  degree,  and  the  new  skin 
is  apt  to  break  down. 

The  Ollier-Thiersch's  Method. — Oilier,  of  Lyons,  in  1872  succeeded  in 
transferring  large  pieces  of  epidermis.  In  1886  Thiersch,  of  Leipzig,  set 
forth  the  technic  practically  as  it  is  employed  to-day.  The  OUier-Thiersch 
method  is  performed  as  follows:  Thoroughly  asepticize  the  ulcer,  the  siu-- 
rounding  skin,  and  the  site  from  which  the  graft  is  to  come  (the  inner  side 
of  the  arm  or  the  thigh) ,  and  wash  away  the  mercurial  preparation  with  nor- 
mal salt  solution.  Apply  dressings  wet  with  salt  solution.  On  bringing  the 
patient  into  the  operating-room  remove  the  dressings  from  the  ulcer,  scrape 
the  ulcer  and  its  edges,  irrigate  with  salt  solution,  and  compress  to  arrest 
hemorrhage.  Grafts  are  then  obtained  by  putting  the  prepared  skin  upon 
the  stretch  and  cutting  strips  wath  a  razor.  While  the  razor  is  being  used 
the  part  is  constantly  irrigated  with  salt  solution.  Mixter's  apparatus  enables 
one  to  perform  this  operation  with  great  neatness  and  speed.  This  apparatus 
consists  of  a  knife  and  an  open  square  with  sharp  points  on  the  under  surface. 


1262  Plastic  Surgery  . 

The  square  is  forced  down  upon  the  front  of  the  thigh,  the  epidermis  mounts 
up  in  the  opening  to  above  the  level  of  the  metal  sides,  and  the  grafts  may 
be  cut  w^ith  ease.  The  graft  contains  the  epidermis,  the  rete,  and  part  of 
the  true  skin.  In  Halsted's  clinic  the  skin  of  the  thigh  is  made  tense  by 
pressing  upon  it  with  a  piece  of  asepticized  wood,  the  wood  is  drawn  slowly 
along,  and  is  followed  closely  by  the  sharp  cathn,  with  which  the  surgeon 
cuts  long  grafts.  The  grafts  are  pressed  into  place  upon  the  raw  surface, 
and  each  graft  overlaps  a  little  the  edges  of  the  wound  and  the  adjacent 
grafts.  The  skin-wound  is  dressed  antiseptically,  and  the  grafted  area  is 
dressed  as  in  Reverdin's  method.  Recently  it  has  been  suggested  that  a 
ring  of  aseptic  gauze  be  made  to  encircle  the  limb  below  the  grafted  area,, 
and  another  ring  above  the  grafted  area;  on  these  pads  little  strips  of  wood 
wrapped  in  aseptic  gauze  are  so  laid  as  to  make  a  cage,  and  around  this 
cage  the  dressings  are  applied  (moist  chamber  plan)  (Fig.  758). 

Wolfe's  Method. — It  was  pointed  out  by  Wolfe,  of  Glascow,  that  a  piece 
of  skin,  comprising  the  entire  thickness  of  that  structure,  can  be  successfully 
transplanted  without  a  pedicle.  The  ulcer  is  extirpated  and  asepticized  and 
bleeding  is  arrested.  The  flap  is  cut  one-si.xth  larger  than  the  surface  to 
be  covered.     Fat  is  kept  out  of  the  graft.     The  bit  of  tissue  is  laid  upon 


Fig.  758.— Mayer's  dressing  for  Thiersch's  method  of  skin-grafting  ("American  Text-book  of 

Surgeiy"). 

the  wound,  the  edges  of  the  graft  being  brought  against  the  edges  of  the  raw 
area.  It  is  not  necessary  to  employ  sutures.  The  part  is  dressed  in  a  moist 
chamber.     If  the  graft  perishes,  remove  it. 

Subcutaneous  Injection  of  Paraffin  for  Prosthetic  Purposes. 

— The  principle  of  injecting  solidifying  oils  into  tissues  to  mechanically  obtain 
effects  w^as  first  laid  down  by  J.  Leonard  Corning  in  1891.  The  use  of 
paraffin  was  introduced  by  Gersuny  to  amend  the  deformity  of  a  saddle- 
nose.  It  has  been  used  to  limit  incontinence  of  feces,  incontinence  of  urine 
in  women,  to  prevent  reunion  of  nerves  after  division,  to  replace  a  testicle, 
to  obliterate  smallpox  marks,  to  narrow  a  hernial  ring,  to  correct  sinking 
of  the  cheek  after  removal  of  the  upper  jaw,  and  for  other  purposes  (Mosz- 
kowicz,  in  "Wien.  klin.  Woch.,"  June  20,  1901).  Paraffin  is  not  toxic. 
Its  injection  may  produce  some  swelling  and  redness,  but  applications  of 
cold  quickly  control  inflammation.  In  two  or  three  months  the  paraffin  be- 
comes hard  like  cartilage  and  encapsuled.  It  is  questionable  whether  or 
not  it  is  subsequently  destroyed  and  replaced  by  granulation  tissue.  Some- 
times sloughing  takes  place  in  the  skin  above  it. 

Prepare  the  paraffin  as  follows:  In  Gersuny's  clinic  solid  paraffin  is  mixed 
with  liquid  paraffin.  The  melting-point  of  the  mixture  should  be  about  104° 
F.     It  is  rendered  sterile  by  boiling,  is  injected  by  a  warm  syringe,  and  as 


Correction  of  Saddle-nose  by  the  Insertion  of  a  Plate        1263 

a  semisolid,  the  skin  having  been  first  warmed  by  a  hot  sponge.  After  in- 
jection it  is  molded  into  proper  shape.  It  sets  in  half  a  minute.  It  is  not 
wise  to  use  a  mixture  with  a  much  higher  melting-point,  because  it  would 
possibly  cause  thrombosis  of  veins.  There  are  difficulties  and  even  dangers 
in  the  use  of  paraffin  for  saddle-nose.  It  should  only  be  used  when  the  skin  is 
loose  and  elastic.  It  should  never  be  used  if  there  is  great  deformity,  because 
then  the  amount  required  would  surely  cause  dangerous  tension.  It  is  difficult 
to  prevent  the  injected  material  from  passing  down  the  sides  of  the  nose  and  up 
into  the  forehead.  Cases  of  embolism  causing  bhndness  have  been  reported. 
The  skin  may  slough  if  the  injection  is  too  hot  or  if  it  produces  much  tension. 
Correction  of  SaddIe=nose  by  the  Insertion  of  a  Plate.— 
Saddle-nose  is  a  condition  in  which  the  bones  and  cartilages  have  been  destroyed 
by  ulceration  or  collapsed  by  injury.  It  is  useless  to  attempt  correction  by 
skin  flaps  alone.  Paraffin  injections  (page  1262)  may  be  used  in  the  less  severe 
cases.    In  a  bad  case  we  must  transplant  bone  flaps  or  insert  a  plate  for  sup- 


Fig-  759-— Indian  method  of  rhinoplasty. 


Fig.  760. — Italian  method  of  rhinoplasty. 


port.  The  bone-flap  operation  is  seldom  satisfactory  and  of  necessity  creates 
a  hideous  scar.  The  insertion  of  a  plate  may  give  an  excellent  result,  although 
the  future  is  always  uncertain.  In  2  cases  I  have  seen  sloughing  occur  over 
the  plate  months  after  the  operation.  In  one  of  these  cases  the  sloughing  was 
due  to  a  blow  from  a  cow's  tail. 

The  plate  used  may  be  of  silver,  gold,  or  celluloid.  An  incision  is  made  to 
permit  the  insertion  of  the  plate.  I  agree  with  Leonnard  Freeman  ("Annals 
of  Surgery,"  August,  1907)  that  the  incision  along  the  bridge  and  the  incision 
in  the  septum  below  the  tip  are  both  objectionable.  The  first  leaves  an  un- 
sightly scar  and  does  not  allow  for  stretching  of  the  skin.  The  incision  at  the 
tip  gives  unsatisfactory  access  to  the  tissues  requiring  separation  and  is  liable 
to  infection  from  the  nostril. 

The  best  incision  is  Freeman's.  This  is  a  short  incision  across  the  root  of 
the  nose  between  the  eyes.  The  skin  is  undermined  along  the  bridge  to  the 
tip  and  along  the  sides.     The  undermined  skin  can  be  stretched  if  necessary. 


1264  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Rhinoplasty. — The  complete  operation  may  be  performed  by  trans- 
ferring a  flap  from  the  forehead.  This  is  known  as  the  Indian  operation. 
It  was  employed  for  centuries  in  India,  and  interest  in  it  was  awakened  in 
England  about  1820  by  Mr.  Carpue.  The  edges  of  the  defect  are  made 
raw.  A  model  of  the  desired  nose  is  made  out  of  gutta-percha,  and  its  out- 
lines are  marked  upon  the  forehead,  and  the  cut  is  made  one-quarter  of  an 
inch  outside  of  the  outline  so  as  to  allow  room  for  retraction.  The  flap  is 
turned  down  and  sutured  in  place  (Fig.  759),  care  being  taken  not  to  cut 
off  the  blood-supply  in  the  pedicle.  Plugs  of  gauze  or  tubes  are  inserted 
to  support  the  flap. 

The  complete  operation  can  be  performed  by  the  Italian  method  (Taglia- 
cotian  method).  This  method  was  first  described  in  Tagliacozzi's  book, 
which  was  pubhshed  in  1597.  In  this  operation  the  flap  is  marked  out 
on  the  arm,  is  made  twice  the  size  of  the  desired  nose,  and  is  left  attached 
by  a  broad  pedicle.  The  nasal  surface  is  rendered  raw  at  proper  regions, 
and  the  flap  is  sutured  in  place,  the  hand  being  held  upon  the  head  by  a 
special  apparatus  (Fig.  760).  The  raw  surface  upon  the  arm  is  dressed.  In 
about  three  weeks  the  flap  is  cut  loose  from  the  arm,  and  is  pared  and 
corrected  as  may  be  necessary. 

The  operations  for  harelip  and  cleft  palate,  and  plastic  operations  on 
muscles,  nerves,  tendons,  and  bones,  are  considered  in  other  portions  of  the 
work. 


XXXVI.   DISEASES  AND   INJURIES  OF  THE  QENITO=URINARY 

ORGANS. 

Hematuria. — By  this  term  is  meant  the  voiding  of  bloody  urine  or  of 
pure  blood,  the  blood  arising  from  any  portion  of  the  urinary  apparatus, 
and  the  condition  being  a  symptom  and  not  a  disease.  Hematuria  may  be  a 
symptom  of  disease  or  of  injury  of  some  part  of  the  urinary  system,  of  blood- 
disorganizations  (purpura,  scurvy,  or  variola),  or  of  metallic  poisoning  (mer- 
cury, lead,  or  arsenic).  The  color  of  the  urine  in  hematuria  may  be  any- 
thing between  a  light  red  and  a  decided  black,  but  these  colors  may  be  pro- 
duced by  agents  other  than  blood.  Senna  and  rhubarb  make  urine  red; 
carboHc  and  sahcylic  acids,  brown  or  greenish-black;  beet-root  and  sorrel, 
the  color  of  blood;  methylene-blue,  blue.  In  jaundice,  melanosis,  and  splenic 
fever  the  urine  becomes  brown.  Be  sure  that  bloody  urine  in  the  female  is 
not  due  to  admixture  with  menstrual  blood. 

Tests  for  Blood. — Spectroscope  Test. — Bloody  urine,  if  fresh  and 
diluted  with  water,  shows  the  two  absorption-bands  of  oxyhemoglobin.  The 
addition  of  ammonium  sulphid  causes  the  two  bands  to  give  place  to  the 
band  of  reduced  hemoglobin.  If  bloody  urine  stands  for  some  time,  the 
four  bands  of  methemoglobin  are  discovered  (v.  Jaksch). 

Heller's  Test. — Add  potassium  hydrate  to  the  urine,  and  boil;  a  red 
precipitate  of  earthy  phosphates  and  hematin  forms.  Throw  the  precipitate 
upon  a  filter  and  treat  it  with  acetic  acid;  a  red  solution  is  produced,  which 
soon  fades. 

Rosenthal's  Test. — Take  the  precipitate  from  caustic  potash,  dry  it. 


Ureter-catheter  ism  "    1265 

and  test  it  for  hematin;  put  some  of  the  dry  sedament  on  a  slide,  add  a  crystal 
of  common  salt,  apply  a  cover-glass,  and  cause  a  few  drops  of  glacial  acetic 
acid  to  flow  under  the  glass;  warm,  but  do  not  boil.  Teichmann's  crystals 
will  appear  on  coohng. 

Struve's  Test. — Test  the  urine  with  hydrate  of  potassium,  and  add  acetic 
acid  in  excess;  a  dark  precipitate  forms,  which  will  yield  crystals  of  hematin 
when  treated  with  sal  ammoniac  and  glacial  acetic  acid. 

Almen's  Test. — Take  10  c.c.  of  urine,  and  pour  upon  its  surface  a  mixture 
of  equal  parts  of  tincture  of  guaiac  and  old  oil  of  turpentine;  at  the  point 
of  junction  of  this  fluid  with  the  urine  there  forms  a  white  ring  which  turns 
blue. 

Microscopic  Test. — The  microscope  shows  numerous  corpuscles  except 
in  a  very  alkaline  urine,  when  but  few  corpuscles  may  be  found. 

In  hemoglobinuria — a  condition  sometimes  occurring  in  burns,  acute  mala- 
dies, and  metallic  poisoning — there  is  present  blood-coloring  matter,  which 
is  shown  by  Heller's  test  and  by  Almen's  test.  The  spectroscope  shows 
methemoglobin.  The  microscope  shows  no  corpuscles  or  only  a  few,  but 
discloses  masses  of  pigment. 

Bleeding  from  the  Kidney=substance. — Bleeding  from  the  pelvis  of 
the  kidney  and  from  the  ureter  may  be  due  to  inflammation,  congestion, 
contusion,  stone,  vicarious  menstruation,  hemorrhagic  diathesis,  powerful 
diuretics,  fevers,  purpura,  tumors,  catheterization  of  the  bladder,  etc.  Blood 
is  thoroughly  mixed  with  the  urine,  and  no  sediment  forms  (smoky  urine). 
The  corpuscles  are  profoundly  altered,  are  devoid  of  coloring-matter,  and 
show  pale-yellow  rings.  The  severity  of  the  hemorrhage  is  measured  by 
the  number  of  the  corpuscles.  Von  Jaksch  states  that  the  diagnosis  between 
renal  and  ureteral  hemorrhage  rests  on  the  nature  of  the  casts  and  the  epithe- 
lium present.  From  the  pelvis  of  the  kidney  and  from  the  ureter  comes 
small  epithelium,  the  cells  from  the  superficial  layers  being  polygonal  or 
elliptical,  those  from  the  deeper  layers  being  oval  or  irregular.  In  hemorrhage 
from  the  ureter  the  cells  are  few;. in  hemorrhage  from  the  pelvis  they  are 
plentiful  and  rest  upon  one  another  like  "tiles  on  a  roof"  (v.  Jaksch).  Cells 
from  the  tubules  of  the  kidney  are  small,  granular,  and  polyhedral,  have 
large  nuclei,  and  are  often  so  arranged  as  to  form  cyhnders  (epithelial  casts). 
The  un'ne  during  and  immediately  after  a  renal  hemorrhage  is  apt  to  be 
acid  unless  alkalies  have  been  administered,  unless  the  bleeding  has  been 
severe,  or  unless  pus  is  present  in  the  urine.  A  very  large  renal  hemor- 
rhage may  cause  the  passage  of  almost  pure  blood.  In  renal  hematuria 
there  are  aching  in  the  loin,  numbness  of  the  corresponding  leg,  and  often 
renal  colic.  The  use  of  the  cystoscope  enables  the  surgeon  to  determine  if 
the  hemorrhage  is  vesical  or  renal,  and  if  it  comes  from  one  or  both  kid- 
neys. If  the  bladder-fluid  is  kept  clear,  the  blood  can  be  seen  flowing  out 
of  the  ureter  of  the  damaged  organ,  or  if  both  ureters  are  catheterized  a 
sample  of  urine  can  be  obtained  from  each  kidney. 

Ureter=catheterism. — Catheterization  of  the  ureters  may  give  informa^ 
tion  of  the  greatest  value.  It  enables  the  surgeon  to  obtain  the  urine  from 
one  kidney  unmixed  with  urine  from  the  other  kidney  and  uncontaminated 
by  material  from  the  bladder  or  urethra.  By  this  method  we  can  determine 
if  pus,  blood,  bacilli,  etc.,  come  from  the  ureter  or  kidney,  and  from  which 
80 


1266  Diseases  and  Injuries  of  the  Genito- urinary  Organs 

ureter  or  kidney.  A  stricture  or  a  calculus  of  a  ureter  can  be  located; 
hydronephrosis  and  pyonephrosis  can  be  diagnosticated;  the  presence  of  both 
kidneys,  and  if  either  kidney  is  diseased  or  if  both  are  diseased,  and  the 
secretory  capacity  of  each  kidney  in  a  given  time,  can  be  ascertained.  The 
method  is  also  employed  to  treat  various  conditions  of  the  ureter  and 
kidney. 

Kelly  impressed  upon  the  profession  that  the  ureters  in  women  can  be 
catheterized,  when  the  patient  by  the  knee-chest  posture  permits  the  atmos- 
pheric distention  of  the  bladder,  so  that  the  ureteral  orifices  can  be  inspected 
through  a  speculum.  Light  is  reflected  into  the  speculum,  a  forehead  mirror 
and  an  electric  light  being  employed.  It  may  be  necessary  to  dilate  the 
ureter  before  inserting  the  speculum.  It  is  rarely  necessary  to  give  a  general 
anesthetic.     Kelly  moistens  a  bit  of  cotton  wrapped  on  a  metal  rod  in  a 


Fig.  761.— Nitze's  instrument  in  use  ("  Berl.  klin.  Wochen."). 


10  per  cent,  solution  of  cocain,  introduces  it  just  \\'ithin  the  external  urethral 
orifice,  and  holds  it  there  for  five  minutes  before  beginning  the  operation. 
WTien  the  ureteral  orifice  of  one  side  is  found  by  inspection  through  the 
speculum,  he  introduces  a  sterile  flexible  silk  catheter  lubricated  with  boro- 
glvcerid  and  it  is  pushed  up  from  four  to  six  inches  in  the  ureter.  A  similar 
tube  is  introduced  into  the  other  ureter  and  the  separated  urines  are  collected 
in  test-tubes.  (See  Kelly's  *' Operative  Gyna?colog}-. ")  The  catheterization 
of  the  ureters  by  this  method  can  be  performed  only  by  a  dextrous  and  ex- 
perienced man;  but  such  an  individual  can  do  it  with  ease  and  celerity;  as 
practised  by  Kelly  himself,  it  seems,  until  one  tries  it,  the  perfection  of  sim- 
pUcity. 

Kelly  has  catheterized  the  ureter  in  man  by  inserting  a  straight  speculum, 
placing  the  patient  in  the  knee-chest  position  to  inflate  the  bladder  with  air, 


Segregation  of  Urine 


1267 


and  introducing  a  metallic  catheter.     For  a  discussion  of  the  technic  of  cath- 
eterizing  the  ureters  see  Cystoscopy,  p.  1297. 

Segregation  of  Urine. — Professor  Harris,  of  Chicago,  has  devised  an 
excellent  instrument  (Fig.  762)  which  in  many  cases  greatly  simplifies  the 


Fig.  762. — Harris's  instrument  fitted  lor  use. 

problem  of  obtaining  unmi.xed  urine  from  each  ureter.  The  double  catheter 
is  passed  into  the  bladder.  The  lever  is  inserted  in  the  rectum  of  the  male 
and  the  vagina  of  the  female.  The  lever  is  fastened  to  the  perforated  frame 
from  the  double  catheter.  The  double  catheter  is  now  opened  in  the  bladder, 
and  the  blades  of  the  instrument  are  held  in  position  by  a  spring.  The 
end  of  the  lever  in  the  vagina  or  rectum  humps  up  the  floor  of  the  bladder 


Fig.  763. — Lewis's  ureter-cystoscope. 

between  the  separated  ends  of  the  divided  catheter,  and  forms  a  longitudinal 
septum  or  watershed  between  the  ureteral  orifices.  The  end  of  each  catheter 
lies  in  the  bottom  of  a  pocket  in  the  side  of  the  watershed.  "  By  producing 
a  very  slight  exhaustion  of  the  air  in  the  v-ials  by  means  of  the  bulb,  the  urine 


1268         Diseases  and  Injuries  of  the  Genito-urinary  Organs 


as  fast  as  it  escapes  from  the  ureters,  drops  directly  into  the  ends  of  the 
catheters  and  flows  at  once  into  the  vials,  right  and  left  respectively."* 

In  using  this  instrument,  place  the  patient  flat  on  his  back  upon  a  table, 
the  thighs  and  legs  being  flexed,  and  the  feet,  hips,  and  head  being  on  the 
same  level.  Irrigate  the  bladder  thoroughly  with  sterile  water,  and  have 
150  c.c.  of  fluid  in  the  bladder  when  the  blades  are  opened.  Leave  the 
instrument  in  place  for  thirty  minutes.  It  is  rarely  necessar}-  to  give  an 
anesthetic.  In  some  cases  cocain  must  be  used,  and  in  some  cases  of  painful 
cystitis  ether  should  be  given.  Harris  says  the  instrument  should  not  be 
used  if  there  is  a  growth  of  the  bladder  that  bleeds  easily,  if  the  bladder 
is  contracted,  or  if  there  is  a  very  large  prostate  or  a  vesical  stone. j 

In  catheterization  of  the  ureters  there  is  always  some  danger  of  carrying 

infection  upward  from  the  bladder,  and 
sometimes  catheterization  is  impossible. 
It  15  impossible  if  great  quantities  of 
blood  or  pus  make  the  urine  opaque,  or 
if  inflammation  of  the  bladder  wall  hides 
one  or  both  ureteral  orifices.  The  Harris 
method  of  segregation  produces  consid- 
erable pain,  but  is  free  from  this  danger. 
As  a  matter  of  fact,  however,  Harris's 
method  often  possesses  elements  of  un- 
certainty, because  the  septum  may  not 
be  perfect  and  the  urine  from  one  side 
sometimes  contaminates  the  urine  from 
the  other.  The  separator  de^^sed  by 
Luys  in  1901  finds  some  warm  advo- 
cates (Fig.  764) .  It  causes  less  pain  and 
accompUshes  more  certain  results  than 
the  instruments  of  Harris  or  Cathehn. 
Barringer  ("Am.  Jour.  Med.  Sciences," 
]\Iarch  1907)  points  out  that:  "There 
are  certain  classes  of  cases  in  which  the 
separator  cannot  be  used.  They  are  the 
folio \\'ing:  (A)  Those  in  which  the  blad- 
der capacity  is  less  than  20  cc;  (B)  those 
in  which  the  urethra  is  not  penetrable  to 
the  instrument;  and  (C)  those  in  which 
the  base  or  neck  of  the  bladder  is  dis- 
torted by  (a)  marked  prostatic  hj-pertro- 
phy;  (b)  extreme  anteversion  or  ante- 
flexion of  the  uterus;  (r)  certain  uterine 
tumors;  and  {d)  marked  cystocele."  Catheterization  of  the  ureters  is  not  so 
safe  as  separation,  is  far  more  difficult,  but  gives  more  certain  results. 

Vesical  hemorrhage,  including  hemorrhage  from  the  prostate, 
may  follow  the  reUef  of  retention  of  urine,  may  be  due  to  stone,  inflammation, 
tumors,  etc.,  or  may  arise  from  traumatisms,  instrumental  or  other^\ise.     The 

*  Jour.  Cutan.  and  Gen.-Urin.  Dis.,  May,  1899. 
t  M.  I.  Harris,  in  Medicine,  April,  1898. 


Fig.  764. — Luys'  separator:  a.  The 
composite  instrument  read\"  for  intro- 
duction ;  i  and  k,  discharge  tubes  ;  h, 
screw  to  regulate  the  tension  of  the 
membrane  ;  b,  flat  middle  piece  ;  c  and 
d,  grooved  lateral  portions  ;  e,  tip  unit- 
ing the  parts  ;  gf,  rubber  membrane, 
tense.  The  chain  is  not  visible  in  the 
figure  (Sahli). 


Frequency  of  Micturition  1269 

color  of  the  urine  is  usually  bright  red,  but  if  long  retained  in  the  bladder 
it  becomes  black  and  often  tarry.  The  reaction  is  alkaline.  The  clots,  when 
floated  out,  are  large  and  without  definite  shape.  In  micturition  the  urine 
is  clear  or  only  a  little  colored  at  the  beginning,  but  becomes  darker  and 
darker  as  micturition  ends,  at  which  time  the  flow  may  consist  of  almost 
pure  blood.  In  very  small  vesical  hemorrhages  the  urine  may  be  smoky. 
Crystals  of  triple  phosphate  indicate  bladder  disorder.  The  microscope  shows 
colorless  and  swollen  corpuscles  and  many  polygonal  cells.  Symptoms  of 
bladder  mischief  usually  exist,  but  cystoscopic  examination  or  exploratory 
suprapubic  cystotomy  may  be  required  for  the  diagnosis. 

Urethral  Hemorrhage. — In  urethral  bleeding  blood  appears  inde- 
pendently of  micturition,  or  blood  comes  out  first  and  is  followed  by  clear 
urine.  Urethral  hemorrhage  arises  from  acute  urethritis,  from  an  inflamed 
stricture,  from  the  passage  of  an  instrument,  or  from  some  other  traumatism. 

The  source  of  urethral'  hemorrhage  can  be  ascertained  by  the  use  of  the 
endoscope. 

Pain  in  Qenito=urinary  Diseases. — Pain  as  a  symptom  of  genito- 
urinary disease  may  be  found  at  some  point  distant  from  the  seat  of  lesion. 
A  stone  in  the  bladder  causes  pain  in  the  head  of  the  penis  just  back  of  the 
meatus;  stone  in  the  kidney  induces  pain  in  the  loin,  the  groin,  the  thigh, 
and  the  testicle;  inflammation  of  the  testicle  causes  pain  in  the  line  of  the 
cord  in  the  groin.  In  other  cases  of  genito-urinary  disease  pain  is  felt  at 
the  seat  of  lesion,  as  in  urethritis  and  prostatitis.  Pain  felt  before  micturi- 
tion, and  being  relieved  by  the  act,  is  found  in  cystitis  and  in  retention  of 
urine.  Pain  is  felt  during  micturition  in  inflammation  of  the  bladder,  pros- 
tate, and  urethra,  and  in  the  passage  of  gravel  or  stone.  Pain  which  is  acute 
at  the  end  of  micturition  is  noted  in  stone  in  the  bladder,  in  inflammation 
of  the  neck  of  the  bladder,  and  in  inflammation  of  the  prostate  gland.  The 
pain  of  stone  in  the  bladder,  it  may  be  observed,  is  ameliorated  by  rest  and 
is  aggravated  by  exercise.  The  pain  of  acute  prostatitis  is  intensified  by 
defecation. 

Frequency  of  Micturition. — Frequent  micturition  arises  from  irri- 
tation of  the  sensory  nerves,  from  phimosis,  contracted  meatus,  inflammations, 
very  acid  urine,  calcuh,  urethral  stricture,  and  hyperesthesia  of  the  urethra. 
Frequency  of  micturition  may  be  due  to  spinal  irritability  from  concussion 
or  from  sexual  excess,  from  contraction  of  the  bladder  rendering  the  viscus 
unable  to  hold  much,  from  worry,  anxiety,  fear,  or  from  excessive  urinary 
secretion,  as  in  diabetes  or  in  the  first  stage  of  contracted  kidney.  Frequent 
micturition  exists  in  obstruction  by  enlarged  prostate  and  in  atony  of  the 
bladder-walls.  Hypersecretion  of  urine  plus  bladder  intolerance  is  known  as 
"  nervousness, "  and  is  found  in  hysteria.  Frequency  of  micturition  increased 
by  movement  is  observed  in  stone  and  tumor  of  the  bladder.  Nocturnal  fre- 
quency of  micturition  is  present  in  cases  of  enlarged  prostate  and  atony  of 
the  muscular  walls  of  the  bladder.  Frequency  of  micturition  with  diminution 
of  stream-caliber  suggests  a  constriction  of  the  urethral  diameter;  frequency 
of  micturition  with  diminished  force  suggests  a  posterior  stricture,  enlarged 
prostate,  or  bladder  atony.  Slowness  of  micturition  hints  at  enlarged  pros- 
tate, atony,  or  urethral  stricture. 


1270         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Sir  Henry  Thompson's  diagnostic  questions  are  as  follows: 

"i.  Have  you  any,  and,  if  so,  what,  frequency  in  passing  water?  Is  fre- 
quency more  manifest  during  the  night  or  the  day?  Is  frequency  more 
manifest  during  motion  or  rest  ?     Does  any  other  circumstance  aflfect  it  ? 

"2.  Is  there  pain  on  passing  urine,  and,  if  so,  is  it  before,  during,  or 
after  the  act?  What  is  its  character — acute,  smarting,  dull,  transitory,  or 
continuous?  What  is  its  seat?  Is  it  felt  at  other  times,  and  is  it  produced 
or  intensified  by  sudden  movements  ? 

"3.  What  is  the  character  of  the  stream?  Is  it  small  or  large;  twisted  or 
irregular;  strong  or  weak;  continuous,  remitting,  or  intermitting?  Does  it 
come  by  the  meatus,  or  partly  or  entirely  through  fistula?  ? 

"  4.  Is  the  character  of  the  urine  altered  ?  What  is  its  appearance,  color, 
odor,  reaction,  and  specific  gravity?  Is  it  clear  or  turbid,  and,  if  turbid, 
is  it  so  at  the  time  of  passing?  Does  it  vary  in  quantity?  Are  the  normal 
constituents  increased  or  diminished  ?  Does  it  contain  abnormal  elements, 
as  albumin  or  sugar?  What  inorganic  deposits  are  found?  What  organic 
materials  are  met  with  ? 

"5.  Has  the  urine  ever  contained  blood?  If  so,  was  the  color  brown  or 
bright  red;  were  the  blood  and  urine  thoroughly  mixed;  was  the  blood  passed 
at  the  end  or  at  the  beginning  of  micturition,  or  did  it  come  only  with  the 
last  drops  of  urine ;  or  was  it  passed  independently  of  micturition  ? 

"  6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  permanent  or  transitory, 
and  for  the  occurrence  of  severe  paroxysms  of  pain  in  these  regions. " 

The  Determination  of  the  Excretory  Capacity  of  the  Kidneys 
in  Health  and  in  Disease. — The  Phloridzin  Test.— This  test  is  made 
with  comparative  ease  and  often  aids  the  surgeon  in  determining  whether  he  is 
justified  in  performing  some  operation  of  cjonvenience.  It  enables  him  to  esti- 
mate with  a  fair  amount  of  accuracy  the  capacity  for  elimination  possessed  by 
the  kidneys.  The  test  depends  on  the  fact  that  the  healthy  epithelium  of  the 
glomeruli  and  tubes,  when  stimulated  to  activity  by  phloridzin,  forms  sugar 
from  that  drug  and  thus  produces  temporary  glycosuria.  When  the  epithelium 
is  diseased,  little  or  no  glycosuria  occurs.  The  test  is  applied  as  follows:  The 
dose  is  about  5  to  10  milligrams  of  phloridzin,  according  to  the  body-weight 
of  the  patient.  It  is  administered  hypodermatically,  the  bladder  having 
been  emptied  beforehand.  If  the  eliminating  powers  of  the  kidney  are  at 
a  healthy  level,  sugar  should  appear  in  the  urine  within  half  an  hour  of  the 
injection.  If  at  the  end  of  this  time  only  a  small  amount  of  sugar  can  be 
detected,  one  may  assume  that  the  kidneys  are  affected;  and  if  no  sugar  can 
be  found,  a  serious  renal  disease  may  be  assumed  to  exist. 

The  actual  standard  that  is  to  be  considered  as  the  normal  amount  of  sugar 
which  should  be  eliminated  after  the  administration  of  phloridzin  is  a  matter 
of  some  uncertainty.  It  is  usually  estimated  at  0.3  per  cent.,  a  less  amount 
of  sugar  than  this  being  taken  as  an  evidence  of  renal  difhculty  (Watson 
and  Bailey,  in  "Report  of  Boston  City  Hospital  for  1902").  The  sugar  is 
separated  from  the  phloridzin  in  the  epithehum  of  the  glomeruli  and  tubules 
of  the  cortex  of  the  kidney.     The  drug  seems  to  be  entirely  harmless. 

It  is  because  phloridzin  is  acted  upon  by  the  kidney-epithelium  that  this 
test  is  better  than  the  methylene-blue  test.  The  latter  does  not  really  measure 
the  excretory  power  of  the  kidney-epithelium :  it  merely  shows  to  what  degree 


Tumors  of  the  Kidney  1271 

the  kidney  is  permeable  in  the  mechanical  sense.  Personally,  I  should  not 
be  disposed  to  set  aside  older  and  more  thorough  methods  of  urinary  analysis 
for  the  phloridzin  test,  although  I  believe  that  it  has  a  range  of  distinct  use- 
fulness. 

The  Methylene-blue  Test  (The  Method  of  Achard  and  Castaign).— When 
methylene-blue  is  injected  hypodermatically  it  normally  appears  in  the  uiine 
within  half  an  hour  and  disappears  in  from  thirty-six  to  forty-eight  hours. 
If  the  blue  color  is  not  manifest  in  the  urine  for  an  hour  or  more,  there  is 
impairment  of  renal  permeability.  Accuracy  in  the  test  is  not  possible  unless 
the  amount  of  the  methylene-blue  actually  passing  into  the  urine  in  a  given 
time  is  determined.  The  dose  given  hypodermatically  is  0.05  gm.  in  i  c.c. 
of  sterile  water.  The  test  is  unreliable  and  the  blue  color  may  appear  in 
the  urine  in  half  an  hour  in  some  cases  of  marked  kidney  disease. 

Cryoscopy  (Koranyi's  Method). — Cryoscopy  is  the  determination  of 
the  freezing-point  of  a  liquid  and  the  comparison  of  this  with  the  freezing- 
point  of  distilled  water.  It  is  applied  particularly  to  blood  and  urine.  This 
method  is  complex  and  difficult  of  application,  and  requires  a  considerable 
amount  of  fluid.  The  freezing-point  of  a  fluid  depends  upon  the  number 
of  molecules  it  contains.  The  freezing-point  goes  hand  in  hand  with  molec- 
ular concentration — great  concentration  gives  a  low  freezing-point,  little 
concentration  a  high  freezing-point.  Cryoscopy  of  the  blood  and  urine  is 
used  to  determine  the  adequacy  of  renal  activity.  Normal  blood  freezes 
at  about  — 0.56°  or  — 0.57°  C.  Healthy  urine  freezes  between  — 0.9°  and  — 2° 
C.  In  renal  inadequacy  the  freezing-point  of  the  blood  is  lower  than  nor- 
mal and  the  freezing-point  of  the  urine  is  higher.  It  is  held  that  surgical 
operation  is  contraindicated  if  there  is  such  a  degree  of  renal  inactivity  that 
the  freezing-point  of  the  blood  is  at  or  below  — 0.6°  C.  and  if  the  freezing- 
point  of  the  urine  is  at  or  above  1°  C. 


Diseases  and  Injuries  of  the  Kidney  and  Ureter. 

Tumors  of  the  Kidney. — Tumors,  innocent  or  malignant,  may  arise 
in  the  kidney.  Among  the  innocent  tumors  are  fibroma,  lipoma,  angioma, 
and  adenoma.  Hypernephroma  of  the  kidney  arises  from  fragments  of  adre- 
nal tissue  included  in  the  kidney.  They  were  thought  to  be  renal  lipomata 
until  1883,  when  Grawitz  showed  they  contained  adrenal  elements  ("  Virchow's 
Archiv.,"  xciii) .  The  name  hypernephroma  was  suggested  by  Birch-Hirschfeld 
in  1896.  A  hypernephroma  may  arise  directly  from  the  suprarenal  gland  or  it 
may  arise  from  an  adrenal  "rest"  or  aberrant  gland.  Such  rests  may  be  met 
with  in  the  substance  of  the  kidney,  under  the  renal  capsule,  in  the  perirenal 
tissue,  in  the  testicle,  the  ovary,  the  liver,  the  inguinal  canal,  the  mesentery, 
among  the  spermatic  vessels,  in  the  broad  Hgament,  in  the  renal  plexus,  or  in 
the  solar  plexus  (W.  W.  Keen) .  The  term  hypernephroma  is  appHed  to  any 
growth  which  arises  from  adrenal  cells  "whether  the  growth  be  adenoma, 
carcinoma,  or  sarcoma  in  type"  (Duffieldin  "N.  Y.  Med.  Jour.,"  May  i,  1909). 
The  tissue  of  a  hypernephroma  is  identical  with  the  adrenal  gland,  and  it 
contains  fat  and  glycogen.  The  exact  nature  of  such  a  tumor  is  unsettled. 
It  is  probably  an  adenoma,  but  some  consider  it  to  be  a  sarcoma  and  others 
a  carcinoma.     Some  tumors  give  no  e\'idence  of  malignancy;  some  are  very 


1272  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

malignant.  A  malignant  hypernephroma  grows  rather  rapidly,  eventually 
attains  a  large  size,  and  is  sometimes  painful.  A  patient  in  the  Blockley 
Hospital  from  whom  I  removed  a  hypernephroma  complained  of  tenderness 
in  the  left  side  and  occasional  attacks  like  renal  colic  during  which  he  passed 
bloody  urine.  The  tumor  could  be  easily  palpated  in  the  left  loin.  The 
kidney  was  removed  and  resembled  a  huge  kidney  of  nearly  normal  shape,  but 
nodular  in  outline.  Dr.  CopHn  found  it  to  be  hypernephroma.  In  this  case 
there  was  no  increase  of  arterial  tension.  The  patient  died.  Another  case 
was  a  woman  of  forty-five,  who  was  brought  to  the  Jefferson  Hospital.  She 
had  suffered  from  pain  in  the  loin  for  months.     It  was  paroxysmal,  but  lacked 


Fig.  765. — Sarcoma  of  kidney  with  metastasis  (Hon\'itz). 

the  radiation  of  renal  colic.  Hematuria  appeared  long  after  the  pain  had 
begun.  It  was  persistent,  but  small  in  amount.  Palpation  detected  a  tumor 
and  the  :c-rays  showed  enlarged  kidney.  There  was  no  increase  of  arterial 
tension.  Recovery  followed  nephrectomy.  Very  malignant  cases  have 
proved  fatal  within  six  weeks  after  symptoms  were  observed.  Some  patients 
have  lived  three  years.  A  hypernephroma  of  malignant  nature  involves 
adjacent  structures,  and  gives  rise,  after  a  time,  to  metastases,  particularly  by 
way  of  the  blood.  The  bones  are  most  liable  to  metastatic  deposit,  but  such 
deposits  may  occur  in  the  lungs,  liver,  and  other  regions.  In  a  case  upon 
which  I  operated  for  a  supposed  adenomatous  goiter  the  condition  was  really 
metastatic  hypernephroma.     Hypernephroma ta  are  infinitely  more  common 


Nephroptosis,  Prolapse  of  the  Kidney,  or  Mobile  Kidney     1273 

in  the  kidney  than  anywhere  else.  They  tend  particularly  to  occur  in  middle 
Hfe.  Sarcoma  or  carcinoma  may  arise  in  the  kidney.  Sarcoma  is  most  com- 
mon in  the  young,  and  may  reach  an  enormous  size  (F'ig.  765).  A  malignant 
tumor  of  the  kidney  produces  hematuria,  the  urine  often  containing  blood-casts 
of  the  ureter,  kidney,  and  pelvis,  and  sometimes,  though  rarely,  characteristic 
cells.  Pain  is  often  present  in  the  loin  and  thigh,  and  there  may  be  cohc-like 
attacks  when  clots  are  passing  through  the  ureter.  Emaciation  is  rapid  and 
pronounced.  A  tumor  can  usually  be  palpated.  The  only  possible  treatment 
for  a  malignant  growth  is  early  nephrectomy.  In  some  few  cases  an  inno- 
cent tumor  can  be  removed  by  a  partial  nephrectomy.  A  malignant  tumor 
requires  a  complete  nephrectomy.  In  making  a  diagnosis  of  renal  tumor 
use  the  cystoscope.  If  blood  is  coming  from  a  ureter,  note  if  it  is  from 
only  one  or  from  both.  Blood  from  both  would  contraindicate  nephrectomy. 
Before  removing  a  kidney  it  is  necessary  to  be  sure  that  the  patient  is  pos- 
sessed of  two  kidneys.  Note  if  urine  flows  from  each  ureter,  or,  if  uncer- 
tain, catheterize  the  ureters. 

Nephroptosis,  Prolapse  of  the  Kidney,  or  Mobile   Kidney.— 

There  are  two  forms  of  this  condition:  (i)  Movable  kidney,  which  is  an  organ 
freely  moving  back  of  the  peritoneum,  either  within  the  cavity  of  its  fibro- 
fatty  capsule  or  entirely  without  its  capsule  (this  condition  is  acquired) ;  and 
(2)  floating  or  wandering  kidney,  an  organ  having  a  mesonephron  and  lying 
within  the  peritoneal  cavity  (this  rare  condition  is  always  congenital).  Keen 
states  that  there  may  be  drawn  a  clear  theoretical  distinction  between  mov- 
able and  floating  kidney,  but  practically  there  is  no  rigid  line  of  demarca- 
tion, as  a  movable  kidney  may  have  as  large  a  range  of  movement  as  a  floating 
kidney.  The  kidney  is  normally  somewhat  mobile,  and  nephroptosis  is 
considered  to  exist  only  when  the  range  of  movement  exceeds  distinctly  what 
is  normal.  Normally,  on  inspiration  the  kidney  descends  about  half  an  inch. 
It  is  seldom  that  a  normal  kidney  can  be  palpated  in  men,  but  in  most  women 
the  right  kidney  can  be  palpated,  and  in  some  women  the  left  organ  can  also 
be  felt.  Harris  ("Jour.  Amer.  Med.  Assoc,"  June  i,  1901)  describes  three 
degrees  of  movable  kidney.  In  cases  of  the  first  degree,  one-half  of  the 
organ  can  be  distinctly  grasped  and  the  kidney  can  be  made  to  recede.  In 
cases  of  the  second  degree  both  hands  can  be  brought  together  above  the 
kidney.  In  cases  of  the  third  degree  the  kidney  has  descended  as  low  as 
the  pelvic  brim  or  has  moved  to  or  beyond  the  umbilicus.  The  organ  may 
drop  below  the  brim  of  the  pelvis,  may  cross  the  vertebral  column,  or  may 
reach  the  anterior  abdominal  wall.  When  a  movable  kidney  becomes  fixed 
in  an  abnormal  situation,  the  organ  is  spoken  of  as  dislocated. 

Women  suffer  from  movable  kidney  more  often  than  do  men.  Kiister 
estimates  that  4.41  per  cent,  of  women  examined  in  general  surgical  practice 
have  movable  kidney.  Edebohls  finds  it  in  20  per  cent.,  and  Harris  in  56 
per  cent.,  of  cases  in  gynecological  practice.  In  about  one-half  of  the  cases 
it  gives  rise  to  little  or  no  trouble.  A  movable  kidney  is  found  in  the  great 
majority  of  cases  upon  the  right  side.  In  many  cases  it  is  bilateral,  the 
right  kidney  being  usually  the  most  mobile.  Splanchnoptosis  may  be  asso- 
ciated with  acquired  nephroptosis.  Floating  kidney  is  always  congenital. 
The  condition  is  occasionally,  but  rarely,  found  in  children,  though  congen- 
ital cases  occasionally  occur.     In  a  congenital  case  there  is  not  splanchnop- 


1274  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

tosis.  Tuffier  has  reported  3  cases  in  children  six,  nine,  and  ten  years  of 
age  respectively,  and  J.  Cromby  reported  18  cases  of  floating  kidney  in  chil- 
dren, the  youngest  patient  being  three  months  of  age  (quoted  by  Harris  in 
"Jour.  Amer.  Med.  Assoc,"  June  i,  1901).  Among  the  assigned  causes  of 
the  movable  condition  are  to  be  named  traumatism;  strains;  abdominal- wall 
laxity  from  pregnancy,  removal  of  a  tumor,  or  tapping  for  ascites;  absorp- 
tion of  peritoneal  fat  from  wasting  disease  (Edebohls);  tight  lacing;  uterine 
displacements;  and  enteroptosis  leading  to  traction  on  the  transverse  meso- 
colon. The  condition  is  certainly  often  associated  with  ptosis  of  the  other 
abdominal  viscera  (enteroptosis,  gastroptosis,  etc.). 

Traumatism  is  rarely  the  immediate  and  essential  cause  of  a  true  movable 
kidney.  In  some  cases  people  assert  that  pain  began  immediately  after  a 
blow,  an  attack  of  coughing,  violent  vomiting,  lifting,  straining  at  stool  or 
in  parturition,  or  a  fall.  In  such  cases  the  kidney  may  have  been  mobile 
before  the  accident.  Again,  pain  is  not  proof  of  the  inauguration  of  mova- 
bility.  It  is  probable,  however,  that  traumatism  may  loosen  the  kidney 
and  that  mobility  may  subsequently  develop.  Gutterbock  says  that  a  kidney 
in  normal  relations  cannot  be  rendered  mobile  by  a  simple  fall  or  a  trivial 
force.  Loosening  can  be  induced  only  by  rupturing  surrounding  tissues; 
and  if  this  happens,  symptoms  of  a  distinct  nature  will  indicate  the  seat  of 
injury.  Harris  makes  out  a  strong  case  for  the  view  that  the  condition  is 
due  to  the  relation  existing  between  the  location  of  the  kidney  and  the  body 
form.  He  divides  the  body  into  three  zones.  The  upper  zone  contains  the 
lungs  and  heart.  The  middle  contains  the  liver,  stomach,  spleen,  pancreas, 
and  the  greater  part  of  each  kidney.  The  lower  contains  the  intestinal  canal 
and  the  lesser  part  of  each  kidney.  When  there  is  a  naturally  small  or  a 
diminished  capacity  of  the  middle  zone,  the  kidney  is  displaced  downward. 
The  right  kidney  is  pressed  upon  by  the  heavy  liver,  which  drives  it  down; 
the  left  kidney  is  pressed  upon  by  the  comparatively  small  spleen.  Hence 
movable  kidney  is  more  common  on  the  right  side  than  on  the  left.  The 
upper  pole  of  the  kidney  is  first  pushed  forward  and  then  the  entire  organ 
descends  (M.  L.  Harris,  in  "Jour.  Amer.  Med.  Assoc,"  June  i,  1901). 
Harris  maintains  that  the  amount  of  mobility  depends  upon  the  degree  of 
contraction  of  the  middle  zone  and  upon  internal  traumatisms  (lifting,  strain- 
ing, coughing,  etc.). 

Symptoms  of  Both  Forms. — There  may  be  no  discomfort  whatever,  or 
the  patient  may  be  a  confirmed  invalid.  The  usual  symptoms  are  epigastric 
pain  (just  to  the  left  of  the  middle  line),  which  disappears  when  the  kidney 
is  replaced,  dragging  pain  in  the  loin,  and  paroxysms  like  nephritic  colic. 
Sudden  attacks  of  violent  pain  in  the  kidney  or  stomach  may  occur — attacks 
which  are  accompanied  by  nausea,  vomiting,  great  weakness  or  collapse, 
vertigo,  chills,  and  subsequently  elevated  temperature  (Dietl's  crises).  Dietl's 
crises  are  due  to  kinking  or  twisting  of  the  ureter  or  renal  vessels  or  to  inflam- 
mation of  the  kidney.  They  may  be  caused  by  physical  exertion  or  indis- 
cretion in  diet  and  may  be  followed  by  hydronephrosis  or  strangulation 
of  the  renal  vessels.  A  few  years  ago  I  operated  upon  a  man  sufi"ering  from 
a  violent  and  prolonged  crisis  and  found  a  twist  of  the  vessels  and  ureter. 
In  a  Dietl's  crisis  there  is  congestion  or  strangulation  or  both  (C.  P.  Noble). 
An  incomplete  or  temporary  twist  of  the  renal  pedicle  may  induce  simply 
pain  in  the  abdomen  and  loin,  hematuria,  albuminuria,  and  cylindruria. 


Symptoms  of  Nephroptosis  1275 

The  question  as  to  whether  or  not  abdominal  pain  is  due  to  movable 
kidney  is  sometimes  in  doubt.  The  localization  of  the  pain  may  lead  us  to 
suspect  appendicitis.  Some  surgeons  think  that  catarrhal  appendicitis  is 
often  associated  with  movable  kidney,  but  I  do  not  think  the  association  is 
common.  "Dr.  Kelly  has  shown  us  how  to  solve  this  doubtful  question 
between  appendicular  pain  and  the  pain  of  movable  kidney.  He  catheter- 
izes  each  ureter  separately,  and  introduces  into  each  catheter  as  much  as 
the  renal  pelvis  will  hold  without  causing  pain.  He  then  measures  this 
fluid  from  each  side,  and  determines  whether  it  is  in  excess  of  an  estimated 
average.  If  it  is  in  excess,  he  is  sure  that  dilatation  has  begun.  He  then 
injects  the  kidney  again,  with  the  deliberate  purpose  of  producing  pain; 
and  if  the  patient  recognizes  this  pain  due  to  the  distention  as  of  the  same 
-character  and  in  the  same  position  as  thaj;  which  he  has  previously  felt,  Dr. 
Kelly  assumes  that  the  pain  has  been  due  to  the  kidney,  and  not  to  the  appen- 
dix, and  recommends  an  operation  to  fix  the  kidney"  (the  author,  in  "New 
York  Med.  Jour.,"  August  4,  1906).  Usually  in  a  case  of  movable  kidney 
there  is  a  sense  of  a  moving  body  in  the  abdomen,  and  the  patient  has  aggra- 
vated indigestion,  often  accompanied  by  vomiting.  Constipation  is  the  rule, 
and  violent  attacks  of  cardiac  palpitation  are  common.  Most  subjects  of 
this  kidney  mobility  are  extremely  nervous — many  of  them  hysterical  or  hypo- 
chondriacal. Persistent  vasomotor  paresis  causes  cold  hands  and  feet  and 
often  albuminuria.  Temporary  jaundice  is  not  uncommon.  There  is  fre- 
quently irritability  of  the  bladder.  Vertigo  and  insomnia  are  present  in  many 
cases.  The  patient  cannot  sleep  when  lying  on  the  sound  side  (Goelet). 
In  women  the  sexual  organs  are  almost  invariably  deranged,  and  menstrua- 
tion aggravates  the  pain  and  discomfort.  All  the  symptoms  are  intensified 
by  exertion  and  are  modified  by  rest.  The  urine  is  normal,  except  after 
violent  exercise,  when  it  may  contain  blood.  Splanchnoptosis  may  also 
exist,  and  if  it  does,  the  pulsations  of  the  abdominal  aorta  are  strongly  notic- 
able  because  that  structure  is  bared  by  gastroptosis.  The  proof  of  the  exis- 
tence of  movable  kidney  is  the  finding  of  a  tumor,  movable  on  respiration, 
change  of  position,  and  palpation,  shaped  like  that  organ,  pressure  upon 
which  occasions  no  sensation  or  causes  pain  or  a  sickening  feeling.  A  "  lum- 
bar recess"  (Morris)  may  sometimes  be  found,  and  percussion  over  the  loin 
gives  resonance.  In  some  cases  a  movable  kidney  can  be  readily  detected 
Avhen  the  patient  stands  up,  but  is  difficult  to  find  when  he  is  recumbent. 
Franks's  method  of  examination  is  very  satisfactory.  The  patient  is  placed 
recumbent.  If  dealing  with  a  right  kidney,  the  surgeon  stands  to  the  right 
side  and  pushes  four  fingers  of  his  left  hand  in  the  loin  below  the  twelfth  rib, 
and  rests  the  thumb  lightly  in  front  just  below  the  ribs.  The  patient  takes  a 
full  breath  and  holds  it  a  moment,  and  just  before  he  empties  his  lungs  the 
surgeon  presses  his  thumb  up  deeply  below  the  ribs.  During  expiration  the 
thumb  follows  the  liver,  and  the  fingers  press  toward  the  front.  If  with  the 
right  hand  the  kidney  can  be  felt  entirely  below  the  left  hand,  the  case  is  one 
of  movable  kidney.  If  such  a  condition  is  detected,  press  hard  with  the  right 
hand,  and  gradually  loosen  the  grasp  of  the  left  hand,  and  the  kidney  will 
slip  between  the  fingers  and  ascend.  A  normally  mobile  kidney  descends 
so  that  its  lower  end  can  be  felt,  but  it  moves  back  during  expiration.*  Goe- 
*  Brit.  Med.  Jour.,  Oct.  12,  1895. 


1276  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

let  uses  Kendal  Franks's  method  of  palpation,  but  has  the  patient  stand, 
with  the  weight  resting  on  the  leg  of  the  sound  side  and  with  the  leg  of  the 
impaired  side  sHghtly  flexed  and  resting  on  the  toes.  The  body  leans  a  little 
forward.  A  movable  kidney  must  not  be  mistaken  for  a  distended  gall-blad- 
der, a  tumor  of  the  mesentery,  stomach,  or  omentum,  a  phantom  tumor,  an  ova- 
rian tumor,  or  a  cancer  of  the  pancreas.  A  distended  gall-bladder  can  be  pushed 
upward,  but  not  backward,  and  not  downward  unless  the  liver  is  movable;^ 
it  is  extremely  tender,  and  cannot  be  pushed  out  of  reach.  A  kidney  can  be 
pushed  upward  and  backward^n  fact,  in  all  directions.  An  enlarged  gall- 
bladder can  always  be  palpated.  A  movable  kidney  which  is  not  enlarged 
can  be  felt  at  times  and  not  at  others  (Henry  AI orris).  A  movable  kidney 
may  pass  between  the  examiner's  fingers,  and  if  pushed  into  the  loin,  it  tends 
to  remain;  but  if  a  distended  gall-bladder  is  pushed  into  the  loin,  it 
springs  out  as  soon  as  pressure  is  relaxed  (Henry  Morris).  It  is  important 
to  remember  that  in  about  one-half  of  the  cases  of  movable  right  kidney  the 
left  kidney  is  also  movable,  but  to  a  less  degree.  Appendicitis  is  thought  by 
some  to  be  more  frequent  in  individuals  with  movable  kidney  than  in  those  who 
do  not  suffer  from  it.  Sometimes  a  movable  kidney  endangers  life,  rupture 
of  the  kidney,  twisting  or  rupture  of  the  ureter,  or  strangulation  of  the  renal 

vessels  occurring,  the  uldmate  cause  of 
death  being  albuminuria,  uremia,  or 
hydronephrosis. 

Treatment.  —  Mobile  kidney  is 
treated  as  follows:  If  the  kidney  is  but 
slightly  mobile  and  there  are  no  local 
symptoms,  the  treatment  should  be 
non-operative,  (i)  The  rest-treatment 
of  S.  Weir  Mitchell  may  be  tried;  it 
often  markedly  mitigates  the  symp- 
toms, but  does  not  seem  to  cure.  (2) 
Mechanical  support  should  always  be 
tried.  The  most  satisfactory  mode  of 
apphing  it  is  by  the  corset  recom- 
mended by  Gallant  ("Amer.  Jour.  Ob- 
stet.,"  July,  iQoi).  This  corset  is  long 
and  straight  in  front,  and  when  apphed, 
fits  firmly  over  the  hips  and  lower  ab- 
domen, less  firmly  at  the  waist,  and 
least  firmly  above. 

Gallant  directs  that  the  patient  lie 
down,  the  head  being  on  a  pillow  and 
the  knees  drawn  up.  While  in  this 
attitude  the  corset  is  put  on  and  it  is  laced  from  below  up.  If  the  attempt 
to  apply  the  corset  develops  tenderness,  keep  the  padent  at  rest  in  bed  until 
it  can  be  applied  without  pain.  In  some  cases  conservative  treatment  is  not 
indicated;  in  others  it  fails. 

In  every  case  of  very  movable  kidney  and  in  some  cases  in  which  mova- 
bility  is  not  great  operation  is  indicated. 

"  In  a  case  in  which  the  kidney  exhibits  trivial  raovability,  but  in  which 


Fig.  766.— A.  H.  Goelet's  method  of  palpation 
tor  the  detection  of  a  prolapsed  kidney. 


Treatment  of  Nephroptosis  1277 

the  range  of  mobility  is  found  to  be  gradually  and  certainly  increasing,  or 
in  any  case  of  kidney  movability  in  which  there  are  distinct  local  symptoms, 
operation  is  indicated.  The  distinct  local  symptoms  mean  the  beginning  of 
actual  harm  to  the  kidney,  and  the  progressive  increase  of  movability  means 
the  ultimate  attainment  of  a  wide  range  of  movement.  A  kidney  which  is 
widely  movable  may  at  any  time  twist  upon  the  ureter  and  the  renal  vessels; 
and  it  is  certain  to  suffer  from  partial  or  slight  twists,  probably  many  times 
repeated  in  the  twenty- four  hours,  even  if  a  severe  twist  does  not  occur.  A 
deduction  from  the  foregoing  statements  is  that  a  patient  suffering  with  neph- 
roptosis, even  when  the  mobility  is  slight,  should  be  examined  at  regular 
intervals,  to  note  whether  the  area  of  movement  is  extending,  or  whether 
local  symptoms  have  arisen.  Three  local  symptoms  that  should  be  regarded 
as  indications  for  operation  are  severe  pain  in  the  renal  region,  distinct  ten- 
derness of  the  kidney,  and  enlargement  of  the  kidney"  (the  author,  in  "New 
York  Med.  Jour.,"  August  4,  1906).  Billington  ("Brit.  Med.  Jour.,"  May  i, 
1909)  formulates  the  following  indications  for  operation: 

1.  When  renal  pain  is  so  severe  or  persistent  as  to  cause  serious  incon- 
venience. The  ordinary  dragging  pain  in  the  loin  is  not  an  indication.  Bil- 
lington refers  to  severe  pain  due  to  perirenal  inflammation,  ureteral  obstruc- 
tion, or  impeded  venous  return. 

2.  When  there  are  harassing  and  depressing  gastric  and  colonic  troubles 
(gross  lesions  being  absent). 

3.  Cases  of  spinal  and  cerebral  neurasthenia. 

4.  Cases  of  lunacy.  Personally  I  do  not  operate  on  groups  3  and  4  unless 
there  are  signs  of  grave  renal  disaster. 

The  usual  operation  chosen  will  be  nephropexy,  very  seldom  nephrectomy, 
(i)  Nephropexy  is  the  operation  employed  in  most  instances  (page  1293).  I' 
is  the  author's  experience  that  if  the  patient  has  had  marked  nervous  symp- 
toms for  a  long  time,  nephropexy  will  rarely  cause  them  to  pass  away  perma- 
nently, even  though  the  kidney  remains  firmly  anchored.  (2)  Nephrec- 
tomy is  necessary  only  in  very  rare  cases;  it  may  be  done  for  dislocated  kidney, 
when  grave  kidney  disease  exists,  or  when  nephropexy  has  failed  in  a  case  of 
great  severity. 

In  many  cases  of  this  trouble  no  operation  should  be  performed,  the  use 
of  Gallant's  corset  securing,  perhaps,  decided  or  complete  relief.  I  do  not 
operate  if  the  kidney  is  only  slightly  movable  and  if  there  are  no  local  symp- 
toms or  if  there  are  merely  the  general  symptoms  of  hysteria.  If  the  mobility- 
is  slight  and  the  hysterical  and  neurotic  condition  is  pronounced,  anchoring 
the  kidney  will  not  cure  the  nervous  condition.  In  these  nervous  cases,  asso- 
ciated with  prolapse  of  the  kidney,  there  is  usually,  also,  prolapse  of  the  other 
abdominal  viscera;  and  both  kidneys  are,  as  a  rule,  movable,  the  right,  how- 
ever, being  decidedly  more  movable  than  the  left. 

If  there  is  but  shght  mobihty  of  the  kidney,  but  the  range  of  movement 
is,  week  by  week  and  month  by  month,  increasing,  or  if  we  find  a  case  of 
movable  kidney  in  which  there  are  distinct  local  symptoms,  an  operation  should 
be  performed.  The  existence  of  definite  local  symptoms  means  beginning 
harm  to  the  kidney;  and  if  we  find  the  area  of  movement  gradually  increas- 
ing, we  know  that  eventually  it  will  become  extensive.  Any  widely  movable 
kidney  may  twist  the  ureter  and  the  renal  vessels,  producing  serious  trouble 


1278  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

or  even  disaster,  and  consequently  should  be  fixed  by  operation.  Even  if  a 
severe  twist  does  not  take  place,  it  is  bound  to  sufi'er  from  partial  or  slight 
twists.  Such  kidneys  will  eventually  become  hydronephrotic.  The  meaning 
of  the  term  slight  mobihty  is  indicated  on  a  previous  page  (p.  1273). 

One  is  not  unusually  in  doubt  in  cases  of  movable  kidney  whether  a  pain 
indicates  local  trouble  with  the  kidney  or  catarrhal  appendicitis,  because 
the  pain  may  be  located  in  the  appendix  region.  Kelly,  of  Johns  Hopkins 
Hospital,  has  shown  how  to  solve  this  problem  (p.  1275). 

There  are  many  operations  for  movable  kidney.  In  all  of  them  the 
kidney  is  exposed  in  the  loin.  Some  make  a  vertical  and  some  an  oblique 
incision.  Edebohls  makes  a  vertical  incision,  forces  the  kidney  out  of  the 
wound,  incises  the  fibrous  capsule  longitudinally,  turns  a  cuff  down  on  each 
side,  and  applies  sutures.  These  sutures  traverse  the  kidney-substance  and 
the  fold  of  capsule  on  each  side.  The  upper  suture  catches  the  periosteum 
of  the  last  rib;  the  other  sutures  catch  the  lumbar  fascia.  Drainage  is  not 
required,  and  the  suture  material  employed  is  kangaroo-tendon  or  chromi- 
cized  catgut. 

Many  surgeons  simply  pass  sutures  through  the  uncut  capsule  and  the 
kidney-substance  and  thus  fasten  the  kidney  to  the  lumbar  fascia.  Others 
split  the  capsule  and  pass  sutures  through  the  edge  of  the  capsule  and  the 
wound-edges,  but  not  through  the  kidney-substance. 

To  promise  success,  an  operation  ought  to  restore  the  kidney  nearly  to 
its  normal  position  and  fix  it  permanently  in  place.  It  is  undesirable  to  inflict 
damage  on  the  kidney  itself,  and  I  do  not  believe  in  any  operation  that  passes 
sutures  through  the  kidney-substance.  In  cases  in  which  decapsulation  is 
performed,  the  kidney  will  grow  fast  without  any  special  method  of  suturing. 

Most  of  the  operations  suggested  do  not  place  the  kidney  sufficiently  high 
up  to  get  it  into  a  fair  position.  Kelly's  operation  gets  it  higher  than  most 
of  them,  and  Goelet's  operation  gets  it  well  into  place.  In  many  of  the  suture 
operations  the  sutures  are  placed  in  the  convex  surface  of  the  kidney  or 
the  kidney  capsule,  and  on  fixing  the  kidney  by  tying  the  sutures  there  is 
a  permanent  quarter  twist  of  the  in-eter — a  condition  that  may  be  responsi- 
ble for  great  pain.  This  may  be  obviated  entirely  by  the  ingenious  method 
of  Goelet  ("Annals  of  Surgery,"  Dec,  1903).  I  believe,  however,  that  the 
suture  operations  which  do  lift  the  kidney  well  up  toward  its  proper  place 
and  in  which  the  sutures  are  applied  on  the  posterior  surface  and  not  the  con- 
vexity, tilt  the  upper  pole  fonvard  into  a  permanent  and  perhaps  disastrous 
position.  Such  operations  lift  the  kidney  from  below  its  mid-line  and  thus  fix 
the  lower  half  of  the  organ,  but  leave  the  upper  half  unfixed.  I  believe,  too,  that 
in  many  cases  in  which  kidneys  have  been  sutured  they  get  loose  again  and  that 
the  best  operation,  after  all,  is  that  by  the  use  of  slings  of  iodoform  gauze  (page 
1293).  _ 

Injuries  of  the  Kidney. — Laceration  or  rupture  is  caused  by  falls 
and  by  blows  upon  the  back  or  the  belly. 

Symptoms. — In  some  cases  the  parenchymatous  structure  is  torn,  but 
the  capsule  is  not  torn,  and  in  consequence  urine  and  blood  are  not  extrava- 
sated  into  the  perineal  connective  tissue  or  into  the  peritoneal  cavity.  In 
other  cases  the  parenchyma  and  capsule  are  both  torn  and  urine  and  blood 
are  extravasated.     The  laceration  may  be  t~ivial,  may  be  considerable,  or 


Injuries  of  the  Kidney  1279 

may  tear  the  kidney  apart.     The  symptoms  depend  on  the  gravity  of  the 
injury.     A  slight  tear  without  involvement  of  the  capsule  may  produce  prac- 
tically no  symptoms  at  all.     A  more  severe  injury  produces  shock,  and,  if 
profuse    bleeding    occurs,    the 
general    symptoms    of    hemor- 
rhage.    In  intraperitoneal  rup- 
ture there  is  profuse  and  usu- 
ally    fatal     hemorrhage.      In 
laceration  of  the  kidney  there  are 
severe  pain  in  the   loin,   which 
shoots    into    the    testicle,    and 
lumbar  tenderness.     If  there  is 
considerable  perirenal  bleeding, 
the  loin  will  be  full,  and  dull  on 
percussion,  and  if   the  hemor-      -c      .         „        ^^ 

'^  rig.  707. —    Purse-string  suture     applied  to  a  perfora- 

rhage  is  large,  a  palpable  mass  tion  (after  Schachner). 

will  form  after  a  time  and  after 

some  days  the  skin  will  become  discolored.  There  is  frequent  and  painful 
micturition  and  sometimes  suppression  of  urine.  Hematuria  occurs  in  renal 
laceration  unless  the  rupture  was  intraperitoneal  or  the  ureter  was  torn,  in 
which  case  there  are  evidences  of  profuse  internal  hemorrhage,  abdominal 
rigidity,  etc.  (Daniel  N.  Eisendrath,  "Jour.  Am.er.  Med.  Assoc,"  Oct.  25, 
1902).  It  is  important  to  remember  that  hematuria  can  arise  from  simple 
renal  contusion,  and  that  kidney  damage  does  not  of  necessity  cause  bloody 
urine.  If  there  is  hematuria,  the  use  of  the  cystoscope  or  catheterization  of 
the  ureters,  or  the  employment  of  Harris's  segregator,  will  demonstrate  from 
which  kidney  the  blood  comes.  A  kidney-laceration  may  be  followed  by 
secondary  hemorrhage,  perirenal  suppuration,  hydronephrosis,  or  pyoneph- 
rosis, and  may  cause  kidney  displacement. 

Treatment. — In  an  intraperitoneal  rupture  laparotomy  should  be  per- 
formed because  of  abdominal  hemorrhage.  As  a  rule,  nephrectomy  is  neces- 
sary,  but  it  may  be  possible  to  arrest  hemorrhage  by  packing.  If  the  shock 
is  pronounced  and  if  there  is  increasing  fulness  in  the  loin,  whether  hema- 
turia exists  or  not,  or  if  blood  comes  profusely  from  the  ureter,  whether  or 
not  there  is  much  shock  or  lumbar  fulness,  make  an  exploratory  lumbar 
incision  and  stop  the  bleeding  by  packing  or  by  a  purse-string  suture  (Figs. 
767,  768),  or,  if  necessary,  perform  partial,  or  even  complete,  nephrectomy. 
Ordinarily,  when  there  is  not  great  shock,  increasing  lumbar  swelling,  or 
severe  hematuria,  treat  by  rest  in  bed  and  by  feeding  with  liquid  food  or  by 
nutritive  enemata  to  prevent  vomiting.  Opium,  tannic  acid,  or  gallic  acid 
may  be  used.  Apply  ice-bags  to  the  loin  and  the  side  of  the  abdomen,  and 
after  bleeding  ceases  strap  the  loin  and  apply  a  binder.  If  large  blood-clots 
in  the  bladder  cause  pain  or  retention  of  urine,  introduce  a  catheter  and 
inject  the  bladder  with  boric  acid,  or  use  the  tube  and  evacuator  of  a  Bige- 
low  apparatus.  If  this  procedure  .fails,  open  the  bladder  by  a  suprapubic 
incision  and  drain. 

Results  of  Operation. — Up  to  1894  there  had  never  been  a  case  of  intra- 
peritoneal rupture  operated  upon;  since  then  6  have  been  operated  upon 
and  all  recovered  (Daniel  N.  Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct. 


i28o  Diseases  and  Injuries  of  the  Genito-urinarv  Organs 

25,  1902).  Kiister  collected  47  cases  of  nephrectomy,  and  S3  per  cent, 
recovered.  Keen  estimates  the  mortality  of  primary  nephrectomy  for  rupture 
at  20  per  cent.,  and  of  secondary  nephrectomy  at  38.5  per  cent.  Without 
operation  intraperitoneal  rupture  is  inevitably  fatal.  Six  recorded  cases 
operated  upon  recovered.  Of  extraperitoneal  ruptures,  70  per  cent,  recover 
without  operation  (Eisendrath).  Francis  S.  Watson  ("Boston  Med.  and 
Surg.  Jour.,"  July  16,  1903)  has  collected  660  cases  of  subparietal  injur}'  of 
the  kidney.  The  following  statistics  are  of  interest:  Treated  expectantly:  273 
cases  with  81  deaths,  a  mortality  of  29.6  per  cent.  Treated  by  operations 
other  than  nephrectomy:  99  cases  with  7  deaths,  a  mortality  of  7.7  per  cent. 
Treated  by  nephrectomy:  115  cases  with  25  deaths,  a  mortality  of  21.7  per 
cent. 

Perforating  wounds  of  the  kidney,  if  purely  posterior,  do  not  involve 
the  peritoneum;    if  anterior,  they  do.     The  symptoms  are  escape  of  blood 


Fig.  768. — Showing  the  application  of  a  double  "  purse-string"  suture  for  the  arrest  of  hemorrhage  in 

large  wound  (after  Schachner). 

and  urine  by  the  wound;  hematuria  is  usual,  but  not  invariable;  pain  as  in 
rupture;  the  patient  may  be  unable  to  micturate;  and  nausea,  vomiting,  and 
constitutional  signs  of  hemorrhage  exist.  Traumatic  peritonitis,  perinephric 
abscess,  or  general  sepsis  may  ensue.  Confirm  the  diagnosis  by  exploration 
with  the  finger.  Extraperitoneal  injuries  give  a  good,  and  intraperitoneal 
a  bad,  prognosis. 

Treatment. — If  the  wound  of  the  kidney  is  extraperitoneal,  enlarge  the 
lumbar  wound  to  permit  of  drainage,  and  arrest  hemorrhage  by  packing  and 
hot  water  or  by  a  purse-string  suture  (Figs.  767,  768).  Asepticize  the  wound, 
insert  a  drainage-tube  down  to  the  kidney,  dress  often  with  bichlorid  gauze, 
keep  the  patient  in  bed  on  a  low  diet,  and  give  gaUic  acid  and  opium.  In  some 
cases  nephrectomy,  partial  or  complete,  will  be  required.  In  intraperitoneal 
wounds  perform  an  abdominal  section  and,  as  a  rule,  remove  the  damaged 
organ  (see  Nephrectomy). 

Wounds  of  the  Ureters. — Rupture  from  external  violence  is  anex- 
tremelv  rare  accident.  There  are  3  undoubted  cases  on  record  (Daniel  N. 
Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct.  25,  1902).  A  rupture  or 
wound  from  accidental  violence  is  almost  invariably  associated  with  other 
serious  injuries.  The  ureter  may  be  wounded  by  the  surgeon  accidentally 
during  the  performance  of  an  abdominal  operation,  or  it  may  be  wounded 
intentionally,  as  in  Morris's  cases,  in  which  a  malignant  growth  was  incor- 


Renal  Calculus  1281 

porated  wdth  the  ureter.  There  is  particular  danger  of  injuring  the  ureter 
in  operations  upon  intraligamentary  growths,  because  the  ureter  is  displaced 
and  often  resembles  an  adhesion.  The  rule  of  surgery  is  that  when  working 
about  the  ureter  the  surgeon  neither  clamps  nor  cuts  any  structure  without 
a  careful  preliminary  examination.  Rupture  causes  severe  shock  and  extra- 
vasation of  urine  around  the  kidney  or  into  the  peritoneal  cavity.  In  extra- 
peritoneal rupture  a  palpable  mass  forms  in  the  loin.  When  the  ureter  is 
divided  in  an  operation,  a  flow  of  urine  is  seen. 

Treatment. — The  upper  three-fourths  of  the  ureter  can  be  reached  by 
an  extraperitoneal  incision,  which  is  a  prolongation  of  the  incision  for  lumbar 
nephrectomy,  running  from  the  twelfth  rib  downward,  and  forward  to  one 
inch  anterior  to  the  anterior  superior  spine  of  the  ilium,  and  then  parallel 
to  Poupart's  ligament  until  a  point  is  reached  above  its  middle  (Fenger). 
Israel's  incision  begins  at  the  anterior  edge  of  the  erector  spinae  mass,  one 
finger's  length  below  the  twelfth  rib,  is  taken  forward  parallel  with  the  rib 
until  it  reaches  the  line  of  the  rib's  tip,  and  is  then  carried  toward  the  middle 
of  Poupart's  ligament  until  the  line  for  ligation  of  the  common  iliac  artery 
is  reached,  and  is  then  taken  toward  the  middle  line  as  far  as  the  outer  border 
of  the  rectus  muscle.  The  lower  one- fourth  of  the  ureter  can  be  reached 
by  abdominal  section  or  by  sacral  resection  (Cabot),  but  best  by  an  incision 
like  that  for  extraperitoneal  ligation  of  the  ihac  vessels.  If  it  seems  probable 
that  the  ureter  is  wounded  or  ruptured,  explore,  and  if  this  is  found  to  be 
the  case,  endeavor  to  restore  the  continuity  of  the  tube.  A  longitudinal 
cut  can  be  sutured  ^^^th  fine  catgut.  If  the  ureter  is  cut  across  near  the  bladder, 
implant  the  proximal  end  into  the  bladder  and  ligate  the  distal  end  (Van  Hook, 
Penrose,  Kelly).  If  it  is  cut  above  the  bladder  portion,  perform  lateral 
implantation  by  Van  Hook's  method  (page  1296). 

A  longitudinal  wound  of  the  ureter  inflicted  during  an  abdominal  opera- 
tion should  be  sutured,  but  if  the  duct  cannot  be  readily  reached,  simply 
make  a  posterior  incision  and  drain  with  rubber  tissue,  as  the  longitudinal 
wound  will  heal  by  granulation  if  no  sutures  are  inserted  (Van  Hook).  In  a 
case  of  transverse  division  perform  uretero-ureterostomy  or  vesical  implanta- 
tion; or,  if  neither  of  these  methods  is  feasible,  make  a  urinary  fistula  or 
perform  nephrectomy. 

Renal  Calculus. — A  stone  in  the  kidney  is  formed  by  the  precipitation 
of  urinary  salts  into  the  renal  epithelial  cells  and  the  gluing  together  of  these 
salts  and  cells  by  material  from  mucus  or  blood-clot,  this  mass  serving  as  a 
nucleus  on  which  accretion  takes  place.  IMost  calculi  escape  when  small, 
as  gravel.  The  cause  is  a  highly  acid  urine,  which  induces  catarrh  of  the 
renal  tubes.  Such  high  concentration  of  urine  is  favored  by  a  sedentary  life, 
by  the  ingestion  of  much  alcohol  or  nitrogenous  food,  by  constipation,  by 
an  inactive  skin,  and  by  a  torpid  liver.  The  children  of  poverty  are  liable 
to  calculi  because  of  the  use  of  unsuitable  foods  and  the  formation  of  great 
amounts  of  nitrogenous  waste.  ]\Iales  suffer  more  often  than  do  females; 
certain  locations  favor  the  development  of  the  malady,  and  a  family  tendency 
sometimes  exists. 

Symptoms.- — The  symptoms  of  stone  in  the  kidney  may  not  appear  for 
years,  but  generally  they  are  manifested  early.  There  may  be  no  pain.  There 
had  been  none  in  13  cases  out  of  24  which  came  to  autopsy  and  were  reported 


1282  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

by  Clark.  Usually  there  is  pain;  the  severity  of  the  pain  depending  upon  the 
roughness  and  movability  rather  than  upon  the  size  of  the  stone.  A  fixed 
stone  in  the  kidney  and  a  smooth  stone  in  the  pehis  may  cause  little  or  no 
pain.  A  rough  stone  in  the  pelvis  causes  severe  pain.  The  patient  usually 
complains  of  pain  in  the  loin,  and  sometimes  of  pain  in  the  iliac  region.  Deep 
percussion  over  the  kidney  causes  pain  in  the  loin,  even  when  pressure  is 
painless  (Jordan  Lloyd's  symptoms).  Pain  is  aggravated  by  exercise  and 
pressure,  and  the  kidney  is  usually  enlarged.  The  urine  is  often  somewhat 
albuminous,  and  may  from  time  to  time  contain  blood.  Frequency  of  micturi- 
tion is  noted  during  the  day,  but  not  at  night.  The  urine  may  be  purulent. 
Nephritic  colic  is  due  to  the  washing  of  a  calculus  into  the  orifice  of  the  ureter, 
which  it  blocks,  tears,  "or  distends.  The  pain  is  either  sudden  or  gradual  in 
onset,  is  fearful  in  intensity,  and  runs  from  the  lumbar  region  down  the 
corresponding  thigh  and  spermatic  cord  (the  testicle  being  retracted),  and 
into  the  abdomen  and  back.  There  are  nausea,  vomiting,  collapse,  sometimes 
unconsciousness  or  convulsions.  Frequent  attempts  at  urination  are  pro- 
ductive of  pain,  but  of  Httle  urine.  Rectal  tenesmus  is  common.  The  urine 
is  often,  but  by  no  means  always,  smoky  from  blood.  Blood  may  be  found 
by  the  microscope  when  it  cannot  be  detected  by  the  naked  eye.  In  rare  cases 
fatal  hemorrhage  occurs.  Blood  is  present  in  about  one-half  the  cases.  After 
a  time  the  palin  vanishes,  the  stone  ha\'ing  passed  into  the  bladder  or  having 
fallen  back  into  the  pelvis  of  the  kidney.  Shght  attacks  of  colic  occur  from  the 
passage  of  small  stones  or  of  plugs  of  mucus.  A  calculus  retained  in  the  kidney 
eventually  excites  pyelitis,  pus  appears  in  the  urine,  and  soreness  or  pain  in  the 
loin  exists.  Kelly  says:  Even  if  pus  is  found,  we  are  not  always  sure  from 
which  kidney  it  came.  Pain  or  swelling  may  point  to  one  side,  but  we  are 
not  sure  that  the  outer  organ  is  not  also  affected.  The  cystoscope  must  be 
used.  Bloody  or  purulent  urine  may  be  seen  coming  from  one  ureter.  If 
able  to  pass  the  renal  catheter  into  one  ureter,  attach  a  syringe,  and  by  making 
suction,  draw  out  any  pus  which  may  be  present.  In  renal  calculi  cases  this 
fluid  is  apt  to  contain  fragments  of  uric  acid.  By  using  a. renal  bougie  coated 
with  dental  wax  it  may  be  possible  to  make  scratches  on  the  instrument  when 
it  comes  in  contact  with  a  concretion.*  When  a  stone  is  impacted  in  the  pelvis 
the  point  of  greatest  tenderness  on  pressure  is  below  the  last  rib,  by  the  edge 
of  the  erector  spinae  muscle.  In  septic  cases  there  may  be  chills  and  irregular 
fever,  and  often  there  is  leukocytosis.  In  most  cases  a  stone  in  the  kidney  or 
ureter  can  be  skiagraphed.  NephroHthiasis  may  cause  death  by  exhaustion, 
by  sepsis,  by  rupture  of  a  hydronephrosis,  or  by  amyloid  degeneration. 

Treatment. — For  the  gravel  of  the  uric-acid  diathesis  use  alkalies,  espe 
cially  the  liquor  potassli  citratis,  and  reduce  the  amount  of  nitrogen  in  the 
diet  to  a  minimum,  at  the  same  time  washing  out  the  organs  by  copious 
draughts  of  Poland  water  or  Londonderry  lithia.  Piperazin,  in  doses  of  gr.  v 
to  gr.  viij  three  times  a  day,  is  highly  commended.  Exercise  is  to  be  insisted 
on.  WTien  gravel  is  phosphatic,  order  strychnin,  the  mineral  acids,  and 
rest  at  the  seaside.  When  oxalate  of  lime  is  found,  restrict  the  diet,  use  the 
mineral  acids,  recommend  travel  or  rest  amid  new  surroundings,  and  give 
an  occasional  course  of  sodii  phosphas,  5ss  three  times  a  day,  drunk  in  Buf- 
falo lithia  water.  Nephritic  colic  is  relieved  by  hypodermatic  injection  of 
morphin  and  atropin,  the  hot  bath,  diluent  drinks,  or  the  inhalation  of  ether. 
♦Howard  Kelly,  in  Med.  News,  Nov.  30,  1895. 


Calculus  in  the  Ureter  1283 

After  an  attack  use  the  cystoscope,  and  if  a  stone  is  found  in  that  viscus,  wash 
out  the  bladder  with  an  evacuator.  If  a  stone  impacts  in  the  ureter,  perform 
the  operation  of  urelcrolitlwtomy.  The  diagnosis  of  this  impaction  is  in  many 
cases  aided  by  the  x-rays,  but  is  sometimes  possible  only  after  exploratory 
laparotomy.  If  the  symptoms  point  to  stone  in  the  kidney,  medical  treat- 
ment having  been  used  without  avail,  always  take  a  skiagraph.  If  this  shows 
a  stone  and  if  there  are  no  evidences  of  organic  disease  of  the  kidney,  operate. 
If  in  doubt  in  spite  of  the  skiagraph,  make  an  exploratory  lumbar  incision; 
feel  the  surface  of  the  kidney  with  the  finger,  sound  the  inside  of  the  organ, 
with  a  needle,  and  if  a  stone  is  detected,  incise  the  kidney  and  remove  the  stone. 
Keen  is  of  the  opinion  that  operation  should  not  be  performed  if  the  urea  is 
below  I  per  cent.  If,  after  nephrolithotomy,  suppression  of  urine  occurs,  cut  into 
the  other  kidney,  as  in  one-half  of  all  cases  a  stone  will  be  found  lodged  there. 
I  agree  with  Brewer  ("Med.  Record,"  March  20,  1909)  that  "a  kidney  con- 
taining one  or  more  calculi,  and  also  the  seat  of  an  advanced  septic  process, 
should  be  removed  if  the  opposite  organ  is  healthy.  To  leave  such  a  kidney 
is  to  invite  subsequent  trouble  from  recurrence  of  stone,  pyonephrosis,  or  long- 
continued  sepsis."  I  agree  with  him  when  he  says:  "It  is  also  often  safer  to 
remove  a  kidney  with  multiple  calculi  imbedded  in  its  substance  than  to 
inflict  the  trauma  necessary  to  remove  them,  as  alarming  primary  or  secondary 
hemorrhage  is  apt  to  occur."  In  a  recent  case  of  my  own  a  most  persistent 
postoperative  hemorrhage  forced  me  to  perform  nephrectomy  to  save  life. 

Calculus  in  the  Ureter. — A  ureteral  calculus  comes  from  the  kidney, 
sometimes  dropping,  but  more  often  being  forced,  into  the  tube.  A  stone 
may  be  arrested  at  any  one  of  these  points  of  constriction.  There  are  three 
points  of  constriction  in  the  ureter:  one  point  is  about  2  inches  below  the 
renal  pelvis,  another  is  at  the  pelvic  brim,  another  is  about  ^  inch  from  the 
bladder  orifice  of  the  ureter.  The  highest  point  has  a  diameter  of  about 
Y  inch,  the  middle  point  a  diameter  of  about  \  inch,  the  lower  point  a  diameter 
of  about  y  Q-  inch.  A  small  stone  may  completely  block  the  ureter.  A  large 
stone  may  fail  to  completely  block  it  because  the  ureter  dilates  above,  the 
stone  acts  as  a  ball-valve,  and  urine  trickles  by. 

S3miptoms. — Attacks  of  violent  pain  of  the  nature  of  renal  colic,  and 
not  unusually  a  rigor  with  the  attack  and  fever  after  it.  Such  an  attack  may 
be  followed  by  hematuria.  The  urine  should  be  examined  microscopically 
during  several  days  after  a  colic  to  see  if  it  contains  blood  cells.  Tenderness 
can  be  developed  at  the  point  of  impaction,  the  point  of  greatest  tenderness 
being  in  the  loin  helow  the  level  of  the  kidney  or  in  the  iliac  region  (Perkins). 
In  stone  in  the  ureter  pain  is  not  developed  by  pressure  in  the  loin  at  the  level 
of  the  kidney.  If  a  stone  partly  obstructs  the  ureter,  the  urine  is  pale,  of  low 
specific  gravity,  and  free  from  albumin.  Impaction  near  the  bladder  causes 
symptoms  similar  to  stone  in  the  bladder  (Jordan  Lloyd) .  These  symptoms  are 
frequent  micturition,  pain,  pain  in  the  head  of  the  penis,  and  bloody  urine.  If 
a  stone  is  impacted  in  the  lower  end  of  the  ureter  a  finger  in  the  vagina  or 
rectum  will  find  tenderness  and  perhaps  will  feel  the  stone.  In  a  woman, 
a  stone  lodged  in  front  of  the  broad  ligament  may  be  felt  by  a  finger  in  the 
vagina.  Back  of  this  region  and  up  to  the  pelvic  brim  a  stone  may  be  felt 
by  a  finger  in  the  rectum.  A  cystoscopic  examination,  in  unusual  cases,  may 
show  a  portion  of  stone  projecting  from  a  ureter  (Kelly).     Impaction  near 


1284         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  kidney  is  accompanied  by  hematuria  and  pyuria,  lumbar  pain,  pain 
radiating  into  the  groin,  thigh,  or  testicle,  and  retraction  of  the  testicle.  These 
symptoms  are  identical  in  character  with  the  symptoms  caused  by  stone  in 
the  renal  pelvis.  Complete  obstruction  of  the  ureter  causes  hydronephrosis. 
Pyonephrosis  results  from  infection  of  a  hydronephrosis.  In  some  cases  a 
stone  acts  as  a  ball-valve,  plugs  the  ureter  for  a  time,  during  which  a  lumbar 
mass  develops,  and  then  allows  the  urine  to  flow.  A  copious  flow  of  urine  is 
accompanied  by  disappearance  of  the  lumbar  mass.  Complete  urinary  sup- 
pression may  follow  blocking  of  a  ureter  by  a  calculus.  If  a  ureteral  catheter 
tipped  with  wax  is  introduced,  a  calculus  will  make  distinct  scratches  upon  it 
(Kelly).     The  ;r-rays  are  very  valuable  in  diagnosis. 

Treatment. — During  a  painful  paroxysm  give  morphin  and  use  hot 
packs.  The  attack  may  terminate  and  not  return,  because  the  calculus  passes. 
If  such  an  attack  does  pass  away,  the  urine  should  be  examined  after  every 
act  of  micturition  to  see  if  the  stone  is  voided  from  the  bladder.  After  a  day 
or  two,  if  the  stone  does  not  appear,  use  the  cystoscope,  perhaps  catheterize 
the  ureter,  and  thus  discover  if  the  stone  is  in  the  bladder  or  if  it  is  impacted. 
If  the  stone  is  in  the  bladder,  use  the  Bigelow  evacuator  (page  1326)  to  effect 
removal.  The  stone  must  never  be  allowed  to  remain,  as  it  will  surely  enlarge 
and  cause  subsequent  trouble.  If  a  stone  is  impacted  in  the  ureter,  dilate  the 
ureteral  orifice  and  inject  sterile  ohve  oil  through  a  ureteral  catheter.  This 
procedure  facilitates  the  passage  of  a  stone.  Simple  catheterization  of  the 
ureter  may  be  followed  by  expulsion  of  the  stone.  If  in  spite  of  these  proce- 
dures the  stone  remains  impacted  in  the  ureter,  the  question  of  operation 
presents  itself.  An  impacted  stone  is  certainly  a  peril,  but  how  immediate 
the  danger  it  is  often  impossible  to  say.  In  some  cases  stones  have  remained 
impacted  for  many  years  without  obvious  harm.  In  other  cases  the  kidney 
is  rapidly  destroyed.  The  stone  may  pass  after  having  been  retained  for  a 
long  time,  and  drinking  freely  of  water  favors  its  expulsion.  One  of  my  cases 
had  long  had  a  retained  stone,  came  to  the  hospital  for  operation,  and  passed 
the  stone.  Sooner  or  later  a  retained  stone  will  lead  to  disaster  and  it  ought 
to  be  removed  by  operation.  It  will  cause,  if  retained,  thickening  or  ulceration 
of  the  ureter,  dilatation  of  the  ureter  above  it,  and  kidney  trouble.  A  lodged 
stone  increases  gradually  in  size  and  other  stones  may  form  above  it.  The 
extraperitoneal  operation  is  to  be  chosen  in  most  cases.  Even  when  the  stone 
is  impacted  below  the  pelvic  brim,  it  is  usually  better  to  do  the  extraperitoneal 
operation,  stripping  the  peritoneum  and  reaching  the  ureter  from  behind. 
(See  Ureterolithotomy.) 

Abscess  of  the  kidney  is  caused  by  traumatism,  by  calculus,  by  stric- 
ture of  the  urethra,  by  disease  of  the  bladder,  by  the  union  of  miliary  ab- 
scesses, or  by  pyemia. 

The  symptoms  are  pus  in  the  urine  (this  is  usual,  but  not  invariable), 
hematuria  in  traumatic  cases,  and  pain  running  into  the  groin.  The  urine 
in  most  cases  is  alkaline.  Constitutional  symptoms  of  suppuration  exist,  the 
fever  being  far  higher  than  that  generally  met  with  in  renal  tuberculosis.  The 
bladder  should  be  examined  with  a  cystoscope  to  determine  that  the  turbid 
urine  flows  from  the  ureter  and  to  identify  the  diseased  side.  It  is  well,  if 
possible,  to  catheterize  the  ureters. 

The  treatment  in  the  early  stage  is  rest,  morphin,  purgation,  anodynes, 


Perinephric  Abscesses  1285 

an  ice-liag  to  the  loin,  followed  in  forty-eight  hours  ])y  hot  fomentations. 
When  the  diagnosis  is  clear,  incise  the  loin,  open  and  stitch  the  kidney  to 
the  abdominal  wall,  or,  if  the  organ  be  badly  damaged,  remove  it. 

Pyelitis  and  pyelonephritis,  which  usually  affect  only  one  gland, 
are  caused  by  urethral  stricture,  by  stopping  of  the  ureter  by  blood-clot,  by 
vesical  paralysis,  by  stone  in  the  bladder  or  in  the  kidney,  and  by  enlargement 
of  the  prostate  gland. 

Symptoms. — A  patient  who  has,  or  who  has  had,  retention  of  urine 
develops  high  fever,  often  preceded  by  a  chill,  and  headache,  stupor,  and  dry 
tongue  are  noted.  Unlike  acute  Bright's  disease,  there  is  neither  edema 
nor  dry  skin,  convulsions  do  not  occur,  and  the  urine  is  plentiful  and  con- 
tains pus  and  but  rarely  blood.     The  prognosis  is  very  bad. 

The  treatment  is  to  remove  the  obstruction  if  possible.  If  the  urine  be 
acid,  give  liquor  potassii  citratis;  if  alkaline,  give  benzoic  acid.  Gallic  acid, 
eucalyptol,  and  small  doses  of  copaiba  or  cubebs  are  recommended.  Venice 
turpentine,  camphor,  and  opium  may  be  given  in  pill  form.  Quinin  is  used 
to  stimulate  the  patient.  The  bladder  is  to  be  washed  out  every  day  with 
boric-acid  solution  (gr.  iij  to  §j  of  water).  Cups,  dry  or  moist,  and  hot 
sand-bags  or  bran-bags  are  to  be  applied  to  the  loin.  Alcohol  may  be  spar- 
ingly administered.     Urotropin  is  a  useful  drug. 

Perinephritis  is  an  inflammation  of  the  perinephric  fatty  tissue  pro- 
duced by  cold,  febrile  disease,  slight  traumatism,  or  the  spread  of  inflamma- 
tion from  another  part. 

The  symptoms  of  this  condition  are  rigidity  of  the  spine,  the  inclination 
being  toward  the  affected  side,  flexion  of  the  thigh,  pain  in  the  loin  and  iliac 
region,  and  often  pain  in  the  knee.  The  symptoms  resemble  those  of  hip- 
joint  disease  in  the  second  stage.  Suppuration  may  or  may  not  take 
place. 

The  treatment  is  wet  cups  to  the  loin,  ice-bags  to  the  loin,  rest,  purga- 
tion by  salines,  morphin  for  pain,  and,  after  the  acute  stage,  potassium  iodid 
internally  and  ichthyol  locally. 

Perinephric  Abscesses.— An  abscess  in  the  perinephric  fat  is  known 
as  a  perinephric  or  perirenal  abscess.  Primary  abscess  is  caused  by  chills, 
acute  febrile  disturbances,  or  by  pus  flowing  from  some  other  part,  as  the 
spine.  Slight  traumatisms,  by  producing  hemorrhage,  make  the  perinephric 
region  a  point  of  least  resistance  and  lead  to  abscess.  The  causative  injury 
may  be  produced  by  digging,  stamping,  coughing,  falling,  carrying  a  burden, 
lifting  a  weight,  riding  on  a  horse  or  on  a  jolting  wagon.  Consecutive  abscess 
is  secondary  to  kidney  inflammation,  suppuration,  calculus,  tuberculosis,  or 
cyst.  In  the  consecutive  form  the  symptoms  may  be  masked  by  the  malady 
to  which  perinephric  abscess  is  secondary.  As  a  rule,  in  perinephric  abscess 
there  are  found  the  constitutional  symptoms  of  suppuration.  The  local 
symptoms  are  a  deep  aching  and  paroxysmal  pain  in  the  loin,  intensified  by 
lumbar  pressure.  There  may  be  pain  in  the  iliac  region  and  pain  in  the 
knee.  Edema  of  the  corresponding  foot  and  lameness  are  not  unusual.  The 
thigh  is  often  drawn  up.  The  spine  is  rigid  and  inclined  toward  the  diseased 
side.  Edema  of  the  skin  is  usual,  but  fluctuation  is  not.  The  exploratory 
incision  will  settle  a  doubtful  diagnosis. 

The  treatment  is  to  lay  open  the  abscess,  wash  it  out,  and  drain. 


1286  •        Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Stricture  of  the  Ureter. — This  is  usually  at  or  near  the  termina- 
tion of  the  ureter.  It  is  due  to  gonococcic  inflammation,  pyogenic  inflamma- 
tion, or  tuberculosis.  The  symptoms,  as  Howard  Kelly  says,  are  at  first 
those  of  a  vesical  or  renal  inflammation.  The  diagnosis  is  made  by  the 
ureteral  catheter.  We  may  be  unable  to  introduce  it,  we  may  introduce 
it  with  difiiculty  and  find  that  the  pelvis  of  the  kidney  is  distended  and  that 
the  urine  obtained  is  slightly  acid  or  even  alkaline,  much  lower  in  urea  than  the 
urine  from  the  other  kidney,  and  perhaps  contains  pus.  Stricture  of  the 
ureter  causes  hydronephrosis  or  pyonephrosis. 

Treatment. — Dilatation  with  bougies,  resection  of  the  diseased  portion 
and  anastomosis,  resection  of  the  diseased  portion  and  implantation  of  the 
sound  end  into  the  bladder,  or  division  of  the  stricture  and  suture.  In  tuber- 
culosis the  diseased  kidney  and  ureter  may  be  removed. 

Hydronephrosis  is  a  condition  of  the  kidney  resulting  from  an  imped- 
iment to  the  outflow  of  urine  by  obstruction  in  the  ureter,  the  bladder,  or 
the  urethra,  the  calyces  of  the  kidney  becoming  overdistended  with  urine 
and  the  glandular  tissue  being  absorbed  by  pressure.  It  has  been  asserted 
by  Albarran  that  secretion  of  urine  ceases  in  a  kidney  whose  ureter  is  blocked, 
distention  being  due  purely  to  congestion.  Hydronephrosis  may  be  con- 
genital, due  usually  to  twisting  of  the  ureter  or  to  valve-formation  obstructing 
the  ureter  at  its  point  of  junction  with  the  pelvis  of  the  kidney,  the  valve 
being  produced  because  the  ureter  passes  into  the  kidney  pelvis  at  an  un- 
natural angle.  Occasionally  imperforate  meatus  produces  hydronephrosis 
of  both  kidneys.  The  causes  of  the  acquired  form  are  the  pressure  of  pelvic 
growths  or  pregnancy,  inflammation  or  tumor  of  the  bladder,  stone  in  the 
bladder,  kidney,  or  ureter,  twisting  or  kinking  of  the  ureter  of  a  movable 
kidney,  enlargement  of  the  prostate  gland,  and  stricture  of  the  urethra. 
Acquired  hydronephrosis  may  involve  both  kidneys,  all  of  one  kidney,  or 
only  a  part  of  a  single  gland. 

Sjmiptoms. — Hydronephrosis  is  most  frequent  in  females.  When  a  lum- 
bar tumor  is  absent,  there  may  be  no  symptoms,  or  there  may  be  pain  in  the 
back  and  abdomen,  frequent  micturition,  a  persistent  or  intermittent  diminu- 
tion in  urine,  or  even  occasional  anuria.  A  tumor  may  be  found  in  the  loin, 
which  growth  is  dull  on  percussion  and  may  come  and  go,  a  large  urinary  flow 
occasionally  occurring  when  it  disappears.  Hydronephrosis  may  last  a  long 
while  if  only  one  kidney  be  involved,  but  death  is  not  far  distant  if  both 
glands  suffer.  Death  occurs  from  uremia,  from  pressure  on  adjacent  organs, 
or  from  rupture  into  the  peritoneal  cavity.  The  diagnosis  is  aided  by  the 
use  of  the  cystoscope  and  by  catheterizing  the  ureters. 

Treatment  by  aspiration  may  cure,  but  the  operation  may  have  to  be 
done  repeatedly.  Tapping  on  the  left  side  is  performed  just  below  the  last 
intercostal  space;  on  the  right  side  the  tap  is  made  midway  between  the 
last  rib  and  the  crest  of  the  ilium.  Some  few  cases  have  been  cured  by  cathe- 
terizing the  ureter  (Pawlik).  The  proper  operation  in  most  cases  is  neph- 
rotomy, stitching  the  edges  of  the  cut  kidney  to  the  surface.  After  the  kid- 
ney has  been  opened,  explore  the  ureter  by  means  of  a  uterine  sound  or  an 
elastic  bougie.  A  healthy  ureter  will  permit  the  passage  of  an  instrument 
of  the  size  of  from  No.  9  to  No.  12  of  the  French  scale  (Fenger).  If  the 
opening  of  the  ureter  into  the  pelvis  cannot  be    found,  open  the  pelvis  or 


Chronic  Tuberculosis  of  the  Kidney  1287 

open  the  ureter.  A  valve  should  be  slit  longitudinally  and  sutured  vertically 
(Fenger).  If  a  permanent  suppurating  fistula  ensues  or  if  the  organ  is  found 
extensively  damaged,  nephrectomy  is  to  be  performed,  provided  the  other 
kidney  is  in  reasonably  good  condition. 

Pyonephrosis  or  surgical  kidney  is  a  condition  in  which  the  pelvis 
and  the  calyces  of  the  kidney  are  distended  with  pus  or  with  pus  and  urine. 
The  whole  kidney  may  be  destroyed.  This  condition  has  the  same  causes 
as  has  hydronephrosis,  for  it  is  in  reality  usually  an  infected  hydronephrosis. 
In  some  cases  the  inaugviral  malady  is  pyelitis,  which  causes  blocking  of 
a  ureter.  Watson,  of  Boston,  has  reported  two  cases  associated  with  oblitera- 
tion of  the  ureter  by  a  mass  of  fibrous  tissue  (stricture  of  the  ureter). 

Symptoms. — At  first  the  symptoms  are  those  due  to  the  obstructing  cause, 
plus  pyelitis.  Pus  may  appear  in  the  urine  in  incomplete  obstruction,  or 
it  may  intermittently  come  and  go.  Constitutional  symptoms  of  suppuration 
are  soon  manifest.  A  tumor  may  appear  in  the  loin,  like  the  tumor  of  hydro- 
nephrosis. If  only  one  kidney  is  involved,  and  if  the  disease  is  due  to  block- 
ing of  a  ureter,  recovery  is  to  be  expected.  The  diagnosis  is  rendered  more 
certain  by  the  use  of  the  cystoscope  and  by  catheterizing  the  ureters. 

The  treatment  in  the  early  stages  comprises  removal,  if  possible,  of  the 
cause  of  obstruction,  and  the  employment  of  measures  directed  to  the  cure 
of  the  pyelitis.  If  obstruction  is  not  complete,  palliative  measures  may  be 
employed  for  the  tumor.  If  fever  is  continued ;  if  there  is  great  visceral  derange- 
ment; if  pain  is  severe  and  constant;  and  if  the  tumor  continually  grows, 
perform  a  nephrotomy,  stitching  the  organ  to  the  surface  if  possible,  or  remov- 
ing it  if  it  is  hopelessly  disorganized  and  the  other  kidney  is  in  a  good  or  a 
fairly  good  condition. 

Chronic  Tuberculosis  of  the  Kidney.— This  condition  may  begin 
in  one  kidney,  no  other  area  of  infection  existing  in  the  body.  In  such  cases 
the  bacteria  were  deposited  from  the  blood.  Even  when  the  bacteria  are 
deposited  from  the  blood  there  is,  in  most  cases,  a  causal  focus  of  tubercu- 
losis somewhere  in  the  body.  The  other  kidney  is  usually  involved  subse- 
quently, the  process  in  the  first  kidney  affecting  the  bladder  and  secondarily 
the  other  kidney.  The  important  point  is  that  tuberculosis  of  the  kidney 
arising  in  this  manner  is  at  first  a  unilateral  disease. 

Tuberculosis  of  the  kidney  is  seldom  a  primary  disease  and  usually  arises 
secondarily  to  tuberculosis  of  the  prostate,  bladder,  or  epididymis.  In 
such  a  condition  the  kidney  disease  is  bilateral.  Renal  tuberculosis  is  par- 
ticularly common  in  the  third  and  fourth  decades  of  life,  and  is  more  fre- 
quent in  males  than  in  females. 

Symptoms. — Renal  tuberculosis  of  arterial  origin  may  exhibit  no  symp- 
toms until  the  disease  is  far  advanced.  Renal  tuberculosis  secondary  to 
disease  of  the  bladder  or  prostate  always  presents  symptoms.*  A  very  com- 
mon symptom  of  renal  tuberculosis  is  the  sudden  onset  of  polyuria  and  fre- 
quent micturition.  The  patient  is  annoyed  day  and  night,  and  in  some  cases 
micturition  is  distinctly  painful.  Paroxysms  of  renal  pain  are  not  unusual. 
The  urine  is  acid,  and  may  contain  pus  or  blood.  Tubercle  bacilli  may  be 
found  in  the  urine  or  in  the  sediment,  but  they  may  be  absent.  Repeated 
examination  should  be  made  before  it  can  be  stated  certainly  that  bacilli  are 
*  F.  Tilden  Brown,  New  York  Med.  Jour.,  April  lo,  1S97. 


12^ 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


absent.  The  presence  of  bacilli  proves  the  diagnosis,  but  their  absence  does 
not  negative  it  (Willy  Meyer).  If  ]:)acilli  are  not  found,  inject  some  of  the 
urinary  sediment  into  a  guinea-pig,  and  note  if  tuberculosis  arises  in  the 
animal.  Czerny  has  shown  that  in  cases  of  tuberculous  kidney  in  which 
bacilU  are  not  found  in  the  urine,  the  administration  of  tubercuhn  will  cause 
great  numbers  to  appear.  This  agent  will  also  cause  a  marked  febrile  reac- 
tion if  tuberculosis  exists.     The  urine  may  or  may  not  be  albuminous. 

In  many  cases  the  kidney  is  obviously  enlarged,  and  the  renal  area  is  fre- 
quently tender  and  occasionally  painful.  The  patient  loses  flesh,  and  there  is 
nocturnal  fever  followed  by  sweating.  The  use  of  the  cystoscope  furnishes 
important  information.  It  shows  from  which  ureter  turbid  urine  is  coming. 
Catheterization  of  the  ureters  should  be  practised  by  some  one  who  is  accus- 
tomed to  employ  it.  Always  examine  carefully  to  determine  if  one  or  both 
kidneys  are  involved,  if  the  bladder  is  diseased,  and  if  the  prostate  gland 
or  seminal  vesicles  are  tuberculous. 

Treatment. — Lumbar  nephrectomy  is  not  justiiiable  in  the  very  begin- 
ning of  a  case,  because  such  a  patient  may  be  cured  by  a  combination  of 
medical  and  hygienic  treatment,  and  the  weakening  effect  of  the  operation  of 
nephrectomy  may  cause  the  other  kidney  to  develop  tuberculosis  rapidly. 
Tell  such  a  patient  to  lead  an  outdoor  life.  Brown  recommends  camp-life 
in  the  Adirondacks  during  the  summer,  and  sends  such  patients  south  during 
the  winter.  If  a  patient  cannot  go  to  another  climate,  urge  upon  him  the 
necessity  of  being  much  out-of-doors.  Insist  upon  the  taking  of  plenty  of 
nutritious  food.     Courses  of  creasote  or  guaiacol  carbonate  are  given  by  some. 

If  the  kidney  is  markedly  enlarged;  if  there  is  profuse  hematuria;  if  the 
fever  is  high  and  persistent;  if  only  one  kidney  is  involved;  and  if  the  bladder 
and  prostate  are  free  from  disease,  perform  nephrectomy.  In  cases  with 
involvement  of  the  other  kidney  or  of  the  genito-urinary  tract  lower  down, 
nephrectomy  is  not  justifiable,  although  nephrotomy  for  drainage  may  greatly 
benefit  the  patient  for  a  time. 

Operations  on  the  Kidney  and  Ureter.— Operation  for  Chronic 
Nephritis. — In  1897  Mr.  Reginald  Harrison  advocated  puncture  of  the 
kidney  to  relieve  tension  in  cases  of  albuminuria,  and  in  1901  advocated 
incision  of  the  true  capsule  of  the  kidney  and  puncture  of  the  gland  to  accom- 
plish the  same  purpose  ("Brit.  Med.  Jour.,"  Oct.  19,  1901).  Alexander 
Hugh  Ferguson,  in  March,  1899,  reported  two  cases  of  interstitial  nephritis 
cured  symptomatically  by  decapsulation  and  multiple  punctures  ("Jour. 
Amer.  Med.  Assoc,"  March  11,  1899).  Dr.  Geo.  M.  Edebohls  observed, 
between  1892  and  1897,  that  in  certain  cases  of  movable  kidney  with  albu- 
minuria the  albumin  and  casts  disappeared  after  nephropexy.  Rose,  Wolff, 
and  Ferguson  have  observed  the  same  fact.  Harrison  believes  that  reni- 
puncture  removes  the  symptoms  by  abating  tension,  but  Edebohls  concludes 
that  nephropexy  relieves  the  condition  and  possibly  cures  it  by  establishing 
vascular  adhesions  which  carry  an  additional  supply  of  blood.  He  proposed 
to  operate  for  Bright's  disease  in  1899  ("Med.  News,"  April  22,  1899). 
Edebohls  deliberately  operated  for  chronic  nephritis  and  claims  8  complete 
recoveries  from  chronic  Bright's  disease  ("Med.  Record,"  Dec.  21,  1901). 
There  can  be  no  doubt  whatever  that  operation  is  sometimes  followed  by 
polyuria,  disappearance  of  edema  and  other  symptoms,  and  apparent  cure. 


Operations  on  the  Kidney  and  Ureter  1289 

But  in  some  cases  the  disappearance  of  symptoms  has  been  too  rapid  to 
permit  of  the  assumption  that  new  vessels  have  caused  it.  In  such  cases 
it  seems  much  more  probable  that  rehef  of  tension  is  the  real  curative  factor. 
The  capsule  of  the  kidney  is  only  slightly  elastic,  and  tension  may  be  brought 
about  by  an  increase  in  the  blood-supply,  by  edema,  and  by  cell  proliferation. 
Increased  tension  causes  pain  and  perhaps  hematuria,  and  tension  is  reheved 
by  Harrison's  plan  of  incising  the  capsule.  Simple  incision  is  easier,  safer,  and 
just  as  useful  as  strijiping  the  capsule  off  of  the  kidney.  Edebohls  advocates 
decapsulation  and  says  that  the  polyuria  begins  about  the  tenth  day  after 
operation;  that  improvement  begins  in  one  month  and  is  gradual;  that  the 
cure  is  due  to  vascular  adhesions;  that  the  adhesions  contain  more  arteries 
than  veins;  that  the  free  blood-supply  absorbs  exudate  and  products  of 
inflammation,  frees  the  tubes  and  glomeruli  from  pressure  and  constriction, 
causes  the  reestablishment  of  a  normal  circulation  and  the  regeneration  of 
epithehum  ("Med.  Record,"  Dec.  21,  1901). 

The  exact  status  of  the  operation  is  not  as  yet  determined.  It  does, 
however,  seem  to  be  proved  that  operation  is  in  some  cases  followed  by 
apparent  cure  or  great  amelioration  of  the  condition,  ^^llether  permanent 
cure  is  ever  thus  obtained  is  doubtful,  and  the  part  played  by  rest  in  bed 
and  drugs  in  effecting  an  improvement  must  not  be  lost  sight  of.  Cases 
with  pain  and  bloody  urine  are  often  much  improved  by  incising  the  capsule. 
Post-operative  suppression  and  the  anuria  of  acute  infectious  diseases  may 
be  favorably  influenced  by  the  operation.  An  important  fact  which  Rovsing 
maintains  and  Edebohls  proves  is  that  chronic  nephritis  may  be  for  some  time 
a  unilateral  disease.  (Read  the  views  of  Schmidt  in  "Med.  Record,"  Sept. 
13,  1902;  of  Rovsing,  of  Copenhagen,  in  "  Mittheilungen  aus  den  Grenzge- 
bieten  der  Medicin  und  Chirurgie, "  vol.  x,  1902,  and  editorial  in  "Jour. 
Amer.  Med.  Assoc,"  Jan.  11,  1902.) 

The  operation  as  practised  by  Edebohls  may  be  done  on  both  kidneys 
at  one  sitting  or  in  two  seances.  In  some  cases  only  one  kidney  is  sub- 
jected to  operation.  Edebohls  takes  a  verv'  radical  view  and  would  ope- 
rate on  any  case  free  from  incurable  complications — if  an  anesthetic  can 
be  given  and  if  the  life-expectancy  without  operation  is  not  less  than  one 
month  ("Med.  Record,"  Dec.  21,  1901).  Ether  is  given  or  nitrous  oxid 
and  oxygen.  Lay  the  patient  prone  with  an  air-cushion  under  the  belly 
and  expose  the  kidney  by  a  vertical  incision  at  the  edge  of  the  erector  spinae 
mass,  which  cut  does  not  open  the  sheath  of  the  muscle.  Remove  the  fatty 
capsule  from  the  true  capsule,  continuing  the  dissection  around  each  pole 
until  the  pelvis  of  the  kidney  is  reached..  The  kidney  is  extruded  from  the 
wound,  the  true  capsule  is  incised  along  the  convex  border  and  around  each 
pole,  is  separated  from  the  kidney,  and  is  cut  away  close  to  its  junction  with 
the  kidney  pelvis.  The  kidney  is  then  returned  to  its  bed  of  fat,  and  the 
wound  is  closed.  (See  "Med.  Record,"  Dec.  21,  1901.)  Edebohls  does 
not  drain  unless  there  is  considerable  edema.  Edebohls  reports  18  opera- 
tions without  a  death.  In  9  of  the  cases  the  operation  was  done  more  than 
one  year  ago,  and  8  of  them  are  said  to  be  cured.  Personally  I  do  not  believe 
that  the  operation  can  really  cure  Bright's  disease.  It  cannot  restore  altered 
connective  tissue  and  epitheUal  cells.  The  new  blood-supply  must  be  through 
scar  tissue,  and  we  have  yet  to  learn  that  such  a  blood-supply  can  be  good. 


1290         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

The  operation  should  be  restricted  to  acute  nephritis,  to  acute  exacerbations 
in  chronic  cases,  to  conditions  with  severe  renal  pain,  hematuria,  very  high 
albumin  percentage,  or  persistent  and  notable  diminution  in  the  amount  of 
urine  voided  (Ertzbischoff,  in  "  Archiv.  generales  de  Chirurgie,"  April,  1908). 

Nephrotomy. — Nephrotomy  means  incision  of  a  kidney,  but  the  term  is 
sometimes,  though  wrongly,  applied  to  the  exploratory  exposure  of  the  kidney 
without  incision.  When  the  kidney  wound  is  left  open,  as  it  almost  invariably 
is,  the  operation  should  be  called  nephrostomy.  The  operation  is  employed 
to  evacuate  infectious  material,  relieve  tension,  permit  of  the  removal  of  a  cal- 
culus or  exploration  of  the  ureter,  and  for  diagnosis  of  renal  disease.  The  in- 
struments required  are  scalpels,  a  blunt-pointed  bistoury,  dissecting-forceps, 
toothed  forceps,  a  grooved  director,  hemostatic  forceps,  spatulae,  metal  re- 
tractors, a  fountain  syringe,  an  AUis  dissector,  Hagedorn  needles,  and  an  Abbe 
needle-holder.  If  looking  for  a  stone,  have  a  large  harelip-pin  to  sound  with, 
forceps  and  a  scoop  to  remove  the  stone,  and  a  periosteum-elevator  to  scrape 
away  adherent  calcuH.  The  padent  lies  upon  the  sound  side,  a  sand-pillow 
or  a  cylindric  air-bag  being  placed  under  the  flank.  The  incision  is  made 
^  inch  below  the  last  rib  and  close  to  the  outer  border  of  the  erector  spinae 
mass,  and  runs  obliquely  downward  and  forward  toward  the  iliac  crest  for 
3  inches,  the  incision  being  enlarged  later  if  required.  Divide  the  skin,  the 
superficial  fascia,  the  fat,  the  external  oblique,  the  posterior  border  of  the 
internal  oblique,  and  the  outer  edge  of  the  latissimus  dorsi.  This  incision 
exposes  the  lumbar  fascia.  Push  aside  the  last  dorsal  nerve  and  incise  the 
lumbar  fascia,  when  the  perirenal  fat  will  bulge  into  the  wound.  Two  distinct 
layers  of  fat  exist.  Tear  this  fat  through  with  dissecting-forceps  or  with  an 
AUis  dissector  to  expose  the  kidney,  which  can  now  be  opened  while  it  is  forced 
into  the  wound  by  the  hand  of  an  assistant  making  abdominal  pressure. 

Kocher's  incision  for  nephrotomy  is  begun  in  the  angle  between  the 
sacrolumbalis  muscle  and  the  twelfth  rib,  and  is  carried  downward,  forward, 
and  outward  to  the  axillary  Hne  (Fig.  229).  This  incision  divides  the  skin, 
subcutaneous  tissues,  lumbar  fascia,  the  latissimus  dorsi,  and  the  serratus 
posticus  inferior  muscles. 

Edebohls'  method  enables  the  surgeon  to  explore  the  kidney  most  thor- 
oughly because  this  organ  is  brought  outside  of  the  body.  The  patient  Hes 
prone,  with  a  large  cylindrical  inflated  rubber  pad  beneath  his  abdomen.  A 
vertical  incision  is  made  close  to  the  border  of  the  erector  spinae  muscle, 
from  just  below  the  last  rib  to  just  above  the  iliac  crest.  The  sheath  of  the 
muscle  is  not  opened.  The  fibers  of  the  latissimus  dorsi  are  separated  by 
blunt  dissection.  The  iliohypogastric  nerve  is  found  and  retracted.  The 
transversalis  fascia  is  incised  and  the  fatty  capsule  reached.  The  two  layers 
of  the  fatty  capsule  are  torn  through  and  the  kidney  exposed.  The  fatty 
..capsule  is  well  separated  from  the  kidney  front  and  back.  The  patient  is 
pulled  by  the  legs  toward  the  foot  of  the  table,  the  pad  remaining  stadonary. 
This  change  of  position  brings  the  pad  beneath  the  chest,  abdominal  respi- 
ration takes  place,  the  kidney  is  forced  into  the  wound,  and  can  be  easily  with- 
drawn and  thoroughly  examined.  A  common  method  of  opening  the  kidney 
is  to  make  a  longitudinal  incision  through  its  convex  ends  sufficiently  large 
to  admit  the  finger  into  the  renal  pelvis.  This  incision  may  be  enlarged  if 
necessary  until  the  kidney  is  spHt  in  half.     When  the  operation  is  completed 


Nephrectomy  1 29 1 

•close  the  kidney  wound  completely  with  a  round  needle  and  catgut,  unless 
drainage  is  necessary  or  j)acking  is  required.  Another  incision  is  placed  longi- 
tudinally a  little  posterior  to  the  convex  border.  This  goes  through  the 
bloodless  zone  of  Hytl,  and  causes  less  hemorrhage  than  the  incision  along 
the  convexity.  IMarwedel's  incision  is  a  transverse  cut  at  the  middle  of  the 
convex  border  of  the  kidney  into  the  renal  pelvis.  It  is  doubtful  if  this  incision 
is  accompanied  by  less  bleeding  than  longitudinal  incision  of  the  convexity. 
After  the  completion  of  our  work  on  the  kidney  the  lumbar  wound  is  closed 
completely  or  is  partially  closed  to  permit  of  drainage. 

Operation  for  Stone  in  the  Kidney.— (By  Pyelotomy  or  Nephrotomy) . — 
It  used  to  be  held  that  incision  of  the  pelvis  of  the  kidney  is  far  more  apt  to  be 
followed  by  fistula  than  incision  of  the  substance  of  the  kidney.  The  Alayos, 
Bevan,  and  others  have  proved  that  this  conviction  is  untrue.  In  many  cases 
pyelotomy  is  preferred  to  nephrolithotomy.  It  is  used  for  single  stones  of 
moderate  size  in  the  pelvis  and  unaccompanied  by  suppuration.  When  we 
have  a  large  branched  stone,  coral-shaped  stones,  multiple  stones,  and  stones 
accompanied  by  distinct  and  gross  evidences  of  infection,  then  nephrotomy 
should  be  preferred  to  pyelotomy  (Bevan  and  Smith,  in  paper  read  before 
the  American  Surg.  Assoc,  in  igo8).  In  both  operations  the  patient  is 
placed  on  the  sound  side  with  a  sand-pillow  or  cyUndric  air-bag  under  the 
flank.  In  both  cases  the  incision  recommended  for  nephrotomy  is  used.  In 
both  cases  the  kidney  is  lifted  into  the  wound  or  brought  out  of  the  wound  so 
that  it  may  be  satisfactorily  palpated.  In  both  cases  bleeding  is  controlled  by 
having  an  assistant  grasp  the  pedicle  with  his  fingers  or  with  a  pair  of  forceps, 
each  blade  of  which  is  covered  with  a  bit  of  rubber  tube,  while  the  surgeon  opens 
the  pelvis  or  the  kidney  tissue,  removes  the  stone,  and  explores  vdth  the  finger. 

Pyelotomy. — Remove  the  fat  from  the  posterior  surface  of  the  pehis  of  the 
kidney.  We  may  then  be  sure  that  no  aberrant  vessel  is  in  our  way.  The 
normal  vessels  are  all  in  front  of  the  pelvis.  The  posterior  wall  of  the  pelvis  is 
now  opened,  the  stone  is  extracted,  the  pelvis  explored,  the  cut  in  the  pelwis 
sutured  \\\i\\  fine  catgut  sutures,  the  kidney  is  restored  to  place,  a  cigarette 
drain  is  introduced,  and  the  wound  in  the  loin  is  closed. 

Nephrolithotomy. — The  methods  of  incision,  exposure,  and  opening  the 
kidney  are  described  on  page  1290,  under  Nephrotomy.  When  the  kidney 
has  been  opened,  loosen  the  calculus  with  the  nail,  and  remove  it  vdth  the 
finger,  with  a  scoop,  or  with  forceps.  After  removing  the  stone,  suture  the 
incision  vdth  catgut,  and  release  the  pressure  on  the  pedicle.  Hemorrhage 
will  rarely  occur.  If  in  spite  of  this  plan  bleeding  occurs,  take  out  the  stitches 
and  apply  pressure  and  hot  water,  or  in  some  cases  plug  with  iodoform  gauze 
for  twenty-four  hours.  When  hemorrhage  ceases,  put  a  large  drainage-tube 
down  to  the  kidney.  Ck)se  the  w^ound  in  the  muscles  and  integument  and 
dress  antiseptically.  The  dressings  must  be  changed  frequently  and  the  tube 
should  be  shortened  daily.  In  some  cases  nephrectomy  is  necessary  (page 
1 291).  Formerly  in  these  cases  I  always  drained  for  a  time  and  removed  the 
kidney  secondarily,  believing  that  the  patient  would  gain  strength  in  the  inter- 
val and  stand  the  severe  operation  of  nephrectomy  better.  I  am  satisfied  that 
in  most  cases  this  \aew  is  wrong,  because  removal  of  a  kidney  bound  down,  by 
adhesions  is  one  of  the  most  perilous  and  difficult  operations  of  surgery. 

Nephrectomy. — Nephrectomy  is  the  removal  of  a  kidney.     There  are  two 


1292  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

methods  of  nephrectomy — the  lumbar  and  the  ahdominal.  The  first  nephrec- 
tomy was  performed,  according  to  Watson,  in  1861,  by  an  American,  Walcott. 
The  operation  was  transperitoneal  and  was  for  the  removal  of  a  cancerous 
kidney.  Simon,  in  1869,  performed  the  first  lumbar  nephrectomy  and  the 
first  successful  nephrectomy.  Before  performing  nephrectomy  ascertain 
the  competence  of  the  kidneys.  If  at  least  i  per  cent,  of  urea  is  not  Ijcing 
excreted,  it  is  very  unsafe  to  operate.  Be  sure  the  patient  possesses  two 
kidneys.  Examination  of  the  bladder  by  cystoscope  will  show  the  ureteral 
orifices,  a  strong  indication  that  both  kidneys  are  present.  Nevertheless, 
when  we  reflect  that  a  horseshoe  kidney  has  two  ureters,  theproof  is  not  absolute. 
Catheterization  of  the  ureters  is  adWsable  if  it  can  be  performed,  but  it  will 
probably  require  a  specialist  to  perform  it.  Proof  absolute  of  the  presence 
of  two  kidneys  consists  in  feeling  both  of  them.  If  in  doubt  as  to  the  question, 
and  if  uncertain  as  to  the  competence  of  the  organ  which  is  to  be  left,  feel 
each  kidney  during  the  operation  and  before  remonng  either,  or  perform  a 
preliminary  explorator}'  laparotomy. 

Lumbar  Nephrectomy. — The  instruments  required  for  this  operation  are 
scalpels,  a  blunt-pointed  bistour}',  forceps  as  used  in  the  preceding  operation, 
a  clamp,  retractors,  spatulae,  blunt  hooks,  an  aneurysm-needle,  a  pedicle 
needle,  a  grooved  director,  stout  silk,  an  Allis  dissector,  sharp  spoons,  and 
a  Paquelin  cauten.-.  The  patient  is  placed  on  the  sound  side  and  a  pillow 
is  placed  under  the  loin.  Several  incisions  have  been  proposed.  In  many 
cases  the  oblique  incision  is  first  made  to  permit  of  exploration.  This  in- 
cision is  begun  half  an  inch  below  the  last  rib  and  by  the  edge  of  the  erector 
spinae  muscle,  and  is  carried  downward  and  forward  toward  the  iliac  crest. 
In  some  cases  a  kidney  can  be  removed  through  this  cut.  In  other  cases 
the  cut  must  be  enlarged.  It  can  be  enlarged  by  extending  the  cut  down- 
ward. !Morris  enlarges  it  by  adding  to  it  a  vertical  incision,  which  be.gins 
one  inch  below  the  origin  of  the  oblique  cut.  Konig's  incision  for  nephrec- 
tomy consists  of  a  vertical  cut  by  the  edge  of  the  erector  spinae,  carried  almost 
to  the  iliac  crest,  from  which  point  it  is  cur^-ed  forward  toward  the  umbihcus, 
and  is  carried  to  or  even  through  the  rectus  muscle.  After  thorough  ex- 
posure lift  the  kidney  and  separate  it  from  the  peritoneum;  if  possible, 
with  the  finger;  clamp  the  pedicle;  pass  an  armed  aneurysm-needle  between 
the  vessels  of  the  pedicle;  ligate  in  two  places;  cut  between  the  threads; 
and  arrest  hemorrhage  permanently  by  ligation  of  each  vessel.  If  the  ureter 
be  healthy,  Hgate  it  with  silk  and  drop  it  back;  if  it  be  foul  and  purulent, 
scrape  it  with  a  sharp  spoon,  wash  it  with  corrosive  subhmate,  and  touch  it  with 
pure  carbolic  acid,  and  then  either  hgate  it  and  drop  it  back  or  sew  it  into  the 
wound.  If  hemorrhage  persists  from  the  wound,  plug  with  gauze.  Insert  a 
drainage-tube  and  close  the  wound.  If  the  peritoneum  be  accidentally  opened, 
close  it  with  Lembert  sutures.  Kocher's  method  is  excellent,  and  enables  the 
surgeon  to  feel  the  opposite  kidney  before  removing  the  one  which  is  known 
to  be  diseased.  The  incision  is  begun  as  described  on  page  1290,  and  is 
carried  forward  so  as  to  expose  the  reflection  of  the  peritoneum  onto  the 
colon  in  the  posterior  axillary  Hne  (Fig.  229).*  At  this  point  the  peritoneum 
is  opened,  and  the  surgeon's  hand  is  inserted  into  the  abdominal  cavity  and 
feels  the  other  kidney.  If  another  kidney  exists  and  it  is  foimd  to  be  healthy,. 
*  Kocher's     Text-book  of  Operative  Surgery." 


The  Author's  Modification  of  the  Elder  Senn's  Operation    1293 

the  diseased  organ  ma}-  be  removed.  Brewer's  personal  statistics  show  53 
■cases  of  nephrectomy  with  2  deaths,  a  mortality  of  3.8  per  cent.  ("  Med. 
Record,"  March,  20,  1909). 

Abdominal  nephrectomy  is  more  dangerous  than  the  lumbar  operation. 
The  same  instruments  are  required  as  are  used  in  the  preceding  operation. 
The  position  is  supine.  The  incision  is  that  of  Langenbeck — four  inches 
long  in  the  Hnea  semilunaris,  its  center  corresponding  to  the  umbilicus. 
Open  the  abdomen,  introduce  a  hand,  feel  the  kidneys,  and  if  both  show 
serious  disease,  do  not  perform  nephrectomy.  If  we  decide  to  remove  one 
kidney,  keep  the  small  intestine  away  by  pads,  push  the  colon  toward 
the  umbiHcus,  incise  the  outer  layer  of  the  mesocolon,  and  bare  the  kid- 
ney. Strip  off  the  peritoneum  from  the  kidney  and  its  vessels,  and  ligate 
the  vessels  by  passing  strong  silk  through  the  center  of  the  pedicle  with  an 
aneurysm-needle.  Ligate  the  ureter  if  healthy,  and  divide  it.  If  the  ureter 
is  septic,  fasten  it  to  an  opening  made  in  the  loin  by  cutting  onto  forceps 
pushed  to  the  outer  edge  of  the  quadratus  lumborum.  Stop  bleeding,  irri- 
gate the  belly-cavity,  and  dress  as  usual,  emplopng  drainage  only  when  septic 
matter  has  passed  into  the  peritoneal  cavity  or  when  oozing  of  blood  is  per- 
sistent. 

Nephrectomy  in  Children. — The  operation  is  proper  in  certain  non- 
malignant  troubles.  Jepson  did  a  successful  nephrectomy  for  a  congenital 
cystic  kidney  on  a  patient  four  months  and  fourteen  days  of  age.  Rovsing 
did  it  successfully  for  congenital  hydronephrosis,  the  patient  being  nine  months 
old.  Roswell  Park  did  a  successful  nephrectomy  for  congenital  cystic  kid- 
ney on  a  child  twenty-three  months  of  age.  The  value  of  nephrectomy 
for  sarcoma  is  more  than  doubtful.  The  operation  never  really  cures,  and 
if  an  operative  recovery  is  obtained,  the  disease  appears  after  a  time  in  the 
other  kidney.  Jessup  performed  nephrectomy  in  eleven  children  and  every 
case  died  within  two  and  one-half  years  of  the  operation.  The 
operation  often  prolongs  life  and  relieves  discomfort,  but  does  not  cure. 

Partial  Nephrectomy. — This  operation  may  be  performed  in  some  cases 
for  wounds,  cysts,  and  innocent  tumors.  After  removing  the  damaged  or 
diseased  part,  bleeding  points  are  ligated  with  catgut.  The  wound-surfaces 
are  approximated  as  well  as  possible  by  catgut  sutures.  Drainage  is  intro- 
duced. The  value  of  partial  nephrectomy  in  some  cases  seems  certain,  and 
we  should  apply  it  when  possible  instead  of  the  complete  operation,*  except 
in  cases  of  malignant  disease. 

Renipmicture. — This  is  an  operation  devised  by  Reginald  Harrison  for 
the  rehef  of  albuminuria  due  to  elevated  tension.  The  kidney  is  exposed  in 
the  loin,  the  capsule  is  incised,  and  punctures  are  made  in  the  kidney.  Simple 
incision  of  the  capsule  will  usually  relieve  nephralgia.  (See  Operations  for 
Chronic  Nephritis.) 

Nephropexy  is  fixation  of  a  movable  kidney.  The  term  nephrorrhaphy, 
so  long  used  for  the  operation,  really  means  suturing  a  wound  in  the  kidney. 

The  Author's  Modification  of  the  Elder  Senn's  Operation, — Many 
surgeons  feel  that  it  is  not  desirable  to  pass  sutures  through  the  kidney- 
substance,  and  I  have  entirely  abandoned  the  use  of  them  in  operations 

*See  Oscar  Bloch  in  Brit.  Med.  Jour.,  Oct.  17,  1896;  also  reports  of  Czemy,  Barden- 
heuer,  Tuffier,  and  Kiimmell. 


1294  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

for  movable  kidney.  Urinary  fistula  has  followed  suturing.  Again,  the 
value  of  such  sutures  is  very  doubtful.  The  kidney  is  a  very  soft  organ,, 
and  if  it  is  suspended  by  sutures,  they  are  certain  to  cut  out.  In  most  suture 
operations  the  kidney  when  restored  to  place  is  not  placed  sufficiently  high  and 
has  its  ureter  and  vessels  looking  fonvard;  in  other  words,  there  is  a  one-fourth 
twist  in  the  ureter.  In  operations  like  Goelet's  and  Kelly's,  which  raise  the 
kidney  much  nearer  its  proper  level  and  which  do  not  twist  the  ureter  and  renal 
vessels,  the  upper  pole  is  not  anchored  and  tends  to  tilt  forward  (page  1207). 
Senn's  operation  fixes  the  kidney  without  using  sutures. 

The  patient  lies  upon  his  abdomen,  Edebohls's  bag  being  placed  directly  be- 
neath the  lower  abdomen.  A  vertical  or  shghtly  oblique  lumbar  incision  is- 
made,  the  perirenal  fat  is  exposed,  and  its  two  layers  are  torn  through  until  the 
kidney  is  reached.     The  fatty  capsule  is  thoroughly  stripped  from  the  entire 


Fig.  769. — Gatize  slings,  each  composed  of  two  pieces  sutured  together  with  fine  plain  catgut. 


organ.  The  kidney  is  brought  out  of  the  wound.  This  is  accomplished  by 
puUing  the  patient  toward  the  foot  of  the  bed,  so  that  the  pad  gets  under  the 
ribs,  when  traction  on  the  fibro-fatty  capsule  will  cause  the  kidney  to  emerge 
from  the  wound.  The  posterior  fatty  capsule  is  cut  away,  and  also  the  anterior 
fatty  capsule  up  to  the  hilum.  The  true  capsule  of  the  kidney  is  scarified  or, 
if  necessity  exists,  the  organ  is  decapsulated.  I  always  have  packing  prepared 
by  suturing  together  with  the  finest  plain  catgut  the  ends  of  two  pieces  of  iodo- 
form gauze.  Two  such  strands  are  prepared  (Fig.  769).  One  piece  of  iodoform 
gauze  is  placed  under  the  upper  end  of  the  kidney,  and  another  piece  under  the 
lower  end,  the  sling  in  each  instance  being  directly  under  the  kidney  with  the 
suture  line  external  and  not  in  front  as  the  kidney  protrudes  from  the  wound  in 
the  back  (Fig.  770).  When  the  kidney  is  replaced,  the  suture  line  will  he  in 
front  (Fig.  771) .  The  kidney  is  replaced  and  will  then  lie  in  a  sling,  composed  of 
two  pieces  of  gauze,  the  ends  of  which  protrude  from  the  wound,    i^.nother  piece 


Ureterolithotomy 


1295 


is  placed  below  the  lower  renal  pole  to  fill  up  the  space  which  always  exists  there 
and  to  stimulate  granulation.  This  space  below  the  kidney  is  a  frequent  cause 
of  subsequent  loosening  in  most  suture  operations,  because  the  kidney  hangs 
in  it  unsupported,  as  a  bucket  hangs  in  a  well.  Harris  recognizes  this,  and  in 
his  operation  closes  the  space  by  sutures.  Gauze  is  packed  in  over  and  about 
the  kidney,  and  over  this  the  two  long  slings  are  tied.  Several  sutures  are  in- 
serted to  close  the  lumbar  aponeurosis;  some  are  tied  and  some  are  left  untied. 
A  large  gauze  pad  is  placed  upon  the  abdomen  over  the  anterior  surface  of  the 
kidney,  and  the  lumbar  wound  is  dressed  with  gauze.  The  dressing  and  gauze 
pad  are  held  in  place  by  a  binder.  In  about  eight  or  ten  days  the  gauze  should  be 
soaked  with  salt  solution  during  half  an  hour  and  the  packing  removed.     At  this 


Fig.  770. — Right  kidney  projecting  from  wound.  Ob- 
server standing  on  right  side  of  patient :  i  and  2,  Slings 
in  place,  with  sutures  external ;  3,  skin  of  the  back  ;  4,  upper 
renal  pole  ;  5,  lower  renal  pole  ;  6,  convex  border  of  kidney ; 
7,  external  surface  of  kidney.  (Slings  should  be  broader 
than  is  shown  in  cut.) 


Fig.  771.— Right  kidney  re- 
stored to  place,  seen  from  in  front :  i 
and  2,  Slings  in  place,  sutures  ante- 
rior ;  4,  upper  renal  pole  ;  5,  lower 
renal  pole ;  7,  anterior  surface  of 
kidney.  (Slings  should  be  broader 
than  is  shown  in  cut.) 


time  the  catgut  is  destroyed  and  the  gauze  can  be  easily  pulled  out.  The  tied 
sutures  are  cut  and  removed,  the  sutures  left  unfastened  are  tied,  and  a  small 
piece  of  gauze  is  inserted  as  a  drain  between  the  granulating  surfaces.  If  a  con- 
tinuous piece  of  gauze  was  used,  ether  must  be  given  before  removal  is  attempted. 
Further,  in  the  old  operation,  a  large  wound  was  left  to  granulate  and  weeks  were 
often  required  to  obtain  healing.  In  this  operation  the  wound  is  usually  entirely 
healed  in  from  eighteen  to  twenty-one  days.  After  the  performance  of  nephro- 
pexy the  patient  remains  in  bed  for  three  weeks.  By  this  operation  the  kidney 
is  placed  in  a  proper  situation,  is  surrounded  with  granulations,  which  are  con- 
verted into  scar-tissue,  and  the  organ  becomes  encased  in  a  box  of  fibrous 
tissue.     I  believe  that  a  kidney  so  treated  will  probably  remain  fixed. 

Ureterolithotomy. — If  the  stone  is  impacted  in  the  upper  two-thirds  or 
three-fourths  of  the  tube  it  may  be  reached  by  an  incision  from  the  twelfth 
rib  do\\Tiward  and  forward  to  just  anterior  to  the  anterosuperior  spine  of 


1296         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  ilium  and  then  parallel  to  Poupart's  ligament  until  above  its  middle. 
The  peritoneum  is  stripped  up  as  in  extraperitoneal  ligation  of  the  iUac  vessels. 
The  ureter  adheres  to  the  peritoneum.  The  operation  is  strictly  extraperi- 
toneal. The  tube  is  opened  by  a  longitudinal  incision.  The  stone  is  removed. 
The  ureter  is  explored  by  means  of  a  sound  to  see  if  it  is  free  and  may  then  be 
sutured  with  catgut,  but  vdW  heal  perfectly  vrell  without  stitches.  The  tissues 
above  the  ureter  are  sutured  and  a  bit  of  rubber  tissue  is  carried  to  the  duct. 
Gauze  packing  must  not  be  carried  do\\Ti  into  the  ureter,  as  it  would  make  a 
urinar}'  fistula,  ^^^lenever  possible — and  Usually  it  is  possible — reach  the  m"eter 
by  the  extraperitoneal  route,  and  even  well  below  the  brim  of  the  pehis  the 
peritoneum  can  be  stripped  and  the  ureter  opened  from  behind.  If  the  stone 
cannot  be  reached  by  the  extraperitoneal  method,  open  the  peritoneal  canty  and 
incise  the  ureter.  After  remo\"ing  the  stone,  suture  the  wound  in  the  ureter 
VTith  inversion-sutures,  fasten  an  omental  graft  over  the  suture-hne  (Fenger), 
and  drain.  In  a  woman  a  stone  near  the  vesical  opening  can  be  reached  by 
a  vaginal  incision.  Stone  in  the  vesical  portion  of  the  ureter  may  be  removed 
after  the  performance  of  a  suprapubic  cystotomy  or  by  an  operating  cystoscope. 
My  colleague,  Dr.  John  H.  Gibbon,  advocates  a  combined  intra-  and  extra- 
peritoneal route  for  stones  an)T\'here  in  the  lower  two-thirds  of  the  ureter.  The 
peritoneal  incision  permits  of  exploration  and  exact  locahzation  of  the  stone, 
allows  the  surgeon  to  push  the  calculus  from  an  inaccessible  into  an  easily 
reachable  position,  and  makes  the  removal  vastly  easier.  The  stone  is  re- 
moved by  extraperitoneal  incision  of  the  ureter,  and  the  peritoneum  is  closed 
(John  H.  Gibbon,  in  '"Annals  of  Surg.,  Gynecolog}-,  and  Obstetrics,"  May, 
1908). 


Fig.  772 — Yzn  Hook's  method  of  ureteral  anastomosis. 


Uretero-ureterostomy  (Van  Hook's  Operation). — In  this  operation  ligate 
the  lower  end  of  the  divided  ureter  with  silk  or  catgut.  About  one-fourth 
of  an  inch  below  the  ligature  make  an  incision  in  the  long  axis  of  the  tube. 
This  incision  is  in  length  equal  to  twice  the  diameter  of  the  tube.  Each 
end  of  a  piece  of  fine  catgut  is  threaded  to  a  fine  needle.  This  thread  is 
passed  through  the  upper  end  of  the  ureter  (Fig.    772).     The  needles  are 


Cystoscopy  1297 

made  to  enter  the  lower  end  of  the  tube  through  the  door  made  by  the  sur- 
geon. They  are  pushed  through  the  wall  of  the  ureter  one-half  an  inch 
below  the  door  (Fig.  772).  Traction  upon  the  strings  causes  invagination, 
and  the  ligature-ends  are  tied.  If  the  operation  is  intraperitoneal,  the  ureter 
is  wrapped  about  with  peritoneum. 

Intestinal  Implantation  of  che  Ureters. — Thi.s  operation  may  be  em- 
ployed in  exstrophy  of  the  bladder  and  in  vesical  cancer,  in  which  it  is  neces- 
sary to  remove  the  bladder.  After  this  operation  there  is  danger  of  infection 
of  the  ureters  and  consequent  ascending  ureteritis  and  pyelonephritis,  and 
the  presence  of  urine  in  the  bowel  usually  causes  inflammation  of  the  rec- 
tum and  incontinence  of  urine  may  take  place. 

Maydl  asserts  that  a  piece  of  the  bas  fond  should  be  removed  with  the 
ureter,  and  implanted  with  it  into  the  intestine,  the  flange  hanging  free  in 
the  lumen  of  the  gut.  If  this  is  done,  the  relations  of  the  ureter  to  the  mus- 
cular coat  of  the  bladder  are  not  interfered  with,  stricture  is  less  likely  to 
occur,  ascending  infection  is  antagonized,  and  suppurative  conditions  arise 
at  the  margin  of  the  flange,  rather  than,  as  in  other  methods,  directly  in  the 
cut  ureter.  Maydl  has  collected  the  records  of  fourteen  cases  operated  upon 
by  this  method,  with  two  deaths.*  In  vesical  exstrophy  Peterson  transplants 
a  vesical  flap  containing  both  ureteral  orifices  into  the  descending  colon. 

Cystoscopy. — Cystoscopy  is  the  employment  of  the  cystoscope  for  the 
study  of  the  interior  of  the  bladder,  the  prostate,  the  ureteral  orifices,  and 
the  appearance  of  the  fluid  coming  from  each  kidney. 

The  cystoscope  is  an  instrument  of  great  value  in  the  hands  of  an  experi- 
enced man,  but  is  practically  useless  when  employed  by  a  novice.  In  using 
a  cystoscope  the  mucous  membrane  may  be  burned  with  the  lamp.  This 
causes  inflammation,  and  if  an  eschar  forms,  it  will  be  cast  ofl",  exposing  a 
granulating  surface.  Schmidt  calls  attention  to  this  injury,  speaks  of  the  con- 
dition as  idcer  cystoscopiciim,  says  it  is  in  the  fundus,  has  the  shape  of  the  in- 
strument, and  heals  in  from  fourteen  to  twenty-one  days  ("Jour.  Amer.  ^led. 
Assoc,"  July  19,  1902). 

Cystoscopic  examination  of  the  bladder  owes  its  present  position  to  Messrs. 
Max  Xitze  and  Joseph  Leiter,  who  were  the  first  to  introduce  a  practical 
instrument.  The  great  obstacle  in  former  years  was  the  danger  of  burning  the 
mucous  membrane  by  overheating  of  the  lamp.  The  invention  of  the  cold 
lamp  eliminated  that  danger,  and  was  a  great  step  forward.  Xitze  was  the 
first  to  recognize  the  futility  of  examination  by  reflected  light  and  constructed 
an  instrument  with  the  light  on  the  end  which  to-day  is  copied  by  all  of  the 
modern  instruments. 

Cystoscopes  maybe  diWdedinto  several  types:  (i)  The  examining  instru- 
ment; (2)  the  instrument  carrying  ureteral  catheters  or  the  catheterizing  cysto- 
scope; (3)  the  operating  cystoscope.  They  all  have  certain  mechanical  feat- 
ures in  common,  but  differ  in  their  construction  and  lens  arrangement. 

The  examining  instruments  are  of  two  fundamental  types — the  direct  and 
the  indirect.  In  the  direct  there  is  a  straight  telescope  with  a  series  of  wide 
angle  lens  that  give  the  picture  of  the  bladder  in  front  and  slightly  to  the  side. 
In  the  indirect  the  lens  is  so  ground  and  set  as  to  enable  the  operator  to  look 
backward  toward  the  prostate. 

*  Editorial  in  Jour.  Amer.  Med.  Assoc,  May  6,  1899. 
82 


1298  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Catheterizing  cystoscopes  are  also  of  two  kinds — the  direct  catheterizing 
and  the  indirect.  In  the  direct  catheterizing  the  catheters  are  passed  directly 
from  the  carrying  tubes  to  the  ureters.     In  the  indirect  the  catheter  is  bent  or 


Fig.  773. — Marks'  air-dilating  endoscope  for  examination  of  the  anterior  urethra. 

directed  by  a  lever  on  the  end  of  the  instrument  operated  by  a  thumb-screw 
on  the  penile  end.  By  raising  or  lowering  the  lever  the  angle  of  the  catheter  is 
altered  to  facilitate  its  introduction  into  the  ureteral  orifice. 


Fig.  774. — Marks'  air-dilating  endoscope  for  examination  of  the  posterior  urethra. 

It  is  obvious  that  the  bladder  should  be  distended  in  order  to  permit 
a  cystoscopic  examination.  For  this  purpose,  air  or  water  have  been  utilized. 
The  modem  tendency  is  in  favor  of  water  distention.  Some  of  the  operating 
instruments,  notably  that  of  Prof.  Lewis,  use  air. 


Cystoscopy 


1299 


Water  as  a  dilating  medium  is  superior  to  air,  unless  operative  work  is  to 
be  done  through  the  instrument,  in  which  case  the  inevitable  hemorrhage  pre- 
cludes the  use  of  water.  The  air  instruments  show  but  a  small  field  and  the 
distention  causes  pain  and  often  a  mild  cystitis. 

From  the  foregoing  it  is  plain  that  one  type  of  instrument  is  not  suited  to  all 
cases,  and  each  has  its  claim  to  practical  utility.  Some  cases  can  be  most 
readily  catheterized  by  the  direct,  while  others  are  only  reached  by  the  indirect, 
plan.  It  has  been  our  experience  that  if  the  ureteral  orifices  are  normally  placed, 
the  direct  method  is  quicker  and  more  readily  learned  by  the  beginner. 
Where  from  any  cause  the  ureteral  orifice  turns  backward  (which  only  happens 
in  a  very  small  percentage  of  cases)  the  indirect  cystoscope  is  indispensable, 
it  being  practically  impossible  to  reach  the  ureteral  orifice  by  the  direct  instru- 
ment. 

There  are  at  present  many  different  forms  of  cystoscopes  on  the  market, 
notably  among  them   are  the  Nitze,  Casper,  Tilden  Brown,  Cabot's  modi- 


-Universal  cystoscope,  after  E.  Tilden  Brown. 


fication  of  the  Tilden  Brown,  Berger,  Albarran,  Bransford  Lewis,  and  the 
so-called  Universal.  In  the  selection  of  an  instrument  best  suited  to  the 
needs  of  the  general  surgeon,  the  Universal,  sho\\Ti  in  Fig.  775,  wiU  answer  in 
most  cases.  It  combines  both  the  direct  and  indirect  systems  of  catheteriza- 
tion and  the  retrograde  and  direct  systems  of  e.xamination.  The  universal 
instruments  of  Bransford  Le\\is  and  Tilden  Brown  possess  features  of  great 
practical  utiHt\'. 

The  lamp  is  so  situated  in  the  vesical  end  and  the  fenestra  so  arranged  that 
they  throw"  light  both  on  the  concave  and  convex  sides  of  the  tip.  Hence, 
all  systems  may  be  operated  through  a  single  tube  and  changed  without  remov- 
ing the  light  from  the  bladder.  They  pro\-ide  the  follo\ring:  (i)  Direct 
examination  and  lateral  \-iew,  depending  upon  the  angle  of  the  lens  and  the 
instrument.  The  lateral  view  can  be  had  by  ^^'ithd^awing  or  extending  the 
cystoscope  and  also  swinging  it  from  side  to  side.  (2)  Indirect  examination  of 
the  trigone,  prostatic  pouch,  and  prostate.     (3)  Double  direct  catheterizing. 


1300         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

(4)  Double  indirect  catheterizing.  (5)  Retrospective  view  of  the  bladder. 
(6)  Provision  for  continuous  irrigation.  The  latter  may  be  said  to  be  a  very 
necessary  provision,  for,  in  many  cases,  a  successful  examination  and  catheteri- 
zation can  only  be  accompUshed  during  continuous  irrigation  to  remove  blood 
and  pus. 

Sterilization  of  Cystoscopes  and  Ureteral  Catlieters. — In  order  to  sterilize 
the  cystoscope  before  using,  place  it  for  five  minutes  in  a  solution  of  mercury 
oxycyanid  (i :  1000)  or  formaldehyd  (i :  500).  FormaHn  gas  may  also  be  used. 
Some  operators  use  a  5  per  cent,  solution  of  phenol,  in  which  the  instrument  is 
immersed  for  twenty-four  hours,  after  which  it  is  dipped  into  glycerin,  which 
both  neutralizes  the  phenol  and  lubricates  the  tube  The  mercury-  oxycyanid 
solution  is  easily  used  and  is  thoroughly  satisfactory.  Should  formaldehyd  or 
formaUn  gas  be  used,  always  wash  the  instrument  thoroughly  \\'ith  salt  solution 
to  prevent  irritation  by  the  steriUzing  mechum. 

Ureteral  catheters  can  be  sterihzed  by  boihng  for  five  to  ten  minutes  in  an 
open  shallow  dish  in  a  saturated  solution  of  ammonium  sulphate  or  sodium 
chlorid.  The  follo\nng  precautions  must  be  observed :  Each  catheter 
should  be  wrapped  in  gauze  and  the  bottom  of  the  pan  covered.  If  allowed 
to  touch  each  other  or  curl  upon  themselves  the  shellac  coating  will  melt  and 
ruin  the  instrument.  They  may  also  be  sterilized  in  the  same  manner  as  the 
cystoscope,  care  being  taken  (if  formalin  was  used)  to  carefully  wash  away  the 
germicide,  esj)ecially  from  the  lumen  of  the  catheter. 

Contraindications  to  Cystoscopy. — The  bladder  must  hold  at  the  very 
least  100  cc.  of  fluid.  Examination  is  either  impossible  or  unsatisfactory 
if  the  prostate  is  greatly  enlarged.  Contracted  meatus  urinarius  and  stricture 
smaller  than  No.  24  of  the  French  scale  are  correctible  contraindications. 
Papillomata,  tumors,  and  foreign  bodies  of  the  urethra  are  impediments.  In 
acute  Bright's  disease,  instrumentation  may  be  followed  by  suppression.  The 
following  are  further  contraindications,  as  suggested  by  FoUen  Cabot  and 
Henry  G.  Spooner,  in  "IMed.  Record,"  July  11,  1903:  When  it  is  obvious 
that  operative  intervention  would  be  useless;  when  there  is  a  large  tumor;  in 
acute  cystitis;  in  tuberculosis  in  which  the  diagnosis  is  evident  without  the 
cystoscope. 

Technic  of  Cystoscopy. — The  patient  should,  if  possible,  be  carefully 
sounded  for  several  days  pre\ious  to  the  cystoscopic  examination;  this  estab- 
lishes a  tolerance  in  the  urethra.  He  should  be  placed  upon  a  suitable  table, 
such  as  that  devised  by  Tilden  Brown  or  Bransford  Lewis,  as  shown  in  Fig.  776. 

General  anesthesia  is  rarely  necessar}'  provided  the  operator  is  gentle  in  his 
manipulations.  There  are,  however,  some  hypersensitive  urethras  which  it  is 
necessar}'  to  anesthetize.  Cocainization  of  the  urethra  by  instillations  into 
the  posterior  portion  of  the  canal  of  a  dram  of  4  per  cent,  solution  of  cocain 
through  the  Keyes-Ultzmann  syringe  will  often  be  sufficient,  or  the  tablet 
depositor  devised  by  Prof.  Levvis  will  answer.  In  cases  complicated  by  cystitis, 
preliminary  lavage  of  the  bladder  should  be  practised.  This  may  be  given 
through  the  cystoscope  sheath  or  by  means  of  a  soft-rubber  catheter.  If  the 
bladder  is  not  diseased,  it  is  merely  necessary  to  draw  o|if  the  urine.  After  the 
urine  has  been  withdrawn,  the  cystoscope  sheath  should  be  firmly  but  gently 
held  in  place.  The  thumb  of  the  left  hand  presses  downward  while  the  index- 
finger  presses  upward  on  the  under  surface  of  the  sheath.     This  procedure 


Tcchnic  of  Cystoscopy  1301 

raises  the  beak  of  the  instrument  from  the  sensitive  trigone,  where  most  of 
the  pain  and  hemorrhage  are  i)roduced  by  vesical  tenesmus. 

In  regard  to  a  selection  of  the  distending  medium,  the  operator  may  use 
sterile  water,  normal  salt  solution,  boracic  acid  solution,  or  mercury  oxycyanid 
solution  (i :  5000).  The  bladder  should  be  moderately  distended  and,  if  j)os- 
sible,  from  8  to  10  ounces  are  left  in  the  viscus.  In  contracted  or  hypersensi- 
tive bladders  it  is  well  to  elevate  the  hips  and  so  reheve  the  pressure  on  the 
sensitive  vesical  neck  and  trigone. 

The  temperature  of  the  distending  fluid  is  of  great  importance,  particularly 
if  there  is  difficulty  in  finding  the  ureteral  outlet.  If  this  is  the  case,  the  temper- 
ature of  the  fluid  should  be  about  60°  F.    This  enables  the  operator  to  see  a 


Fig.  776. — Tilden  Brown's  cystoscopic  table  with  patient  in  position  for  examination. 

so-called  swirl  when  the  warm  jet  of  urine  mixes  with  the  cold  water  in  the 
bladder.  It  is  sometimes  advisable  to  give  methylene-blue  before  examining 
for  the  same  reason.     The  blue  stream  from  the  ureter  at  once  identifies  it. 

After  the  bladder  is  filled  the  telescope  containing  the  catheters  is  inserted 
and  the  light  turned  on.  The  instrument  is  then  held  in  the  median  hne  and 
pushed  gently  back,  well  into  the  bladder,  always  making  pressure  to  keep  the 
beak  from  impinging  upon  the  floor.  The  cystoscope  is  now  slowly  withdrawn, 
a  careful  watch  being  maintained  through  the  telescope  for  the  interurcterat 
bar.  This  structure  (about  which  there  has  been  much  argument  as  to  whether 
it  really  exists)  marks  the  posterior  border  of  the  trigone.  The  examiner  has 
still  another  guide  in  the  blood-vessels  which  run  in  a  general  way  anteropos- 
teriorly.  There  is  quite  a  distinct  hne  of  demarcation  between  the  fish-net  loop 
arrangement  of  the  sides  and  base  of  the  bladder  from  that  described  in  the 
trigone.  Fig.  777  gives  a  general  idea  of  the  vascular  arrangement.  When  the 
interureteral  bar  or  posterior  border  of  the  trigone  has  been  located,  the  instru- 


I302  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

ment  is  gently  and  slowly  moved  laterally,  so  that  the  border  is  kept  in  the  field 
until  the  end  of  this  structure  is  reached.  It  is  then  held  stationary  for  a 
moment  and  a  sharp  lookout  is  kept  for  the  jet  of  urine  or  the  swirl.  The 
ureteral  orifice  is  thus  indicated.  Should  the  field  become  blurred  by  blood  on 
the  lens,  or  should  the  solution  in  the  bladder  become  mixed  with  blood,  con- 
tinuous irrigation  must  be  kept  up  through  the  cystoscope. 

The  Ureteral  Orifices. — As  before  menrioned,  the  ureteral  orifices  are  usually 
located  at  the  termination  of  the  interureteral  bar,  and  occupy  the  basal  angles 
of  a  triangle  found  by  the  vesical  outlet  and  the  base  of  the  trigone.  They  are 
usually  about  i  to  i^  centimeters  from  the  median  line  and  about  2^  centi- 
meters from  the  vesical  end  of  the  urethra.  They  are  recognized  as  small 
slits  or  tubercles  on  the  surface  of  the  mucous  membrane.  Their  position  is 
not  always  the  same.     Some  of  the  abnormal  positions  more  commonly  met 


Pig.  777. — The  interior  of  the  bladder,  showing  arrangement  of  the  vessels  of  the  trigone: 

A,B,  interureteral  bar. 

with  are  as  follows:  one  ureter  close  to  or  further  removed  from  the  median 
line,  both  ureters  emptying  into  the  bladder  close  to  the  median  line,  generally 
about  one-quarter  or  one-half  the  length  of  the  bar.  Malposition  toward  the 
vesical  outlet  and  in  some  very  rare  instances  both  emptying  on  the  same  side. 
Sacculation  and  pocketing  of  the  bladder  with  swelling  of  the  mucous  mem- 
brane often  makes  localization  difficult.  It  is  then  that  the  administration 
of  methylene-blue  or  indigo-carmin  may  enable  the  investigator  to  more  readily 
locate  them. 

After  locating  the  ureteral  orifice  the  vesical  end  of  the  cystoscope  is  carried 
directly  over  the  entrance  and  the  catheter  projected  against  the  opening,  where 
it  is  allowed  to  remain  for  a  moment  in  order  to  overcome  the  spasm  of  the 
sphincter  muscular  fibers.  The  patient  is  instructed  to  hold  his  breath  and  the 
orifice  is  carefully  watched  until  a  jet  of  urine  is  forced  through,  during  which 
act  the  catheter  is  gently  inserted  in  the  orifice. '  The  urine  dilates  the  opening 
and  greatly  facilitates  the  passage  of  the  instrument.  After  the  catheter  has 
passed  the  sphincter  muscle  it  should  be  carried  up  the  canal  by  very  gentle 


Collection  of  the  Urine  1303 

pressure.  The  practice  of  passing  the  instrument  quickly,  so  commonly 
resorted  to  by  the  novice  in  order  to  gain  time,  is  pernicious,  and  almost  in- 
variably causes  laceration  and  hemorrhage.  Before  inserting  the  catheter 
some  operators  prefer  to  coat  it  with  paraffin  in  order  to  render  it  absolutely 
smooth  and  further  to  assist  in  the  detection  of  calculus.  This  is  not  neces- 
sary.    Any  instrument  with  an  imperfect  eye  should  be  discarded. 

The  round-pointed  catheter  should  be  used  wherever  possible,  as  with 
it  there  is  less  danger  of  injuring  the  delicate  mucous  surfaces  of  the  canal. 
The  sharp-pointed  olivary  tipped  instrument  often  causes  blood  to  appear. 
If  possible,  insert  the  catheter  into  the  pelvis,  for  then  hemorrhage  from 
trauma  is  less  likely  to  invahdate  the  examination,  and  spasm  of  the  ureter, 
with  sucking  in  of  the  mucous  membrane  in  the  eye,  is  less  hkely  to  occur. 
Having  finished  the  catheterization  of  one  side,  the  instrument  handle  is 
swung  to  the  opposite  side  and  a  similar  procedure  is  carried  out.  Always 
have  a  distinguishing  mark  upon  the  catheters.  A  very  good  method  is  to  use 
different  colored  instruments,  so  that  there  may  be  no  confusion  after  with- 
drawal of  the  cystoscope.  In  some  cases  only  one  ureter  can  be  catheterized. 
In  these  cases  the  bladder  should  be  thoroughly  washed  and  the  other  catheter, 
left  on  the  floor  of  the  bladder,  will  collect  the  urine  from  the  uncatheterized 
side  and  give  a  fair  idea  of  the  condition  of  that  kidney. 

Removal  of  the  Cystoscope. — The  light  should  be  turned  off  and  a  small 
amount  of  fluid  allowed  to  escape  through  the  barrel.  The  lens  system  carry- 
ing the  catheter  is  then  loosened  and  gently  rotated  from  side  to  side  to  free 
the  catheters.  During  this  procedure  the  catheters  are  fed  gently  backward, 
but  not  with  sufficient  force  to  cause  kinking,  and  the  lens  system  removed. 
Next  the  sheath  is  withdrawn  by  carrying  it  straight  up  over  the  abdomen. 

Collection  of  the  Urine.— The  catheters  are  carefully  wiped  with  sterile 
gauze  and  permitted  to  drain  into  separate  bottles  or  test-tubes,  marked 
respectively  right  and  left.  The  orifices  of  the  receivers  should  be  plugged  with 
sterile  absorbent  cotton,  which  will  collect  and  prevent  any  admixture  of  urine 
or  water  coming  from  the  bladder  by  capillary  drainage.  The  bottles  should 
also  be  held  in  such  position  as  to  prevent  such  capillary  drainage  reaching 
them.  With  regard  to  the  collection  of  the  samples,  there  are  certain  precau- 
tions that  should  be  observed:  (i)  The  samples  should,  if  possible,  be  collected 
in  three  separate  bottles  from  each  side,  allowing  each  set  to  remain  in  posi- 
tion a  definite  time,  generally  one-half  hour.  These  should  be  carefully 
watched  and  marked  first,  second,  and  third  half-hours.  They  should  each  be 
examined  separately,  and  by  a  summation  of  the  examinations  the  opinion 
should  be  reached.  Almost  invariably  microscopic  blood  can  be  found  in  the 
urine  drawn  by  catheterization  of  the  ureters.  In  a  study  of  15  cases  of 
normal  ureters  where  blood  was  not  present  in  the  combined  urine,  after  the 
greatest  care  in  catheterizing,  microscopic  blood  was  present  in  all  but  3. 
The  erythrocytes  are  usually  most  numerous  in  the  first  bottle,  gradually  dimin- 
ishing, until  in  the  third  there  are  but  very  few  or  none.  Should  the  blood 
increase  in  amount  in  the  bottles,  it  is  an  important  clinical  fact. 

In  some  instances  one  or  both  catheters  fail  to  drain.  This  may  be  due  to  a 
bubble  of  air  in  the  instrument,  impinging  of  the  mucous  membrane  upon 
the  eye,  plugging  by  blood-clot,  mucus,  pus,  or  particles  of  gravel.  A  syringe 
is  then  essential.     The  blunt  needle  should  be  inserted  into  the  catheter  and 


1304  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

suction  applied;  should  this  fail,  not  over  4  cc.  of  sterile  normal  salt  solution 
may  be  injected  through  the  catheter.  This  procedure,  however,  must  be  done 
very  gently,  because  of  the  danger  of  overdilating  the  renal  pelvis  and  thus  pro- 
ducing colic. 

A  uropyknometer  is  used  for  taking  the  specific  gravity  of  small  quantities 
of  urine  removed  by  the  ureteral  catheter. 

The  Operative  Cystoscope. — The  most  practical  operative  cystoscope  is 
that  devised  by  Prof.  Bransford  Lewis.  This  instrument  greatly  facilitates 
the  removal  of  small  portions  of  stone  and  foreign  bodies  from  the  bladder 
and  ureteral  orifices.  It  is  also  most  useful  for  making  applications  to  ulcer- 
ated areas.  It  is  not  wise  to  remove  papillomatous  tumors  by  its  means,  as 
most  villous  papillomatous  growths  sooner  or  later  possess  the  elements  of 
malignancy  and  should  have  their  pedicles  removed  with  a  pordon  of  the  vessel- 
wall,  which  can  only  be  safely  done  after  suprapubic  cystotomy. 

Practical  Value  of  Cystoscopy  and  Ureteral  Catheterization. — The 
cystoscope  has  attained  a  very  important  posidon  in  the  surgeon's  armamen- 
tarium. It  undoubtedly  affords  the  best  method  of  establishing  an  accurate 
diagnosis  founded  on  pathologic  findings.  By  it  one  is  enabled  to  determine 
the  presence  and  character  of  cystitis,  stone,  foreign  bodies,  and  malformations. 
Without  it  the  presence  of  ulcerations  could  merely  be  guessed  at  by  the  clin- 
ical history.  Its  greatest  field  is  in  the  early  diagnosis  of  the  cause  of  renal 
and  vesical  hemorrhages.  In  the  detection  of  renal  neoplasms  it  may  be  said 
to  have  revolutionized  surgery.  It  makes  possible  the  early  removal  of  such 
growths  before  malignancy  has  signed  the  patient's  death  warrant.  Cases  of 
prostatic  hypertrophy,  in  which  the  lobes  project  backward,  cannot  be  accu- 
rately diagnosticated  without  the  cystoscope;  with  it  the  parts  can  be  seen  and 
the  clinical  diagnosis  positively  confirmed.  It  makes  possible  the  removal  of 
foreign  bodies,  such  as  stone,  pieces  of  cotton,  or  fihform  bougie  through  the 
urethra,  thus  saving  formidable  cutting  operations.  It  is  needless  to  mention 
the  great  difficulty  found  by  surgeons  in  former  years  in  determining  the  source 
of  symptomless  hemorrhage,  a  problem  which  is  now  comparatively  easy  of 
solution. 

Ureteral  catheterization  makes  possible  the  irrigation  of  the  ureter  and 
pelvis  of  the  kidney  in  cases  of  ureteritis  and  pyelitis. 

The  technic  of  lavage  is  as  follows:  A  glass  syringe  of  about  50-  to  loo-cc. 
capacity  Is  equipped  with  a  blunt  needle  that  is  passed  into  the  catheter. 
About  5  to  10  cc.  of  the  irrigating  fluid  is  instilled  into  the  catheter  and  per- 
mitted to  run  out.  In  introducing  the  fluid  care  should  be  exercised  lest  the 
renal  pelvis  be  overdilated.  Overdilatation  causes  severe  colic.  For  irrigation 
the  following  solutions  may  be  used:  Saturated  solution  of  boracic  acid  is  gen- 
erally used  as  a  cleanser  before  any  other  fluid  is  employed.  This  may  be 
followed  in  suppurative  conditions  by  a  solution  of  silver  nitrate  (i :  8000  or 
stronger  as  the  case  requires).  The  injection  is  terminated  by  withdrawal  of 
the  catheter  while  irrigating.  Subsequently,  the  bladder  should  be  washed  out 
and  the  patient  given  a  genito-urinary  antiseptic,  of  which  there  is  none  better 
than  urotropin. 

A  differential  diagnosis  must  sometimes  be  made  between  gall-bladder-dis- 
ease appendicitis  and  movable  kidney  with  dilated  pelvis.  This  is  done  by 
determining  the  carrying  capacity  of  the  pelvis.     As  a  rule,  in  movable  kidney 


Disinfection  of  Urethral  Catheters  ^^S^S 

producing  marked  symptoms,  the  renal  pelvis  is  usually  dilated.  When  the 
trouble  is  due  to  the  kidney  the  pain  induced  by  the  distention  is  similar  to 
that  from  which  the  padent  has  suffered.  If  a  stone  is  present  in  the  ureter 
the  a"-ray  picture  will  usually  reveal  it,  but  here  again  there  may  arise  doubt  as 
to  the  exact  course  of  the  canal.  Catheters  f)assed  into  the  ureters  with  a  lead 
wire  in  them  and  the  case  skiagraphed  will  enable  the  radiographer  to  deter- 
mine their  exact  course.  Fig.  778  demonstrates  the  practical  utility  of  such 
manipulation.  *Phleboliths,  fecal  masses,  concretion,  and  calcified  lymph- 
nodes  have  been  mistaken  for  ureteral  stone.  Appendices  have  been  removed 
when  the  source  of  trouble  has  been  impacted  stone  in  the  right  ureter.  An 
impacted  stone  in  the  ureter  may  often  be  dislodged  by  y)assing  a  catheter  into 
the  ureter  and,  if  possible,  beyond  the  stone.     A  few  minims  of  sterile  olive  oil 


Fig.  778.— X-ray  photograph,  showing  the  course  of  the  ureters  by  wires  in   the  catheters. 
(Taken  by  Dr.  W.  E.  Manges.) 

are  then  injected  through  the  catheter,  which  act  as  a  lubricant  and  assist  in 
the  passage  of  the  stone.  Dilatation  of  the  ureteral  orifice,  by  leaving  the  cath- 
eter in  situ  or  passing  a  second  instrument  alongside  of  the  first,  will  often  cause 
the  stone  to  pass  into  the  bladder. 

Disinfection  of  Urethral  Catheters. — MetaUic  instruments  are  cleansed 
by  boiling.  Soft-rubber  and  elastic  catheters  can  be  sterihzed  by  mechanical 
cleansing  with  soap  and  water  and  boiling  for  five  minutes.  The  common 
custom  of  immersing  a  soft-rubber  or  elasdc  catheter  for  five  minutes  in  a 
1 :  2000  solution  of  corrosive  subUmate  is  a  useless  waste  of  time,  as  such  a 
procedure  will  not  sterilize  an  infected  instrument.  Of  course,  a  catheter 
coated  with  varnish  or  resin  cannot  be  boiled  in  water  or  placed  in  steam. 
The  best  method  of  sterilization  for  woven  or  varnished  catheters  is  formalin 
vapor.     Catheters,  after  being  cleansed  mechanically,  should  be  placed  in  ?. 


1306,         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

glass  cylinder  the  bottom  of  which  is  perforated  Hke  a  sieve.  This  jar  is 
placed  for  twenty-four  hours  in  the  vapor  of  formahn.  After  steriHzation  the 
instruments  are  kept  ready  for  use  in  a  glass  cylinder  containing  calcium 
chlorid  (R.  W.  Frank,  in  "Berliner  klin.  Woch.,"  No.  44,  1895).  Before 
using,  the  catheters  are  washed  in  sterile  water  or  salt  solution.  Guyon  prefers 
to  scrub  catheters  with  soap  and  water,  dry  them  outside  and  inside,  and  place 
them  in  the  vapor  of  sulphurous  acid  for  forty-eight  hours. 


Diseases  and  Injuries  of  the  Bladder. 

Retention  of  Urine  in  the  Male.— Retention  of  urine  is  not,  of 
course,  a  disease:  it  is  rather  a  result  of  one  of  a  number  of  different  diseases. 
By  this  term  is  meant  an  absolute  inability  voluntarily  to  micturate.  The 
retention  may  be  complete,  not  a  drop  emerging,  or  it  may  have  been  complete, 
a  dribbling  setting  in  after  a  time,  due  to  paralysis  of  the  bladder,  which  viscus 
becomes  unable  to  contain  more  fluid,  expulsion  of  the  overflow  from  the 
ureters  being  produced  by  atmospheric  pressure.  This  condition  is  known  as 
the  engorgement,  the  overflow,  or  the  incontinence  of  retention.  There  may  be 
retained  urine  in  a  man  with  enlarged  prostate,  a  portion  only  of  the  urine 
being  voided.  This  is  not  retention,  and  the  urine  so  retained  is  called  re- 
sidual urine.  Of  course,  true  retention  may  arise  in  a  person  with  enlarged 
prostate.  Retention  may  be  caused  by — (i)  obstruction,  resulting  from 
urethral  stricture,  hypertrophied  prostate,  inflamed  prostate,  occluded  meatus, 
impacted  calculus,  or  foreign  body,  urethral  tumor,  rupture  of  the  urethra, 
perineal  abscess,  imperforate  prepuce,  congenital  phimosis,  tumor  of  the  penis, 
tumor  of  the  prostate,  prostatic  abscess,  abscess  of  the  penis,  ischiorectal 
abscess,  and  pressure  from  a  large  pelvic  tumor.  The  commonest  obstructive 
cause  is  spasm  of  the  membranous  urethra  arising  during  the  existence  of 
stricture,  acute  gonorrhea,  or  gleet.  (2)  Defective  expulsion,  resulting  from 
impairment  of  the  nervous  apparatus  for  inducing  micturition.  Hysteria  is 
a  rare  cause  in  men.  We  see  retention  without  obstruction  after  vertebral 
fractures  or  spinal  concussion,  in  certain  diseases  of  the  spinal  cord,  some- 
times in  shock  and  peritonitis,  often  in  the  continued  fevers  and  diseases 
characterized  by  muscular  wasting,  from  the  action  of  certain  drugs  (bella- 
donna, opium,  or  cantharides),  and  after  certain  surgical  operations  upon  or 
about  the  rectum.  The  last-named  form  of  retention  is  due  either  to  reflex 
inhibition  of  the  expulsor  muscle  or  to  reflex  stimulation  of  the  sphincter 
vesicas,  causing  it  to  remain  firmly  contracted.  Acute  retention  comes  on 
suddenly  and  is  sometimes  the  first  thing  that  causes  a  sufferer  from  urethral 
stricture  to  seek  a  surgeon. 

Symptoms. — In  acute  retention  there  is  an  agony  of  desire  to  urinate, 
the  patient  making  acutely  painful  straining  efforts,  during  which  feces  are 
often  passed.  There  are  severe  pain  and  aching  in  the  abdomen,  thighs, 
perineum,  and  penis.  All  the  symptoms  rapidly  increase,  a  typhoid  state  is 
inaugurated,  and  death  closes  the  scene  unless  relief  be  given.  If  retention 
is  from  time  to  time  alleviated  by  the  passage  of  a  little  water,  the  symptoms 
are  slower  in  evolution  and  are  less  intense,  and  the  case  is  said  to  be  chronic. 
Some  cases  of  gradual  onset,  due  to  atony,  are  very  insidious,  the  patient 
feeling  no  particular  pain  and  complaining  only  of  the  dribbling,  which  is 


Treatment  for  Retention  of  Urine 


1307 


really  the  overflow  of  retention,  and  is  not  a  sign  that  the  bladder  is  success- 
fully emptying  itself.  In  any  case  of  retention  the  bladder  rises  above  the 
pubes,  and  there  is  found  a  pyriform,  elastic,  fluctuating  mass  in  the  hypo- 
gastrium,  which  mass  is  dull  on  percussion  and  gradually  enlarges  until  the 
bladder  is  evacuated  or  incontinence  sets  in.  The  flanks  give  a  clear  percus- 
sion-note, and  the  tumor  is  more  prominent  when  the  patient  is  erect  than 
when  he  is  recumbent.  Long  continuation  of  obstructive  disease,  producing 
partial  retention  with  or  without  attacks  of  complete  retention,  disorganizes 
the  kidneys.  Acute  and  complete  retention  may  induce  rupture  of  the  ure- 
thra or  urinary  supprqssion. 


■^^- 


Fig.  779.— Gou!ey"s  tunnelled  catheter  threaded  on  a  filiform  bougie. 


\_ 


Fig.  780.— Points  of 
Gouley's  whalebone  guides 
(filiform  bougies). 


Treatment. — Place  the  patient  upon  his  back,  keep  him  warm,  and  if 
instrumentation  does  not  rapidly  succeed,  give  an  anesthetic.  Never  attempt 
to  use  a  catheter  when  the  patient  is  erect.  To  do  so  may  cause  serious  or 
possibly  fatal  shock.  Be  sure  that  every  instrument  is  aseptic.  In  organic 
stricture  try  to  pass  an  elastic,  olivary-pointed  catheter  (Pig.  782,  a).  Do  not 
use  any  force  until  the  neck  of  the  catheter  engages  in  the  stricture.  Then 
an  e.xperienced  operator  may  warily  use  a  certain  amount  of  force,  but  never 
much.  When  the  instrument  enters  the  bladder,  draw  off  but  half  of  the 
urine,  withdraw  the  instrument,  wait  a  few  hours,  insert  it  again,  and  then 
empty  the  bladder  and  wash  out  the  viscus  with  warm  boric-acid  solution.  To 


Fig.  781.— Xelatou's  catheter. 


draw  off  all  of  the  urine  at  once  is  dangerous,  because  the  sudden  relief  of  the 
pressure  upon  distended  veins  leads  to  bleeding  from  the  mucous  membrane 
and  hemorrhage  into  the  bladder-walls.  After  the  bladder  has  been  emptied 
the  patient  is  wrapped  in  blankets,  a  bag  of  hot  sand  or  of  hot  water  is 
placed  against  the  perineum,  and  a  hot-water  bag  is  laid  upon  the  h}TDo- 
gastric  region;  when  he  recovers  from  the  effect  of  the  anesthetic  he  is 
given  suppositories  of  opium  and  belladonna,  and  tablets  of  salol  and 
boric  acid  are  administered  for  several  days.  If  it  is  found  impossible 
to  insert  a  rubber  instrument,  make  an  attempt  to  carry  a  fihform  bougie 
into   the    bladder.     Fig.    780    shows    fihform    bougies.     If  the   stricture  is 


1308  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


known  to  be  organic  from  previous  history,  at  once  insert  a  fihform  bougie. 
On  this  bougie,  after  it  has  been  inserted,  Gouley's  tunnelled  catheter  can 
be  threaded  (Fig.  779)  and  carried  into  the  bladder.  Instead  of  carrying  in 
the  catheter,  we  can  simply  leave  the  filiform  bougie  in  place,  and  fasten  it. 
The  filiform  bougie  will  act  as  a  capillary  drain,  and  in  a  few  hours  will 
empty  the  bladder.  Then  insert  another  bougie  beside  the  first,  and  so  on 
for  several  days,  using  also  opium,  ordering  rest  in  bed,  and  making  no 
attempt  to  dilate  the  stricture  forcibly  until  retention  has  ceased  and  inflam- 
mation has  subsided.  If  no  bougie  can  be  passed,  aspirate  or  perform  cys- 
totomy (suprapubic  or  perineal).  In  spasmodic  stricture  hold  a  good-sized 
metal  catheter  firmly  against  the  face  of  the  spasmed  area;  relaxation  will 
occur  and  the  instrument  will  eventually  pass.  Fig.  783  shows  the  proper 
curve  of  a  metal  instrument.  An  individual  who  has  an  organic  stricture 
which  has  given  but  little  trouble  may  develop  attacks  of  retention  because 

of  inflammatory  edema  of  the 
mucous  membrane  and  spasm 
of  the  urethral  muscles.  These 
attacks  are  temporary,  and  an 
instrument  can  usually  be  in- 
serted when  employed  as 
above  directed.  In  inflamma- 
tion give  a  hot  hip-bath  and 
suppositories  of  opium  and 
belladonna,  and  then  use  a 
hot  sand-bag  to  the  perineum 
and  a  hot-water  bag  over  the 
hypogastrium.  If  these  fail 
or  if  the  symptoms  are  ur- 
gent, pass  a  soft  catheter.  In  the  occluded  meatus  of  the  new-born  incise 
with  a  tenotome.  In  a  congenital  cyst  oj  the  sinus  pocularis  pass  a  steel 
bougie,  which  will  rupture  the  cyst.  In  complete  phimosis  split  up  the  pre- 
puce. In  impacted  stone  try  to  pull  out  the  calculus  with  urethral  forceps; 
if  this  fails,  cut  the  urethra,  or,  in  rare  cases,  push  the  stone  back  into 
the  bladder.  In  jecal  impaction  scrape  out  the  rectum  with  a  spoon.  In 
enlarged  prostate  try  to  pass  an  instrument  of  woven  silk  (Fig.  784)  or 
an  ordinary  Nelaton  catheter  (Fig.  781)  strengthened  by  the  insertion  of  a 
filiform  bougie  nearly  to  the  beak.  If,  however,  the  hypertrophied  tissue 
enters  markedly  into  the  urethra,  Mercier's  coude  catheter  is  used  (Fig.  782,  h), 
or  his  double-elbowed  instrument  (Fig.  782,  c).  If  all  the  above  instruments 
fail,  a  metal  instrument  with  a  large  curve  may  be  employed,  but  it  is  a  danger- 
ous tool  and  one  capable  of  inflicting  grave  injury.  In  retention  jrom  expulsive 
deject  use  a  soft  catheter  (Fig.  781).  Cases  of  retention  after  catheterization 
require  warmth,  confinement  to  bed,  the  administration  of  laxatives,  free  action 
of  the  skin,  and  the  use  of  such  drugs  as  salol,  boric  acid,  urotropin,  and  quinin 
to  asepticize  the  urine.  In  some  few  cases  no  instrument  can  be  inserted  in  the 
bladder.  In  most  of  such  cases  aspirate — which  may  be  done  .several  times 
if  necessary — and  in  a  day  or  two,  when  swelling  and  congestion  abate,  an 
instrument  can  be  passed.  A  small  asepticized  trocar  or  aspirator-needle  is 
pushed  into  the  bladder,  the  trocar  or  needle  being  inserted  in  the  median  line, 


Fig.  782.' — a,  French  olivary  gum  catheter  ;  b,  Mer- 
cier's elbowed  catheter  (coude)  ;  r,  Mercier's  double- 
elbowed  catheter  ;  d,  curved  gum  catheter. 


Congenital  Defects  of  the  Bladder 


1309 


just  above  the  pubes,  and  taking  a  course  downward  and  backward.  The 
parts  are  first  prepared  antiseptically,  and  the  puncture  is  dressed  with  iodo- 
form and  collodion.  Only  half  the  urine  is  withdrawn  at  a  first  aspiration. 
Rectal  puncture  is  now  obsolete.  The  perineal  incision  is  the  one  usually 
employed  for  retention.  It  may  be  done  with  or  without  a  guide.  In  pros- 
tatic retention,  not  relievable  by  a  catheter,  make  suprapubic  drainage  or  do 
prostatectomy. 

Congenital  Defects  of  the  Bladder.— Exstrophy  of  the  Bladder 
{Ectopia  Fg5/f(g)  .—Exstrophy  of  the  bladder  is  a  condition  of  defective  de- 
velopment commoner  in  males  than  in  females.  The  anterior  abdominal 
wall  having  failed  to  close,  the  anterior  wall  of  the  bladder  being  absent,  and 
the  arch  of  the  pubes  not  having  developed,  epispadias  exists,  and  in  many 
cases  the  testicles  do  not  descend  into  the  scrotum.  In  this  condition  the 
posterior  w^all  of  the  bladder  projects  into  or  beyond  the  gap  in  the  abdominal 
wall;   the  urine  constantly  flows  and  renders   the  condition  of  the  patient 


Fig.  783.— .<4  B  £■  shows  the  proper  curve  (reduced  in  size)  for  unyielding  male  urethral  instruments  ; 
C  B  D  shows  an  improper  curve. 

dreadful.     The  condition  shortens  life  and  only  30  per  cent,  of  the  victims 
live  beyond  the  twentieth  year,  death  being  due  to  pyelonephritis. 

The  only  treatment  which  offers  hope  is  oDcration,  and  operation  often 
fails.  If  possible,  operate  when  the  patient  is  about  five  years  of  age.  Various 
operadons  have  been  suggested  for  this  condition,  viz. :  covering  with  skin- 
flaps;  implanting  the  ureters  into  the  bowel  (^Nlaydl,  Albert,  Roux,  Simon, 
and  others) ;  division  of  the  posterior  ligaments  of  the  sacro-iliac  joints,  bring- 
ing the  arch  of  the  pubes  forcibly  together,  the  patient  wearing  a  support 


Fig.  784,— English  silk-web  catheter. 


undl  the  parts  become  firm,  when  the  greatly  narrowed  defect  is  closed  in  by 
integumentary  flaps  and  suturing  the  bladder  edges  {Trendelenburg's  opera- 
tion or  synchondroseototny) ;  osteotomy  through  one  iUum  or  both  ilia  instead 
of  separation  of  the  sacro-iUac  joints  {Berg's  operation),  or  after  extirpating  the 
bladder,  loosening  the  ureters  from  the  bladder,  drawing  them  down,  and 
attaching  them  to  the  end  of  the  penis  (Sonnenberg's  operation) . 

A  bladder  closed  in  by  autoplasty,  by  Trendelenburg's  operation,  or  by 
Berg's  operation  is  never  really  continent,  although  when  the  patient  is  erect 


13 lo  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

and  wears  a  light  compress  he  may  perhaps  be  able  to  hold  water  two  or  three 
hours.  The  above  methods  are  suited  to  young  children  and  are  far  safer  than 
is  ureteral  transplantation.  Tuffier  showed,  nearly  twenty  years  ago,  that 
transplantation  of  the  cut  ureters  into  the  bowel  was  certain  to  be  followed 
by  fatal  infection  of  the  kidney,  and  that  the  only  way  to  prevent  this  was  to 
retain  the  ureteral  orifices  which  contain  valves. 

Maydl  introduced  his  operation  in  1892.  He  implanted  the  trigone  with 
the  ureters  into  the  sigmoid  flexure,  extirpating  the  rest  of  the  bladder.  I 
have  twice  performed  a  modified  Maydl's  operation,  with  one  death  and  one 
recovery,  and  in  the  latter  case  the  result  was  very  satisfactory.  Buchanan 
("Surg.,  Gynecol.,  and  Obstet.,"  Feb.,  1909)  has  collected  80  cases.  In  this 
collection  there  were  23  deaths  (28.7  per  cent.);  7  died  of  peritonitis  and  9  of 
pyelonephrids.  Bergenhem,  in  1894,  devised  extraperitoneal  implantation  of 
the  ureters  and  a  portion  of  bladder  through  two  separate  openings  into  the 
rectum. 

Diseases  and  Injuries  of  the  Bladder.— This  viscus  is  so  deeply 
situated,  and  the  abdominal  walls  are  so  elastic,  that  it  is  rarely  injured  when 
empty.  If  the  bladder  be  full  and  the  abdomen  be  tense — which  is  common 
in  alcoholic  intoxication — force  appHed  upon  the  abdomen  may  injure  the 
bladder. 

Contusion  of  the  Bladder. — In  this  condition  there  are  noted  vesical 
hematuria,  tenesmus,  severe  cystitis,  and  an  impediment  to  the  flow  of  water 
because  of  clots.  Hemorrhage  may  be  very  severe  and  sepsis  may  arise, 
even  causing  death.  When  contusion  exists  retention  is  relieved  by  means 
of  a  clean  soft  catheter;  if  this  fails  because  of  occlusion  of  the  eye  of  the 
catheter  with  blood-clot,  there  must,  from  time  to  time,  be  passed  through 
the  catheter  from  a  fountain-syringe  a  solution  of  sodium  bicarbonate  in 
cooled  boiled  water.  Gross's  blood-catheter  can  be  used,  or  the  evacuator 
of  Bigelow  may  be  employed.  The  patient  is  put  to  bed,  a  hot-water  bag  is 
applied  to  the  hypogastrium,  morphin  is  administered  in  moderate  doses, 
the  bladder  is  washed  out  several  times  a  day  with  boric-acid  solution  to  dis- 
integrate and  remove  blood-clots,  and  the  urine  is  diluted  and  rendered  aseptic 
by  the  stomach  administration  of  salol,  boric  acid,  and  the  free  use  of  bland 
fluids.  Hemorrhage  usually  ceases  on  relieving  distention;  if  it  does  not, 
some  more  radical  measure  must  be  employed  (see  Hematuria). 

Wounds  of  the  Bladder. — Besides  being  contused,  the  bladder  may  be 
injured  by  bullets;  by  stabs  or  punctures  through  the  abdomen,  the  vagina, 
or  the  uterus;  or  by  penetration  by  a  fragment  of  a  fractured  pelvic  bone. 
The  symptoms  of  such  conditions  are  those  of  rupture  of  the  bladder  {q.  v.). 
In  any  intraperitoneal  wound  at  once  open  the  abdomen,  suture  the  wound 
in  the  bladder-wall,  irrigate  the  peritoneal  cavity,  and  drain  the  bladder  by 
means  of  a*  retained  catheter,  a  perineal  section,  or  a  suprapubic  cystotomy. 
In  an  extraperitoneal  wound  drain  the  wound  by  a  tube,  and  drain  the  bladder 
by  a  retained  catheter,  a  perineal  section,  or  a  suprapubic  opening. 

Rupture  of  the  bladder  occurs  in  three  forms:  (i)  intraperitoneal — a 
rupture  involving  the  peritoneal  coat;  (2)  extraperitoneal — a  rupture  of  a  por- 
tion of  the  bladder  not  covered  by  peritoneum;  and  (3)  subperitoneal — a 
rupture  of  the  mucous  and  muscular  coats,  the  urine  diffusing  under  the 
peritoneal  investment.     The  causes  are  of  two  kinds,  predisposing  and  ex- 


Rupture  of  the  Bladder  1311 

citing.  Predisposing  causes  are:  distention  of  thebladder;  drunkenness;  cystitis; 
ulceration;  degeneration  or  atony  of  the  bladder-coats;  prostatic  enlargement, 
and  urethral  stricture.  Distention  of  the  bladder  is  the  great  predisposing 
cause.  It  causes  the  bladder  to  rise  from  the  pelvis  and  so  become  exposed  to  a 
direct  blow,  it  places  the  organ  under  tension,  and  force  tends  to  rupture  the 
weakest  point.  In  about  one-third  of  the  cases  collected  by  Bartels  the  in- 
dividual was  intoxicated  at  the  time  of  the  accident.  Drunkenness  predisposes 
because  a  drunken  man  is  very  liable  to  injury  and  is  apt  to  have  a  distended 
bladder.  Males  are  much  more  liable  to  rupture  than  females  (10  to  i). 
Most  cases  are  between  the  ages  of  twenty  and  forty.  Of  Besley's  23  cases,  i 
was  a  child  of  three,  i  a  man  of  forty-nine,  3  were  in  the  first  and  second  decades, 
5  were  between  twenty  and  thirty,  7  between  thirty  and  forty,  6  between  forty 
and  fifty,  and  in  2  the  age  is  not  given  (paper  before  Chicago  Surg.  Soc, 
Feb.,  1907).  The  condition  is  very  rare  in  children,  but  one  of  Besley's  cases 
was  three  years  of  age,  and  King  recorded  the  accident  in  a  fetus  with  im- 
perforate urethra. 

Exciting  causes  are:  obstruction  to  the  outflow  of  urine  (by  stricture  or  en- 
larged prostate) ;  external  ^•iolence;  falls  upon  the  feet  or  the  buttocks,  as  well  as 
upon  the  abdomen;  lifting;  straining  at  stool,  in  micturition,  or  during  partu- 
rition; and  the  forcing  of  injections  into  the  bladder.  A  distended  bladder  may 
be  ruptured  by  a  concussion.  The  most  usual  cause  of  the  injury  is  a  crush. 
The  mechanism  of  the  injury  is  in  dispute.  It  is  certain  that  the  bladder  must 
have  lost  its  elasticity  by  distention.  When  force  is  applied  to  fluid  (and  fluid 
is  incompressible)  the  bladder  tears  at  its  weakest  point.  The  weakest  point 
is  not  identical  in  all  indi\dduals.  It  may  be  weak  anywhere  from  disease. 
The  most  common  site  of  the  tear  is  at  the  posterosuperior  aspect,  but  it  may 
be  in  front,  at  the  sides,  or  at  the  pubic  or  prostatic  ligament  (Staubenranch) . 
The  mucous  membrance  or  the  peritoneum  may  give  way  first  and  the  tear  may 
be  anteroposterior,  oblique,  or  longitudinal.  Alexander  maintains  that  the 
most  usual  cause  of  the  injury  is  a  crush  which  forces  the  distended  bladder 
against  the  sacral  promontor}',  but  Besley's  (Ibid.)  experiments  do  not  indi- 
cate this  to  be  the  case.  A  common  comphcation,  especially  of  extraperitoneal 
rupture  is  fracture  of  the  pehas,  due  to  the  same  force  that  ruptured  the 
bladder. 

Symptoms,  Diagnosis,  and  Treatment. — The  symptoms  are  not  always 
definite,  and  every  characteristic  one  may  be  for  a  time  absent,  the  patient 
seeming  in  some  rare  instances  of  extraperitoneal  and  intraperitoneal  rupture  to 
possess  the  power  of  retaining  his  urine  and  of  voiding  it.  As  a  rule,  however, 
there  are  found  some  or  all  of  the  following  symptoms,  following  an  accident 
or  occurring  during  the  progress  of  a  causative  disease:  severe  abdominal  pain, 
collapse;  inabihty  to  walk  or  great  difficulty  in  walking;  excessive  desire  to 
urinate,  but  inabihty  to  do  so;  a  catheter,  when  used,  brings  away  pure  blood 
or  a  very  httle  bloody  urine;  the  catheter  occasionally  slips  through  the  tear 
into  the  ca\aty,  and  more  bloody  water  comes  away.  In  some  reported  cases 
clear  water  has  been  withdrawn.  If  a  measured  amount  of  boric  acid  solu- 
tion is  injected,  it  is  improbable  that  all  of  it  can  be  withdrawn  by  the  catheter, 
although  in  some  cases  it  may  all  come  away  (Alexander,  in  "Annals  of  Sur- 
gery," Aug.,  1901) .  Injecting  fluid  fails  to  Hft  the  bladder  into  the  hypogastric 
region  so  as  to  be  recognizable  on  percussion.     Severe  hypogastric  pain  and 


1 31 2  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

rectal  tenesmus  come  on  after  a  temporary  sense  of  relief  from  retention. 
Shock  in  vesical  rupture  is  so  severe  that  death  may  ensue;  if  reaction  follows, 
there  is  dehrium,  often  sepricemia  and  peritonitis;  extensive  infiltrations  of  urine 
may  occur.  In  intraperitoneal  rupture  general  peritonitis  is  certain  to  arise, 
but  its  appearance  may  be  postponed  for  several  days  if  the  urine  is  healthy. 
In  these  cases  the  extravasation  is  noted  as  a  simple  swelling,  probably  on 
one  side  only.  In  extraperitoneal  rupture  the  urine  may  infiltrate  the  peri- 
neum, the  scrotum,  the  thighs,  and  under  the  integuments  of  the  abdomen  and 
the  back,  and  may  soon  induce  sloughing.  In  subperitoneal  rupture  peritonitis 
is  apt  to  arise. 

In  doubtful  cases  pump  air  or  hydrogen  into  the  bladder.  To  insert  air 
a  bicycle  pump  can  be  used  (Brown),  or  a  Davidson  syringe  (Keen).  Keen's 
directions  are  to  insert  a  catheter,  empty  the  bladder  of  urine,  and  connect  to 
the  catheter  a  disinfected  Davidson's  syringe,  a  mass  of  absorbent  cotton 
being  fastened  over  the  distal  end  of  the  syringe.  Air  after  it  has  filtered 
through  the  cotton  is  pumped  into  the  bladder;  an  unruptured  bladder  will 
rise  above  the  pubes  as  a  pyriform  tumor,  tympanitic  on  percussion.  A 
ruptured  bladder  will  not  so  rise.  In  intraperitoneal  rupture  the  air  will 
pass  into  the  general  peritoneal  cavity  and  distention  will  occur.  In  extra- 
peritoneal rupture  injection  will  produce  emphysema  of  the  extravesical 
connective  tissues.  On  remo\ing  the  syringe  the  air  rushes  out  again  if  the 
bladder  is  unruptured,  but  little  if  any  comes  away  if  it  is  ruptured.  Alex- 
ander considers  gaseous  distention  unreliable,  and  claims  that  it  adds  to 
shock  and  disseminates  infection.  His  rule  is  the  wisest  to  follow;  that  is, 
in  a  case  of  suspected  rupture  of  the  bladder,  make  a  suprapubic  incision 
and  inspect  the  prevesical  space  for  signs  of  extraperitoneal  rupture.  If 
extraperitoneal  rupture  is  not  found,  open  the  belly  and  explore. 

Treatment. — In  extraperitoneal  rupture  after  incision  down  to  the  blad- 
der insert  a  drainage-tube.  In  intraperitoneal  rupture,  place  the  patient  in 
the  Trendelenburg  position,  expose  the  bladder  by  incision,  and  suture  the 
opening  in  the  viscus. 

Results. — Baron  Larrey  was  the  first  surgeon  to  state  that  a  wound  through 
all  the  coats  of  the  bladder  might  be  followed  by  recovery.  In  intraperitoneal 
ruptures  if  operation  is  not  performed  the  mortalit}'  is  98  per  cent.  If  opera- 
tion is  performed  many  cases  recover.  Of  the  78  cases  collected  by  Dambriu 
and  Papin,  in  1904,  34  died,  a  mortality  of  43  per  cent.  (Besley,  Ibid.).  In 
extraperitoneal  rupture  without  operation  there  are  11  per  cent,  cures  and 
with  operation  30  per  cent,  (see  Daniel  X.  Eisendrath,  "Jour.  Amer.  Med. 
Assoc,"  Oct.  25,  1902;  Samuel  Alexander,  "Annals  of  Surgery,"  Aug.,  1901). 

Atony  of  the  bladder  is  a  condition  in  which  the  expulsive  power  of 
the  bladder  is  diminished  or  lost  because  of  impairment  of  muscular  tone. 
The  bladder  is  very  thin,  and  the  muscles  are  flaccid  and  often  the  seat  of 
fatty  degeneration.  Sometimes  the  viscus  is  ver}-  large  and  sometimes  it  is 
very  small.  A  slight  degree  of  atony  is  physiological  after  middle  age.  The 
causes  are  senility,  distention  from  true  paralysis,  chronic  overdistention 
from  obstruction,  and  acute  overdistention. 

Symptoms. — In  atony  of  the  bladder  the  patient  passes  water  frequently 
(a  symptom  probably  existing  for  some  years),  and  especially  at  night;  he 
may  even  do  so  while  asleep.     The  stream,  when  voluntarily  passed,  has  no 


Vesical  Calculus,  or  Stone  in  the  Bladder  13 13 

projection,  but  drops  at  once  from  the  end  of  the  penis.  Residual  urine 
exists  for  years  and  may  at  any  time  set  up  cystitis,  and  retention  with  incon- 
tinence is  apt  to  occur.  This  condition  is  not  vesical  paralysis  resulting  from 
a  lesion  of  the  nervous  system. 

Treatment. — In  treating  atony  of  the  bladder  measure  the  residual 
urine:  if  it  amounts  to  four  ounces,  use  a  soft  catheter  night  and  morning;  if 
it  amounts  to  six  ounces,  use  the  catheter  every  eight  hours;  if  it  amounts 
to  eight  ounces,  use  the  catheter  every  six  hours  (J.  W.  White).  The  patient 
should  be  taught  how  to  use  the  catheter  and  how  to  keep  it  sterile.  (For 
methods  of  disinfecting  catheters  see  article  on  page  1305.)  The  bladder  is 
from  time  to  time  washed  out  with  gr.  iij  to  the  ounce  of  boric-acid  solution 
at  a  temperature  of  100°  F.  Strychnin,  electricity,  ergot,  and  urotropin  may 
be  ordered. 

Vesical  Calculus,  or  Stone  in  the  Bladder.— The  salt  normally 
in  solution  in  the  urine  may  deposit  as  calculi  and  may  be  imprisoned  in  any 
portion  of  the  urinary  tract.  The  commonest  calculi  are  those  composed  of 
uric  acid,  urates,  calcium  oxalate,  and  fusible  phosphates.  The  formation 
of  uric-acid  and  urate  calculi  is  explained  under  Renal  Calculus  (page  1281). 
Vesical  calculi  are  usually  renal  calculi  that  have  passed  the  ureter  and  become 
enlarged  by  new  accretions.  Phosphatic  calculi  may  be  formed  in  the  bladder 
when  chronic  cystitis  causes  and  maintains  an  alkaline  urine.  Uric-acid 
calculi  are  smooth,  round  or  oval,  and  hard,  but  easily  broken.  On  section 
they  present  the  color  of  brick-dust  and  are  marked  by  concentric  rings. 
Their  nuclei  are  dark  by  comparison.  They  are  soluble  in  dilute  potassium 
hydrate,  and  with  effervescence  in  nitric  acid.  They  are  combustible,  and 
leave  scarcely  any  ash.  Urate  of  sodium  and  urate  of  ammonium  often  occur 
together  in  stones,  and  these  calculi  are  not  in  rings,  are  not  so  hard  as  the 
uric-acid  stones,  and  are  fawn-colored  on  section.  Oxalate-of-lime  stones 
are  round,  with  many  projecting  nodes  like  the  mulberry,  hence  the  term 
"mulberry  calcvilus."  They  are  very  hard,  and  section  shows  the  color  to 
be  brown  or  green  and  that  they  possess  wavy,  concentric  rings.  This  form 
of  calculus  is  soluble  in  hydrochloric  acid.  Fusible  calculus,  which  is  com- 
posed of  magnesic  ammonic  phosphate  with  phosphate  of  lime,  constitutes 
the  commonest  form  of  phosphatic  stone  and  of  large  stone.  It  is  light,  soft, 
smooth,  and  white,  and  shows  no  laminae  on  section.  Some  rare  forms  of 
stone  are  composed  of  xanthic  oxid,  cystic  oxid,  calcium  phosphate  or  car- 
bonate, and  magnesic  ammonic  phosphate  (triple  phosphate). 

A  stone  may  be  formed  having  layers  of  different  substances;  for  instance, 
there  is  often  found  a  uric-acid  nucleus  surrounded  by  phosphates,  the  latter 
surrounded  by  some  uric  acid  or  urates,  and  these  again  by  phosphates.  In 
some  cases  oxalate  of  lime  alternates  with  uric  acid,  urates,  or  phosphates 
(Bowlby).  Bowlby  states  that  the  alternating  uric-acid  and  phosphatic 
layers  are  due  to  the  altering  reactions  of  the  urine;  that  when  the  urine  is 
acid  uric  acid  is  deposited  on  the  stone,  but  when  cystitis  makes  the  urine 
alkaline  the  stone  receives  a  phosphatic  coat. 

Anything  that  favors  the  formation  of  an  excessive  urinary  deposit  may 

cause  vesical  calculus,  and  among  such  causes  are  defective  digestion,  failure 

in  processes  of  oxidation,  excess  of  sohds  and  nitrogenous  elements  in  the  diet, 

deficient  exercise,  etc.     If  to  the  urinary  condition  established  by  the  above 

83 


1314        Diseases  and  Injuries  of  the  Genito-urinan*  Organs 

factors  catarrh  of  the  genito-urinar}'  tract  is  added,  pus  or  mucopus  in  the 
concentrated  urine  may  induce  stone.  Children  are  predisposed  to  uric-acid 
stones,  and  old  people  to  phosphatic  stones.  In  an  old  man  with  enlarged 
prostate  and  chronic  cystitis  a  stone  forms  rapidly  about  any  accidental 
nucleus.  The  nucleus  may  be  phosphate  cr)-stals  glued  together  by  mucus, 
a  blood-clot,  uric-acid  gravel,  or  a  foreign  body.  Stone  is  rare  in  females 
because  of  the  shortness,  the  large  diameter,  and  the  ready  dilatability  of  the 
urethra.  Stone  is  ver\'  rare  in  the  negro.  Gout,  rheumatism,  Hthemia, 
enlarged  prostate,  vesical  atony,  urethral  stricture,  and  catarrhal  inflamma- 
tion of  the  kidney,  the  ureter,  and  the  bladder  are  predisposing  causes. 

Symptoms. — In  not  a  few  cases  the  vesical  sj-mptoms  are  antedated  by  an 
attack  of  nephritic  colic.  The  severity  of  the  symptoms  of  stone  in  the  bladder 
depends  more  on  the  roughness  of  the  stone  than  on  its  size.  A  small,  rough 
calculus  will  produce  intolerable  anguish,  whereas  several  large,  smooth  stones 
will  cause  but  moderate  pain.  A  patient  with  stone  in  the  bladder  com- 
plains of  frequency  of  micturition,  particularly  in  the  daytime,  the  desire  being 
sudden,  uncontrollable,  and  invoked  or  aggravated  by  exercise.  This  5\Tnp- 
tom  is  more  positive  in  youth  than  in  old  age.  Pain  of  a  sharp,  burning  char- 
acter is  experienced  at  the  end  of  micturition,  due  to  the  contraction  of  the 
emptv  bladder  upon  the  stone  or  stones.  It  disappears  gradually  as  vu-ine 
enters  and  distends  the  bladder.     The  usual  seat  of  this  pain  is  the  under  sur- 


i:ii).jrtiJA-|  [|  n^i 


"\ 


Fig.  785. — Thompson's  calculus  sound. 


face  of  the  head  of  the  peni^,  a  little  behind  the  meatus,  and  the  pain  may 
continue  for  some  time.  By  pulling  on  the  penis  to  relieve  this  pain  the  pre- 
puce of  a  child  may  become  pendulous.  This  pain  varies  in  severity,  being 
worse  during  cystitis  and  after  exercise;  it  may  be  absent  in  encysted  stone, 
it  may  even  almost  disappear,  and  it  is  ahvays  worse  in  the  young  than  in  the 
old.  Stone  in  chronic  cases  of  atony  and  in  cases  of  vesical  paralysis  causes 
neither  marked  pain  nor  frequency  of  micturition.*  In  an  enlarged  prostate 
pain  precedes  the  act  of  micturition,  in  urethral  strictvire  it  accompanies  it,  and 
in  stone,  as  already  stated,  it  joUcm's  it.  (P.  J.  Freyer,  in  "The  Practitioner," 
Feb.,  1898. J  The  symptoms  are  somewhat  complicated  by  the  coexistence 
of  vesical  calculus  and  prostatic  hj-pertrophy.  Attacks  of  cystitis  in  a  man 
with  calculus  are  spoken  of  as  attacks  oj  stone.  When  a  stone  is  small,  it 
may  during  micturition  roll  into  the  urethral  orifice,  and  so  cause  a  sudden 
interruption  of  the  flow  of  urine,  the  stream  again  starting  when  the  patient 
changes  his  position.  This  s\Tnptom  is  seldom  met  with  and  is  particularly 
rare  in  the  old,  the  stone  in  them  dropping  into  the  sac  back  of  the  prostate 
and  below  the  urethral  orifice.  Even  if  this  symptom  occurs,  it  is  not  con- 
clusive, as  a  stalked  tumor,  a  blood-clot,  or  a  mass  of  pus  or  mucus  may 
block  the  urethral  orifice  and  cut  off  the  stream.  Hematuria  may  or  may 
not  be  noted;  it  is  most  usual  after  exercise,  and  occurs  at  the  end  of  the 
urinan.'  act,  the  first  urine  passed  being  clear,  the  later  vu^ine  being  blood- 
*". American  Te-^rt-book  of  Surgery." 


Stone  in  Children  13 15 

tinged,  and  at  the  end  of  the  act  some  drops  of  pure  blood  emerge.  It  is 
not  one  of  the  earliest-  symptoms.  When  it  occurs,  it  puts  the  patient  in  a 
great  fright.  It  does  not  appear  suddenly  and  profusely,  but  as  gradual  and 
trivial  bleeding  and  with  micturition.  Blood  appearing  between  acts  of  mic- 
turition comes  from  either  the  urethra  or  prostate  (P.  J.  Freyer).  The  bleed- 
ing from  a  bladder  tumor  is  profuse  and  the  urine  is  mixed  with  blood  and 
blood-clots  and  tumor  fragments.  Bleeding  from  a  tuberculous  ulcer  of  the 
bladder  often  resembles  the  bleeding  caused  by  stone.  Pus  or  mucopus  will  be 
observed  if  cystitis  occurs  with  calculus  disease.  Priapism  occurs  in  some 
cases.  Pain  of  a  reflex  nature  may  be  felt  in  the  rectum,  in  the  perineum,  or 
in  some  distant  part. 

The  above  symptoms,  even  if  all  are  present,  do  not  prove  that  an  indi- 
vidual has  a  stone  in  the  bladder.  To  prove  the  presence  of  a  stone,  it  must 
be  touched  with  a  sound  and  the  contact  must  be  felt  and  heard.  To  sound 
a  patient,  have  the  bladder  well  filled  with  boric-acid  solution  or  salt  solu- 
tion, and  place  him  recumbent,  with  the  knees  drawn  up.  Never  sound  a 
person  while  he  is  standing,  because  of  the  danger  of  syncope.  In  an  ordi- 
nary case  in  a  male  use  a  sound  with  a  very  slight  curve  (Fig.  785);  in  a 
man  with  hypertrophied  prostate  use  a  sound  with  a  short  and  decided  curve. 
The  caliber  of  a  stone-sound  is  No.  13  of  the  French  scale.  The  instrument 
is  carefully  boiled  and  anointed  with  yellow  liquid  cosmolin.  Examine  the 
entire  bladder  systematically,  and  be  sure  a  stone  is  present  only  when  contact 
with  the  sound  is  both  heard  and  felt.  The  stone  may  be  difficult  to  find,  or 
it  may  elude  the  instrument  entirely  when  it  is  encysted,  when  it  rests  in  a 
diverticulum,  when  it  is  fixed  to  the  roof  or  anterior  wall  of  the  viscus,  or 
when  it  is  crusted  with  lymph  or  blood-clot.  In  doubtful  cases  always  insist 
on  a  second  examination,  giving  ether  if  the  first  was  very  painful.  Occa- 
sionally, as  Freyer  pointed  out  in  1884,  a  small  stone  will  be  found  by  using  a 
Bigelow  evacuator,  the  current  causing  the  calculus  to  knock  against  the  tube. 
In  many  cases  stone  in  the  bladder  may  be  detected  by  means  of  the  x-rays. 
If  a  stone  is  fixed  in  a  diverticulum  or  projects  from  the  ureter,  or  is  in  a  sac 
back  of  the  prostate,  it  may  be  missed  by  sound  and  evacuator  tube  but  be 
shown  by  the  a*-rays.  In  such  a  case  the  bladder  must  be  examined'by  means 
of  a  cystoscope.  A  stone,  when  it  is  detected,  should  always  be  measured 
by  Thompson's  instrument,  an  arrangement  looking  something  like  a  small 
edition  of  a  hthotrite,  but  having  very  delicate  blades.  The  composition  of  the 
stone  is  assumed  from  an  examination  of  fragments  which  pass  by  the  urethra 
or  which  adhere  to  the  measure.  Remember  that  the  outer  layer  of  a  calculus 
may  be  soft  phosphate  and  the  inner  portion  may  be  the  harder  uric  acid,  urate, 
or  oxalate. 

Stone  in  Females. — Calculus  in  the  female  is  a  rare  complaint.  In  over 
900  patients  operated  upon  for  stone  by  Freyer  there  were  only  20  females. 
Pain  and  increased  frequency  of  micturition,  which  are  symptoms  of  stone  in 
men  and  women,  are  in  women  caused  by  other  conditions  as  well,  notably  by 
uterine  disease  and  displacement.  A  straight  sound  is  used  to  examine  a  female 
for  stone.  If  the  surgeon  is  still  uncertain  after  sounding,  he  dilates  the  ure- 
thra and  explores  the  bladder  with  his  little  finger. 

Stone  in  Children. — Can  occur  at  any  age,  and  congenital  cases  have 
been  placed  or  record.     The  uric-acid  stone  is  most  common.     The  symp- 


13 16        Diseases  and  Injuries  of  the  Genito-urinary  Organs 

toms  are  like  those  of  the  aduU.  The  pain  causes  the  male  child  to  pull  at  the 
penis  and  the  prepuce  becomes  pendulous.  If  in  a  child  with  stone  the  stream 
of  urine  is  blocked  from  time  to  time,  the  child  strains  to  empty  the  bladder 
and  after  a  time  a  hernia  may  form  or  prolapse  of  the  rectum  take  place. 

Treatment. — In  people  predisposed  to  stone  (for  instance,  by  lithemia) 
the  physician  should  foresee  the  danger  and  essay  to  antagonize  it.  Insist 
on  the  urine  being  kept  dilute  by  the  freest  use  of  water  and  of  milk,  and 
reduce  to  a  minimum  the  amount  of  alcohol,  meat,  sugar,  and  fat  which  is 
taken.  Let  the  patient  live  chiefly  on  green  vegetables,  salads,  bread,  fruit, 
eggs,  fish,  poultry,  weak  tea  or  coffee,  water,  milk,  and,  if  desired,  a  little  red 
wine.  Continued  purging  does  harm  by  concentrating  the  urine,  though  a 
laxative  may  be  employed  when  indicated.  Moderate  open-air  exercise  is 
of  immense  importance,  sunshine  and  fresh  air  being  nature's  correctives 
for  a  condition  of  imperfect  oxidation  power.  If  the  urine  be  very  acid,  use 
piperazin,  gr.  xv  to  gr.  xx  daily,  liquor  potassii  citratis,  phosphate  of  sodium, 
or  borocitrate  of  magnesium.  If  the  urine  be  phosphatic  and  alkaline,  order 
mineral  acids  and  strychnin,  or,  what  seems  to  be  very  efficient,  urotropin. 
Urotropin  is  given  in  gr.  v  capsules  four  times  daily.  If  the  urine  be  filled 
with  oxalate,  use  the  mineral  acids  with  an  occasional  course  of  phosphate 
of  sodium.  Travel  and  rest  at  the  seaside  or  at  some  spa  are  often  of  service 
in  all  forms.  Always  endeavor  to  prevent  cystitis,  and  treat  it  promptly 
when  it  does  occur.  When  a  stone  is  once  formed,  it  is  an  idle  dream  to  think 
of  dissolving  it.  An  operation  must  be  done.  The  operation  selected  depends 
upon  the  age,  the  state  of  the  bladder  and  the  prostate,  the  dilatability  of  the 
urethra,  the  kidney  condition,  the  size  and  composition  of  the  stone,  and  the 
number  of  calculi  present  (see  Operations  on  the  Bladder). 

Cystitis. — Inflammation  of  the  bladder  is,  as  a  rule,  a  complication 
of  some  other  disease  of  the  genito-urinary  tract,  but  it  may  arise  from  cold 
and  wet.  Traumatism  from  a  catheter,  the  presence  of  a  stone,  the  spread 
of  a  urethral  inflammation,  pus  infection,  vesical  tuberculosis  or  cancer, 
and  the  use  of  such  a  drug  as  cantharides  may  produce  it.  It  appears 
not  unusually  during  an  exanthematous  fever  or  in  conditions  of  vesical 
paralysis;  it  often  follows  retention,  frequently  accompanies  enlarged  pros- 
tate and  urethral  stricture,  and  sometimes  arises  from  concentration  of  urine 
or  accompanies  bladder  growths.  Acute  cystitis  causes  discoloration  and 
swelling  of  the  bladder-walls,  and  there  is  present  a  catarrhal  discharge  which 
is  mixed  with  urinary  elements,  serum,  mucus,  often  pus  and  epithelial  debris. 
Ulceration,  sloughing,  or  false-membrane  formation  may  occur.  Chronic 
cystitis  is  an  inflammatory  condition  always  due  to  bacteria.  We  frequently 
speak  of  a  chronic  cystitis  as  due  to  stone  in  the  bladder,  hypertrophy  of  the 
prostate  gland,  or  tumor  of  the  bladder.  These  conditions  do  not  cause 
chronic  cystitis,  but  act  by  rendering  the  bladder  vulnerable  to  micro-organ- 
isms. Among  the  causative  organisms  we  may  mention  the  bacillus  coli 
communis,  the  gonococcus,  the  bacillus  tuberculosis,  the  bacillus  typhosus, 
and  the  various  pyogenic  bacteria  (Leonard  Freeman).  These  bacteria  may 
gain  entrance  on  instruments  or  by  way  of  the  ureter,  urethra,  the  lymph- 
vessels,  and  possibly  in  rare  instances  by  the  blood. 

In  chronic  cystitis  there  is  an  enormous  production  of  thick,  sticky  mucus 
and  the  urine  becomes  alkaline.     The  excessive  secretion  of  mucus  and  the 


Treatment  of  Acute  Cystitis  ^3^7 

great  number  of  bacteria  convert  the  urea  into  carbonate  of  ammonium,  and 
this  product,  being  irritant  to  the  bladder-walls,  makes  the  inflammation 
worse.  In  chronic  cystitis  the  bladder  is  contracted  and  has  very  thick  walls, 
and  the  mucous  membrane  is  thick,  edematous,  congested,  and  filled  with 
large  veins.  The  bladder  may  be  ulcerated  or  encrusted  with  urinary  salts. 
The  urine  contains  bacteria,  triple  phosphate,  pus,  blood,  and  mucus,  the 
blood  emerging  with  the  last  drops  of  urine.  Pyelitis  may  arise  as  a  result 
of  chronic  cystitis. 

Symptoms  of  Acute  Cystitis. — Great  frequency  of  micturition,  with  the 
passage,  at  each  act,  of  a  very  small  quantity  of  urine;  the  desire  to  urinate  is 
almost  constant,  and  there  is  intensely  painful  straining  (tenesmus).  The 
pain  is  acute  and  scalding,  and  may  be  felt  above  the  pubes  or  in  the  peri- 
neum; it  often  runs  into  the  loins  and  the  thighs  and  radiates  over  the  sacrum. 
Pain  above  the  pubes  indicates  involvement  of  the  fundus,  and  pain  in  the 
perineum  and  in  the  head  of  the  penis  points  to  inflammation  of  the  bladder- 
neck.  The  urine,  at  first  clear,  loses  its  transparency,  becomes  full  of  thick 
mucus,  and  often  contains  a  little  blood  or  pus.  The  patient  not  unusually 
has  some  fever.  A  rectal  examination  causes  violent  pain.  If  ischuria 
takes  place,  there  will  be  a  chill  and  high  fever,  and  anuria  may  occur  or 
vesical  rupture  may  ensue. 

Treatment. — In  treating  acute  cystitis  endeavor  to  remove  the  cause. 
By  allaying  an  irritation  or  removing  an  obstruction  the  bladder  will  often 
become  able  to  empty  itself  of  retained  urine,  which  urine  causes  congestion 
of  the  bladder  and  thus  renders  infection  probable  or  may  be  itself  filled  with 
bacteria.  If  cystitis  arises  from  the  administration  of  cantharides,  put  the 
patient  in  bed  and  give  him  liquor  potassii  citratis.  If  it  comes  from  the  use 
of  a  clean  sound,  order  rest  in  bed,  suppositories  of  opium  and  belladonna, 
diluent  drinks,  and  ammonii  benzoas  or  lupulin.  If  the  inflammation  is 
septic  (as  from  the  use  of  a  dirty  sound)  or  is  very  acute,  put  the  patient  in 
bed,  keep  him  warm,  and  use  a  hot  sand-bag  to  the  perineum  and  hot  fomen- 
tations or  poultices  to  the  hypogastrium.  Hot  hip-baths  may  be  used. 
The  hips  should  be  elevated  and  the  bowels  should  be  emptied  by  the  admin- 
istration of  salines  and  by  glycerin  enemata.  An  exclusive  milk-diet  is  de- 
sirable. The  patient  should  drink  copiously  of  sweetened  water  containing  a 
few  drops  of  aromatic  sulphuric  acid  or  of  milk  of  almonds.  Sterilize  the 
urine  by  the  administration  of  urotropin,  giving  a  capsule  containing  gr.  7J 
of  the  drug  three  times  a  day.  Other  remedies  which  may  be  of  service  in 
sterilizing  the  urine  are  quinin,  boric  acid,  salol,  borocitrate  of  magnesium, 
and  salicylate  of  sodium.  A  valuable  remedy  consists  of  15  grains  of  sali- 
cylate of  sodium  and  15  grains  of  benzoic  acid,  given  three  times  a  day  in  a 
little  chloroform  water.     If  the  pain  and  straining  still  continue,  order — 

I^.     Ext.  hyoscyami, gr.  viij ; 

Ext.  cannabis  indicae, gr.  viij  ; 

Sacchar.  alba, gr.  xlviij. — M. 

Div.  in  pulv.  No.  xxiv. 

Sig. — One  powder  every  four  hours. 


Or, 


1318        Diseases  and  Injuries  of  the  Genito-urinary  Organs 

I^.     Camphorae gr.  viij ; 

Ext.  cannabis  indict, gr.  viij  ; 

Sacchar.  alba, gr.  xlviij. — M. 

Div.  in  pulv.  No.  xx. 

Sig. — One  powder  every  three  hours.  (Von  Zeissl.) 

Suppositories  of  extract  of  belladonna  are  of  great  value.  Suppositories  each 
containing  gr.  j  of  ichthyol  are  of  service,  and  one  may  be  used  every  four 
hours.  If  these  remedies  fail,  the  surgeon  will  be  driven  to  order  opium, 
which,  vmfortunately,  constipates;  when  it  is  given,  secure  evacuations  by  the 
use  of  glycerin  suppositories,  by  the  administration  of  saline  carthartics,  or 
by  the  employment  of  enemata.  If  opium  is  necessary,  it  is  given  in  a  sup- 
pository containing  gr.  j  of  powdered  opium  and  gr.  I  of  the  extract  of  bel- 
ladonna every  three  or  four  hours.  Hypodermatic  injections  of  morphin 
may  be  required.  Wash  the  bladder  out  daily  with  warm  normal  salt  solu- 
tion or  warm  boric-acid  solution.  This  can  be  done  through  a  soft  catheter 
or,  better,  by  hydrostatic  pressure.  If  retention  occurs,  use  a  soft  catheter. 
If  much  blood  is  passed,  give  internally  the  tinctura  ferri  chloridi  and  blister 
the  perineum.  Avery  acute  cystitis  is  rarely  arrested  within  a  week  or  ten 
days. 

Symptoms  of  Chronic  Cystitis. — This  condition  may  be  a  legacy  from 
acute  cystitis  or  it  may  appear  without  any  acute  precursory  phenomena. 
There  will  be  found  frequency  of  micturition,  but  not  so  great  as  in  the  acute 
form.  There  will  be  slight  tenesmus  and  moderate  pain  from  time  to  time, 
radiating  toward  the  head  of  the  penis.  Constitutional  symptoms  arise  only 
when  kidney-damage  has  become  pronounced  or  sepsis  has  occurred  from 
absorption.  The  urine  is  ammoniacal,  fetid,  and  turbid;  it  is  filled  with 
viscid,  tenacious  mucus  or  with  mucopus;  it  contains  a  great  excess  of  phos- 
phates, and  occasionally  clots  of  blood.  The  condition  of  chronic  cystitis 
with  the  production  of  immense  quantities  of  thick  mucus  is  often  called 
''chronic  catarrh  of  the  bladder.'"  Chronic  cystitis  may  eventuate  in  the 
formation  of  stone  or  in  the  production  of  serious  disease  of  the  bladder, 
the  ureters,  and  the  kidneys.     It  often  occasions  retention. 

Chronic  Tuber ctiJoiis  Cystitis. — Chronic  cystitis  may  be  due  to  tubercu- 
losis. Primary  tuberculosis  is  very  uncommon.  Most  cases  of  vesical  tuber- 
culosis are  secondary  to  renal  tuberculosis  or  to  tuberculosis  of  the  pros- 
tate, seminal  vesicles,  or  epididymis.  Some  cases  come  on  suddenly,  many 
tubercle  bacilli  being  found  in  the  urine.  In  many  cases  no  tubercle  ba- 
cilh  are  found.  The  tuberculous  products  caseate  and  ulcers  form  or  fibrous 
organization  takes  place.  A  cystitis  for  which  no  cause  can  be  found,  and 
which  is  accompanied  by  pyuria  and  severe  and  lasting  pain,  is  possibly 
tuberculous.  Pyuria  is  usually  present,  but  in  some  cases  the  urine  is  per- 
fectly clear.  In  some  cases  the  patient  has  painful  paroxysms  of  varying 
duration  and  feels  well  between  the  attacks.  Finding  tuberculosis,  if  of 
the  kidney,  prostate,  vesicle,  or  epididymis,  increases  the  probability  that 
tuberculous  cystitis  exists.  The  diagnosis  is  made  by  the  cystoscope.  Tu- 
berculous ulceration  is  most  common  in  the  trigone  and  about  the  inner  orifice 
of  the  urethra.  A  tuberculous  ulcer  is  small.  The  adjacent  mucous  mem- 
brane is  not  inflamed,  but  contains  grayish-white  nodules  (Louis  E.  Schmidt, 
in  "Jour.  Amer.  Med.  Assoc,"  July  19,  1902). 


Treatment  of  Chronic  Cystitis  13 19 

Treatment. — In  treating  chronic  cystitis  remove  the  cause,  if  possible 
(get  rid  of  a  stone,  evacuate  residual  urine  frequently,  dilate  a  stricture,  and 
remove  a  tumor).  For  chronic  cystitis  certain  remedies  are  taken  by  the 
mouth.  Water  is  drunk  in  large  amounts,  also  iron  spring-water  (Marienbad, 
etc.).  Salol  and  boric  acid,  gr.  v  of  each  four  times  a  day,  are  very  valuable. 
Salol  in  fluid  extract  of  triticum  repens  does  good;  so  does  chlorate  of  potas- 
sium, gr.  X  daily.  Either  borocitrate  of  magnesium,  quinin,  or  salicylate  of 
sodium  with  benzoic  acid  may  often  be  used  with  benefit.  Alum,  tannic 
acid,  uva  ursi,  copaiba,  cubebs,  buchu,  and  turpentine  have  all  been  recom- 
mended, and  possibly  may  be  of  some  benefit.  Urotropin  is  useful  in  many 
cases.  This  drug  prevents  the  development  of  bacteria  in  the  urine  (Nico- 
laier)  and  antagonizes  the  tendency  to  sepsis  and  urinary  poisoning.  It 
is  given  in  5-grain  capsules,  from  four  to  six  being  given  daily.  Whatever 
remedy  is  used,  see  that  the  bowels  move  once  a  day,  and  that  the  skin  is 
active.  Champagne  and  beer  must  be  avoided.  If  residual  urine  gathers,  a 
soft  catheter  must  be  regularly  employed.  If  it  is  possible  to  introduce  a  cath- 
eter of  considerable  size,  catheterization  may  be  all  that  is  needed  in  the  case. 
In  some  cases  of  chronic  cystitis  the  retention  of  a  catheter  from  three  to  five 
weeks  is  of  the  greatest  service.  If  the  case  is  very  severe,  the  bladder  must 
be  washed  out  daily  with  peroxid  of  hydrogen  (25  to  40  per  cent,  solution), 
nitrate  of  silver  (i  :  8000),  boric  acid  (5  to  10  per  cent.),  carboHc  acid  (i  :  500), 
corrosive  sublimate  (from  i  :  20,000  to  i  :  5000),  or  permanganate  of  potas- 
sium (i  14000).  If  nitrate  of  silver  or  permanganate  of  potassium  is  used, 
first  rinse  out  the  bladder  with  distilled  water.  If  any  other  agent  is  used,  first 
wash  out  the  bladder  with  either  boiled  or  distilled  water.  The  daily  injection 
of  a  2  per  cent,  solution  of  ichthyol  may  prove  useful.  Some  surgeons  occa- 
sionally employ,  at  intervals  of  a  number  of  days,  strong  silver  solutions  (30  or 
40  grains  to  the  ounce).  If  a  strong  solution  is  used,  after  the  drug  flows  away 
wash  out  the  bladder  with  a  solution  of  common  salt.  The  bladder  is  usually 
v/ashed  out  by  attaching  to  the  free  end  of  a  soft  catheter,  the  other  end  of 
which  is  in  the  bladder,  a  tube  which  is  connected  with  a  graduated  bottle, 
the  force  being  obtained  by  elevating  the  reservoir  {fountain  irrigation). 
The  bladder  can  be  irrigated  without  using  a  catheter,  the  resistance  of  the 
compressor  muscle  of  the  urethra  being  overcome  by  the  pressure  of  a  column 
of  water.  The  reservoir  is  raised  to  the  height  of  six  feet.  The  patient  sits 
in  a  chair.  The  tube  of  the  reservoir  has  upon  it  a  clamp  to  control  the  flow, 
and  in  its  end  a  large  bulbous  tip  which  will  fill  the  meatus  (Valentine's 
instrument).  The  tip  is  inserted  into  the  urethra,  the  clamp  on  the  tube  is 
loosened,  and  the  patient  its  directed  to  take  a  deep  inspiration.  In  a  short 
time  the  bladder  fills  with  water,  the  tube  is  removed,  and  the  patient  empties 
the  viscus  naturally.  In  some  cases  it  is  necessary  to  wait  quite  a  while  for 
the  column  of  water  to  tire  out  the  muscle.  If  the  fluid  will  not  enter,  direct 
the  patient  to  make  efforts,  as  in  micturating,  the  pressure  of  the  fluid  on 
the  anterior  surface  of  the  cut  off  muscles  being  kept  up.  If  this  fails,  direct 
him  to  urinate,  and  then  the  surgeon  makes  another  attempt  to  get  the  fluid 
to  enter.     After  a  little  practice  a  patient  learns  how  to  admit  the  fluid. 

In  tuberculous  cystitis  Collin  advises  the  instillation  of  30  minims  of  the 
following  mixture  into  the  bladder  and  posterior  urethra:  5  gm.  of  guaiacol, 
I  gm.  of  iodoform,  100  gm.  of  sterile  olive  oil.     About  30  minims  of  this  are 


1320  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

injected  once  a  day.  If  the  cystoscope  discloses  an  ulcer  and  the  kidney  i.^ 
tuberculous,  it  is  useless  to  operate  on  the  ulcer  until  operation  has  been  per- 
formed on  the  kidney.  Sometimes  cureting  through  a  cystoscope  is  useful. 
In  other  cases  the  bladder  must  be  opened,  cureted,  and  drained.  In  ordi- 
nary non-tuberculous  cystitis  Collin  uses  a  i  per  cent,  solution  of  guaiacol 
carbonate  in  oil. 

If  the  ordinary  methods  of  treatment  fail  to  cure  chronic  cystitis;  if  the 
bladder  resents  catheterization  and  irrigation;  if  in  spite  of  irrigation  the 
urine  does  not  become  clear;  and  if  there  are  evidences  of  infection  of  the 
patient  and  breaking  down  of  his  general  health,  drain  by  perineal  or  supra- 
pubic cystotomy  and  through  the  incision  wash  the  bladder  frequently  and 
thoroughly.  If  the  persistent  cystitis  is  due  to  stricture  which  dilatation  fails 
to  cure,  perform  external  perineal  urethrotomy  and  employ  perineal  drainage. 

Ulcer  of  the  Bladder. — May  be  due  to  injury,  cystitis,  tuberculosis, 
malignant  tumor,  or  gonorrhea.  A  form  of  ulceration  particularly  common 
in  anemic  women  is  a  solitary,  punched-out  ulcer  (Louis  E.  Schmidt,  "Jour. 
Amer.  Med.  Assoc,"  July  19,  1902).  Ulcers  may  be  single  or  multiple. 
Perforation  may  occur. 

A  perforation  may  occur  into  the  peritoneal  cavity  or  into  the  perivesical 
cellular  tissue.  In  the  former  case,  after  the  onset  of  marked  hematuria, 
there  are  shock,  abdominal  pain,  and  peritonitis.  In  the  latter  case  there  is 
extravasation  of  urine  or  abscess-formation. 

Tuberculous  ulcer  is  discussed  on  page  1318. 

Schmidt  ("Jour.  Amer.  Med.  Assoc,"  July  19,  1902)  points  out  that 
gonorrheal  ulceration  is  apt  to  be  multiple,  and  causes  severe  pain  and  bloody, 
turbid  urine.  As  a  rule,  when  the  bladder  is  ulcerated,  the  urine  contains 
blood,  blood-clots,  or  tissue  debris,  but  the  urine  may  be  clear  when  there  is  a 
tuberculous  ulcer  or  solitary  ulcer  (Schmidt,  in  previously  quoted  paper). 

Diagnosis  is  usually  made  by  the  cystoscope.  In  some  cases  it  is  made 
by  exploratory  suprapubic  incision. 

Treatment. — If  there  is  one  ulcer,  or  if  there  are  a  few  ulcers,  curet  through 
an  operating  cystoscope  (Schmidt),  use  irrigations,  and  keep  the  urine  aseptic. 
In  wide-spread  ulceration  perform  suprapubic  cystotomy,  curet  the  diseased 
mucous  membrane,  and  insert  a  drainage-tube.  In  some  cases  of  mahgnant 
growth  the  cautery  is  used  as  a  palliative  measure.  Perforation  is  treated 
as  is  rupture  of  the  bladder  (page  13 10). 

Tumors  of  the  Bladder. — These  growths  are  usually  said  to  be  very 
rare,  but  in  Guyon's  statistics  they  are  found  to  constitute  3.9  per  cent,  of  all 
cases  of  genito-urinary  disease.  They  are  almost  5  times  as  common  in 
males  as  in  females.  They  are  most  frequently  met  with  between  the  ages 
of  fifty  and  sixty,  although  myxoma  is  met  with  only  in  childhood  and  sarcoma 
is  most  common  in  the  young  (Lincoln  Davis,  in  "Annals  of  Surgery,"  April, 
1906).  Persistent  vesical  irritation  may,  perhaps,  be  an  element  in  causing 
tumor.  Tumors  of  the  bladder  may  be  either  innocent  or  malignant,  the  latter 
being  the  commonest.  Innocent  tumors  which  may  arise  from  the  bladder 
are  papillomata  or  villous  tumors,  adenomata,  mucous  polypi  (myxomata), 
fibrous  polypi,  myomata,  and  angiomata.  Cysts  may  also  arise.  Malig- 
nant tumors  are  sarcoma  (rare)  and  carcinoma  (encephaloid,  rare;    epithe- 


Treatment  of  Tumors  of  the  Bladder  132 1 

lioma,  common).  The  majority  of  bladder  carcinomata  are  secondary  to 
growths  of  the  rectum,  prostate,  or  uterus.  Adenocarcinoma  and  scirrhous 
carcinoma  are  practically  always  secondary  to  rectal,  prostatic,  or  uterine 
tumors.  Papillary  cancer  and  epithelioma  are  not  unusually  primary  (Man- 
dlebaum,  in  ''Surg.,  Gynecol.,  and  Obstet.,"  1907).  Any  tumor  of  the 
bladder,  innocent  or  malignant,  will   eventually  cause  death  if  allowed  to 

remain. 

Symptoms.— The   innocent    tumors   rarely   cause   cystitis   or   irritation, 
though  by  obstructing  the  ureters  or  the  urethra  they  may  induce  disease  of 
the  kidneys.     Hematuria  is  almost  invariably  present  at  some  time  in  the 
course  of  a  bladder  tumor.     It  is  apt  to  be  profuse,  and  the  urine  contains 
blood,  blood-clots,  and  perhaps  fragments  of  tumor.     The  bleeding  is  intermit- 
tent, may  occur  even  when  the  patient  is  at  rest,  and,  except  in  malignant  dis- 
ease, is  seldom  preceded  or  accompanied  by  pain.     Bleeding  usually  occurs  at 
the  termination  of  micturition,  the  first  urine  being  clear  and  the  last  red  or 
clotted.     Often  hemorrhage  is  the  only  phenomenon  produced  by  a  papilloma 
or  a  mucous  polypus.     :Malignant  tumors  cause  cystitis,  and  the  urine  contains 
mucus,  blood,  and  pus.     The  growth  may  become  crusted  with  salts  from  the 
urine.  '  Cancer  is  distinctly  and  often  horribly  painful.     In  malignant  disease 
ulceration  may  occur  into  the  peritoneal  cavity  or  gut.     A  malignant  tumor  pro- 
gresses much  more  rapidly  than  an   innocent  growth,  although  in  cancer 
metastases  are  not  formed  so  early  as   in  some  other  regions.     Innocent 
tumors  are  felt  with  difficulty  with  the  sound,  but  malignant  tumors  are 
easily  felt.     In  some  cases  a  tumor  can  be  detected  by  a  bimanual  examina- 
tion (a  finger  in  the  rectum  and  the  fingers  of  the  other  hand  on  the  abdo- 
men).    ]Make  a  careful  study  to  determine  whether  or  not  a  growth  has 
infihrated  the  prostate,  the  seminal  vesicles,  the  rectum,  or  the  perivesical 
tissues.     Bleeding  follows  the  use  of  a  sound.     There  may  be  difficulty  in 
starting  the  stream  in  micturition,  or  there  may  be  interruption  or  ''stammer- 
ing'' of  the  stream.     The  urine  should  be  examined  microscopically  to  see 
if  it  contains  villi,  portions  of  fibroma,  colonies  of  cancer-cells,  or  fragments 
of  epithelioma.     A  cystoscope  should  be  employed  in  order  to  reach  a  diag- 
nosis.    If  the  urethra  is  too  narrow  for  the  cystoscope,  this  channel  must 
be  dilated.     If  there  is  profuse  bleeding,  an  irrigating  cystoscope  must  be  em- 
ployed.    In  doubtful  cases  explorator>'  suprapubic  cystotomy  is  advisable. 

Treatment.— Complete  extirpation  of  the  bladder  for  cancer  has  been 
performed  by  Bardenheuer  and  others.  It  is  usually  done  in  two  stages, 
in  the  first  operation  the  ureters  of  a  man  being  transplanted  into  the  rectum, 
the  ureters  of  a  woman  into  the  rectum  or  vagina.  About  three  weeks  later 
the  bladder  is  removed.  The  adjacent  lymph-nodes  along  the  internal  ihac 
vessels  and  in  front  of  the  sacrum  must  be  removed  in  all  cases.  The  surgeon 
should  bear  in  mind  that  scirrhus  and  adenocarcinoma  are  secondary  growths, 
and  if  he  cannot  remove  the  primar>'  growth  he  should  not  extirpate  the  bladder. 
The  complete  procedure  has  been  carried  out  successfully  at  one  operation 
(Tuffier  and  Dujarier,  "Rev.  de  Chir.,"  April,  1898).  Some  surgeons  prefer 
preliminan-  double  lumbar  nephrostomy;  others  transplant  the  ureters  to 
the  skin  surface.  The  operation  of  complete  extirpation  is  of  questionable 
value. 


1322  Diseases  and  Injuries  of  the  Geni to-urinary  Organs 

In  Rafin's  collection  of  30  cases  there  were  17  deaths.  One  case  was  alive 
five  years  after  operation,  i  fifteen  months,  and  i  seven  months  after.  Wat- 
son's table  of  25  cases  shows  14  deaths  and  only  2  of  the  survivors  were  ahve 
and  free  from  recurrence  after  three  years. 

Complete  extirpation  should  be  employed  only  when  cancer  involves  the 
bladder  extensively.  I  agree  with  Berg  ("Annals  of  Surg.,"  Sept.,  1908)  that 
if  less  than  one-third  of  the  bladder  is  involved  the  operation  should  be  partial 
cystectomy  \vith  implantation  of  the  ureters  into  the  portion  of  bladder  remain- 
ing. The  surgeon  removes  the  anatomically  related  area  and  always  bears  in 
mind  that  adenocarcinoma  and  scirrhus  are  secondary  growths  in  the  bladder. 
Partial  cystectomy  saves  the  fatal  operation  of  transplanting  the  ureters  as 
is  ordinarily  done,  or  the  dangerous  operation  of  lumbar  nephrostomy  with  all 
of  its  unpleasant  consequences.  In  Rafin's  collection  of  96  cases  there  were 
21  deaths  (a  mortaUty  one-half  that  of  complete  cystectomy);  50  cases  were 
traced — 5  were  well  over  three  years  and  16  over  six  months  (Berg,  Ibid.). 

Many  surgeons  content  themselves  in  vesical  cancer  with  suprapubic  cystot- 
omy, removing  the  growth  and  a  portion  of  the  bladder-wall.  If  removal 
is  not  possible,  curet,  cauterize,  and  drain.  In  innocent  tumor  the  growth 
and  a  portion  of  the  bladder-wall  are  removed,  usually  through  a  suprapubic 
incision.  The  perineal  operation  only  enables  the  surgeon  to  reach  and  re- 
move growths  of  small  size,  pedunculated  growths,  and  growths  near  the  neck 
of  the  bladder.  (See  Operations  on  the  Bladder.)  Henry  Morris  lays  down 
the  following  rule:  "When  an  infiltrating  growth  is  felt,  per  rectum  ox  per 
vaginam,  or  with  the  sound,  to  be  involving  a  large  surface  of  the  bladder- 
wall,  to  be  infiltrating  its  coats,  especially  in  the  neighborhood  of  the  ure- 
ters and  neck  of  the  bladder,  no  operation  whatever  should  be  proposed 
unless  the  hemorrhage  is  copious  or  the  symptoms  of  cystitis  severe,  and 
then  an  incision  for  palliative  purposes  only  should  be  made"  (Treves's 
"System  of  Surgery"). 

Operations  on  the  Bladder. — Lateral  Lithotomy. — Lithotomy  is 
the  removal  of  a  stone  from  the  bladder.  Lateral  lithotomy  is  an  operation 
which  is  every  year  becoming  less  popular,  but  which  is  still  at  times 
employed  by  surgeons,  especially  for  stone  in  children.  This  operation 
should  not  be  performed  if  the  stone  is  over  two  inches  in  its  short  diameter; 
it  is  rarely  justifiable  if  the  stone  weighs  three  ounces  or  more  (Cage) ;  and 
it  must  not  be  performed  for  encysted  stone,  or  on  a  person  with  a  deep  peri- 
neum, a  narrow  pelvic  outlet,  or  an  enlarged  prostate.  For  one  week  before 
the  operation  keep  the  patient  in  bed,  wash  out  the  bladder  daily  with  hot 
boric-acid  solution,  and  administer  salol  and  boric  acid  by  the  mouth,  gr.  v 
of  each  four  times  a  day.  The  night  before  the  operation  give  a  saline,  order 
a  hot  bath,  and  have  the  perineum,  the  scrotum,  the  buttocks,  and  the  inner 
sides  of  the  thighs  cleansed  and  dressed  antiseptically.  In  the  morning  an 
enema  is  to  be  given.  At  the  time  of  operation  the  bladder  should  con- 
tain several  ounces  of  boric-acid  solution.  The  instruments  required 
are  a  lithotomy  knife,  a  straight  probe-pointed  bistoury,  a  grooved  staff,  a 
stone-sound,  stone-forceps  and  scoops,  a  tenaculum,  an  aneurysm  needle, 
a  fountain  syringe,  curved  needles  and  a  needle-holder,  hemostatic  forceps,  a 
tube  with  chemise  (Fig.  209),  a  Paquelin  cautery,  a  Clover  crutch,  and 
a  hthotrite. 


Suprapubic  Lithotomy  1323 

Place  the  patient  upon  his  back,  anesthetize  him.  and  find  the  stone  by 
sounding.  If  the  stone  is  not  discovered  by  the  sound,  do  not  operate.  Place 
the  buttocks  so  that  they  project  beyond  the  edge  of  the  table,  introduce  the 
staff  into  the  bladder,  flex  the  legs  and  thighs,  and  fasten  the  patient  in  the 
lithotomy  position  with  a  crutch.  During  the  first  incision  the  handle  of  the 
staff"  is  held  toward  the  belly;  after  the  first  cut  the  staff  is  set  perpendicularly 
and  is  hooked  up  under  the  pubes.  An  incision  is  made,  starting  just  to  the 
left  of  the  raphe  of  the  perineum  and  one  and  a  quarter  inches  in  front  of  the 
edge  of  the  anus,  and  passing  downward  and  outward  to  between  the  anus 
and  the  ischial  tuberosity,  but  one-third  nearer  the  former  than  the  latter.  In 
the  adult  this  incision  is  three  inches  long.  The  first  incision  is  superficial 
and  does  not  reach  the  staff,  but  it  is  this  incision  which  may  cut  the  rectum. 
After  making  the  first  cut  the  nail  of  the  left  index-finger  feels  for  the  groove 
of  the  stafT,  the  staff  is  hooked  up,  the  knife  is  entered  into  the  groove  and  is 
pushed  into  the  bladder,  and  as  it  is  withdrawn  the  wound  is  enlarged.  As 
the  knife  enters  the  bladder  there  is  a  gush  of  fluid.  The  finger  follows  the 
knife  and  stretches  the  wound,  the  staff  is  withdrawn,  and  the  stone  is  felt  for 
and  extracted  with  forceps.  Liston  showed  years  ago  the  value  of  keeping 
the  finger  in  the  wound.  This  maneuver  retains  some  water  in  the  bladder, 
and  as  a  consequence  causes  the  stone  to  rest  at  the  lowest  part  of  the  viscus, 
and  when  the  forceps  are  introduced  they  at  once  come  upon  the  stone.  In 
withdrawing  the  stone  make  traction  in  the  axis  of  the  pelvis,  and  do  not  rotate 
the  calculus  until  it  is  entirely  out  of  the  prostatic  urethra.  Wash  or  scrape 
away  debris  or  incrustation  from  the  wall  of  the  bladder,  see  that  no  other 
stone  is  present,  syringe  out  the  viscus  with  warm  salt  solution,  insert  a  tube, 
apply  antiseptic  dressings  around  the  tube,  and  put  on  a  T-bandage.  The  end 
of  the  tube  which  is  external  to  the  dressings  is  fastened  to  the  tails  of  the 
T-bandage.  A  rubber  cloth  is  put  on  the  bed,  under  the  body  and  legs,  and 
the  patient's  buttocks  rest  upon  a  mass  of  old  hnen.  the  scrotum  being  raised 
on  a  pad.  The  knees  are  bent  over  pillows.  Change  the  linen  as  soon  as 
it  becomes  wet.  Remove  the  tube  in  forty-eight  hours.  The  urine  begins 
to  come  by  the  urethra  from  the  eighth  to  the  twelfth  day.  In  children  the 
incision  is  not  so  long,  it  is  dilated  with  forceps  instead  of  with  the  finger, 
and  no  tube  is  required.  In  lateral  lithotomy  the  prostatic  and  membranous 
portions  of  the  urethra  are  opened,  the  prostate  gland  is  partly  divided  with 
the  knife,  and  the  wound  is  dilated  with  the  finger.  One  objection  to  the 
operation  is  that  it  is  possible  to  cut  the  rectum,  and  another  is  that  inflam- 
mation may  occlude  the  ejaculatory  ducts. 

Suprapubic  Lithotomy. — This  operation  is  the  removal  of  a  stone 
through  an  opening  above  the  pubes.  It  is  in  many  instances  the  preferable 
operation.  The  mortahty  of  this  operation  is  higher  in  children  than  that  of 
lateral  hthotomy;  in  adults  and  in  individuals  beyond  middle  life  the  mor- 
tahty is  decidedly  less  than  is  that  following  the  lateral  operation.  It  is  used 
for  the  removal  of  multiple  calculi,  for  very  hard  stones,  for  stones  above 
one  and  a  half  inches  in  diameter,  for  calculi  in  men  with  enlargement  of 
the  prostate,  for  foreign  bodies  incrusted  with  sediment,  when  the  perineum 
is  deep,  when  the  pelvic  outlet  is  narrow,  for  encysted  stones,  for  calculi  asso- 
ciated with  a  vesical  tumor,  and  when  the  urethra  will  not  permit  the  use  of  a 


1324  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

lithotrite.  The  patient  is  prepared  as  for  lateral  lithotomy,  except  that  the 
pubes  are  shaved,  and  the  lower  part  of  the  abdomen  and  the  upper  part  of 
the  thighs  are  disinfected.  During  the  operation  the  penis  is  wrapped  with 
a  piece  of  antiseptic  gauze.  The  instruments  required  are  a  scalpel,  a  probe- 
pointed  bistoury,  scissors,  a  tenaculum,  blunt  hooks,  hemostatic  forceps, 
retractors,  dissecting  forceps,  a  dry  dissector,  an  electric  forehead-light,  a 
rectal  bag,  a  brass  syringe  or  a  bicycle  pump,  a  sound,  rubber  tubing,  rubber 
catheters,  stone-forceps  and  scoops,  a  bladder-tube,  curved  needles  and  a 
needle-holder,  and  a  graduated  glass  jar  for  injecting  the  bladder. 

In  performing  the  operation  place  the  patient  in  the  Trendelenburg  posi- 
tion. It  is  necessary  to  distend  the  bladder  and  raise  it  in  order  to  have  the 
prevesical  space  uncovered  by  peritoneum.  Have  an  assistant  oil  the  rectal 
bag  and  push  it  above  the  sphincters.  Draw  off  the  urine  with  a  soft  catheter, 
wash  out  the  bladder  with  warm  boric-acid  solution  (gr.  iij  of  boric  acid  to 
Sj  of  water),  and  inject  the  bladder  with  the  same  solution.  In  a  child  under 
the  age  of  five  inject  three  to  four  ounces;  in  an  adult  inject  ten  to  twelve 
ounces.  Withdraw  the  catheter  and  tie  a  tube  around  the  penis  to  prevent 
the  escape  of  fluid.  After  injecting  the  bladder  with  fluid,  if  the  viscus  is  not 
well  lifted,  inject  the  rectal  bag  with  water  and  clamp  its  tube  with  forceps. 
In  a  child  inject  from  two  to  four  ounces  of  warm  water  into  the  rectal  bag; 
in  an  adult  inject  ten  ounces.  Bristow  suggested  the  injection  of  air  into  the 
bladder.  Some  surgeons  simply  inject  air  by  means  of  a  catheter  and  a  brass 
syringe  or  a  Davidson  syringe.  If  air  is  injected,  a  rectal  bag  is  not  u.sed, 
and  the  patient  is  placed  on  his  back  rather  than  in  the  position  of  Trendelen- 
burg. The  best  method  of  injecting  air  is  that  of  F.  Tilden  Brown,  by  means 
of  a  bicycle  pump.  A  catheter  is  introduced,  the  bladder  is  washed  out,  the 
catheter  is  fastened  to  a  bandage,  the  bicycle  pump  is  attached,  the  opera- 
tion is  proceeded  with,  and  when  the  transversalis  fascia  is  exposed  the 
bladder  is  filled  with  air,  the  soft  catheter  is  clamped,  and  the  bladder  is 
opened.*  Make  a  three-inch  longitudinal  incision  in  the  median  hne  of  the 
hypogastric  region,  terminating  over  the  symphysis.  When  the  prevesical 
connective  tissue  is  reached,  cut  it.  If  the  peritoneum  should  appear,  push 
it  up.  Hold  the  wound-edges  apart  with  retractors.  The  large  veins  are 
seen,  giving  the  bladder  a  blue  color.  Avoid  these  veins  if  possible,  but  even 
if  they  should  be  cut  bleeding  will  usually  cease  when  the  bladder  is  opened 
and  the  rectal  bag  is  removed.  Clamp  bleeding  vessels;  catch  the  bladder 
transversely  with  a  tenaculum  at  the  upper  angle  of  the  wound;  open  the 
viscus  in  the  middle  line  above,  and  cut  toward  the  pubes;  catch  the  edges  of 
the  bladder  with  hemostatic  forceps,  and  remove  the  tenaculum.  Explore  the 
bladder,  remove  the  stone  or  stones,  scrape  away  incrustations,  hgate  bleed- 
ing vessels  outside  the  bladder,  and  irrigate  the  viscus  with  hot  sahne  solu- 
tion. Introduce  a  tube  into  the  bladder,  and  attach  to  its  external  end  a  long 
tube  to  siphon  off  the  urine.  The  bladder  can  be  drained  very  satisfactorily  by 
Keen's  siphonage  apparatus  (Fig.  786).  Suture  the  muscles  and  fascia  at  the 
upper  part  of  the  wound.  Dress  with  dry  antiseptic  gauze  and  a  rubber-dam, 
the  dressings  and  binder  being  split  to  go  around  the  tube.  Catch  the  urine 
which  siphons  over  in  a  bottle  containing  some  antiseptic  fluid.     Change  the 

*  F.  Tilden  Brown,  "Annals  of  Surgery,"  Feb.,  1897. 


Litholapaxy 


1325 


dressings  as  often  as  they  become  wet.  Take  out  the  tube  in  four  or  five  days, 
and  allow  the  wound  to  heal  by  granulation.  The  patient  may  get  up  in  two 
weeks.  Many  Continental  surgeons  advocate  immediate  suture  of  the  bladder 
after  incision.  Albert,  Vincent,  Bassini,  DeVlaccos,  and  others  advocate 
immediate  suture.  The  suture  material  should  be  catgut.  After  suture 
L  catheter  is  kept  in  the  bladder  to  drain  the  viscus.  Immediate  suture 
may  be  employed  in  patients  of  any  age,  but  should  not  be  used  if  the  urine 
is  very  septic  or  if  pyelonephritis  exists.  In  some  cases  the  attempted 
ck^sure  will  fail;  in  others  it  will  only  partially  succeed;  in  many  it 
v.ill  prove  successful;  but  even  if  it  only  partially  succeeds  it  will  tend  to 


Fig.  786. — Cathcart  drainage. 


The  Y-tube  is  of  glass  and  is  darkened  in  order  to  be  shown 
against  a  white  background. 


prevent  dissemination  of  urine  in  the  prevesical  cellular  tissue.  The  chief 
causes  of  death  after  suprapubic  lithotomy  are  septicemia,  secondary  hem- 
orrhage, celluHtis,  peritonitis,  and  suppression  of  urine.  J.  W.  White  esti- 
mates the  relative  mortality  of  suprapubic  and  lateral  lithotomy  as  follows: 
In  children  the  suprapubic  operation  gives  a  mortality  of  12  per  cent., 
the  perineal  of  3  per  cent.  In  adults  the  suprapubic  gives  a  mortality  of  12 
per  cent.,  the  perineal  from  8  to  12  per  cent.  In  eld  men  the  suprapubic 
gives  a  mortality  of  25  to  30  per  cent.,  the  perineal  30  to  40  per  cent. 

Crushing  of  Vesical  Calculi, — This  is  now  done  in  one  sitting,  the  old 
operation  of  Civiale,  which  required  repeated  crushings,  being  obsolete. 

Litholapaxy  (Bigelow's  operation,  or  rapid  lithotrity)  is  the  operation 
for  removing  a  stone  from  the  bladder  in  one  sitting  by  thoroughly  crushing 


1326  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  stone  and  completely  washing  away  the  fragments.  This  operation  is 
wonderfully  successful  if  done  by  an  expert.  Few  of  us  do  it  sufficiently 
often  to  learn  how  to  perform  it  with  great  rapidity,  certainty,  and  safety. 
It  is  the  best  operation  in  most  cases,  if  performed  by  a  very  skilful  man.  It  is 
the  operation  in  the  majority  of  cases  for  even  the  general  surgeon  to  select, 
but  the  general  surgeon  will  have  better  results  in  certain  difficult  cases  after 
suprapubic  lithotomy  than  after  litholapaxy.  Sir  H.  Thompson  says  this 
method  is  suited  to  twenty-nine  cases  out  of  thirty.  Litholapaxy  should  be 
employed  if  the  bladder  will  hold  at  least  four  ounces  of  fluid  and  is  in  a  fairly 
healthy  condition;  if  the  urethra  is  tolerant  and  penetrable  by  instruments; 
if  the  stone  is  not  too  hard,  does  not  weigh  over  two  and  three-quarter  ounces, 
and  is  not  over  two  inches  in  diameter.  It  is  not  suited  for  multiple  calculi, 
for  large  and  hard  calculi,  for  encysted  stones,  or  for  a  patient  with  marked 


Fig.  787.— Bigelow's  latest  evacuator. 


enlargement  of  the  prostate  gland,  with  vesical  atony,  or  with  cystitis.  An 
easily  dilatable  stricture  need  not  prevent  the  surgeon  doing  htholapaxy. 
The  stricture  can  first  be  dilated,  and  later  Bigelow's  operation  can  be  per- 
formed, but  firm,  gristly  strictures  demand  a  cutting  operation.  If  the  ure- 
thra is  intolerant  of  instrumentation,  the  patient  being  prone  to  febrile 
attacks  when  it  is  attempted,  cut  instead  of  crushing.  An  individual  labor- 
ing under  kidney  disease  will  do  better  after  this  operation  than  after 
cutting  (Cage).  In  diabetes,  locomotor  ataxia,  and  conditions  of  exhaustion 
patients  are  best  treated  by  Bigelow's  operation,  unless  cystitis  exists. 

The  Indian  surgeons  have  had  the  most  admirable  results  from  litho- 
lapaxy. It  has  often  been  claimed  that  such  results  were  due  to  racial  pecu- 
Harities  of  the  patients  and  various  factors  regarding  their  habits,  diet,  etc. 
The  fact,  however,  that  some  of  these  very  surgeons  have  returned  to  England 


Litholapaxy  1327 

and  repeated  their  successes  in  London,  shows  how  large  a  part  masterlj 
dexterity  played  in  obtaining  success. 

J.  A.   Cunningham  *  reports  upon   10,073   Indian  cases  of  litholapaxy. 
The  mortality  was  3.96  per  cent. 

Cabot,  of  Boston,  in  116  cases  had  but  four  deaths,  and 
two  of  these  were  due  to  pneumonia. 

The  preparation  of  the  bladder  is  the  same  as  for 
lithotomy.  Be  sure  to  measure  the  stone,  and  to  ascertain 
also  whether  a  lithotrite  can  readily  be  introduced  and 
manipulated.  The  instruments  required  are  a  stone- 
sound,  lithotrites  (several  sizes,  Figs.  788-790),  an  evacu- 
ating bulb  and  tubes  (straight  and  curved,  Figs.  787, 
791),  soft  catheters,  a  glass  irrigator  to  inject  the  bladder, 


Fig.  7S8.— Bigelow's 
lithotrite. 


Fig.  789.— Thompson's 
lithotrite. 


Fig.  790 — Forbes's 
lithotrite. 


and  instruments  in  case  the  surgeon  is  forced  to  cut.  The  patient  is 
anesthetized  and  is  placed  upon  his  back,  a  pillow  is  inserted  under  the 
pelvis,  and  he  is  well  wrapped  up.  The  urine  is  drawn  and  a  measured 
amount  of  warm  boric  acid  is  allowed  to  flow  into  the  bladder.  This 
*Brit.  Med.  Jour.,  Aug.  7,  1887. 


1328  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


plan  is  better  than  having  the  patient  retain  his  urine,  as  in  the  latter  case  there 
is  no  certainty  as  to  the  amount  of  fluid  in  the  viscus.  It  is  well  to  introduce 
at  least  five  or  six  ounces  of  fluid,  if  possible.  If  the  bladder  will  not  hold 
four  ounces  the  operation  is  unsafe  (Thompson).  The  hthotrite,  preferably 
the  instrument  of  Forbes  (Fig.  790),  is  now  introduced,  the  handle  being 
gradually  raised  to  a  vertical  po.sition  as  the  penis  is  drawn  up  on  the  shaft, 
but  not  being  depressed  until  the  instrument  has  passed  by  its  own  weight 
into  the  prostatic  urethra.  Thompson's  plan  for  catching  the  stone  is  as 
follows:  After  introducing  the  Hthotrite,  let  its  lower  end  rest  for  a  few  seconds 
on  the  bottom  of  the  bladder,  so  that  currents  will  subside;  then  draw  back 

ihe  male  blade,  wait  a  moment,  close  the 
blades,  anfl  in  almost  every  instance  the 
stone  will  be  caught.  If  the  stone  is 
caught,  press  firmly  to  see  that  the  cal- 
culus is  well  held,  lock  the  instrument, 
and  break  the  foreign  body  by  screwing. 
When  resistance  suddenly  ceases  the 
stone  has  either  slipped  or  has  been 
crushed;  if  crushed,  the  blades  should 
have  been  felt  forcing  through  the  stone 
and  the  calculus  should  have  been  heard 
to  break.  When  resistance  ceases  catch 
and  crush  again  as  above  directed.  Rapid 
movements  with  the  Hthotrite  are  im- 
proper, as  they  establish  currents  which 
are  apt  to  push  away  the  stone.  If  the 
above  maneuver  does  not  catch  the  stone, 
see  if  the  calculus  be  near  the  neck  of  the 
bladder.  Pull  the  instrument  close  to  the 
vesical  neck,  and  open  it,  not  by  pulling 
the  male  blade,  but  by  pushing  the  female 
blade.  If  the  operator  still  fails  to  catch 
the  stone,  or  if,  after  crushing,  a  large 
fragment  knocks  against  the  evacuator, 
which  fragment  cannot  pass,  conduct  a  careful  search:  turn  the  blades  to  the 
right  side,  open,  and  close;  then  to  the  left  side,  open,  and  close;  next  turn  the 
point  around  behind  the  prostate  and  open,  and  close.  After  making  a  side 
search  with  the  Hthotrite,  turn  the  instrument  very  slowly,  so  as  to  detect  the 
catching  of  the  bladder-wall  if  it  has  occurred,  and  crush  the  stone  in  the 
middle  of  the  bladder  with  the  blades  up.  After  crushing  several  times, 
proceed  to  evacuate.  Fill  the  aspirator  with  warm  saline  fluid.  Insert 
an  evacuating  catheter,  its  point  being  in  the  center  of  the  bladder,  let 
the  fluid  and  fragments  run  out,  and  attach  the  aspirator  to  the  catheter; 
turn  the  valve,  and  compress  and  relax  the  bulb  so  that  an  ounce  or  more 
of  fluid  is  forced  in  at  each  squeeze,  the  compression  coinciding  with  expira- 
tion. The  debris  falls  into  a  bulb,  and  the  pumping  is  continued  until  the 
fragments  cease  to  pass,  whereupon  the  point  of  the  catheter  is  pushed  against 
the  floor  of  the  bladder  and  another  trial  is  made.  If  fragments  which  cannot 
gain  exit  are  felt  knocking  against  the  tube,  withdraw  the  evacuator,  crush 


Fig.  791. — Thompson's  evacuator. 


Litholapaxy  in  Male  Children  1329 

again,  and  again  use  the  aspirator.  When  no  more  debris  comes  away  and 
no  more  fragments  are  felt,  withdraw  the  tube  and  carefully  sound  the  blad- 
der. Keyes  advises  the  operator  to  seek  for  a  final  fragment  by  listening 
with  a  stethoscope  while  pumping  at  the  bulb  and  searching  the  bladder 
with  the  tube.  This  operation  will  rarely  occupy  over  forty  minutes,  though 
Bigelow  has  protracted  it  for  three  hours,  the  patient  recovering.  A  serious 
complication  is  severe  bleeding,  due  to  damage  done  with  the  instrument  or 
to  the  presence  of  a  tumor  which  easily  bleeds.  The  injection  of  moderately 
hot  water  or  of  adrenalin  solution  (i  :  10,000)  usually  checks  hemorrhage, 
but  if  bleeding  is  dangerous  in  amount  the  operation  of  litholapaxy  should  be 
abandoned  and  suprapubic  lithotomy  be  performed. 

If  clogging  of  the  lithotrite  with  fragments  occurs,  forcible  pushing  of 
the  blades  together  repeatedly  will  probably  amend  it ;  but  it  will  never  happen 
if  the  surgeon  uses  a  proper  form  of  instrument.  A  lithotrite  with  a  fenes- 
trated blade  will  not  lock.  Forbes's  lithotrite  is  a  very  powerful  instrument, 
the  blades  of  which  will  not  lock.  If  the  blades  of  a  lithotrite  should  become 
forcibly  and  hopelessly  locked,  make  a  perineal  section,  clear  out  the  blades, 
close  them,  and  then  withdraw  the  instrument. 

After-treatment. — Put  the  patient  to  bed,  apply  a  bag  of  hot  water  to  the 
hypogastrium,  and  give  him  a  hypodermatic  injection  of  morphin  as  he  re- 
covers from  ether.  Give  a  hot  hip-bath  every  night,  and  administer  liquor 
potassii  citratis  in  moderate  doses  every  day.  If  urethral  fever  occurs,  use 
quinin  and  morphin,  wash  out  the  bladder  several  times  daily  with  warm 
boric-acid  solution,  and  tie  in  a  rubber  catheter.  If  retention  occurs,  use 
the  catheter.  If  cystitis  appears,  treat  as  in  an  ordinary  case.  The  urine 
ceases  to  be  bloody  in  two  or  three  days,  and  the  patient  may  get  up  in  a  week. 

Litholapaxy  in  Male  Children. — It  was  considered  until  quite  recently 
that  a  child,  because  of  the  small  size  of  the  bladder,  the  small  diameter  of  the 
urethra,  and  the  readiness  with  which  the  mucous  membrane  is  lacerated  by 
even  shght  violence,  was  a  bad  subject  for  crushing.  Lateral  lithotomy  is 
known  to  be  eminently  successful  when  performed  upon  children.  The 
elder  Gross  did  this  operation  upon  72  children  with  only  2  deaths.  Keegan, 
however,  has  persuaded  the  profession  that  rapid  lithotrity  is  perfectly  appli- 
cable to  children :  He  shows  that  the  bladder  of  a  child  of  even  less  than  two 
years  of  age  is  quite  large  enough  to  allow  the  surgeon  to  manipulate  an  in- 
strument :  that  the  mucous  membrane  is  in  no  danger  if  the  operator  be  care- 
ful, and  that  the  urethra  is  by  no  means  so  small  as  was  supposed.  The 
urinary  meatus  must  often  be  incised,  and  after  doing  this,  Keegan  states, 
there  can  be  passed  in  a  boy  of  from  three  to  six  years  a  No.  7  or  8  hthotrite 
(English),  and  in  a  boy  of  from  eight  to  ten  years  a  No.  10  or  even  a  No.  14- 
It  is,  however,  just  to  state  that  the  operation  is  more  dehcate  than  a  hke 
procedure  on  older  persons,  and  that  no  one  is  justified  in  doing  it  who  has 
not  had  considerable  experience  in  adult  cases.  Furthermore,  it  should  be 
noted  that  Keegan's  mortality  by  this  operation  has  been  4.3  per  cent.,  while 
Gross's  mortality  from  lateral  lithotomy  on  children  was  2.67  per  cent. 

Special  points  0}  litholapaxy  on  male  children  are  as  follows:  use  well- 
fenestrated  hthotrites;  have  a  stylet  to  punch  out  the  fragments  blocking  the 
evacuator;  and  crush  the  stone  to  a  fine  mass.  There  can  usually  be  em- 
ployed a  No.  8  Hthotrite  and  a  No.  8  evacuating-tube  (English  scale). 


1330  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Perineal  Lithotrity  (Keith's  Operation). — This  operation  is  employed 
by  some  surgeons  in  deahng  with  very  hard  or  very  large  calcuh  in  male 
adults,  or  in  cases  in  w^hich  it  is  impossible  to  introduce  a  lithotrite  into  the 
bladder.  Keith's  operation  consists  in  opening  the  urethra  from  the  peri- 
neum, passing  a  lithotrite  through  the  wound,  into  the  urethra  and  along  the 
urethra  into  the  bladder,  and  crushing  the  stone,  introducing  an  evacuator 
and  removing  the  fragments.  In  Keith's  operation  the  incision  is  median, 
and  opens  the  membranous  urethra.  In  very  large  stones,  Milton  thinks 
the  surgeon  should  open  the  bladder  as  in  ordinary  lateral  lithotomy,  in- 
troduce a  lithotrite  through  the  incision,  and  crush  the  stone  before  extract- 
ing it,  thus  avoiding  the  infliction  of  injury  upon  important  structures. 


Fig.  792.— Thompson's  vesical  forceps  for  removing  growths  in  the  bladder;  for  growths  close  to 
the  neck  of  the  bladder,  with  separation  of  the  blades,  to  avoid  nipping  the  neck  of  the  bladder. 


Operation  for  Stone  in  Women. — If  the  stone  be  small,  give  the  patient 
ether,  place  her  in  the  lithotomy  position,  dilate  the  urethra  with  the  uterine 
dilator  until  it  admits  the  index-finger,  and  remove  the  stone  with  the  finger, 
the  scoop,  or  the  forceps.  If  the  stone  is  found  to  be  too  large  to  pass,  crush 
it  with  a  lithotrite  and  get  rid  of  the  debris  by  the  evacuator.  Large  stones 
(two  ounces)  may  require  suprapubic  lithotomy.  Vaginal  lithotomy  is  never 
required.  If  done,  it  is  very  likely  to  leave  as  a  legacy  a  vesicovaginal  fistula. 
In  female  children  dilate  the  urethra,  crush  the  stone,  and  evacuate. 

Cystotomy. — This  term  means  the  opening  of  the  bladder,  and  it  is 
usually  applied  to  an  opening  made  for  drainage,  for  diagnosis,  for  the  re- 
moval of  stones  or  tumors,  or  for  the  treatment  of  ulcers.  This  opening  may 
be  done  by  (i)  a  suprapubic  cut  (as  in  suprapubic  lithotomy),  (2)  a  lateral 


Suprapubic  Cystotomy 


1331 


Fig.  793.— Senn's  silver  tube. 


perineal  cut  (as  in  lateral  lithotomy),  or  (3)  a  median  perineal  cut  (as  in 
median  lithotomy). 

The  operation  may  be  completed  in  one  sitting,  or  the  bladder  may  be 
only  exposed,  the  opening  of  it  being  delayed  for  several  days  until  it  becomes 
adherent  to  the  margins  of  the  wound  (Senn's  operation).  Senn's  operation 
prevents  infiltration  of  urine  into 
the  prevesical  space,  and  it  is  ad- 
visable to  select  it  if  the  urine  is 
very  foul. 

A  sinus  may  persist  after 
suprapubic  cystotomy,  but  usu- 
ally the  wound  heals  unless  it  is 
kept  open  by  some  expedient. 

The  effects  of  suprapubic 
drainage  are  very  beneficial  in 
cases  of  chronic  cystitis  associated 

with  hypertrophy  of  the  prostate  gland,  the  urine  being  foul.  Drainage 
causes  the  urine  to  become  clear  and  the  mucous  membrane  of  the  bladder 
to  become  normal.  If  the  opening  is  made  as  a  permanent  drain,  there 
will  usually  be  incontinence,  as  the  new  channel  has  no  sphincter  action 
(Dandridge).  Figs.  793,  794,  795,  79^,  have  tubes  for  prolonged  drainage. 
Suprapubic  Cystotomy. — The  operation  is  employed  to  allow  the  sur- 
geon to  explore  the  bladder,  to  treat 
an  ulcer,  to  provide  drainage,  or  to 
remove  a  tumor.  If  the  operation 
is  for  calculi,  it  is  known  as  supra- 
pubic lithotomy  (page  1323).  Atter 
the  bladder  is  opened  its  interior 
can  be  illuminated  by  the  rays  of 
an  electric  lamp,  which  appliance  is 
fastened  with  a  mirror  to  the  fore- 
head of  the  operator.  If  an  ulcer 
is  found,  it  is  scraped  with  a  curet 
or  a  spoon.  Most  cases  of  tumor 
require  suprapubic  cystotomy.  It  is 
true  that  a  small  single  growth  at 
the  vesical  neck  is  accessible  by 
median  cystotomy,  but  the  area  for 
manipulation  is  very  narrow  and  the 
growth  cannot  be  seen.  Every  large 
growth,  all  cases  of  multiple  tumors, 
and  all  cases  of  tumor  in  individuals 
with  great  depth  of  perineum  or  with 
enlarged  prostate  require  suprapubic 
cystotomy,  an  operation  which  allows 
one  to  feel  and  to  see  the  growth,  which  gives  room  for  manipulation,  and  which 
permits  thorough  exploration  of  the  entire  bladder.  The  patient  is  put  in 
the  Trendelenburg  position  if  water  distention  is  used,  but  is  placed  horizon- 
tally if  air  distention  is  employed.     After  opening  the  bladder  as  for  stone 


Fig-  794 — Senn's  tube  applied.  The  instrument 
does  not  press  upon  the  sensitive  neck  of  the  blad- 
der. 


1332  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

(page  1323)  hold  the  edges  of  the  incision  apart  by  means  of  a  speculum 
(speculum  of  Keen  or  Watson)  or  with  retractors,  and  reflect  the  electric 
light  into  the  wound.  Growths  when  seen  can  be  twisted  off,  a  pair  of 
forceps  holding  the  base  and  another  pair  being  used  to  twist.  Broad 
growths  should  be  transfixed,  ligated,  and  severed.  Some  growths  (as  can- 
cer) are  removed  piece  by  piece  with  Thompson's  forceps  (Fig.  792),  the  base 
of  the  tumor  being  scraped.  Soft  growths  are  scraped  away  with  a  curet, 
a  spoon,  or  a  finger-nail.  If  bleeding  is  severe,  check  it  by  pressure,  by  hot 
water,  by  a  i  :  10,000  solution  of  adrenalin  chlorid,  or  even  by  the  actual 
cautery.  In  some  cases  the  wound  is  allowed  to  heal  rapidly.  In  others  the 
bladder  is  drained  for  a  considerable  time.  In  some  it  is  kept  open  perma- 
nently. Permanent  drainage  is  desirable  in  some  cases  of  enlarged  prostate, 
and  in  such  cases  Senn's  tube  may  be  employed  (Figs.  793  and  794),  or 
Stevenson's  tube  (Figs.  795  and  796). 

Median  Cystotomy. — The  same  incision  is  made  in  the  perineal  raphe  in 
median  cystotomy  as  for  median  lithotomy.  A  grooved  staff  is  introduced 
and  is  hooked  up  under  the  pubes;  an  incision  is  made  into  the  membranous 
urethra,  and  is  extended  backward  for  three-quarters  of  an  inch,  and  a  finger 
is  carried  into  the  bladder.  If  searching  for  a  growth,  find  it  with  the  finger, 
catch  it  with  Thompson's  forceps,  and  twist  it  off.  Soft  growths  can  be 
scraped  away.  Stop  bleeding  by  digital  pressure  or  by  injections  of  hot 
water  or  adrenahn  chlorid  (i  :  10,000).  If  median  cystotomy  does  not  allow 
access  to  the  tumor,  perform  suprapubic  cystotomy. 

Growths  in  the  Female  Bladder. — Dilate  the  urethra  as  in  a  case  of 
stone,  and  scrape,  twist,  or  pull  the  growth  away  or  ligate  it.  If  the  growth 
is  large  or  if  there  are  multiple  growths,  perform  suprapubic  cystotomy. 


Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicle,  Prostate, 
Seminal  Vesicle,  Spermatic  Cord,  and  Tunica  Vaginalis. 

Injuries  of  the  penis  and  urtthra  may  arise  from  traumatism  to  the  peri- 
neum or  the  penis,  from  cuts  and  twists  of  the  penis,  from  the  popular  "  break- 
ing" of  a  chordee,  from  tying  strings  around  the  organ,  from  forcing  rings 
over  it,  from  the  passage  of  instruments,  or  from  the  impaction  of  calculi. 

Violence  inflicted    upon  an  erect   penis 
may    fracture    the    corpora    cavernosa. 
The  writer  saw  one   man  with  a  glass 
rod  broken  off  in  the  canal,  he  having 
been  in  the  habit  of  introducing  it  at  the 
dictate  of  morbid  sexual  excitement.     A 
patient  in  the  Insane  Department  of  the 
Philadelphia  Hospital  pushed  a  ring  over 
his  penis,   which   organ   ulcerated   into 
the  urethra.     These  injuries  are  treated 
on  general  principles. 
Perinea!    Bruises. — If    the    perineum    be   bruised  without  rupture  of 
the  urethra,  the  perineum  and  scrotum  swell  and  become  discolored;  water 
is  passed  with  difficulty  because  the  extravasated  mass  of  blood  in  the  peri- 
urethral tissues  occludes  the  canal  more  or  less;  the  water  is  not  bloody;  and 


Fig.  795. — Stevenson's  suprapubic  drain- 
age-tube. 


Rupture  of  the  Urethra 


1333 


there  are  pain  and  profound  shock.  Some  authors  designate  as  rupture  those 
cases  in  which  laceration  of  the  spongy  tissue  occurs,  without  invohement  of 
the  mucous  meml:)rane  or  of  the  fibrous  coat,  but  they  are  properly  contusions. 
Treatment.— Place  the  patient  in  bed  and  establish  reaction,  and  when 
reaction  is  complete  employ  opiates  for  the  relief  of  pain.  Apply  an  ice-bag 
to  the  perineum.  If,  not- 
withstanding these  measures, 
swelling  continues,  introduce 
a  silver  catheter  (No.  12  Eng- 
lish), tie  it  in,  and  make  pres- 
sure upon  the  perineum  by  a 
firmly  applied  T-bandage  or 
by  a  crutch  braced  against  the 
foot-board  of  the  bed.  Even 
w^hen  swelling  is  slight,  reten- 
tion of  urine  may  occur  from 
projection  of  a  submucous 
blood-clot  into  the  canal  of 
the  urethra.  In  some  cases  it 
may  become  necessary  to  in- 
cise and  evacuate  the  blocd- 
clot.  After  twenty-four  hours 
have  passed,  if  hemorrhage 
has  ceased,  substitute  a  hot- 
water  bag  for  the  ice-bag, 
and  empty  the  bladder  regu- 
larly with  a  soft  catheter. 
Occasionally,  though  rarely, 
an  abscess  forms.  Pimctund 
wounds  of  the  urethra  require 
ordinary    dressings.      Incised 

wounds  of  the  urethra,  when  longitudinal,  are  closed  by  suture.  Healing  is 
rapid,  and  ill  consequences  are  not  to  be  feared.  Stricture  does  not  follow. 
When  the  wound  is  transverse,  introduce  a  catheter,  suture  the  wound  over 
the  instrument,  and  remove  the  catheter  at  the  end  of  the  third  day.  If  a 
catheter  cannot  be  introduced,  employ  sutures,  but  at  the  first  evidence  of 
extravasation  open  the  wound,  and  if  drainage  is  not  free  perform  external 
perineal  urethrotomy. 

Rupture  of  the  Urethra. — By  this  term  is  meant  a  lacerated  or  a  con- 
tused wound  of  the  urethra,  destroying  partially  or  entirely  the  integrity  of 
the  canal.  A  lacerated  wound  may  be  induced  by  fracture  of  the  cavernous 
bodies  during  erection,  the  symptoms  being  severe  hemorrhage,  intense  pain, 
retention  of  urine,  and  inability  to  pass  an  instrument;  infiltration  of  urine 
occurs,  and  gangrene  is  a  com.mon  result.  The  writer  has  seen  one  case  of 
rupture  of  the  penile  urethra  due  to  a  man's  shpping  while  shaving,  the  penis 
being  caught  in  a  partially  open  drawer,  the  drawer  being  shut  by  his  body 
coming  against  it.  Rupture,  how-ever,  is  almost  invariably  located  in  the  peri- 
neum, and  it  arises  when  the  urethra  is  suddenly  and  forcibly  pressed  against 
the  arch  of  the  pubes  by  a  blow,  by  a  kick,  or  by  falling  astride  a  beam  or  a 


Fig.  796.— Stevenson's  suprapubic  drainage-tube  in  place 
and  attached  to  a  receptacle  for  urine. 


1334  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


fence-rail.  Retention  of  urine  due  to  stricture  may  lead  to  extravasation 
of  urine.  The  lesion  of  urethral  rupture  consists  in  some  cases  of  lacera- 
tion of  the  spongy  tissue  and  the  mucous  membrane,  a  cavity  being  formed 
which  communicates  with  the  canal,  and  which  fills  with  urine  during  mic- 
turition. In  other  cases  not  only  the  spongy  tissue  and  the  urethral  mucous 
membrane  are  rent  asunder,  but  the  fibrous  coat  is  also  torn,  the  canal  opening 
directly  into  the  perineal  tissues,  among  which  a  huge  cavity  forms,  that 
fills  with  blood  and  later  with  urine  and  pus.  The  urethra  may  be  torn 
entirely  across,  but  in  most  cases  a  small  portion  at  least  of  its  circumference 
is  uninjured.  Rupture  never  occurs  primarily  and  alone  in  the  prostatic 
urethra;  it  is  extremely  rare  in  the  membranous  urethra  unless  due  to  pelvic 
fracture;  and  it  is  very  unusual  in  the  penile  urethra.     The  seat  of  rupture 

in  the  great  majority  of 
cases  is  in  the  region  of 
the  bulb.  \'ery  rarely  is 
the  skin  broken. 

Symptom  s. — The 
symptoms  of  rupture  of 
the  urethra  are  consider- 
able pain,  aggravated  by 
motion,  pressure,  and  at- 
tempts to  pass  water; 
great  shock;  in  some 
cases  micturition  is  still 
possible,  blood  preceding 
and  also  discoloring  the 
stream,  for  some  blood 
usually  runs  into  the 
bladder;  retention  of  urine 
quickly  arises;  in  a  vast 
majorit3'  of  the  cases  re- 
tention is  absolute  from  the  very  first,  and  it  is  due  to  the  interrup- 
tion in  .the  integrity  of  the  canal  and  to  the  occlusion  of  the  chan- 
nel by  blood-clots.  Bleeding,  which  is  usually  free,  lasts  for  several 
hours,  some  little  blood  generally  appearing  externally  and  much  being 
retained  in  the  perineum,  inducing  progressive  swelling.  The  pres- 
ence of  a  large  swelhng  is  regarded  as  evidence  of  urethral  rupture.  The 
blood  which  is  eftused  in  the  perineum  may  extend  under  the  fascia  to 
the  penis  and  scrotum  (Fig.  797).  The  swelling  soon  becomes  reddish, 
purple,  or  even  black,  pressure  upon  it  is  apt  to  cause  blood  to  run- from  the 
meatus,  and  it  is  augmented  in  volume  when  attempts  are  made  to  urinate. 
After  a  time,  if  the  surgeon  does  not  act,  the  urine  fills  the  perineal  cavity  and 
widely  infiltrates,  and  there  ensue  gangrene,  sloughing,  and  sepsis,  life  being 
endangered  or  fistulae  being  left  as  legacies.  The  course  of  the  extravasated 
urine  will  often  enable  one  to  locate  the  seat  of  injury.  In  rupture  of  the 
membranous  urethra,  if  uncomplicated,  the  urine  remains  between  the  two 
layers  of  the  triangular  ligament  until  a  channel  is  opened  for  it  by  sloughing 
or  by  the  knife.  When  extravasation  occurs  behind  the  posterior  layer  of 
the  ligament  the  urine  finds  its  way  to  the  perineum  in  the  neighborhood  of 


Fig.  797  — Ruptured  urethra. 


Foreign  Bodies  in  the  Urethra  1335 

the  anus.  When  the  rupture  is  in  front  of  the  anterior  layer  of  the  ligament 
the  urine,  directed  by  the  deep  layer  of  the  superficial  fascia,  finds  its  way 
into  the  scrotum  and  up  on  the  belly,  but  does  not  pass  into  the  thighs.  A 
contusion  is  distinguished  from  a  rupture  by  the  facts  that  in  the  former  the 
perineal  swelling  is  not  very  extensive  and  does  not  enlarge  on  attempting 
micturition,  while  in  the  latter  it  is  extensive  and  does  enlarge  on  attempting 
to  pass  water.  Furthermore,  contusion  does  not  cause  urethral  hemorrhage, 
while  rupture  does.  A  contusion  sometimes,  but  not  often,  prevents  the 
passage  of  a  catheter;  a  rupture  almost  always,  but  not  invariably,  does  so. 
The  mortality  from  severe  rupture  with  extravasation  is  about  14  per  cent. 
(Kaufman). 

Treatment. — In  some  cases  it  is  possible  to  suture  the  urethra,  and  this 
procedure  should  be  carried  out  when  possible.  In  order  to  suture,  perform 
suprapubic  cystotomy  and  also  make  a  perineal  section.  Find  the  posterior 
end  of  the  ruptured  urethra  by  passing  a  catheter  from  the  bladder  into  the 
urethra.  Suture  with  silk.  The  sutures  pass  through  all  of  the  coats  of  the 
urethra.  The  roof  of  the  canal  is  sutured  first,  then  a  steel  sound  is  intro- 
duced from  the  meatus,  and  the  urethra  is  sutured  around  the  instrument. 
The  sound  is  withdrawn  and  the  bladder  is  drained  by  Cathcart's  siphon  as 
illustrated  in  Fig.  786.  In  recent  cases  of  ruptured  urethra  the  usual  treat- 
ment is  as  follows:  Immediately  perform  median  perineal  section  and  turn 
out  the  clot;  trim  off  lacerated  edges;  find  the  proximal  end  of  the  urethra, 
pass  a  catheter  from  the  meatus  into  the  bladder,  and  leave  it  in  situ  until  heal- 
ing has  begun  around  it.  If  the  catheter  cannot  be  passed  from  the  meatus, 
open  the  bladder  above  the  pubes  and  find  the  posterior  urethra  by  retrograde 
catheterization.  In  retrograde  catheterization  we  push  an  instrument  from 
the  bladder  into  the  wound  and  use  it  to  guide  a  catheter  from  the  meatus  into 
the  bladder.  When  rupture  occurs  back  of  a  stricture  it  is  a  good  plan  to 
excise  the  cicatricial  tissue.  In  cases  with  extravasation  make  a  median 
incision  and  numerous  transverse  cuts  to  secure  drainage  for  areas  of  retained 
urine  or  pus.  Then,  at  once  perform  suprapubic  cystotomy.  Drain  supra- 
pubically  and  from  the  perineum  for  about  two  weeks,  by  which  time  slough- 
ing tissue  will  have  separated.  Then  find  the  posterior  urethra  by  retrograde 
catheterization  and  do  a  perineal  operation  to  repair  the  damaged  urethra. 
(See  Eugene  Fuller,  in  "N.  Y.  Med.  Jour.,"  Nov.  23,  1901.)  The  wound 
is  packed  with  iodoform  gauze,  and  the  bowels  are  tied  up  with  opium  for  a 
few  days.  Many  surgeons  strongly  disapprove  of  the  custom  of  retaining 
the  catheter,  believing  that  the  instrument  does  no  real  good,  as  urine  is  cer- 
tain to  get  between  the  catheter  and  the  walls  of  the  urethra.  In  fact,  it  is 
quite  enough  to  stuff  the  wound  with  gauze,  the  patient  urinating  through 
the  wound  for  the  first  few  days,  after  which  time  a  catheter  is  used  at  regular 
intervals.  Whatever  method  is  employed,  healing  will  require  from  six  to 
eight  weeks,  and  the  patient  must  during  the  rest  of  his  hfe,  from  time  to 
time,  introduce  large-sized  bougies. 

Foreign  Bodies  in  the  Urethra. — These  bodies  may  be  calcuH, 
bodies  introduced  by  injury,  as  shot,  bone,  etc.,  bodies  entering  from  a  fis- 
tulous opening  into  the  rectum,  or  bodies  introduced  from  the  meatus,  as 
broken  bits  of  catheters,  straws,  pins,  etc. 


1336  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

The  symptoms  vary  with  the  size  and  the  nature  of  the  body.  Some- 
times there  are  almost  no  sym{)toms;  at  other  times  there  are  found  great 
pain,  retention  of  urine,  and  hemorrhage.  Examination  is  made  by  feeling 
carefully  with  a  finger  in  the  rectum  and  by  searching  very  gently  with  a 
sound,  taking  care  not  to  push  the  body  back.  If  the  bladder  is  well  filled 
with  water  when  the  body  becomes  impacted,  inject  a  little  oil  into  the  meatus, 
close  the  lips  with  the  fingers,  and  direct  the  patient  to  forcibly  attempt 
urination,  the  surgeon  opening  the  meatus  when  the  urethra  is  widely  dis- 
tended, the  foreign  body  being  often  forced  out.  If  this  maneuver  fails,  and 
the  foreign  body  is  impacted  in  the  pendulous  urethra,  prevent  its  backward 
passage  by  at  once  tying  a  rubber  tube  around  the  penis.  Try  to  squeeze  the 
body  out,  and,  if  unsuccessful,  endeavor  to  catch  it  with  a  wire  loop,  with  a 
scoop,  or  with  the  long  urethral  forceps.  If  these  methods  fail,  cut  down 
upon  the  body  and  remove  it,  dividing  any  existing  stricture.  If  it  is  lodged 
just  back  of  the  meatus  incision  of  the  meatus  will  permit  extraction.  If  a 
hairpin  is  in  the  canal,  the  feet  of  the  pin  are  almost  always  pointing  to  the 
meatus;  to  prevent  them  catching  on  attempted  withdrawal,  the  penis  must 
be  squeezed  to  approximate  the  feet,  and  when  they  are  adjacent  a  part  of  a 
silver  catheter  is  slipped  over  to  retain  them  in  this  position,  when  the  pin 
can  be  extracted.  If  this  fails,  drag  the  penis  against  the  belly,  by  rectal 
touch  force  the  sharp  ends  of  the  pin  out  through  the  integument,  cut  one 
end  off,  and  then  withdraw  the  other.  An  ordinary  large-headed  pin  is  forced 
out  in  the  same  way,  and  when  the  head  is  turned  externally  it  is  extracted 
by  way  of  the  meatus.  If  a  hard  or  sharp  foreign  body  is  lodged  in  the 
prostatic  urethra,  do  not  catch  it  with  an  instrument  and  try  to  drag  it  for- 
ward. To  do  so  will  be  apt  to  tear  the  membranous  urethra.  It  is  better  to 
push  it  into  the  bladder  and  remove  it  later  by  cutting,  or,  if  it  be  a  stone,  by 
crushing  (H.  Hartmann,  in  "La  Presse  Med.,"  July  24,  1901).  If  a  litho- 
trite  loaded  with  fragments  be  caught  in  the  urethra,  the  surgeon  must 
perform  a  perineal  section,  to  enable  him  to  clean  and  close  the  blades. 
After  the  blades  have  been  closed  the  instrument  may  be  easily  withdrawn. 

Urethrorrhea  is  not  urethral  inflammation,  but  is  a  condition  of  sensi- 
tiveness of  the  urethra  and  oversecretion  of  the  glandular  elements.  It  may 
be  due  to  masturbation,  sexual  excess,  and  also,  as  Sturgis  points  out,  to  with- 
drawal during  sexual  intercourse,  and  to  ungratified  sexual  passion.  A  drop 
or  two  of  transparent  mucus  is  found  at  the  meatus  in  the  morning,  and  a 
considerable  amount  may  flow  away  while  straining  at  stool  or  upon  the  dimi- 
nution of  an  erection.  This  flow  at  stool  is  often  called  defecation  spermat- 
orrhea. This  discharge  stains  but  does  not  stiffen  linen  (Sturgis).  The 
discharge  contains  mucus,  mucous  corpuscles,  epithelial  cells,  sometimes 
spermatozoids,  but  no  gonococci  or  pus  organisms.  The  patient  may  be 
well  in  all  other  respects,  but  in  many  cases  there  are  neurasthenic  symp- 
toms, sexual  weakness,  or  even  impotence. 

Treatment. — In  an  uncomplicated  case  improvement  or  cure  will  follow 
upon  the  abandonment  of  evil  habits.  If  complications  arise,  they  must  be 
treated. 

Urethritis,  or  Inflammation  of  the  Urethra.— Urethral  inflamma- 
tions can  be  divided  into  two  classes:  (i)  simple,  non-specific,  in  which  infec- 
tion is  due  alone  to  pyogenic  cocci  (particularly  the  bacillus  coli  communis 


Gouty  Urethritis  1337 

and  the  staphylococcus  pyogenes),  and  (2)  specific,  in  which  the  gonococcus  is 
present. 

Non-specific  or  simple  urethritis  may  be  due  to  several  causes,  such  as 
traumatism;  great  acidity  of  the  urine;  chancre  in  the  urethra;  contact  with 
menstrual  fluid,  leukorrheal  discharge,  the  discharge  from  malignant  disease 
of  the  uterus,  ordinary  pus,  or  acrid  vaginal  discharge;  the  passage  of  instru- 
ments; the  administration  of  irritant  diuretics;  strong  injections;  worms  in  the 
rectum;  a  febrile  malady;  venereal  excess  and  masturbation;  the  passage  or 
impaction  of  foreign  bodies,  and  papillomata  of  the  urethra.  A  temporary 
and  mild  urethritis  sometimes  accompanies  early  syphilitic  eruptions.  Simple 
urethritis  is  less  severe  and  prolonged  than  gonorrheal  urethritis,  though 
clinically  in  the  early  stage  the  physician  cannot  invariably  distinguish  between 
the  two  forms.  The  diplococci  of  gonorrhea  are  never  found  in  the  discharge  of 
simple  urethritis,  although  there  may  be  numerous  other  diplococci.  In 
medicolegal  cases  testimony  is  not  admitted  as  to  the  presence  or  absence  of 
diplococci,  as  judges  do  not  admit  that  their  presence  proves  or  their  absence 
disproves  gonorrhea.  In  the  non-specific  intlamm.ation  pus  is  not  always 
present,  many  cases  stopping  short  of  pus-formation  after  a  varying  period  of 
catarrh,  but  any  catarrh  may  become  purulent.  A  simple  urethritis  may  be 
caused  or  may  be  prolonged  for  an  indefinite  period  by  the  presence  of  large 
amounts  of  oxalate  in  the  urine  or  the  existence  of  the  uric-acid  diathesis  (see 
Gouty  Urethritis). 

Treatment. — Seek  for  the  cause  and  remove  it.  Correct  any  abnormal 
condition  of  the  urine  by  means  of  suitable  diet,  drugs,  and  mode  of  life. 
Mild  astringent  injections  are  useful.  It  may  be  necessary  to  flush  the  urethra 
repeatedly  with  a  solution  of  silver  nitrate  (i:  8000). 

Traumatic  Urethritis. — The  onset  pain  in  traumatic  urethritis  is  coinci- 
dent with  the  introduction  of  the  foreign  body.  The  discharge,  which  may 
be  bloody,  mucous,  mucopurulent,  or  purulent,  comes  on  within  twenty-four 
hours. 

Treatment. — If  the  inflammation  is  shght,  prescribe  diluent  drinks,  pare- 
goric, a  saline,  or  the  following: 

I^.     Tinct.  belladonncc f  oss 

Sodii  bromid oiv 

Tinct.  opii  camphorat f 5j 

Syrupus  zingib f  o  ss 

Aquas  destil q.  s.  ad.  f  ovj. — M. 

Sig. — A  tablespoonful  every  six  hours. 

If  the  inflammation  is  severe,  put  the  patient  to  bed,  apply  hot  fomentations 
to  the  perineum,  give  diluent  drinks,  employ  suppositories  of  opium  and 
belladonna,  and  watch  for  fever  and  other  compHcations. 

Gouty  Urethritis. — This  condition  first  manifests  itself  in  the  posterior 
urethra,  not  in  the  anterior,  as  does  clap.  Its  symptoms  are  great  vesical 
irritability;  pain  on  urination;  discharge,  usually  scanty,  associated  with  uric 
acid  in  the  urine  or  other  symptoms  of  gout.  The  treatment  comprises  dieting 
and  the  usual  remedies  for  gout.  Purgatives  are  given  freely,  and  full  doses 
of  colchicum,  piperazin,  urotropin,  or  the  alkalies;  hot  baths,  low  diet,  diluent 
drinks,  and  diaphoretics  are  indicated.  A  chronic  discharge  from  the  pros- 
tatic region  is  apt  to  linger;  for  this  there  is  nothing  better  than  the  usual 


1338         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

gouty  remedies  and  saline  waters  with  copaiba,  cubebs,  or  sandalwood  oil. 
In  many  cases  it  is  necessary  to  flush  the  urethra  once  a  day  with  a  solution 
of  silver  nitrate  (i  :  8000). 

Eczematous  Urethritis. — Berkley  Hill  states  that  this  disease  is  very 
obstinate,  is  probably  associated  with  gout,  and  is  met  with  in  adults  of  full 
habit  or  who  are  beer-drinkers  and  who  have  eczema  of  the  surface  of  the 
body.  He  states  also  that  the  glans  penis  near  the  meatus  is  red  and  tender, 
and  that  the  interior  of  the  urethra  is  in  the  same  condition.  Pain  is  constant, 
and  it  is  aggravated  on  micturition.  The  discharge  is  scanty.  The  treatment 
comprises  injections  of  cold  water  or  irrigation  with  iced  water,  and  internally 
the  administration  of  arsenic  with  the  alkalies. 

Tuberculous  urethritis  is  due  to  a  tuberculous  ulcer,  which  is  most  apt 
to  be  seated  near  the  vesical  neck.  There  is  a  little  pain  on  micturition,  but 
there  is  intense  pain  at  one  spot  on  passing  a  bougie.  The  discharge  is  sUght 
and  at  times  bloody.  The  bladder  is  very  irritable,  and  severe  cystiris  arises 
and  persists.  The  treatment  includes  warmth,  nutritious  diet,  and  cod-Uver 
oil,  removal  to  an  equable  chmate,  and  hving  as  much  as  possible  out  of  doors. 
The  chmate  of  southern  California  is  pecuharly  well  suited  to  these  cases. 
The  bladder  is  washed  out  once  a  day  with  boric  acid  solution.  Iodoform 
emulsion  is  injected  daily.  Tuberculin  may  prove  of  value  (page  247). 
After  a  time  the  surgeon  will  probably  be  forced  to  drain  by  perineal  or  supra- 
pubic cystotomy. 

Examination  when  a  Urethral  Discharge  Exists.— Learn  accu- 
rately the  history.  Obtain  some  of  the  discharge  and  examine  an  unstained 
slide  and  a  slide  stained,  for  gonococci.  In  some  cases  take  cultures.  Learn 
the  amount  of  the  twenty-four  hours'  urine  and  study  a  sample  chemically 
and  microscopically,  being  sure  to  determine  the  amount  of  urea.  Learn  if 
the  discharge  discolors  or  stiffens  linen;  if  it  is  only  found  in  the  morning; 
if  it  simply  glues  the  lips  of  the  meatus  together;  if  it  is  seen  during  the  day; 
if  it  is  noted  particularly  or  only  after  sexual  excitement  or  straining  at  stool. 
Inquire  as  to  pain,  frequency  of  micturition,  passage  of  blood,  nocturnal 
emissions,  manner  of  urinating,  etc.  In  many  cases  insert  a  finger  in  the 
rectum,  feel  the  prostate  and  vesicles,  massage  them,  and  see  if  discharge 
appears  at  the  meatus  after  stripping  the  penis.  If  discharge  does  appear, 
collect  a  specimen  and  examine  it.  In  some  cases  it  is  necessary  to  pass 
a  sound.  Follow  Valentine's  advice  and  cleanse  the  meatus,  glans,  pre- 
puce, and  urethra  before  passing  a  sound.  Cleanse  the  meatus,  glans, 
and  prepuce  with  a  i  :  6000  solution  of  corrosive  sublimate.  Irrigate  the 
urethra  with  boric-acid  solution  and  fill  the  clean  urethra  with  emulsion 
of  iodoform  and  glycerin  (5  per  cent.),  and  after  using  the  instrument  irrigate 
again  with  boric-acid  solution  (Valentine's  method).  Examine  the  urine 
by  the  three-glass  test. 

The  Three-glass  Test  (Valentine's  Plan). — Take  as  many  three-ounce 
tubes  as  are  required  to  receive  all  the  urine  from  the  bladder.  The  first  tube 
contains  the  washings  from  the  anterior  vu-ethra.  The  second  and  other 
tubes,  additional  material  from  the  bladder.  The  last  tube  contains  material 
expressed  from  the  posterior  urethra,  prostate,  and  seminal  vesicles.  Ex- 
amine the  urine  and  the  sediment  in  the  first  two  glasses  and  in  the  last 
glass,     Note  particularly  if  shreds  are  present.     The  shreds  of  gonorrhea  are 


Gonorrhea  in  the  Male  1339 

white  in  color  and  of  variable  length,  and  tloat  in  the  urine.  They  are  com- 
posed of  pus-corpuscles  and  of  epithelial  cells  which  have  undergone  fatty 
degeneration.  Many  of  these  shreds  form  in  the  ducts  of  Cowper's  glands, 
but  the  glands  of  the  entire  length  of  the  urethra  also  furnish  them. 

Gonorrhea  (Clap;  Specific  Urethritis;  Tripper;  Venereal 
Catarrh). — Gonorrhea  is  an  acute  inflammation  of  the  genital  mucous 
membrane,  of  venereal  origin,  due  to  the  deposition  and  multiplication  of 
gonococci  in  the  ceils  of  the  membrane  and  a  mixed  infection  with  the  cocci 
of  suppuration.  The  disease  is  inaugurated  by  gonococci.  After  a  few  days 
or  more  secondary  pyogenic  infection  develops  and  complications  may  result 
from  the  gonococci  or  from  the  bacteria  causing  the  mixed  infection.  The  dis- 
ease attacks  with  the  greatest  ease  surfaces  covered  with  squamous  epithelium. 
The  gonococci  enter  into  and  multiply  in  the  superficial  epithelial  and  pass  to 
between  the  deeper  cells,  where  they  lodge  and  multiply  as  the  superficial 
cells  are  cast  off.  The  pus  from  the  urethra  contains  epithelial  cells  with 
gonococci  inside  of  them,  and  also  pus-cells  with  gonococci  within  them  as  a 
result  of  phagocytosis.  Cultures  are  made  with  difficulty.  Gonococci  do  not 
stain  by  Gram's  method  but  stain  best  with  a  weak,  watery  solution  of  an 
anilin  dye.  These  bacteria  are  said  not  to  be  pathogenic  to  animals, 
although  some  observers  deny  this  assertion.  Gonorrhea  is  one  of  the  most 
common  and  widely  disseminated  diseases.  Probably  one-half  of  all  sterile 
women  and  many  sterile  men  have  been  rendered  sterile  by  this  disease. 
It  is  responsible  for  not  a  few  cases  of  abortion,  for  an  enormous  majority 
of  female  pelvic  diseases,  and  it  causes  many  cases  of  blindness  from  infection 
of  children's  eyes  during  delivery. 

Gonorrhea  in  the  Male. — In  the  male,  clap  begins  within  the  meatus 
and  fossa  navicularis  and  extends  backward  throughout  the  length  of  the 
urethra.  The  mucous  membrane  swells  and  becomes  hyperemic,  and  there 
is  a  discharge,  first  of  mucus  and  serum,  and  then  of  pus.  In  severe  cases 
the  discharge  is  bloody  {black  gonorrhea).  For  a  week  or  more  the  inflam- 
mation increases,  then  becomes  stationary  for  a  time,  and  then  declines, 
the  discharge  growing  less  profuse  and  thinner,  a  watery  discharge  lasting 
for  some  little  time.  An  ordinary  case  of  genuine  gonorrhea  lasts  from  six 
to  ten  weeks,  and  even  a  case  Hmited  purely  to  the  anterior  urethra  will  rarely 
be  cured  within  four  or  five  weeks.  During  the  acute  stage  the  entire  penis 
swells  and  the  corpus  spongiosum  becomes  infiltrated  with  inflammatory 
exudate.  An  interesting  fact  is  that  gonorrhea  may  induce  mild  septicemia 
without  demonstrable  complications,  the  condition  causing,  according  to 
Thayer  ("Am.  Jour.  Med.  Sciences,"  Nov.,  1905),  a  continued  fever  which, 
perhaps,  lasts  a  number  of  weeks.  In  true  gonorrheal  septicemia  the  blood 
must  contain  gonococci.  In  the  case  recorded  by  Thayer  and  in  the  case 
recorded  by  Blumer  and  Hayes,  cultures  were  obtained  from  the  blood. 
Gonorrhea  may  produce  grave  septicemia  and  systemic  complications.  It 
tends  particularly  to  attack  serous  membranes  or  other  endothelial  structures 
(joints,  pericardium,  endocardium,  pleura,  tendon-sheaths,  intima  of  vessels, 
etc.).  Among  the  complications  are  gonorrheal  arthritis,  myelitis,  polio- 
myelitis, and  multiple  neuritis.  There  are  3  cases  of  gonorrheal  myositis 
on  record  (Martin  W.  Ware,  "Am.  Jour.  Med.  Sciences,"  July,  1901).  Phle- 
bitis may  arise.     Mild  endocarditis  may  arise  or  severe  endocarditis  may 


1340  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

occur,  identical  symptomatically  with  ulcerative  endocarditis  due  to  other 
bacteria.  In  6  reported  cases  of  endocarditis  gonococci  were  obtained  by 
cultures  from  the  blood  intra  vitam  (Thayer,  in  "Am.  Jour.  Med.  Sciences," 
Nov.,  1905).  Cerebral  embolism  may  result.  Cerebrospinal  meningitis 
can  occur  (fluid  obtained  by  lumbar  puncture  contains  gonococci). 

Gonorrheal  rheumatism  is  discussed  on  page  645.  Gonorrheal  peritonitis 
is  rare.  Infection  of  the  peritoneum  through  the  blood  is  very  rare.  The 
majority  of  cases  of  gonorrheal  peritonitis  occur  in  women  and  are  due  to 
direct  extension  from  the  Fallopian  tubes.  Gonococci  have  not  been  found 
in  the  exudates  of  cases  of  pleuritis  and  pericarditis  supposed  to  be  of  gonor- 
rheal origin.  A  child  may  contract  gonorrheal  ophthalmia  during  delivery, 
and  any  person  may  develop  it  by  getting  gonococci  into  the  eyes. 

Symptoms  of  Acute  Inflammatory  Gonorrhea. — The  period  of  incubation 
of  gonorrhea  is  from  a  few  hours  to  two  weeks.  The  usual  period  is  from  three 
to  five  days,  when  symptoms  of  the  prodromal  stage  or  stage  of  onset  are  noticed. 
The  patient  notices  on  arising  a  drop  of  thin  fluid  which  glues  the  hps  of  the 
meatus  together,  and  he  feels  some  heat  and  itching  or  tickling  about  the  mea- 
tus or  in  the  navicular  fossa.  There  may  be  uneasiness  or  actual  pain  uncon- 
nected with  urination,  and  there  is  sure  to  be  scalding  pain  on  urination.  The 
meatus  is  red  and  swollen,  has  a  glazed  appearance,  may  be  covered  with  a  little 
mucopus,  and  the  lips  are  glued  together  by  the  discharge.  It  may  be  possible 
to  squeeze  out  a  drop  or  two.  Even  this  early  the  fluid  contains  gonococci. 
The  urine  appears  clear,  but  on  shaking,  some  flakes  are  noted.  They  are 
epithelial  cells.  Within  forty-eight  hours  the  first  stage,  the  florid  stage,  the 
aci{te  stage,  or  the  stage  of  increase,  becomes  established.  The  meatus  is 
now  red,  swollen,  and  everted  (fish -month  meatus) ;  the  entire  glans  may  be 
red  and  swollen;  if  the  prepuce  is  long,  it  becomes  swollen,  reddened,  and 
constricted,  and  in  many  cases  very  edematous;  the  lymphatics  by  the  frenum 
and  on  the  dorsum  of  the  penis  may  be  red,  swollen,  tender,  and  cord-like; 
micturition  causes  severe  pain  {ardor  urime),  which  is  due  to  distention  of 
the  inflamed  urethra  and  to  stinging  by  the  acid  urine.  Bumstead  thus 
described  the  act  of  micturition  in  acute  gonorrhea:  "During  the  act  the 
patient  involuntarily  relaxes  the  abdominal  walls,  holds  his  breath,  and 
keeps  the  diaphragm  elevated  in  order  to'  diminish  the  pressure  on  the  bladder 
and  lessen  the  size  and  force  of  the  stream  "  ("Venereal  Diseases,"  by  Robt.  W. 
Taylor).  Because  of  the  narrowing  of  the  canal  the  stream  of  urine  becomes 
narrow,  weak,  twisted,  forked,  or  is  delivered  in  little  bursts  or  drops.  Re- 
tention may  result  from  spasm  of  the  muscles.  When  the  acute  or  florid  stage 
is  fully  developed,  the  entire  urethra  is  inflamed  from  the  meatus  to  the 
triangular  ligament;  there  is  constant  uneasiness  or  actual  pain  in  the 
penis  and  perineum,  increased  by  walking  and  by  sitting  down  suddenly 
or  carelessly.  Insomnia  is  common;  chordee  occurs,  especially  when  the 
patient  is  warm  in  bed.  By  chordee  we  mean  a  condition  of  painful  erection 
in  which  the  penis  is  markedly  bent.  The  rigid  infiltration  of  the  corpus 
spongiosum  prevents  it  distending  to  accommodate  itself  to  the  enlarged  cor- 
pora cavernosa,  and  in  consequence  the  organ  curves.  There  is  frequent 
micturition,  with  tenesmus  and  a  profuse  creamy  discharge,  which  is  yellow, 
greenish,  or  even  bloody.  The  discharge  soils  and  stains  the  victim's  linen 
and  may  crust  upon  the  linen,  the  meatus,  or  the  glans.     The  commonest  com- 


Irritative  or  Abortive  Gonorrhea  1341 

plications  of  this  stage  are  balanitis  (inflammation  of  the  mucous  membrane  of 
the  glans  penis),  balanopostliitis  (inflammation  of  the  surface  of  the  glans  and 
the  mucous  membrane  of  the  prepuce),  phimosis  (thickening  and  contraction  of 
the  foreskin,  so  that  the  glans  cannot  be  uncovered) ,  and  paraphimosis  (catching 
and  fixation  of  the  retracted  prepuce  behind  the  corona  glandis,  with  such 
swelling  of  the  glans  and  prepuce  that  it  is  impossible  to  bring  the  prepuce 
forward  over  the  glans).  This  is  a  dangerous  condition  and  it  should  be  re- 
duced at  once.  In  the  second  or  stationary  stage,  which  lasts  from  the  end  of 
the  first  to  the  end  of  the  second  week,  the  acute  symptoms  of  the  first  stage 
continue.  The  most  common  complications  of  this  stage  are  peri-nrethral 
abscess  or  phlegmon  (infection  of  a  urethral  gland  or  of  submucous  structures), 
fclliculitis  (inflammation  of  the  follicles  of  Littre),  hemorrhage,  retention  of 
urine  (which  is  rare),  gonorrheal  arthritis,  lymphangitis,  and  diminutive 
bubo  on  the  dorsum  of  the  penis  (bubomdus) ,  soHtary  and  painful  bubo  of  the 
groin,  which  may  suppurate,  Cowperitis  (inflammation  of  Cowper's  glands), 
inflammation  of  the  prostate  or  of  the  bladder,  gonorrheal  ophthalmia,  and 
chordee  (painful  erection  with  downward  bending  of  the  penis).  In  the  third 
or  subsiding  stage  the  symptoms  gradually  abate,  the  discharge  becoming 
scantier  and  thinner,  and  finally  drying  up.  This  stage  is  of  uncertain  dura- 
tion, and  in  it  there  may  occur  epididymitis,  or  inflammation  of  the  epididymis. 
Among  possible  complications  we  may  mention  peri-urethral  abscess  or 
phlegmon,  Cowperitis,  cystitis,  prostatitis,  bubonulus,  folliculitis,  gonorrheal 
arthritis  (page  645),  infective  endocarditis,  tenosynovitis,  pyeHtis,  puru- 
lent ophthalmia,  perichondritis,  and  peritonitis.  Every  urethral  discharge 
should  be  examined  for  gonococci  in  order  to  make  a  positive  diagnosis. 
This  examination  is  made  several  times  during  the  progress  of  the  case, 
so  as  to  determine  when  the  organisms  disappear.  The  examination  can 
be  easily  made.  Place  a  drop  of  discharge  upon  a  cover-glass,  lay  another 
cover-glass  over  this,  and  slide  the  glasses  apart.  Dry  and  fix  the  slides  in  the 
flame  of  an  alcohol  lamp.  Bring  the  cover-glasses  in  contact  with  a  saturated 
solution  of  methylene-blue  in  5  per  cent.  carboUc  acid  water.  The  staining- 
material  is  allowed  to  remain  in  contact  with  the  slides  for  five  or  ten  minutes, 
the  glasses  are  washed  with  water,  are  then  placed  in  a  solution  of  5  drops 
of  acetic  acid  to  20  c.c.  of  water,  and  kept  there  "  long  enough  to  count  one, 
two,  three  slowly,"  and  again  washed  with  water.  Examination  with  the 
microscope  shows  the  gonococci  stained  blue.*  In  doubtful  cases,  when 
the  microscope  fails  to  show  gonococci,  make  cultures.  Cultures  should 
always  be  taken  from  a  discharge  in  a  child,  from  the  fluid  of  an  inflamed 
joint,  from  the  discharge  in  gleet  or  purulent  ophthalmia,  and  from  the  blood 
in  obscure  infections. 

Subacute  or  catarrhal  gonorrhea  develops  in  men  who  have  previously 
had  gonorrhea,  as  a  result  of  prolonged  or  repeated  coition  or  of  contact  with 
menstrual  fluid  or  leukorrheal  discharge.  There  is  profuse  mucopurulent 
discharge,  very  Httle  pain  on  micturition,  but  seldom  chordee  or  marked  irri- 
tability of  the  bladder. 

Irritative   or   Abortive    Gonorrhea. — In   this   disease   the   symptoms, 
which  are  identical  with  those  of  beginning  clap,  do  not  increase,  but  are  apt 
to  disappear  within  ten  days. 
*  Schiitz's  method,  as  set  forth  by  R.  \X.  Taylor  in  his  work  upon  "  Venereal  Diseases." 


1342  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Chronic  Urethral  Discharges.— Chronic  urethral  catarrh,  which 
may  follow  gonorrhea,  is  characterized  by  the  occasional  presence  of  a  drop 
of  clear,  tenacious  liquid.  This  discharge  becomes  more  profuse  as  a  result 
of  sexual  excitement  or  the  abuse  of  alcohol. 

The  persistence  of  a  small  amount  of  milky  discharge,  because  of  locali- 
zation of  inflammation  in  one  spot  or  the  production  of  a  granular  patch  or  a 
superficial  ulcer,  characterizes  chronic  gonorrhea.  There  is  some  scalding 
on  urination;  erections  produce  aching  pain;  there  are  pain  in  the  back  and 
redness  and  swelling  of  the  meatus.  All  the  symptoms  are  intensified  by 
sexual  excitement,  by  coitus,  by  violent  exercise,  or  by  alcohohc  excess. 

Gleet. — If  a  chronic  urethritis  lasts  over  ten  weeks,  it  is  called  gleet.  In 
gleet  the  lips  of  the  meatus  are  stuck  together  in  the  morning,  and  squeezing 
them  discloses  a  drop  of  opalescent  mucopurulent  fluid.  During  the  day  the 
discharge  is  rarely  found.  The  discharge  is  yellow  or  has  a  yellowish  hue; 
it  stains  the  linen  distinctly,  and  contains  pus,  shreds,  epithelium,  and  at 
times  gonococci.  The  urine  is  clear  and  contains  pus,  gonorrheal  shreds, 
and  comma-shaped  hooks.  The  discharge  is  not  obviously  purulent,  and 
contains  amyloid  corpuscles.  There  are  frequency  of  micturition,  pains 
in  the  back,  and  dribbhng  of  urine,  and  a  bougie  may  find  a  stricture  of 
large  caliber,  or  at  least  will  discover  that  the  urethra  is  rigid  from  in- 
flammatory infiltration.  A  discharge  may  be  maintained  by  chronic  pros- 
tatitis. In  this  condition  there  are  frequency  of  micturition;  a  sense  of 
weight  or  dull  pain  in  the  perineum;  diminished  projectile  force  of  the  stream 
of  urine;  there  is  often  a  tendency  to  sexual  excitement  and  premature  emis- 
sion. In  prostatorrhea  a  milky  discharge  gathers  in  the  urethra  during  sleep 
and  flows  during  muscular  effort  or  while  the  patient  is  at  stool.  The  linen 
is  stained  but  slightly  and  the  lips  of  the  meatus  are  not  glued  together  on 
waking.  There  is  a  history  of  masturbation  or  sexual  excess.  The  condition 
is  not  aggravated  particularly  by  alcohol  or  sexual  intercourse.  In  chronic 
anterior  urethritis  there  is  a  discharge  from  the  meatus  or  sticking  to- 
gether of  the  lips  in  the  morning.  In  chronic  posterior  urethritis 
there  is  no  discharge  of  pus  from  the  meatus.  If  the  three-glass  test  is 
made,  it  will  be  found  that  in  a  ca.se  of  chronic  anterior  urethritis  only 
the  first  portion  will  be  cloudy  and  show  shreds;  if  he  suffers  from  pos- 
terior urethritis  of  not  very  long  standing,  both  portions  will  be  a  little  clouded, 
the  first  containing  clap  shreds,  the  last  hook-shaped  shreds.  In  a  very 
chronic  case  neither  sample  will  be  cloudy,  but  the  first  portion  will  contain 
shreds.  In  gleet  the  rigidity  of  the  urethra  causes  the  retention  of  small 
quantities  of  urine  after  each  act  of  micturition,  back  of  the  thickened  areas. 
This  retained  urine  decomposes  and  adds  to  inflammation.  Indulgence  in 
alcohol,  sexual  excitement,  or  sexual  intercourse  aggravates  the  condition. 

Treatment  of  Acute  Gonorrhea. — General  Care. — Wash  the  hands  after 
touching  the  parts  and  dry  them  on  an  individual  towel,  which  is  not  used 
upon  the  face.  Wear  a  suspensory  bandage.  Avoid  violent  exercise,  espe- 
cially bicycle  riding,  and  also  wet.  Moderate  exercise  is  allowable.  The 
patient  must  not  only  refrain  from  sexual  intercourse,  but  must  not  permit 
himself  to  indulge  in  sexual  excitement,  and  must  not  drink  a  drop  of  liquor, 
malt,  vinous,  or  spirituous,  unless  he  is  a  heavy  or  a  regular  drinker,  in  which 
case  we  should  permit  the  moderate  use  of  well  diluted  rye  or  Scotch  whisky. 


Treatment  of  Acute  Gonorrhea  1343 

Some  men  become  actually  ill  without  their  regular  daily  stimulants  and  such 
men  should  have  them  in  moderation.  Some  surgeons  permit  the  moderate 
use  of  claret  to  all  patients.  At  least  twice  a  day  wash  the  penis  for  five  minutes 
in  a  cup  of  warm  water  containing  Sj  of  salt.  Passing  the  urine  while  the  penis 
is  immersed  in  warm  fluid  lessens  ardor  urinse.  If  the  foreskin  is  long,  catch 
the  discharge  on  a  bit  of  absorbent  cotton  caught  under  the  prepuce  and 
change  it  at  each  act  of  micturition.  If  the  foreskin  is  short,  cut  a  small 
opening  in  a  square  piece  of  old  linen,  slip  the  linen  over  the  glans,  catch  it 
back  of  the  corona,  and  bring  the  ends  forward  with  the  prepuce.  Never 
permit  the  cotton  or  linen  to  stick  fast  and  plug  up  the  lips  of  the  meatus. 
This  may  be  prevented  by  applying  sterile  vaselin  to  the  lips  of  the  meatus. 
If  the  glans  is  completely  naked,  pin  an  old  stocking  foot  upon  the  under- 
shirt, put  absorbent  cotton  in  the  toe,  and  place  the  penis  within  this  bag. 
Never  tie  or  fasten  any  material  about  the  penis.  The  patient  should  drink 
freely  of  plain  water  or  of  water  containing  a  little  bicarbonate  of  sodium.  He 
should  obtain  one  bowel  movement  every  day.  I  am  accustomed  to  direct 
the  patient,  in  accordance  vvith  Guiteras's  rule  (Begg,  in  "Phila.  Med.  Jour.," 
June  7,  1902),  to  avoid  tea,  much  coffee,  pickles,  spices,  condiments,  rhubarb, 
tomatoes,  and  asparagus.  Carbonated  beverages,  salt,  preserved  fish,  and 
cheese  are  detrimental.     Excessive  smoking  is  forbidden. 

Abortive  treatment  may  be  tried  if  the  case  is  seen  early.  The  use  of  strong 
solutions  of  powerful  germicides  has  been  abandoned  because  of  the  great 
pain  they  produce  and  the  inevitable  subsequent  crippHng  of  the  urethra. 

Abortiv^e  treatment  is  applicable  only  to  specially  selected  cases  and  even 
then  usually  fails.  It  should  never  be  used  after  the  gonococci  have  invaded 
the  submucosa,  but  only  during  the  prodromal  stage,  when  it  is  hoped  that  the 
germs  are  upon  and  not  in  the  mucous  membrane.  This  stage  usually  lasts 
but  a  few  hours,  usually  not  over  forty-eight.  The  patient  generally  presents 
himself  after  this  period  is  passed.  When  the  symptoms  as  described  in  the 
prodromal  period  prevail,  the  abortive  treatment  may  be  tried,  after  explaining 
to  the  patient  that  it  will  cause  some  pain  and  discomfort  and  in  the  end  may 
fail  or  even  aggravate  the  inflammation. 

Germicides  may  be  used  and  with  some  chance  of  killing  the  infection,  for 
as  yet  the  organisms  are  growing  upon  the  superficial  strata  of  epithelium 
much  as  a  sod  of  grass  upon  soil.  When  the  deeper  structures  have  been  in- 
vaded it  is  folly  to  attempt  to  abort. 

The  method  advocated  by  White  and  Martin  and  which  has  proved  success- 
ful in  Prof.  Onille  Horwitz's  clinic  in  a  very  Hmited  number  of  selected  cases 
is  as  follows:  After  urination  four  drops  of  a  4  per  cent,  solution  of  eucain  is 
injected  into  the  urethra;  after  which  i  or  2  drams  of  \  per  cent,  solution 
of  protargol  is  instilled  and  retained  for  three  minutes.  The  injecions  are 
repeated  every  two  hours  while  awake. 

Each  time  the  bottle  is  half  emptied  it  is  replenished  with  sterile  water  to 
its  full  capacity,  until  the  end  of  the  third  day.  If  successful,  recovery  is  ac- 
complished in  about  seven  days.  Should  a  mucoid  discharge  persist  an  anti- 
septic astringent  injection  is  employed  to  complete  the  cure.  During  the  treat- 
ment the  patient  must  be  kept  at  rest.  The  diet  should  be  bland  and  Hght  and 
the  usual  balsamic  remedies  are  administered.  If  the  symptoms  become  hyper- 
acute, stop  the  treatment  at  once  and  give  a  sedative. 


1344         Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Another  abortive  method  is  the  use  of  hot  retro-injections  of  corrosive  subli- 
mate solution  (1:20,000),  2  pints  being  run  through  the  urethra  once  a 
day.  If  in  seventy-two  hours  the  symptoms  are  not  greatly  improved, 
abortive  treatment  should  be  abandoned.  Recent  studies  render  it  almost 
certain  that  there  is  no  real  abortive  treatment.  Abortive  treatment,  to 
be  efficient,  would  have  to  be  carried  out  before  the  gonococci  penetrated 
the  epithelial  cells;  in  other  words,  would  need  to  be  instituted  before  the 
distinct  symptoms  of  the  disease  appear.     Janet  says    that  we    must   alter 

our  conception  as  to  what  constitutes 
abortive  treatment,  and  he  doubts  if 
a  case  of  true  gonorrhea  was  ever  really 
aborted.*  The  method  of  irrigation 
with  solutions  of  permanganate  of  po- 
tassium is  really  a  prophylactic  treat- 
ment. Janet  applies  his  treatment  as 
evidences  of  trouble  present  themselves, 
and  before  acute  symptoms  appear, 
and  claims  that  in  most  persons  the 
disease  can  be  arrested  in  from  eight 
to  twelve  days.  The  same  plan  of 
treatment  is  useful  in  a  well-developed 
case. 

Irrigation  can  be  used  in  an  incipi- 
ent or  in  a  well-developed  case.  Janet's 
method  is  as  follows:  An  irrigator  is 
filled  with  a  warm  solution  of  perman- 
ganate of  potassium  (i  :4ooo).  The 
patient  after  emptying  his  bladder  is 
seated  upon  a  chair  and  his  sacrum 
rests  upon  the  extreme  front  edge  of 
the  chair  (Valentine).  The  reservoir 
is  joined  to  a  glass  nozzle  by  a  rubber 
tube.  The  nozzle  is  introduced  into 
the  meatus,  and  the  fluid  is  permitted 
to  run  gradually  at  first,  with  full 
force  later.  In  anterior  trouble  the 
fluid  is  allowed  to  run  out  of  the 
meatus  by  the  side  of  the  nozzle. 
The  anterior  urethra  is  always  irri- 
gated first,  the  reservoir  being  two 
feet  above  the  chair. 

In  posterior  urethritis,  after  the  an- 
terior urethra  has  been  irrigated,  the 
reservoir  is   raised  from  si.x  to  seven 
feet  above  the  bed,  the  meatus  is  held 
tight  about  the  nozzle,  and  the  fluid  overcomes  the  force  of  the  compressor 
muscles  of  the  urethra  and  the  bladder  sphincter  and  enters  the  bladder, 
If  the  muscles  do  not  quickly  relax,  continue  the  hydrostatic  jiressure  for 
*  Ann.  d.  mal.  d.  org.  gen.-urin.,  1896,  p.  1031. 


Fig.  798. — Valentine's  urethral  and  intravesi- 
cal irrigator  :  a,  Board  with  attachments  to  be 
screwed  to  wall ;  c,  open  collar ;  d,  pulley ;  e, 
cord  ;  J~,  ring  to  suspend  percolator ;  £■,  brass  rod  ; 
A,  percolator ;  t,  rubber  tube ;  j,  ring  for  fourth 
finger;  A,  flange  to  graduate  pressure;  /.shield; 
wj,  ring  to  suspend  sliield  ;  «,  nozzle  attached. 


Treatment  of  Acute  Gonorrhea 


1345 


several  minutes,  when  relaxation  will  usually  occur;  but  if  it  does  not  do  so, 
tell  the  patient  to  breathe  slowly  and  deeply,  and  to  make  efforts  at  urina- 
tion (Valentine).  When  the  bladder  is  full  the  tube  is  withdrawn  and  the 
patient  micturates.  This  procedure  is  practised  once  or  twice  a  day  for  five 
or  six  days,  or  even  longer,  and  the  strength  of  the  solution  is  gradually 
increased  up  to  i  :  1000.  It  has  been  claimed  that  after  one  or  two  weeks 
of  this  treatment  gonococci  permanently  disappear  in  the  majority  of  cases. 
Fig-  79^  shows  the  irrigator  devised  by  Ferd.  C.  Valentine.  Valentine,  of 
New  York,*  has  constructed  the  following  table,  which  is  of  use  to  a 
practitioner  who  wishes  to  employ  irrigations  with  permanganate  of  potas- 
sium in  the  treatment  of  acute  gonorrhea: 


First   day, 
First  day, 
Second  day. 
Second  day, 
Third  day. 
Third  day, 
Fourth  day, 


first  visit. 
7  P.  M. 
9  A.  M. 
7  P.  M. 
9  A.   M. 

7  p.  M. 

9  A.   M. 


Anterior  irrigation 1  :  3000 


Fourth  day, 

7  p. 

M 

Fifth  day, 
Sixth  day. 
Seventh  day, 

Noon 
Noon. 
Noon. 

Eightli  day, 

9  A. 

M 

Eighth  day, 

7  P- 

M 

Ninth  day, 

9  A. 

M 

Ninth  day, 

7  P- 

M 

Tenth  day, 

9  A. 

M 

Tenth  day. 

7  P- 

M. 

Anterior 

Anterior 

Anterior 

Intravesical 

Anterior 

Intravesical 

Intravesical 

Anterior 

Intravesical 

Intravesical 

Intravesical 

Intravesical 

Anterior 

Intravesical 

Anterior 

Intravesical 

Anterior 

Intravesical 

Anterior 

Intravesical 

Anterior 

Intravesical 

Anterior 


I  :  4000 
I  :  3000 
I  :  4000 
I  :  6000 
I  :  5000 
I  :  5000 
I  :  5000 
I  :  2000 
I  :  5000 
I  :  5000 
I  :  5000 
I  :  5000 
I  :  3000 
I  :  5000 
I  :  2000 
I  :  4000 
I  :  1000 
I  :  4000 
I  :  1000 
I  :  4000 
I  :  1000 
I  :  5000 
I  :  500 


For  full  directions  regarding  this  method  see  Valentine's  excellent  book, 
"The  Irrigation  Treatment  of  Gonorrhea."  If  a  stricture  exists,  it  is  not 
advisable  to  employ  this  treatment.  Excellent  results  can  be  obtained  by 
irrigations  with  fluid  containing  silver  nitrate  (i  :  12,000  to  i  :  8000). 

When  a  patient  is  treated  by  irrigation,  after  the  entire  subsidence  of 
acute  symptoms,  a  thin,  colorless  discharge  may  persist.  This  can  be  cured 
by  the  use  of  astringents.  Two  or  three  times  a  day  an  astringent  is  injected 
by  means  of  a  half-ounce  syringe.  Dalton's  formula  is  very  useful:  Zinc 
oxid  and  lead  acetate,  of  each,  J  gr.  to  3  gr. ;  tincture  of  catechu,  from  ttlx  to 
trpcxx;  glycerin,  from  3ss  to  3j;  and  water  to  5j. 

Many  writers  oppose  the  irrigation  treatment,  claiming  that  it  increases 
the  liability  to  complications,  especially  prostatic  infiltration,  and  enhances 
the  danger  of  recurrence.  I  believe  in  the  method.  I  do  not  think  it  shortens 
the  duration  of  the  disease,  but  do  believe  that  it  mitigates  its  intensity,  makes 
the  patient  much  more  comfortable,  and  quickly  causes  the  discharge  to 
become  mucopurulent.  That  it  increases  complications  and  the  danger  of 
reinfection  is  very  doubtful.  Much  of  the  trouble  which  has  followed  its 
use  has  been  due  to  raising  the  reservoir  to  too  great  a  height. 

*  "The  Irrigation  Treatment  of  Gonorahea." 
85 


1346  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Irritative  gonorrhea  will  subside  in  a  few  days.  The  above  directions 
should  be  followed,  and  the  anterior  urethra  should  be  washed  out  several 
times  daily  with  peroxid  of  hydrogen,  or  irrigated  once  a  day  with  a  hot  solu- 
tion of  permanganate  of  potassium  (i  :  4000).  In  catarrhal  gonorrhea,  at 
once  order  injections  (i  grain  to  the  ounce  of  sulphate  of  zinc;  or  zinci  sulphas 
gr.  viij,  plumbi  acetas  gr.  xv,  water  oviij;  or  gr.  v  of  sulphocarbolate  of  zinc 
to  5j  of  water;  or  White's  prescription  of  3j  each  of  acetate  of  zinc  and  tannic 
acid,  3iij  of  boric  acid,  .Ivj  of  liq.  hydrogen,  peroxid.).  For  injecting  use  a 
blunt-pointed  hard-rubber  syringe  of  a  capacity  of  three  or  four  drams.  Let 
the  patient  urinate  and  then  sit  on  a  chair,  his  buttocks  hanging  over  the 
edge;  throw  a  syringeful  of  the  solution  into  the  urethra  and  let  it  run  out  at 
once  and  throw  in  another  syringeful  and  hold  it  in  from  three  to  five  minutes. 

In  ordinary  acute  gonorrhea  the  old  rule  was  to  order  balsams.  The 
common  custom  is  to  give  two  capsules  three  times  a  day,  each  capsule  con- 
taining 5  grains  of  salol,  5  grains  of  oleoresin  of  cubebs,  10  grains  of  balsam 
of  copaiba,  and  i  grain  of  pepsin.  Clinical  observation  indicates  that  the 
balsams  are  of  distinct  value  in  gonorrhea.  When  used  early,  the  discharge 
tends  to  become  mucopurulent  and  the  acute  symptoms  subside  (S.  Behr- 
mann,  in  "  Dermatologisches  Centralblatt,"  Berlin,  Nov.  and  Dec,  1901). 
Many  practitioners  will  not  use  balsams  until  the  third  week.  Bacteriological 
studies  indicate  that  copaiba,  when  eliminated  in  the  urine,  has  a  certain 
amount  of  power  in  inhibiting  the  growth  of  gonococci,  but  that  cubebs  and 
sandal  have  not  such  power.  Yet  sandal  is  more  useful  than  copaiba  as  a 
remedy.  Salol  is  distinctly  germicidal,  hence  it  is  given  with  the  balsams. 
In  a  case  treated  with  balsams  an  astringent  injection  is  usually  employed. 
The  injection  is  used  two  or  three  times  a  day,  immediately  after  micturition. 
As  the  inflammation  subsides  increase  the  strength  of  the  injection.  A  good 
plan  is  to  order  an  eight-ounce  bottle  and  eight  half-grain  powders  of  sulphate 
of  zinc.  Direct  the  patient  to  fill  the  bottle  with  water,  in  which  one  powder 
is  dissolved;  when  this  is  used  dissolve  two  powders  in  a  bottleful  of  water, 
and  so  progressively  increase  the  strength.  When  the  discharge  ceases  stop 
the  injections  gradually.  Whenever  a  syringeful  is  taken  from  the  bottle  a 
syringeful  of  water  is  put  into  the  bottle,  and  thus  pure  water  is  soon  obtained, 
at  which  point  injection  is  discontinued.  If  an  astringent  injection  causes 
much  pain,  use  a  sedative  injection — 3ij  of  boric  acid,  gr.  viij  of  aqueous 
extract  of  o[)ium,  and  oviij  of  hquor  plumbi  subacetatis  dilutus.  I  have  had 
as  much  success  with  the  above  simple  method  as  with  the  most  complicated 
of  plans.     Complication  and  complexity  are  not  criterions  of  usefulness. 

Argonin,  which  is  a  combination  of  albumin,  silver,  and  an  alkali,  is  highly 
recommended  by  some  authors  as  a  local  remedy  for  gonorrhea  (Schaffer, 
Guthiel).  A  solution  of  this  material  is  non-irritant,  the  silver  is  not  pre- 
cipitated by  chlorids,  and  the  agent  destroys  gonococci.  It  is  used  by  injec- 
tion or  irrigation.  If  used  by  irrigation,  employ  a  i  :  500  solution  twice  a 
day.  If  used  as  an  injection,  employ  a  i  :  200  solution  six  or  eight  times  a 
day.  When  the  discharge  is  found  free  from  gonococci  and  remains  free  for 
three  days,  stop  the  argonin  and  use  an  astringent  injection. 

Protargol,  metallic  silver  combined  with  a  proteid,  is  a  yellow  powder  solu- 
ble in  water,  the  solution  not  being  acted  on  by  light.  It  is  a  non-irritant 
germicide.     Neisser,   after  demonstrating  the  presence  of  the  gonococcus, 


Treatment  of  Acute  Gonorrhea  1347 

administers  protargol  by  injection,  the  first  injections  being  of  a  strength  of 
0.25  per  cent.,  the  strength  being  gradually  increased  to  0.5  per  cent.,  and 
finally  to  i  per  cent.  In  the  beginning  he  orders  three  injections  a  day, 
each  injection  being  retained  from  fifteen  to  thirty  minutes;  after  several 
days,  when  the  symptoms  improve  he  gives  only  one  or  two  injections  a  day, 
and  these  are  continued  for  ten  days  after  gonococci  disappear  from  the  dis- 
charge. After  protargol  is  abandoned  an  astringent  injection  should  be  used 
for  a  time.  Some  surgeons  use  a  i  :  1000  solution  of  protargol,  and  irrigate 
the  anterior  urethra  and  flush  the  bladder  twice  a  day.  The  most  powerful 
and  useful  of  the  silver  salts  is  argyrol,  or  silver  vitellin.  This  salt  was 
discovered  by  A.  C.  Barnes  and  H.  Hiller  ("Med.  Record,"  May  24, 
1902).  It  is  an  extremely  soluble  preparation,  contains  30  per  cent,  of 
silver,  does  not  coagulate  albumin,  and  is  not  precipitated  by  chlorids. 
When  injected  into  the  urethra  it  enters  deeply  into  the  mucous  mem- 
brane and  is  powerful  in  destroying  gonococci.  (See  "A  Clinical  Study  of 
a  New  Silver  Salt  in  the  Treatment  of  Gonorrhea,"  by  H.  M.  Christian,  in 
"Med.  Record,"  vol.  Ixii,  1902.)  In  most  cases  gonococci  disappear  within 
two  weeks.  The  injection  used  at  first  may  be  of  a  strength  of  2  per  cent. 
The  dn.g  should  be  retained  in  the  urethra  four  or  five  minutes,  and  three  or 
four  injections  should  be  given  each  day.  The  strength  of  the  injection  can 
be  gradually  increased  to  5  per  cent,  or  even  more.  Picric  acid  has  been 
highly  commended  as  an  injection.  The  strength  of  solution  is  i  :  200,  and 
it  is  to  be  retained  in  the  urethra  three  or  four  minutes  (de  Brun's  method). 

Methylene-blue  internally  is  occasionally  of  service  in  gonorrhea.  A 
capsule  containing  gr.  ij  of  the  drug  is  given  three  times  a  day.  It  makes  the 
urine  greenish-blue  and  occasionally  induces  strangury.  Urotropin  renders 
the  urine  sterile.     Salicylate  of  sodium  may  be  of  value  late  in  the  case. 

Christian's  plan  of  treating  acute  gonorrhea  is  very  useful.  It  is  as  fol- 
lows: Two  solutions  are  used  during  the  first  ten  days.  Three  times  a  day 
a  solution  of  permanganate  of  potash  is  injected  (gr.  ^  of  permanganate  of 
potash  in  8  ounces  of  water),  six  syringefuls  being  used  at  each  seance.  After 
a  washing  with  permanganate  protargol  is  injected  (gr.  x  of  protargol  to  liv 
of  water)  and  retained  ten  minutes.  At  the  end  of  four  days  the  strength 
of  the  protargol  is  increased  to  gr.  xx  in  3iv  and  the  strength  of  the  perman- 
ganate to  I  :  4000.  During  the  third  week  abandon  the  above-mentioned 
solutions,  put  the  patient  on  balsams,  and  use  an  astringent  injection.  Chris- 
tian uses  gr.  X  of  sulphate  of  zinc,  gr.  ij  of  subcarbonate  of  bismuth,  2  ounces 
of  solution  of  hydrastis,  and  4  ounces  of  water.  Cure  is  obtained  in  six  or 
seven  weeks. 

In  his  clinic  in  Jefferson  Hospital  my  colleague,  Prof.  Horwitz,  employs  the 
foUowdng  plan  of  treatment:  A  capsule  containing  balsam  of  copaiba,  salol, 
oil  of  sandalwood,  and  methylene-blue  is  given  half  an  hour  after  each  meal : 

I^.      Methvlene-blue gr.  xxx 

Balsami  copaibas  \ ^-  ^-^^_^ 

Olei  santah  j 

Pone  in  capsulas  No.  xxx. 

Sig. — One  after  each  meal. 

The  patient  begins  at  once,  three  times  a  day,  the  use  by  hand  injection 
of  a  10  per  cent,  solution  of  argyrol. 


1348         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

At  each  day  injection  the  fluid  is  retained  within  the  canal  five  minutes. 
At  the  bedtime  injection  the  fluid  is  retained  for  fifteen  minutes.  At  first 
only  about  3j  is  injected  at  a  time,  but  as  the  urethra  becomes  accustomed 
to  fluid  distention  the  amount  is  gradually  increased,  until  finally  .5iv  are 
given. 

Argyrol  is  less  irritant  and,  it  is  said,  more  strongly  germicidal  than  the 
other  preparations,  but  it  cannot  penetrate  deeply  into  the  tissue  and  is  of  Uttle 
value  excej)t  in  the  period  of  onset  or  early  in  the  acute  stage.  Many  patients 
object  to  argyrol  because  it  leaves  a  dark  stain  on  any  fabric  with  which  it 
comes  in  contact,  but  this  stain  can  be  easily  removed  by  the  application  of 
a  1 :  1000  solution  of  corrosive  sublimate. 

When  the  stage  of  decline  begins  (toward  the  end  of  the  second  week)  a 
combined  astringent  and  antiseptic  treatment  is  used. 

The  capsules  of  methylene-blue,  copaiba,  salol,  and  sandal,  and  the  in- 
jections of  argyrol  are  discontinued.  A  capsule  containing  oleoresin  of  cubebs, 
oil  of  sandal,  and  balsam  of  copaiba  is  given  before  each  meal,  and  a  cay)sule  of 
urotropin  is  given  after  each  meal.  An  injection  of  protargol  (|  of  i  per  cent.) 
is  given  three  times  a  day.  This  remedy  is  germicidal  and  also  astringent. 
The  strength  is  gradually  increased  until  a  i  per  cent,  solution  is  used.  By  the 
end  of  the  fourth  week  the  patient  has  reached  the  terminal  stage.  Now 
capsules  of  sandal  and  salol  are  substituted  for  the  cubebs,  sandal  and  coapiba 
and  an  astringent  injection  is  ordered.  The  following  injection,  recommended 
by  J.  Wm.  White,  is  very  satisfactory: 

I^.      Hydrarg.   chlor.   corros gj-  i 

Zinci  sulphocarbolas OSS 

Acidi  boraci 5  ij 

Acidi  carbolici ITLxv 

Boroglycerid  (25  per  cent.) foij 

Aquae  destil q.  s.  ad.   f  o  vj.- — M. 

Sig. — Inject.     Dilute  if  it  causes  much  pain. 

When  the  mucoid  condition  predominates  in  the  discharge  the  following  is 
useful : 

I^.     Zinci  sulph gr-  xv 

Plumbi  acetati. gr.  xxx 

Glycerol  tannin  I  ..    -^. 

Hydrastin  (Lloyd's)  J aa  t  oiv 

Mucil.  acaciae f oiv 

Aquas  destil q.  s.  ad.  f  5vj. — M. 

Sig. — As  injection. 

The  formula  of  the  "injection  Brue"  is  as  follows: 

I^.     Plumbi  acetat gr.  xxx 

Zinci  sulphat gr.  xvj 

Ext.  krameria^  fl f  3iv 

Tinct.  opii f  3iij 

Aquffi  destil q.  s.  ad.  fovj. — M. 

Sig. — As  injection. 

When  all  symptoms  have  disappeared,  the  injection  is  gradually  diluted. 
Whenever  a  syringeful  of  the  fluid  is  taken  from  the  bottle,  a  syringeful  of 


Treatment  of  Complications  1349 

water  is  put  in.  When  the  fluid  becomes  pure  water,  the  injection  is  discon- 
tinued. The  capsules  are  stopped  by  gradual  diminution  in  the  number  of 
daily  doses.  For  three  weeks  after  the  entire  disappearance  of  all  symptoms 
alcohol  is  forbidden  and  sexual  indulgence  is  prohibited.  Should  a  relapse 
occur  the  patient  is  at  once  placed  upon  treatment  as  for  the  acute  stage,  and 
when  the  stage  of  decline  again  ensues  he  is  placed  on  the  previously  mentioned 
antiseptics  and  astringents.  Relapses  are  caused  by  a  localized  lesion  or 
lesions  in  the  anterior  or  posterior  urethra,  hence  as  soon  as  all  acute  symptoms 
subside  an  endoscopic  examination  is  to  be  made  and  proper  treatment  is  to  be 
applied  to  the  localized  lesion.  If  during  the  treatment  of  gonorrhea  a  com- 
plication develops,  local  treatment  of  the  urethra  is  at  once  discontinued  and 
constitutional  treatment  suited  to  the  new  condition  is  prescribed. 

If  the  onset  of  gonorrhea  is  marked  by  violent  inflammatory  symptoms 
(chordee,  hemorrhage,  severe  pain,  swelling,  profuse  purulent  discharge), 
local  treatment  of  the  urethra  is  contraindicated. 

If  the  invasion  is  hyperacute,  no  local  treatment  of  the  urethra  is  permis- 
sible until  the  disease  assumes  the  character  of  ordinarj'  gonorrhea. 

Not  unusually  gonorrhea  passes  into  a  low  grade  of  anteroposterior  ure- 
thritis that  proves  most  rebellious  to  treatment.  This  condition  is  especially 
common  when  a  too  stimulating  treatment  has  been  used.  A  mild  astringent 
injection  is  used  three  times  a  day.  Every  second  or  third  day  an  injection  of 
nitrate  of  silver  (i :  4000)  is  given.  If  the  silver  salt  sets  up  an  acute  inflamma- 
tion the  treatment  used  in  the  acute  stage  of  gonorrhea  is  given  until  the 
symptoms  abate. 

A  valuable  plan  in  rebellious  anteroposterior  urethritis  is  daily  irrigation 
of  the  anterior  urethra  A\ath  a  warm  solution  of  permanganate  of  potassium 
(i :  6000) ,  followed  by  the  passage  of  a  soft  catheter  and  the  filling  of  the  bladder 
with  a  like  solution.  The  patient  empties  his  bladder  after  the  catheter  is 
withdrawn  and  thus  flushes  the  entire  urethra  with  the  permanganate.  The 
strength  of  the  solution  is  gradually  increased  up  to  i :  2000. 

Weiss  uses  corrosive  sublimate  (i :  20,000)  in  the  manner  just  described. 
It  is  particularly  valuable  in  cases  of  bacterial  contamination,  the  gonococci 
having  disappeared. 

Treatment  of  Complications. — Ardor  urincB  is  relieved  by  urinating 
while  the  penis  is  immersed  in  hot  water  and  by  administering  an  alkaline 
diuretic.  Chordee  requires  a  bowel  movement  in  the  evening,  and  sleeping 
in  a  cool  room,  under  light  covers,  and  on  a  hard  mattress;  bromid  is  given 
several  times  daily,  and  a  considerable  dose  is  given  at  night;  it  may  be  neces- 
sary to  use  suppositories  of  opium  and  camphor  or  to  give  hyoscin.  Balanitis 
requires  frequent  washing  with  warm  water,  drying  with  cotton,  and  dusting 
with  bora  ted  talc  or  with  boric  acid  and  subnitrate  of  bismuth  (1:6).  Balano- 
posthitis  requires  soaking  in  hot  w^ater,  and  injections  of  black  wash  under  the 
prepuce  until  edema  of  the  foreskin  subsides,  and  then  cleanliness  and  the 
application  of  a  drying  powder.  Phimosis  requires  soaking  the  penis  in  hot 
water,  and  injections  of  hot  water  beneath  the  foreskin,  followed  by  black  wash, 
If  this  fails,  circumcision  must  be  performed.  If  paraphimosis  occurs,  grasp 
the  head  of  the  penis  with  the  left  hand,  squeeze  the  blood  out,  and  try  to 
push  the  head  back,  while  with  the  right  hand  the  penis  is  pulled  upon  as  if 


1350  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  surgeon  intended  to  hft  the  individual  by  the  organ.  If  this  fails,  cut  the 
collar  on  the  dorsum  with  scissors;  or,  what  is  better,  for  it  gives  free  expo- 
sure, incise  each  side  of  the  prepuce  between  the  middle  of  the  dorsum  and 
the  frenum.  Bubo  requires  the  application  of  iodin,  ichthyol,  or  blue  oint- 
ment, the  use  of  a  spica  bandage,  and  rest.  If  a  bubo  suppurates,  it  must  be 
opened  or  aspirated.  Acute  posterior  urethritis  is  treated  by  rest,  and  if  the 
symptoms  are  severe,  by  rest  in  bed.  If  the  balsams  do  not  irritate,  they  are 
given;  if  they  do,  they  are  withdrawn.  Urotropin  or  salol  is  given  and  the 
patient  is  placed  upon  a  milk-diet  with  orders  to  drink  largely  of  flaxseed  tea. 
Alkaline  fluids  do  harm  by  favoring  ammoniacal  decomposition  of  the  urine. 
Injections  and  irrigations  are  abandoned.  Pain  and  vesical  spasm  are  con- 
trolled by  suppositories  of  opium  and  belladonna.  If  retention  of  urine 
occurs,  have  the  patient  urinate  while  in  a  hot  bath;  if  this  fails,  use  a  soft 
catheter.  Acute  vesiculitis  is  treated  as  is  acute  prostatitis.  Chronic  vesicu- 
litis is  considered  on  page  1369.  Pyelitis  is  treated  by  rest  in  bed,  hot  baths, 
wet  cupping  of  the  loin,  or  milk-diet,  the  use  of  diuretics,  the  taking  of  a  large 
quantity  of  bland  liquid,  and  the  administration  of  salol  or  urotropin.  Fol- 
liculitis is  treated  by  rest  and  the  application  of  a  hot-water  bag  to  the  peri- 
neum (if  that  be  the  part  involved).  If  pus  forms,  evacuate  by  incision. 
Later  the  follicle  may  be  dissected  out  or  destroyed  by  cauterization.  ,  If 
the  follicle  opens  into  the  urethra  it  may  be  cauterized  through  an  endoscope. 
Peri-urethritis  is  treated  by  rest  and  hot  applications.  If  pus  forms,  an  inci- 
sion must  be  made.  If  the  abscess  is  permitted  to  break  into  the  urethra, 
rest  and  hot  fomentations  may  be  used,  but  at  the  first  sign  of  urinary  ex- 
travasation make  an  external  incision.  Cowperitis  is  treated  in  the  same 
way  as  peri-urethritis.  Gonorrheal  rheumatism  is  considered  on  page  045. 
Acute  prostatitis  and  cystitis  require  confinement  to  bed,  a  milk-diet,  the  use 
of  diuretics,  hot  applications  to  the  perineum  and  hypogastrium,  sup- 
positories of  opium,  and  belladonna  or  ichthyol,  leeching  the  perineum, 
the  discontinuance  of  balsams  and  injections,  and  the  administration  of 
urotropin  or  salol.  Abscess  oj  the  prostate  requires  instant  incision.  In 
retention  oj  urine  the  patient  should  try  to  pass  the  urine  while  in  a  hot  bath; 
if  this  fails,  a  soft  catheter  is  used.  After  relieving  the  bladder  put  the  patient 
to  bed  and  apply  hot  sand-bags  as  for  acute  prostatitis.  Chronic  prostatitis 
requires  cold  hip-baths,  cold-water  enemata,  deep  urethral  injections,  plain 
diet,  avoidance  of  alcohol  and  over-exertion,  counter-irritation  of  the  peri- 
neum, and  the  relief  of  stricture  or  phimosis.  Great  benefit  is  occasionally 
derived  from  passing  a  soft  bougie  covered  with  blue  ointment  or  with  a  10 
per  cent,  ointment  of  protargol.  If  epididymifis  arises,  put  the  patient  to 
bed,  abandon  injections,  shave  the  hair  from  the  groin,  leech  over  the  cord, 
elevate  the  testicles,  and  apply  an  ice-bag.  Give  a  cathartic,  a  fever  mixture, 
and  suitable  doses  of  bromid  of  potassium  and  morphin.  The  application 
twice  a  day  of  20  drops  of  guaiacol  in  o]  of  cosmolin  or  olive  oil  gives  great 
relief.  When  swelling  lingers,  after  tenderness  subsides  strap  the  testicle 
with  adhesive  plaster.  A  lingering  case  is  benefited  by  the  internal  use  of 
iodid  of  potassium  and  the  local  application  of  ichthyol.  In  gonorrheal 
ophthalmia  secure  a  watch-crystal  over  the  unaffected  eye,  put  the  patient 
in  a  darkened  room,  rub  the  infected  conjunctival  sac  with  cotton  soaked  in  a 


Treatment  of  Chronic  Gonorrhea 


1351 


2  per  cent,  solution  of  silver  nitrate,  wash  out  the  affected  eye  often  with  hot 
boric-acid  solution,  keep  the  pupil  dilated  with  atropin,  leech  the  temple,  and 
give  purgatives.     Always  send  for  an  ophthalmologist. 

When  is  Gonorrhea  Cured? — When  actual  discharge  ceases,  a  patient 
considers  himself  cured  and  yet  he  may  have  residuals  of  infection  which  are 
liable  at  any  time  to  awaken  into  activity  and  produce  anew  an  acute  condi- 
tion. Gonococci  are  frequently  retained  in  the  urethral  glands  and  folhcles 
or  in  areas  surrounded  by  indurated  mucous  membrane.  A  man  is  considered 
to  be  well  when  shreds  and  pus  disappear  from  the  urine,  when  an  examination 
of  expressed  mucus  on  three  successive  days  fails  to  find  gonococci,  and  when 
there  has  been  no  discharge  for  ten  days.  Furthermore,  we  must  be  sure 
that  the  prostate,  Cowper's  glands,  and  the  seminal  vesicles  are  free  from 
disease. 

Treatment  of  Chronic  Gonorrhea  and  of  Chronic  Urethritis  follow- 
ing Gonorrhea. — The  iirst  thing  to  do  is  to  determine  the  cause  of  the  pro- 
longation of  the  discharge.     Valentine's  hst  of  causes  should  be  borne  in 


Fig.  799. — Bougie-a-boule. 


mind  ("Med.  Record,"  June  29,  1901).  They  are  as  follows:  (i)  Lack  of 
treatment;  (2)  misdirected  treatment;  (3)  insufficient  treatment;  (4)  over- 
treatment;  (5)  infraction  of  dietetic  or  hygienic  regulations;  (6)  constitu- 
tional disturbances;  (7)  congenital  or  acquired  deformities  and  complica- 
tions; (8)  involvement  of  the  urethral  adnexa;  (9)  marital  reinfection.  In 
a  case  in  which  a  discharge  persists  or  recurs,  the  symptoms  and  general 
condition  must  be  closely  studied,  the  discharge  must  be  examined  micro- 
scopically, the  condition  of  the  urine  must  be  determined,  and  the  urethra 
must  be  explored. 

Exploration  of  the  urethra  is  inaugurated  by  inspection  and  external  pal- 
pation. Palpation  detects  induration,  peri-urethritis,  foUicular  abscess  or 
inflammation,  Cowperitis,  etc.  The  prostate  and  seminal  vesicles  are  ex- 
amined by  a  finger  in  the  rectum.  The  interior  of  the  urethra  is  explored 
with  a  soft  bougie-a-boule  (Fig.  799).  On  withdrawing  this  instrument  the 
shoulder  catches  in  any  contracture.  It  is  to  be  borne  in  mind  that  a  large 
steel  sound  can  often  be  introduced  with  ease  when  the  bougie-a-boule  makes 
evident  that  a  contracture  exists.  The  emergence  of  the  instrument  is  arrested 
by  a  patch  of  thickening,  a  granular  area,  a  zone  of  epithelial  proliferation, 


1352  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

a  papilloma,  or  a  stricture.     In  fact,  anything  which  lessens  the  urethral 
caliber  interferes  with  the  withdrawal  of  the  bougie-a-boule.     It  does  not  do 

to  conclude  that  stricture 
exists  simply  because 
some  lessening  of  caliber 
is  appreciated.  The 
bougie-a-boule  iinds  its 
chief  use  in  exploring  the 
anterior  urethra.  If  in- 
troduced into  the  deep 
urethra  its  emergence  will 
he  normally  checked  as 
its  shoulder  comes  against 
the  posterior  layer  of  the 
triangular  hgament.  , 

In  most  cases  the 
diagnosis  is  only  certainly 
determined  by  the  use  of 
the  urethroscope.  This 
instrument  has  been  per- 
fected of  recent  years  and 
is  now  an  absolutely  es- 
sential part  of  an  arma- 
I  use  Valentine's  instrument  and  find  it  most  satisfactory  (Figs. 


Fig.  800, — Valentine's  urethroscope. 


mentarium. 


Fig.  801.— Valentine's  urethroscopic  tube. 

800-803).     The  anterior  and  posterior  urethra  can  be  thoroughly  examined 
with  the  utmost  ease.     Before  inserting  a  urethroscopic  tube  place  the  patient 


Fig.  802. — Valentine's  obturator. 

recumbent  and  cleanse  the  foreskin,  glans,  and  anterior  urethra  as  directed 
in  the  section  on  Cystoscopy.     Insert  a  tube  which  readily  passes  the  meatus, 


Fig.  803, — Valentine's  light  carrier. 


first  cleansing  the  tube  and  obturator  by  burning  alcohol  upon  them.     Carry 
the  tube  to  the  anterior  layer  of  the  triangular  ligament.     Withdraw  the 


Chronic   Urethral    Discharjres 


1353 


obturator  and  insert  the  hght.  Turn  on  the  hght.  mop  the  urethra  with  bits 
of  cotton  wTapped  on  a  stick,  and  slowh-  withdraw  the  tube,  examining  the 
urethra  as  its  walls  fall  together  back  of  the  retractmg  tube.  After  with- 
drawal of  the  tube  irrigate  the  anterior  urethra.  To  examine  the  deep  urethra, 
carry  the  instrument  through  the  prostatic  urethra.  After  the  examination 
give  an  intravesical  irrigation. 

When  the  cause  of  a  discharge  is  once  determined,  rational  treatment  can 
be  instituted,  and  to  determine  the  cause  the  electric  urethroscope  is  indispen- 
sable. An  erosion  of  the  mucous  membrane  or  a  granular  patch-  requires 
touching  from  time  to  time  with  a  solution  of  silver  nitrate  (i  or  2  per  cent.). 
These   applications   are   made   through   the   tube   of   the   urethroscope.     A 


Fig.  807.  — Oberlander's  anteroposterior  dilator. 


stricture  or  an  infiltration  is  treated  by  gradual  dilatation.  This  combines 
pressure  and  massage.  If  the  cahber  of  the  urethra  is  less  than  No.  2 1  of  the 
French  scale,  conical  steel  sounds  are  used  twice  a  week.  If  there  is  much 
hyperesthesia  they  are  retained  but  a  brief  time;  but  as  hyperesthesia  dimin- 
ishes the  period  of  retention  is  lengthened,  until  an  instrument  can  be  kept 
in  place  without  causing  severe  suffering  for  ten  or  fifteen  minutes.  It  is 
noc  desirable  to  use  cocain,  as  it  is  distinctly  dangerous,  obtunds  the  sen- 
sibihty  so  that  undue  violence  may  be  used,  and  increases  the  post-operative 
^"nflammation.  Before  and  after  using  an  instrument  the  urethra  must  be 
cleansed  as  previously  directed  (page  1338). 


1354  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

When  the  urethra  becomes  tolerent  to  instrumentation,  a  special  dilator 
Ls  employed  to  act  particularly  on  the  area  of  disease.  If  in  the  beginning  of 
treatment  the  caliber  of  the  urethra  is  equal  to  or  greater  than  No.  21  of  the 
French  scale,  it  is  rarely  necessary  to  precede  the  dilator  by  the  use  of  conical 
sounds.  Figs.  804,  805,  806,  and  807  show  various  dilators.  Most  dilators 
should  be  inserted  in  a  sterile  rubber  cover  before  being  used,  otherwise  they 

will  cut,  tear,  or  pinch 
the  urethra.  Koll- 
mann's  dilator  will  not 
injure  the  mucous 
membrane  and  can  be 
used  without  a  cover 
tt;    a  e    I-  1.        •     1    !^      •  (ris-  804).     A  dilator 

rig.  808.— KoHmaiiii  s  gland  syringe.  v      &  t/ 

should  be  lubricated 
with  lubrichondrin  or  synol  soap.  If  a  two-bladed  dilator  is  used  at  first, 
a  four-bladed  dilator  must  be  subsequently  employed. 

A  dilator  is  cleansed  by  scrubbing  its  blades  with  soap  and  water,  sticking 
them  in  alcohol,  withdrawing,  and  burning  the  alcohol  retained  in  the  in- 
strument. 

The  following  rules  are  of  the  first  importance  (Ferd.  C.  \'alentine,  in 
"Med.  Record,"  June  29,  1901): 

1.  The  first  dilatation  must  stop  at  that  point  at  which  the  first  resistance 
to  further  dilatation  is  felt  by  the  operator's  fingers  turning  the  screw  that 
separates  the  blades. 

2.  Dilatations,  if  done  by  a  novice,  must  in  the  beginning  of  treatment 
be  repeated  no  oftener  than  every  three  or  four  days. 

3.  Each  dilatation,  in  point  of  time,  must  reach  no  greater  duration  than 
two  minutes  over  that  of  the  preceding  session. 

4.  No  dilatation  must  exceed  one-half  number  Chariere  above  the  number 
attained  at  the  next  prior  seance,  regardless  of  any  lack  of  resistance  that  may 
be  present. 

As  a  rule,  glandular  and  follicular  infiltrations  are  cured  by  the  u.se  of 
the  dilator.  If  they  are  not,  they  must  be  treated  through  the  tube  of  the 
urethroscope.  The  interior  of  a  follicle  may  be  cauterized  with  an  electric 
wire  or  subjected  to  electrolysis,  or  touched  with  a  3  per  cent,  solution  of 
silver  nitrate.  A  thickened  crypt,  or  gland,  or  follicle,  or  an  area  of  indura- 
tion, may  be  slit  with  a  knife.  A  polyp  can  be  removed  with  a  .snare,  the 
cautery,  or  special  forceps.  In  a  chronic  inflammation  of  the  urethra,  in 
which  the  inflammation  is  superficial  and  in  which  the  glands  are  not  in- 
volved, irrigations,  urethral  and  intravesical,  constitute  the  best  treatment. 
(See  Valentine's  treatise  on  "The  Irrigation  Treatment  of  Gonorrhea,  its 
Local  Complications  and  Sequels.") 

In  any  lingering  case  of  gonorrhea  examine  the  urine,  and  direct  suitable 
treatment  for  oxaluria,  lithemia,  or  phosj)haturia,  if  any  one  of  these  condi- 
tions exists.  Such  morbid  states  of  the  urine  are  occasionally  responsible  for 
great  prolongation  of  the  inflammation.  In  some  cases  a  discharge  is  kept 
up  by  inflammation  of  the  seminal  vesicles  (page  1369). 

Gonorrhea  of  the  anus  and  rectum  occasionally,  though  very  rarely, 


Gonorrhea  in  the  Female  1355 

occurs.  It  may  result  from  pederasty,  or  in  a  woman  from  a  tlow  of  infectiou> 
material  from  the  genitalia  to  the  anus.  It  causes  severe  burning  pain,  aggra- 
vated by  defecation.  The  parts  are  red,  swollen,  and  tender.  The  discharge 
IS  prc'fuse,  being  at  first  cream  white,  and  then  thicker  and  greenish.  The 
diagnosis  rests  upon  the  history  and  the  finding  of  gonococci  in  the  discharge. 
The  disease  rarely  extends  above  the  anus. 

Treatment. — If  the  anus  only  is  involved,  spray  several  times  daily  with 
peroxid  of  hydrogen,  wash  with  salt  solution,  irrigate  with  permanganate  of 
potash  (i  :4ooo),  dust  with  talc  powder,  and  interpose  a  piece  of  iodoform 
gauze  between  the  inflamed  surfaces.  An  ulcer,  a  fissure,  or  an  excoriation 
is  touched  with  lunar  caustic.  If  the  rectum  becomes  involved,  secure  a 
daily  bowel  movement  and  irrigate  the  rectum  twice  a  day  with  boric-acid 
solution  or  permanganate  of  potash  (i  :4ooo). 

Gonorrhea  of  the  Mouth. — This  is  a  very  uncommon  malady.  It 
occurs  in  infants  more  often  than  in  older  people.  Infection  in  infants  may 
take  place  during  birth  if  the  mother  has  gonorrhea.  The  svinptoms  are 
those  of  \-iolent  stomatitis.  The  diagnosis  is  suggested  by  the  condition  of 
the  mother  and  is  proved  by  finding  gonococci  in  the  discharges  from  the 
mouth. 

Treatment. — Wash  the  mouth  frequently  ^^•ith  boric  acid  and  listerine 
(gr.  xlviij  to  Sviij),  and  swab  the  diseased  areas  at  intervals  with  a  10  per 
cent,  solution  of  arg}'rol. 

Gonorrhea  of  "the  Nose. — It  is  alleged  that  this  condition  can  arise, 
but  an  absolutely  authentic  case  does  not  seem  to  be  on  record. 

Gonorrhea  in  the  Female. — There  is  much  dispute  as  to  the  parts 
infected.  Some  observers  maintain  that  the  vaginal  epithehum  never  con- 
tains gonococci  and  that  gonococci  found  in  a  vaginal  discharge  have  come 
from  the  cervix  or  uterine  canal.  Beyond  a  doubt,  however,  when  young 
women  who  have  not  borne  children  contract  gonorrhea  the  vulva  and  vagina 
usually  suffer.  In  older  women  and  in  women  w^ho  have  borne  children 
the  vaginal  tissues  are  altered  and  the  cells  are  not  nearly  so  prone  to  infec- 
tion; hence  in  such  subjects  the  vagina  often  or  usually  escapes.  The  initial 
infection  is  in  many  cases,  in  the  cervical  canal,  in  some  in  the  \ailva  or  ure- 
thra. No  matter  what  part  was  first  attacked,  other  parts  usually  become 
quickly  involved  in  the  acute  process.  The  urethra  is  involved  in  ahnost 
every  case.  Chronic  gonorrhea  is  prone  to  linger  in  the  urethra,  in  the 
glands  of  BarthoHn,  in  the  cer\ncal  canal,  or  within  the  uterus  or  in  the 
Fallopian  tubes.  The  great  danger  of  gonorrhea  in  the  female  is  in  the 
development  of  ascending  infection  of  the  fining  membrane  of  the  uterus, 
which  may  reach  the  tubes,  ovaries,  and  peritoneum. 

When  infection  occurs  during  pregnancy  or  when  pregnancy  occurs 
during  infection  of  the  cervical  or  uterine  canal,  abortion  may  take  place. 
Again,  a  pregnant  woman  may  not  abort  but  may  go  on  to  term  and  the  child 
may  receive  a  conjunctival  infection  during  delivery  and  rapidly  develop 
purulent  ophthalmia. 

In  some  cases  when  pregnancy  occurs  during  the  existence  of  gonorrhea, 
the  disease  seems  to  pass  away  and  yet  the  child  gets  conjunctival  infection 
during  delivery  or  the  mother  subsequently  develops  pus-tubes. 


1356  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Treatment.— Place  the  patient  in  bed  during  the  acute  stage  of  the  dis- 
ease, give  hot  hip-baths,  keep  the  bowels  open  by  means  of  saline  purga- 
tives, insist  on  a  fluid  diet  consisting  chiefly  of  milk,  and  flush  out  the  ure- 
thra by  having  the  patient  drink  considerable  quantities  of  water.  The 
external  genital  organs  should  be  sprayed  with  peroxid  of  hydrogen  every 
two  or  three  hours,  and  after  spraying  should  be  dried  with  absorbent  cotton 
and  dusted  with  equal  parts  of  starch  and  powdered  oxid  of  zinc,  or  with 
powdered  stearate  of  zinc.  Pads  of  cotton  fixed  in  place  by  a  bandage  are 
used  to  catch  the  discharge.  If  urethritis  exists  in  this  stage,  we  may  give 
alkahes,  balsams,  and  astringent  urethral  injections. 

When  the  acute  s}Tnptoms  have  somewhat  abated,  an  attempt  should  be 
made  to  prevent  ascending  infection  from  the  cer\'ical  canal.  The  mucous 
membrane  of  the  canal  may  be  cureted  away  or  be  destroyed  by  pure  car- 
bolic acid  or  nitrate  of  silver.  A  wiser  plan  is  to  paint  the  cervical  canal 
daily  with  iodin  or  a  10  per  cent,  solution  of  arg}Tol,  painting  the  vaginal 
portion  of  the  cervix  at  the  same  time  with  the  same  drug.  The  vagina  is 
irrigated  twice  a  day  with  a  warm  solution  of  permanganate  of  potash 
(i  :  4000)  and  is  lightly  packed  with  iodoform  gauze.  When  the  vulva  is 
particularly  involved,  treat  that  part  by  applying  lead-water  and  laudanum 
locally  or  paint  the  vulva  with  silver  solution  (gr.  xl  to  5j).  If  the  vulvo- 
vaginal gland  suppurates,  open  it. 

If  vaginitis  exists  and  continues  in  spite  of  the  treatment  suggested  above, 
wash  out  the  vagina  every  two  hours,  first  with  Oj  of  hot  solution  of 
bicarbonate  of  sodium,  next  with  Oj  of  hot  water,  and  finally  'with  Oj  of 
astringent  solution  (a  teaspoonful  of  lead  acetate,  a  teaspoonful  of  zinc 
sulphate,  a  teaspoonful  of  alum,  or  four  teaspoonfuls  of  tannin  to  the  pint  of 
hot  water)  (White).  As  the  attack  subsides,  use  vaginal  suppositories,  each 
containing  gr.  v  of  tannic  acid.  In  some  cases  apply  solutions  of  silver 
nitrate  (1  :  200)  or  of  arg}Tol  (10  per  cent.),  and  insert  tampons  of  ichthyol 
(8  per  cent.)  moistened  with  boroglycerid  (Le  Blonde). 

In  chronic  cases  of  urethritis  use  strong  solutions  of  silver  nitrate  and 
irrigate  the  urethra  and  bladder  with  silver  nitrate  (i  :  8000). 

For  uterine  gonorrhea  obser^-e  the  same  general  management.  Swab 
out  the  uterus  with  tincture  of  iodin  or  nitrate  of  silver  and  insert  tampons 
of  iodoform  gauze. 

Gonorrhea  in  Children. — Male  Children. — This  disease  is  not  very 
common.  When  it  affects  children  under  twelve,  it  is  usually  due  to  some 
abandoned  and  diseased  female  having  brought  the  child's  penis  in  con- 
tact with  her  sexual  organs.  It  may  result  from  introducing  infected  mate- 
rials into  the  penis.  The  s^-mptoms  are  similar  to,  but  more  acute  than,  those 
met  with  in  an  adult.  The  finding  of  the  gonococci  is  chnical  but  not  abso- 
lute legal  proof  of  the  existence  of  gonorrhea,  and  it  is  to  be  remembered 
that  boys  may  suffer  from  catarrhal  urethritis  as  a  result  of  introducing  irri- 
tants, from  balanoposthitis,  or  from  overacid  urine.  Legal  proof  is  afforded 
by  the  growth  of  the  suspected  micro-organisms  on  artificial  blood-serum. 

The  treatment  consists  of  confinement  to  bed  during  the  acute  stage,  bland 
drinks,  Hght  diet,  etc.  Circumcision  is  necessary  if  phimosis  exists.  When  the 
acute  symptoms  subside,  injections  are  used  as  in  an  adult. 


Gonorrhea  in  Female  Children  1357 

Female  Children. — Gonorrhea  is  more  common  in  female  children 
than  in  male  children,  and  the  vagina  is  involved  as  well  as  the  vulva  and 
m-ethra. 

A  female  child  may  suffer  from  catarrhal  inflammation  of  the  vulva, 
as  a  result  of  the  contact  of  foul  urine,  of  feces,  of  the  presence  of  seatworms,  or 
of  neglect  of  bathing.  In  such  a  case  the  vagina  and  urethra  escape.  Involve- 
ment of  the  vagina  and  urethra  strongly  suggests  gonorrhea.  A  recently  bom 
child  or  a  young  infant  may  acquire  gonorrhea  directly  from  a  diseased 
mother,  or  indirectly,  by  pus  upon  linen,  the  mother's  fingers,  etc.  A  dis- 
eased nurse  may  infect  the  baby.  Older  children  who  have  ceased  to  nurse 
may  get  the  disease  from  infected  linen,  bathtubs,  etc.,  and  may  by  these 
means  infect  child  after  child  in  an  institution.  Xow  and  then  the  disease 
arises  by  a  diseased  man  or  woman  dehberately  bringing  the  child's  private 
parts  in  contact  with  their  own  diseased  organ. 

The  disease  is  acute:  the  urethra,  vulva,  and  vagina  are  usually  involved; 
the  discharge  is  profuse,  purulent,  and  often  bloody.  During  the  first  day 
or  two  the  discharge  exhibits  leukocytes  but  no  gonococci,  and  the  normal 
flora  of  the  urethra  disappear;  later  gonococci  appear  (Harmsen,  "Zeits.  f. 
Hyg.  u.  Infektionskr.,"  1906,  vol.  iii).  Microscopic  examination  of  the  dis- 
charge is  absolutely  necessary-.  Dry  cover-slip  preparations  are  made  so 
as  to  obtain  clap  shreds  from  the  discharge.  An  attempt  should  be  made  to 
obtain  cultures.  The  gonococcus  is  very  difficult  to  maintain  in  culture;  it 
must  be  frequently  transferred,  and  it  grows  best  in  an  incubator  at  a  tem- 
perature of  36°  C.  Xo  attempt  is  made  to  grow  it  upon  ordinary  culture- 
media.  The  finger  may  be  sterilized  and  punctured,  blood  thus  obtained  be- 
ing smeared  upon  ordinarv*  agar.  Upon  this  composite  material  growth  can 
be  obtained.  Animal  blood  serum  is  not  a  good  medium,  but  human  blood 
serum  is  (Lehmann  and  Neumann).  Human  blood  serum  is  obtained  by 
opening  a  vein  or  from  a  fresh  placenta. 

Lehmann  and  Neumann  ("Atlas  and  Principles  of  Bacteriolog}'")  find 
the  following  a  satisfactory  medium:  Agar,  containing  i  per  cent,  peptone 
and  5  per  cent,  glycerin,  which  has  been  liquefied  and  cooled  to  50°  C,  is 
mixed  "with  one-half  its  volume  of  ascites  fluid  or  the  fluid  from  ovarian 
cj'sts."  Plate  cultures  and  streak  cultures  should  be  made.  This  excessive 
care  in  proving  the  presence  of  the  gonococcus  is  imperatively  necessar}''  in 
female  children  because  of  the  medico-legal  questions  which  may  arise  in  such 
a  case  and  also  because  of  the  danger  of  infecting  others. 

Surgeons  are  apt  to  be  doubtful  about  the  diagnosis  in  many  supposed 
cases  of  gonorrhea  in  female  children.  The  clinical  picture  may  simply  be 
that  of  catarrhal  vulvo-vaginitis,  it  may  be  that  of  gonorrhea.  The  finding 
of  the  gonococcus  is  regarded  as  conclusive  from  a  clinical  standpoint,  but  not 
from  the  legal  point  of  view.  Again,  as  Taylor  points  out,  in  some  cases  in 
which  the  clinical  and  microscopic  evidence  seems  to  prove  the  existence  of 
gonorrhea  no  proof  can  be  obtained  that  the  condition  is  of  venereal  origin, 
and  that  in  some  cases  in  which  ever}-thing  indicates  that  the  disease  began 
as  a  catarrhal  \a1lvo-vaginiti5,  a  condition  seemingly  identical  with  gonorrhea 
has  arisen.  Obtaining  a  culture  of  gonococci  is  conclusive.  The  treatment 
consists  in  taking  ever}'  care  to  prevent  diffusion  of  the  infection  to  others  and 


1358  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

to  the  patient's  own  eyes.  She  is  put  to  bed,  given  frequent  baths,  and  fed 
upon  milk,  etc.  Irrigations  of  bicarbonate  of  sodium  are  employed,  followed 
by  protargol  (1:5000,  according  to  White  and  Martin).  Later  astringent 
injections  are  indicated. 

Treatment  of  Gonorrheal  Arthritis  and  Endocarditis. — In  a  communication 
in  the  Journal  A.  M.  A.,  Jan.  27,  1906,  pages  261-263,  Messrs.  Rogers  and 
Torrey  described  the  method  of  preparation  of  an  antigonococcic«serum  for 
the  treatment  of  gonorrheal  arthritis.  This  serum  in  its  present  form,  as  manu- 
factured by  a  good  chemical  company,  seems  to  be  of  some  real  value  in  the 
treatment  of  gonorrheal  infections  of  joints,  tendon-sheaths,  and  allied  struc- 
tures. Dr.  Thomas  W.  Stellwagen,  of  the  genito-urinary  department  of  Jeffer- 
son Hospital,  has  used  the  material  in  a  series  of  26  cases  of  acute  and  chronic 
gonorrheal  arthritis  with  gratifying  results. 

Preparation  0/  the  Serum. — To  quote  from  Messrs.  Rogers  and  Torrey's  re- 
ports: "Rabbits  were  at  first  used  exclusively  in  producing  the  serum.  Although 
a  very  potent  serum  may  be  obtained  from  these  animals,  it  was  found  that 
the  serum  itself  is  decidedly  toxic  for  some  individuals  and  may  produce  a 
rather  alarming  reaction.  This  matter  will  be  discussed  presently  in  greater 
detail.  In  order  to  obviate  this  serious  objection  we  have  experimented  with 
goats  and  sheep.  Similar  objectionable  properties,  although  less  in  degree, 
were  found  to  be  present  in  goat  serum,  but  from  sheep  serum  they  seem  to  be 
entirely  absent.  Accordingly  in  later  work  only  these  animals  have  been 
used.  They  should  be  fuU  grown,  uncastrated  males.  In  immunizing  these 
animals  it  has  been  found  advantageous  to  pursue  the  following  plan:  The 
first  inoculation  may  consist  of  the  twenty-four-hour  surface  growth  from 
18  square  inches  of  soHd  culture  medium,  emulsified  in  about  30  cc.  of  physi- 
ologic saUne  solution,  and  heated  for  one-half  hour  at  65°  C." 

In  Stellwagen's  studies  and  use  of  the  serum  it  was  found  that  the  best 
results  were  obtained  by  giving  the  injections  as  close  to  the  area  of  infection 
as  possible  and,  further,  to  give  them  every  day.  The  only  untoward  results 
noticed  were  now  and  then  an  eruption  of  wheals  or  urticaria  accompanied  by 
slight  headache  and  itching,  vdth  a  trivial  rise  of  temperature.  The  acute 
cases  generally  showed  marked  improvement  after  about  the  seventh  injection. 
The  serum  also  seemed  to  be  of  use  in  other  complications,  such  as  orchitis, 
prostatitis,  and  epididymitis.  Stellwagen  maintains  that  the  serum  is  a  valua- 
ble adjunct  in  treatment,  especially  where  the  older  standard  remedies  are  slow 
to  produce  a  result.  Its  great  claim  to  preference,  however,  has  been  in 
arthritis  and  other  synovial  infections,  in  which  it  seems  to  be  distinctly 
valuable. 

The  serum  must  not  be  confused  vnth  the  vaccine,  which  is  decidedly 
uncertain.  In  the  clinic  of  the  Jefferson  Hospital,  where  the  vaccines  have 
been  used,  they  did  not  produce  the  happy  results  that  other  clinicians  have 
ascribed  to  them. 

Stricture  of  the  urethra,  or  narrowing  of  the  urethral  caHber,  is 
divided  into  inflammatory,  spasmodic,  and  organic.  The  so-called  inflam- 
matory or  congestive  stricture  is  not  a  stricture,  but  is  an  inflammatory  swell- 
ing of  the  mucous  membrane. 

Spasmodic  stricture  does  not  exist  alone,  but  complicates  organic  stricture, 
a  hyperesthetic  urethra,  or  an  inflamed  bladder. 


Symptoms  and  Results  of  Stricture  1359 

Organic  stricture  is  a  fibrous  narrowing  of  the  urethra,  due,  as  a  rule,  to 
chronic  gonorrheal  inflammation  or  to  traumatism.  True  organic  stricture 
is  very  rare  in  children,  but  can  occur.  Al^be  reported  a  case  of  impassable 
stricture  in  the  deep  urethra  of  a  male  child  two  and  one-half  years  of  age, 
due  to  urethral  gonorrhea.  There  were  also  two  strictures  of  the  anterior 
urethra.  External  urethrotomy  was  performed.  Traumatic  strictures  occur 
in  the  bulbous  or  membranous  urethra,  and  are  due  generally  to  force  applied 
to  the  perineum,  the  urethra  being  squeezed  between  the  subpubic  ligament 
and  the  vulnerating  body.  Strictures  resulting  from  gonorrheal  inflamma- 
tion occur  in  the  penile,  bulbous,  or  membranous  urethra.  Stricture  never 
forms  in  the  prostatic  urethra  except  as  a  result  of  traumatism.  Recent 
non-traumatic  strictures  are  soft  and  are  easily  distended.  Old  strictures 
and  traumatic  strictures  are  very  dense.  A  resihent  stricture  is  one  which 
contracts  quickly  after  dilatation.  The  nearer  a  stricture  is  to  the  meatus, 
the  more  fibrous  it  is. 

A  congenital  stricture  is  congenital  narrowness  of  a  portion  of  the  urethra, 
usually  the  portion  near  the  meatus.  The  more  fibrous  a  stricture  is,  the 
more  it  narrows  the  urethra  and  the  less  dilatable  it  is.  A  stricture  may  be 
annular  (forming  a  ring  around  the  urethra),  tubular  (surrounding  the  ure- 
thra for  a  considerable  distance),  or  bridle  (when  a  band  crosses  the  urethra 
from  wall  to  wall).  A  stricture  of  large  caliber  will  admit  an  instrument 
larger  than  a  No.  15  French  sound.  A  stricture  of  small  caliber  will  not 
admit  a  No.  15  French  sound.  An  impermeable  stricture  will  not  admit  the 
passage  of  any  instrument.  Impermeable  is  more  or  less  a  relative  term. 
A  stricture  may  be  impermeable  when  an  anesthetic  is  not  used,  and  perme- 
able when  the  patient  is  anesthetized,  or  may  be  impermeable  to  one  surgeon, 
but  permeable  to  another.  Impermeability  is  often  a  temporary  condition 
due  to  inflammatory  edema  about  an  organic  stricture. 

Symptoms  and  Results  of  Stricture. — There  is  usually  a  history  of 
repeated  attacks  of  urethritis.  A  chronic  discharge  may  exist,  the  amount 
of  which  is  variable.  There  is  a  feeling  of  weight  in  the  perineum,  soreness 
of  the  back,  and  frequency  of  micturition.  Hypochondriacal  tendencies 
are  usual.  In  a  deep  stricture  there  is  difficulty  in  starting  the  stream  in 
micturition.  In  most  cases  the  stream  is  small,  twisted,  and  forked.  There 
is  often  interruption  or  "stammering"  of  the  stream,  and  it  dribbles  long 
after  the  conclusion  of  the  act,  so  that  the  penis  must  be  "milked"  before  it 
is  returned  within  the  clothing.  The  urethra  back  of  the  stricture  dilates, 
a  pouch  forms,  drops  of  urine  collect  and  decompose,  and  a  chronic  inflam- 
mation results  in  the  mucous  membrane  or  the  parts  adjacent,  which  inflam- 
mation may  go  on  to  ulceration  or  to  peri-urethral  abscess.  A  urinary  fistula 
results  from  the  opening  externally  of  a  peri-urethral  abscess.  Retention 
of  urine  may  occur,  not  from  actual  obliteration  of  the  tube  by  the  growth 
of  the  stricture,  but  by  closure  of  the  lumen  of  the  urethra  by  muscular  spasm 
and  by  edematous  swelling  in  the  neighborhood  of  the  stricture.  Edematous 
swelling  may  be  due  to  cold,  wet,  venereal  excitement,  the  use  of  alcohol, 
overexertion,  etc.  Spasm  of  the  muscles  results,  and  contact  of  the  urine 
increases  the  spasm,  and  spasm  plus  edema  of  the  mucous  membrane  closes 
the  urethra.     Spasm  may  exist  in  the  urethra  itself  and  in  the  muscles  of  the 


1360  Diseases  and  Injuries  of  the  Genitourinary  Organs 


\ 


neck  of  the  bladder,  but  is  only  a  temporary  condition.     In  old  strictures 
the  bladder  is  hypertrophied  and  often  fasciculated,  and  is  very  liable  to 
cystitis.     The  diagnosis  of  stricture  and  of  its  location  is  made  by  the  use 
of  exploratory  bougies.     In  this  examination  the  author 
follows  to  a  great  extent  the  plan  of  Ramon  Guiteras, 
which  is  as  follows:  *  Have  the  patient  pass  urine  into 
two  glasses.     Examine  the  urine  for  clap-shreds.     Cloudiness 
in  the  first  glass  shows  that  urethral  dis- 
charge exists.    Cloudiness  in  the  second  glass 
points  to  cystitis.     The  patient  is  placed  re- 
cumbent with  his  shoulders  elevated,  and  the 
urethra  is  washed  out  with  warm  salt  solution 
or  boracic  acid.   Bulbous  sounds  are  inserted, 
beginning  with  No.  1 5  French.    If  this  passes 
with  ease,  take  a  larger  size  and  note  where 
strictures  are  situated  by  the  catch  on  with- 
drawal.    If   No.    15   does   not   pass,   use   a 
smaller  size.     Remember  that  the  posterior 
layer  of   the   triangular   ligament  catches  a 
bulbous  instrument  on  withdrawal.     If  the 
meatus  is  too  small  to  permit  of  exploration, 
divide  it  with  a  curved  bistoury,  cutting  from 
within  outward.     After  cutting  the  meatus 
bleeding  is  arrested  with  styptic  cotton,  and 
a  piece  of  absorbent  cotton  is  tucked  into 
the  cut.     After  each  act  of  micturition  the 
patient  inserts  a  fresh  bit  of  cotton,  and  after 
three  days  the  urethral  examination  is  pro- 
ceeded with. 

Treatment. — A  stricture  of  large  caliber 
in  the  deep  urethra  requires  gradual  dilata- 
tion. A  steel  bougie  is  introduced  every 
fifth  day,  the  size  being  gradually  increased. 
Never  anoint  a  bougie  with  cosmolin,  as  it 
may  become  a  nucleus  for  a  stone  in  the 
bladder;    use   oil,   glycerin,   synol    soap,   or 

^.    „       lubrichondrin.     Before    passing    an    instru- 
Fig.  809.  .         ^  11-  1 

— Syme's  mcnt  the  patient  urmates  and    his    urethra 

staff.  is  washed  out  with  salt  solution  or  boracic 

acid  solution.  Glans,  meatus,  and  urethra  are 
cleansed  as  directed  on  page  1338.  The  sound  is  ren- 
dered sterile  by  boiling  before  using.  Gradual  dilata- 
tion can  be  effected  by  the  use  of  the  dilator  of  Ober- 
lander,  the  tube  being  distended  to  the  extent  of  three 
millimeters  every  fifth  day.     If  after  dilatation  there 

is  urethral  spasm,  pain,  or  very  frequent  micturition,  suspend  the  treatment 
for  a  number  of  days  and  order  each  night  a  hot  hip-bath  and  a  dose  of  pare- 

*  Med.  Record,  Nov.  14,  1896. 


Fig.  810. — Maisonneuve's 
urethrotome. 


Treatment  of  Stricture 


1361 


goric.  In  effecting  gradual  dilatation  by  sounds  the  instrument  should  be  intro- 
duced every  fifth  day.  During  the  treatment  the  patient  should  not  use  alcohol, 
should  refrain  from  sexual  excitement,  should  avoid  cold 
and  damp,  and  should  take  internally  capsules  containing 
boric  acid  and  salol.  It  is  rarely  necessary  to  dilate 
above  No.  32  French.  After  the  surgeon  finishes  treat- 
ment he  teaches  the  patient  to  use  an  instrument  and 
directs  him  to  pass  it  once  a  month.  Strictures  in  the 
pendulous  urethra,  if  soft,  are  treated  by  gradual  dila- 
tation ;  if  fibrous  and  contractile,  by  internal  urethrotomy. 
In  performing  internal  urethrotomy  prepare  the  patient 
carefully;  for  several  days  before  the  operation  give  salol 
and  boric  acid  by  the  mouth,  and  wash  out 
the  bladder  repeatedly  with  boric-acid  solu- 
tion. Be  thoroughly  aseptic.  Anesthetize 
the  patient.  Before  cutting  irrigate  the 
urethra  with  warm  normal  salt  solution, 
and  after  cutting  irrigate  again  and  tie  in 
a  rubber  catheter.  These  precautions  will 
prevent  urethral  fever.  In  cutting,  insert 
Gross's  urethrotome  (Fig  812)  back  of  the 
stricture,  spring  out  the  blade,  cut  the 
stricture  on  the  roof  of  the  urethra,  close 
the  blade,  withdraw  the  instrument,  and 
pass  a  full-sized  bougie. 

Stricture  of  the  meatus  requires  incision 
with  a  knife  and  the  use  of  a  meatus  bougie 
until  heahng  is  complete.  Strictures  of 
small  cahber  in  front  of  the  membranous 
urethra  require  gradual  dilatation  and,  if 
this  fails,  internal  urethrotomy  or  divulsion. 
Internal  urethrotomy  can  be  performed  with 
the  urethrotome  of  Maisonneuve  (Fig.  810). 
This  instrument  is  shaped  like  a  sound,  has 
a  groove  upon  its  surface,  and  into  this 
groove  a  shaft  carrying  a  triangular  knife 
can  be  inserted.  The  staff  is  screwed  to  a  guide,  the  guide  is 
carried  into  the  bladder  and  the  staff  follows  it.  The  point  of 
the  staff  is  carried  to  the  prostatic  urethra  and  the  guide  curls 
up  in  the  bladder.  The  penis  is  held  upon  the  stretch,  the 
blade  is  inserted  and  pushed  down  through  the  stricture.  This 
instrument  cuts  the  stricture,  but  not  the  healthy  urethra.  For 
divulsion  the  patient  is  prepared  as  for  internal  urethrotomy. 
The  divulsor  of  Gross,  or  of  Sir  Henry  Thompson,  or  of  Gouley 
(Figs.  811,  813,  814)  is  introduced,  the  blades  are  separated, -the 
instrument  is  withdrawn,  a  large  bougie  is  passed,  and  a 
tied  in  the  bladder.  Strictures  of  small  caliber  in  the  deep  urethra 
require  gradual  dilatation;  if  this  fails,  employ  external  urethrotomy, 
strictures  of  the  deep  urethra,  if  only  a  filiform  bougie  can  be  in- 
86 


Pig.  811.— Gross's   ure- 
thral dilator. 


Fig.  812. — 
S.  W.  Gross's 
exploratory 
urethrotome. 

catheter  is 


In 


1362  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

troduced,  the  bougie  may  be  left  in  place,  and  in  a  day  or  two  another 
can  be  slipped  in  beside  it,  until  in  a  few  days  the  channel  becomes 
permeable  to  a  metal  bougie.  A  tunnelled  catheter  can  be  shpped  over 
the  fihform  bougie,  both  be  withdrawn,  and  a  metal  bougie  passed.  A 
tunnelled  and  grooved  staff  can  be  carried  in  over  the  bougie  and  external 
urethrotomy  be  performed.  Thompson's  dilator  can  be  carried  in  over  the 
fihform  and  the  stricture  be  divulsed.  Fort's  method  of  electrolysis  is  said 
to  be  of  value,  but  I  have  had  no  personal  experience  with  it.     Fort  treats 

stricture  by  linear  elec- 
trolysis. His  instrument 
looks  like  a  whip,  and  it 
has  a  platinum  blade  pro- 
jecting from  about  the 
center.  The  blade  is  con- 
nected with  the  negative 
pole  of  a  galvanic  battery  and  the  positive  pole  is  placed  over  the  pubes. 
The  guide  carrying  the  blade  is  inserted  into  the  urethra,  and  when 
the  blade  comes  against  the  stricture  the  current  is  turned  on  and  the 
platinum  passes  rapidly  through  the  constriction.  The  current  is  turned 
off  and  the  instrument  is  carried  onward  until  it  strikes  another  stricture, 
when  the  current  is  again  turned  on,  and  so  on.  The  necessar}^  current- 
strength  is  10  to  15  ma.  The  operation  requires  twenty  to  thirty  seconds  and 
causes  but  little  pain.     After  its  performance  a  sound  is  passed  (a  No.  22 


Fig.  813.— Thompson's  divulsor. 


Fig.  814.— Gouley's  divulsor. 

of  the  French  scale).  The  patient  need  not  be  confined  to  bed  after  this 
operation.  By  Fort's  method  we  act  purely  upon  the  diseased  tissue.  In 
impassable  stricture  of  the  deep  urethra  perform  external  perineal  urethrotomy 
without  a  guide  (the  operation  of  Wheelhouse) . 

If  a  perineal  fistula  exists,  dilate,  divulse,  or  cut  the  stricture;  retain  a 
catheter  in  the  bladder  for  forty-eight  hours.  After  this  period  dilate  every 
few  days  with  a  metal  instrument.  Every  morning  and  evening  draw  the 
urine  with  a  soft  catheter,  introduce  boric-acid  solution  into  the  bladder, 
remove  the  catheter,  and  let  the  man  empty  his  bladder  naturally.  A  portion 
will  flow  from  the  fistula  and  a  part  from  the  meatus.  Day  by  day  the  quan- 
tity which  comes  from  the  fistula  lessens,  and  finally  the  abnormal  opening 
heals. 

Urethral  Fever. — Any  operation  upon  the  urethra  may  be  followed 
by  a  chill  owing  to  shock  (urethral  shock),  and  this  may  be  followed  by  a 
nervous  fever.  Urethral  fever  proper  is  sapremia  following  a  urethral 
operation.     This  condition  is  due   to   absorption  of  toxic   elements  which 


Urinary  Fever  1363, 

may  be  in  the  urine,  may  have  been  in  the  urethra,  or  may  have  been 
introduced  from  without.  It  usually  follows  the  first  urinary  act  after  opera- 
tion. It  begins  with  a  violent  chill  and  presents  the  characteristics  of  a  septic 
fever.  It  is  accompanied  by  a  marked  tendency  to  urinary  suppression^ 
and  may  eventuate  in  septicemia  or  pyemia.  Urethral  fever  can  be  pre- 
vented by  rigid  antisepsis.  If  this  fever  should  arise,  a  catheter  must  be  tied 
in  the  bladder,  the  bladder  and  urethra  must  be  repeatedly  irrigated  with 
aseptic  or  antiseptic  fluids,  and  the  patient  must  be  given  urinary  antiseptics 
and  stimulants  by  the  mouth. 

Urinary  Fever. — Sir  Benjamin  Brodie  pointed  out  that  the  with- 
drawal of  residual  urine  in  a  case  of  enlarged  prostate  may  be  followed  by 
very  serious  symptoms.  The  condition  is  spoken  of  as  urinary  fever,  and 
is  said  by  many  to  be  due  to  the  sudden  and  complete  emptying  of  a  bladder 
which  has  become  accustomed  to  retaining  permanently  a  considerable 
quantity  of  urine.  Modern  studies  prove  that  urinary  fever  is  due  to  infection 
of  the  bladder  and  kidneys,  and  not  simply  to  the  sudden  withdrawal  of  all  of 
the  urine  from  the  bladder,  although  such  a  procedure  leads  to  vesical  con- 
gestion and  probably  favors  infection.  The  bacteria  most  often  found  are 
pyogenic  cocci,  colon  bacilli,  and  micro-organisms  which  cause  putrefaction 
and  decomposition  of  urea. 

The  condition  does  not  arise  promptly,  suddenly,  and  violently,  as  does 
urethral  fever,  but  begins  rather  insidiously  after  several  days.  Mr.  C. 
Mansell  Moullin  thus  describes  the  condition:  * 

"  So  far  as  the  broader  features  are  concerned,  the  symptoms  that  present 
themselves  in  these  cases  are  remarkably  uniform.  They  do  not  begin  at 
once.  Nearly  always  some  few  days  elapse  before  there  is  anything  to  excite 
suspicion.  Then  the  urine  becomes  cloudy,  though  it  may  still  retain  its 
acid  reaction.  A  small  quantity  of  albumin,  more  than  can  be  accounted 
for  by  the  amount  of  pus  that  is  present,  makes  its  appearance.  Under  the 
microscope  there  are  a  few  hyaline  casts,  perhaps  a  blood-corpuscle  or  two, 
numerous  pus-corpuscles,  and  myriads  of  bacteria.  The  specific  gravity  is 
lower  than  it  ought  to  be,  and  is  lower  than  it  was  before  the  catheter  was 
used.  The  total  amount  passed  in  the  twenty-four  hours  may  either  increase 
until  it  is  as  much  as  seven  or  eight  pints,  or  diminish  until  it  scarcely  reaches 
twenty  ounces.  There  is  seldom  any  definite  rigor,  but  there  may  be 
numerous  slight  chills.  The  pulse  grows  more  rapid  and  feeble.  The 
tongue  becomes  red  and  dry.  There  is  complete  anorexia.  Delirium  sets 
in  at  night,  and  in  a  considerable  proportion  of  cases  the  symptoms  rapidly 
grow  worse  and  worse  until,  at  the  end  of  a  few  days,  the  patient  sinks  into 
a  semi-comatose  condition  from  which  he  seldom  rallies.  Post-mortem 
there  are  all  the  signs  of  recent  acute  cystitis  and  pyelonephritis.  The  mu- 
cous membrane  lining  the  pelvis  and  calices  of  the  kidneys,  the  ureters, 
and  the  bladder  is  swollen  and  stained  by  old  and  recent  hemorrhages,  and 
here  and  there  a  thin  layer  of  pus  is  adherent  to  it.  The  pelvis  and  the 
ureters  are  dilated,  the  apices  of  the  pyramids  are  eaten  away,  the  cortex  is 
shrunken  and  hard,  the  capsule  is  adherent,  and  in  places  between  the 
tubules  are  minute  collections  of  pus  differing  in  shape  and  outline  accord- 
ing to  the  anatomical  arrangement." 

*  Lancet,  Sept.  lo,  1898. 


1364  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Treatment. — Aseptic  catheterization  is  necessan,-  if  we  would  avoid 
urinary  fever;  and  as  the  urethra  contains  some  of  the  causative  organisms, 
the  prepuce,  glans,  and  meatus  should  be  washed  with  soap  and  water  and 
irrigated  with  boric-acid  or  permanganate  of  potassium  solution,  and  the 
urethra  be  irrigated  with  boric-acid  solution  or  permanganate  of  potassium 
before  the  sterile  catheter  is  introduced  to  draw  the  urine. 

If  urinary  fever  arises,  it  may  be  possible  to  control  it  by  frequently  irri- 
gating the  bladder  with  warm  normal  salt  solution,  solution  of  nitrate  of 
silver  (i  :  8000),  or  boric-acid  solution,  and  by  administering  stimulants, 
diuretics,  diaphoretics,  saline  cathartics,  and  nutritious  food.  In  severe  cases 
perform  suprapubic  cystotomy  for  drainage. 


<t 


Fig.  815. — Wheelhouse's  staff. 

Perineal  section  is  external  perineal  urethrotomy.  There  are  three 
methods — the  operation  of  Syme,  of  Wheelhouse,  and  of  Cock. 

Syme's  Operation. — This  operation  is  employed  if  a  stricture  is  very 
contractile,  if  dilatation  fails  to  cure,  or  if  urethral  instrumentation  invari- 
ably causes  pronounced  urethral  fever.  The  patient  is  anesthetized,  Syme's 
staff  (Fig.  809)  is  introduced,  and  the  surgeon  makes  an  incision  in  the  mid- 
line of  the  perineum  and  exposes  the  staff  just  above  the  shoulder  of  the 
instrument.  The  knife  is  carried  along  the  groove  and  divides  the  stricture. 
A  catheter  is  passed  into  the  bladder  from  the  meatus  and  is  retained  for 
several  days,  and  the  wound  is  dressed  antiseptically.  After  the  catheter  is 
removed  it  must  be  used  every  six  hours  until  the  urine  comes  entirely  by 
the  meatus.  During  the  rest  of  the  patient's  Ufe,  a  full-sized  sound  should 
be  passed  at  regular  intervals. 


Fig.  816. — Teale's  probe  gorget. 


Wheelhouse's  Operation. — This  operation  is  employed  for  the  treat- 
ment of  impermeable  stricture.  Wheelhouse's  staff  is  passed  into  the  urethra 
until  it  blocks  on  the  stricture.  The  perineum  is  incised  down  to  the  staff 
and  in  front  of  the  stricture.  The  edges  of  the  cut  urethra  are  held  apart 
with  forceps,  the  surgeon  seeks  for  the  opening  through  the  stricture,  passes 
a  fine  probe  through  it,  divides  the  stricture,  carries  into  the  bladder  from  the 
wound  an  instrument  known  as  a  probe  gorget  to  dilate  the  canal  and 
furnish  a  soUd  floor  to  facilitate  the  introduction  of  a  catheter.  With  the  gorget 
in  place  a  metal  catheter  is  carried  from  the  meatus  into  the  bladder.  The 
gorget  is  removed  and  the  catheter  is  tied  in  place.  After  three  or  four  days  the 
catheter  is  removed  and  is  then  passed  frequently.     The  perineal  wound  is, 


Hypospadias 


1365 


of  course,  dressed  antiseptically.  Figs.  815  and  816  show  the  instruments 
for  Wheelhouse's  operation. 

Cock's  Operation. — This  operation  opens  the  urethra  back  of  the  stricture 
and  without  a  guide  and  relieves  retention  of  urine.  The  surgeon  introduces 
into  the  rectum  the  index-finger  of  the  left  hand,  and  the  tip  of  the  finger  is 
rested  upon  the  apex  of  the  prostate  gland.  The  surgeon  incises  the  median 
line  of  the  perineum,  the  back  of  the  knife  being  toward  the  anus.  When 
the  point  of  the  knife  is  felt  to  be  near  the  finger  the  handle  is  lowered  slightly, 
the  blade  is  placed  a  little  obhque,  and  the  urethra  is  opened.  A  catheter  is 
passed  into  the  bladder  from  the  wound  and  retained  for  a  time,  and  the 
stricture  is  subsequently  treated. 

Epispadias  is  a  congenital  cleft  in  the  corpora  cavernosa,  the  roof  of 


Fig.  817. — Beck's  operation  for  h>-pospadias. 

the  urethra  being  completely  or  partly  absent.  In  complete  epispadias  there 
are  absence  of  the  pubic  arch  and  exstrophy  of  the  bladder. 

Partial  epispadias  may  sometimes  be  remedied  by  a  plastic  operation. 

Hypospadias  is  a  congenital  cleft  on  the  floor  of  the  urethra,  the  meatus 
opening  on  the  floor  at  some  point  between  the  scrotum  and  the  end  of  the 
glans  penis,  the  channel  in  front  of  the  meatus  being  a  gutter  and  not  a  tube. 

H}-po5padias  of  the  glans  is  the  most  common  form.  In  this  condition 
the  urethra  has  no  floor,  as  it  passes  beneath  the  glans,  the  site  of  the  urethra 
is  indicated  by  a  groove,  and  the  foreskin  is  absent  below.  Partial  h}-po- 
spadias  requires  no  treatment  except  possibly  dilatation  or  incision  of  the 
meatus.  People  who  sufi^er  from  it  are  ver}-  prone  to  develop  chronic  urethral 
inflammation.  In  hypospadias  of  the  penis  the  iU-developed  cord-like  corpus 
spongiosum  draws  the  penis  to  the  scrotum.  In  this  variety  of  the  deformity 
the  penis  is  ver}'  short. 


1366         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

In  complete  hypospadias  the  opening  of  the  urethra  is  back  of  the  scrotum 
in  the  perineum,  the  penis  is  dwarfed  and  bound  down,  and  looks  not  unlike 
a  clitoris,  the  scrotum  is  divided  into  two  portions,  a  gap  existing  between 
them,  and  in  many  cases  the  testicles  have  not  descended.  Such  individuals 
are  occasionally  mistaken  for  females.  In  the  penile  complete  forms  of 
hypospadias  a  plastic  operation  should  be  performed  between  the  eighth  and 
tenth  years  of  age.  Such  an  operation  unfortunately  may  fail.  Hypospadias 
is  rare  in  women,  but  it  may  occur.  In  such  a  case  the  urethra  opens  into 
the  vagina.  Fig.  817  shows  the  ingenious  operation  successfully  practised 
by  Carl  Beck  for  penile  hypospadias. 

Chancroid  (soft  chancre;  the  local  venereal  sore)  is  an  ulcer,  usually  of 
venereal  origin.  The  name  chancroid  was  introduced  by  Clerc,  who  believed 
that  a  soft  sore  resulted  from  inoculating  a  person  already  syphilitic  with  the 
products  of  a  hard  sore.  He  further  held  that  when  a  soft  sore  arose  the 
syphilitic  poison  lost  its  infective  properties,  and  "could  be  transmitted  as 
a  soft  sore  to  a  healthy  person,  and  not  cause  general  infection."  *  The 
■chancroidal  ulcer  is  not  connected  with  the  syphilitic  poison,  but  is  developed 
by  inoculation  with  the  bacterium  of  Ducrey.  Until  recently  it  was  believed 
that  a  chancroid  was  not  produced  by  a  special  poison,  but  arose  after  in- 
oculation with  inflammatory  products  or  irritating  secretions.  It  seems  to 
have  been  proved,  however,  by  Krefting  and  Colombini  that  the  organism 
discovered  by  Ducrey  in  1889  is  the  real  cause.  This  organism  is  grown 
on  a  medium  of  fresh  blood  and  bouillon  or  in  "unmixed  human  blood." 
(See  Lincoln  Davis,  "  Observations  on  the  Distribution  and  Culture  of  the 
Chancroid  Bacillus."  Report  of  Research  Work,  1902-1903;  the  Division 
of  Surgery  of  the  Medical  School  of  Harvard  University.)  As  a  rule, 
chancroids  are  of  venereal  origin,  and  result  from  contact  with  other  chan- 
croids, pus,  mucopus,  or  areas  of  ulceration.  A  chancroid  appears  soon 
after  intercourse,  usually  within  five  days,  always  within  ten  days.  It 
is  first  manifested  by  a  pustule  which  ruptures  and  discloses  an  ulcer.  This 
ulcer  has  sharply  defined  and  undermined  margins;  it  looks  "punched  out"; 
the  base  is  gray  and  sloughy;  the  discharge  is  profuse,  purulent,  foul,  and 
auto-inoculable,  and  causes  fresh  chancroids  by  flowing  over  the  parts.  The 
area  around  a  chancroid  is  red  and  inflamed,  and  considerable  pain  is  apt 
to  be  complained  of.  The  original  chancroid  spreads  and  new  sores  appear. 
The  edge  of  a  chancroid  is  rarely  indurated  unless  caustics  have  been  used 
or  there  is  mixed  infection  with  syphilis.  Inflammatory  induration  fades 
gradually  into  the  tissues,  but  the  induration  of  a  hard  chancre  is  sharply 
defined.  Fournier  says  that  a  chancroid  may  have  a  hard  base  if  the  sore  is 
located  in  the  sulcus  back  of  the  glans,  on  a  lip  of  the  meatus,  or  on  the  lower 
border  of  the  prepuce  of  a  man  with  phimosis,  or  when  the  ulcer  is  inflamed. 
The  surgeon  should  always  ask  if  the  sore  has  been  cauterized  and  how  it 
has  been  treated.  When  a  chancroid  after  a  time  displays  marked  and 
sharply  outlined  induration  it  points  to  mixed  infection  of  chancroid  and 
syphilis.  Chancroids  are  not  followed  by  constitutional  symptoms,  but  are 
apt  to  be  accompanied  by  painful  inflammatory  buboes  which  are  prone  to 
suppurate.  In  hospital  practice  about  30  per  cent,  of  patients  develop  bu- 
boes. The  bubo  may  be  one-sided  or  bilateral.  The  adenitis  of  chancroid 
*  "  Syphilis,"  by  Alfred  Cooper. 


Treatment  of  Chancroid 


1367 


is  due  in  the  majority  of  cases  to  the  absorption  of  toxins  and  pus  may  be 
free  from  bacteria.  Cases  have  been  reported  in  which  non-indurated  sores 
were  followed  by  syphilis.  It  is  probable  that  a  mixed  infection  existed, 
and  that  induration  was  overlooked,  because  a  papular  initial  lesion  was 
underneath  the  chancroidal  ulcer.  When  inflammation  in  chancroids  is 
high,  a  rapidly  destructive  ulceration  known  as  phagedena  may  arise  (Figs. 
818  and  819),  but  this  process  is  more  common  in  syphilitic  sores. 

Treatment. — Ordinary  cases  of  chancroid  are  treated  by  spraying  with 
peroxid  of  hydrogen,  drying  with  cotton,  touching  each  sore  first  with  pure 
carbolic  acid  and  then  with  pure  nitric  acid,  and  dressing  with  black  wash 
or  dusting  with  iodoform  or  with  calomel.  Every  few  hours  the  patient 
soaks  the  penis  in  hot  salt  water  (a  teaspoonful  of  salt  to  a  pint  of  water), 
sprays  the  sores  with  peroxid  of  hydrogen,  dries  with  cotton,  and  dresses  with 
black  wash  or  dusts  with  iodoform  or  with  calomel.  As  soon  as  granulation 
begins  the  sores  should  be  dressed  with  i  part  of  ointment  of  nitrate  of  mer- 


Fig.  818. — Buttonhole  perforation  of  the 
prepuce  following  phagedenic  chancroid 
(Honvitz). 


Fig.  819.— Buttonhole  perforation  of  the 
prepuce  following  phagedenic  chancroid  (Hor- 
witz). 


cury  to  7  parts  of  cosmolin.  Mild  cases  do  well  without  cauterizing,  peroxid 
of  hydrogen  being  frequently  used  and  a  drying  powder  being  employed. 
In  chancroids  with  phimosis  slit  up  the  foreskin,  smear  the  raw  edges  of  the 
wound  with  pure  carbolic  acid,  and  treat  the  ulcers  by  cauterization.  A 
regular  circumcision  often  fails  because  of  infection  of  the  stitch-holes.  Phage- 
dena requires  the  internal  use  of  iron,  quinin,  and  milk-punch,  and  the  local 
use  of  powerful  caustics  (bromin  or  nitric  acid  or  even  the  actual  cautery). 
In  some  cases  continuous  antiseptic  irrigation  is  valuable.  When  a  bubo  first 
begins,  order  rest,  apply  iodin  or  an  ointment  of  belladonna  or  ichthyol,  and 
make  pressure  by  a  spica  bandage  of  the  groin.  Some  surgeons  advise  the 
injection  of  20-40  minims  of  a  solution  of  carbolic  acid  (gr.  x  to  the 
ounce),  but  I  have  never  seen  any  benefit  from  it.  Some  inject  a  i  per 
cent,  solution  of  bichlorid  of  mercury,  but  the  proceeding  causes  intense 
pain.  Welander  recommends  the  injection  of  a  i  per  cent,  solution  of  ben- 
zoate  of  mercury.     I  have  had  no  experience  with  this  method.       If  the 


1368  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Fig.  S20. —  Circum- 
cision completed  (Es- 
march  and  Kowalzig). 


bubo  persists,  even  though  it  does  not  suppurate,  it  should  be  completely 
excised.  If  pus  forms,  several  methods  of  treatment  are  open  to  us:  aspi- 
ration, injection  with  a  solution  of  carbolic  acid,  squeezing  out  the  acid  and 
injecting  10  per  cent,  ointment  of  iodoform  and  glycerin,  and  sealing  the 
opening  with  collodion  (Scott  Helms).  Hayden  makes  a  puncture,  squeezes 
out  the  pus,  washes  out  the  cavity  with  peroxid  of  hydro- 
gen, and  then  with  corrosive  sublimate  solution,  injects 
warm  iodoform  ointment,  and  dresses  with  cold,  moist, 
corrosive  sublimate  gauze  to  set  the  ointment.  Otis, 
Fontain,  Perry,  and  others  commend  this  plan.  We  have 
sometimes  found  it  to  succeed.  If  the  above-mentioned 
plan  fails,  if  it  is  not  used,  or  if  an  ulcer  or  sinus  exists, 
incise,  curet,  cauterize  with  pure  carbolic  acid,  cut  away 
hopelessly  infiltrated  skin,  and  pack  the  wound  with 
iodoform  gauze.  In  some  cases  it  will  be  necessary  to  extirpate  fragments  of 
gland. 

Phimosis  is  a  condition  of  the  prepuce  that  renders  retraction  over  the 
glans  impossible.  It  is  usually  congenital,  but  it  may  arise  from  inflamma- 
tion. Congenital  phimosis  causes  retention  of  sebaceous  matter,  which  de- 
composes and  lights  up  inflammation  and  the  prepuce  is  apt  to  grow  fast  to 
the  glans.  Congenital  phimosis  may  induce  irritability  of  the  bladder,  in- 
continence of  urine,  prolapse  of  the  rectum,  and  various  ner\'ous  symptoms. 
The  treatment  is  circumcision.     Asepticize  the  parts.     Grasp  the  foreskin 

and  the  mucous  membrane 
with  two  forceps,  draw  the 
prepuce  forward,  catch  the  skin 
(at  the  point  it  is  desired  to 
cut)  horizontally  between  the 
arms  of  the  handle  of  a  pair  of 
scissors,  and  cut  off  the  re- 
dundant prepuce.  Retrench 
the  excess  of  mucous  mem- 
brane by  cutting  around  with 
scissors  one-quarter  of  an  inch 
from  the  glans,  stitch  the  skin 
to  the  mucous  membrane  with 
catgut,  and  dress  with  sterile 
gauze  (Fig.  820). 

Fracture  of  the  penis, 

which  is  a    laceration    of    the 
cavernous  bodies  with  extrava- 
sation   of  blood,   occurs   occa- 
sionally during  coition.     The  treatment  consists  of  cold  and  bandaging  to 
arrest  bleeding,  and  occasionally  incisions  to  let  out  clot. 

Gangrene  of  the  penis  arises  from  phagedena,  from  tying  constricting 
bands  around  the  organ,  from  fracture  with  excessive  hemorrhage,  and  from 
paraphimosis.     If  extensive,  it  requires  amputation. 

Cancer  of  the  penis  (Fig.  821)  is  commonest  in  persons  with  phimosis. 
In  a  limited  epithelioma  of  the  foreskin  circumcision  is  performed  and  the 


Fig.  821.— Cancer  of  penis  (Horwitz). 


Tuljcrculosis  of  the  Seminal  Vesicles  1369 

glands  of  the  groin  are  removed;    if  cancer  affects  the  glans,  amputation  of 
the  penis  and  removal  of  the  inguinal  glands  must  be  done. 

Amputation  of  the  Penis. — Ricord  advised  cutting  off  the  organ  with 
a  single  stroke  of  the  knife,  making  four  slits  in  the  mucous  membrane  of 
the  urethra,  and  stitching  each  of  these  flaps  to  the  skin.  Treves  sphts 
the  skin  of  the  scrotum  along  the  raphe,  separates  the  halves  of  the  scrotum 
down  to  the  corpus  spongiosum,  passes  a  metal  catheter  down  to  the 
triangular  ligament,  inserts  a  knife  between  the  corpus  spongiosum  and 
the  corpora  cavernosa,  withdraws  the  catheter,  cuts  the  urethra  across, 
detaches  the  urethra  from  the  penis  back  to  the  triangular  ligament,  cuts 
around  the  root  of  the  penis,  divides  the  suspensory  ligament,  detaches 
each  crus  from  the  pubes,  slits  up  the  corpus  spongiosum  half  an  inch, 
stitches  its  edges  to  the  rear  end  of  the  scrotal  incision,  introduces  a  drain- 
age-tube, ligates  the  vessels,  and  sutures  the  wound. 

Seminal  Vesiculitis. — Inflammation  of  the  seminal  vesicles  is  due 
to  the  extension  of  a  gonorrheal  inflammation,  to  a  pyogenic  process,  or  to 
tuberculosis. 

Acute  inflammation  is  made  evident  by  frequent  and  painful  micturition, 
pains  in  the  anus,  rectum,  and  •  perineum,  and  possibly  the  hip-joint,  back, 
and  thigh.  Defecation  and  micturition  are  excessively  painful.  Persistent 
erections  may  take  place,  and  in  some  cases  bloody  ejaculations  occur.  Rectal 
examination  detects  the  enlarged  and  tender  vesicles  external  to  the  lateral 
lobes  of  the  prostate  and  on  a  higher  level. 

Treatment. — Abandon  local  urethral  treatment,  and  treat  the  patient  as 
for  acute  prostatitis. 

Chronic  vesiculitis  may  result  from  the  acute  form  or  may  develop  in- 
sidiously in  an  individual  with  gonorrhea.  It  is  one  of  the  causes  of  chronic 
urethral  discharge.  The  patient  suffers  from  imperative  and  frequent  de- 
mands to  micturate,  and  he  has  a  gleety  discharge  which  becomes  worse  and 
better,  but  does  not  disappear.  This  chronic  inflammation  is  believed  to  per- 
sist because  of  narrowing  of  the  duct  and  consequent  incomplete  drainage  of 
the  vesicle.  In  chronic  seminal  vesiculitis  there  is  usually  sexual  weakness, 
nocturnal  emissions  occur,  and  the  semen  may  contain  blood. 

Treatment. — Treat  the  posterior  urethritis  by  ordinary  methods.  Use 
hot  rectal  enemata.  Milk  the  ducts  by  Fuller's  method  once  every  seven 
days.  During  massage  the  patient's  bladder  should  be  full.  He  leans 
over  a  chair-back,  the  knees  being  straight  and  the  body  at  a  right  angle 
to  the  thighs.  The  surgeon  covers  his  finger  with  a  rubber  stall  and  anoints 
it  with  oil  or  synol  soap,  and  introduces  it  into  the  rectum,  and  makes  pres- 
sure over  the  pubes  with  the  fist  of  the  other  hand.  The  finger  comes  in 
contact  with  the  lower  half  of  the  vesicle;  it  makes  firm  pressure  for  a 
moment,  and  is  then  drawn  slowly  toward  the  duct.  This  stroking  is 
repeated  several  times.  The  other  vesicle  is  treated  in  the  same  manner. 
This  maneuver  empties  the  vesicle  and  hastens  the  resolution  of  inflam- 
mation. After  the  completion  of  the  stripping  the  patient  should  micturate, 
and  the  bladder  and  urethra  should  be  irrigated. 

Tuberculosis  of  the  Seminal  Vesicles. — Primary  tuberculosis  is 
very  unusual.  As  a  rule,  there  is  antecedent  tuberculosis  of  the  testicle 
or  prostate  gland.     About  50  per  cent,  of  the  cases  occur  in  individuals  under 


1370  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

forty  years  of  age.  The  diseased  vesicle  is  at  first  nodular  and  indurated, 
but  later  undergoes  caseation  and  softening.  Finally  the  disease  passes 
through  the  capsule  and  invades  adjacent  structures.  Dreyer  collected  36 
cases  and  found  that  in  34  of  them  the  lungs  were  involved. 

Tuberculous  vesiculitis  may  be  unilateral  or  bilateral.  In  unilateral 
tuberculous  epididymitis  the  corresponding  vesicle  is  apt  to  become  diseased. 
In  bilateral  disease  of  the  testicles  both  vesicles  are  liable  to  involvement. 
Peritoneal  tuberculosis  may  follow  tuberculous  vesiculitis.  In  very  unusual 
cases  spontaneous  cure  is  obtained  by  fibrous-tissue  formation.  On  palpa- 
tion a  tuberculous  vesicle  is  found  to  contain  here  and  there  hard  and  but 
slightly  tender  nodules. 

Treatment. — If  tuberculous  epididymitis  is  followed  by  tuberculous 
vesiculitis,  it  is  justifiable  to  remove  the  vesicle  after  removing  the  tes- 
ticle, provided  the  prostate  and  other  parts  of  the  genito-urinary  tract  are 
free  from  disease  and  there  is  no  distant  lesion  of  tuberculosis.  If  both 
testicles  are  removed,  both  Vesicles  can  be  extirpated.  If  a  vesicle  or  both 
vesicles  suffer  from  primary  tuberculosis,  operation  is  advised  by  some  sur- 
geons.    Reported  cases,  however,  do  not  seem  to  favor  operation. 

Kraske,  Schede,  and  Rydygier  have  removed  the  vesicles  after  preliminary 
resection  of  the  sacrum.  Zuckerkandl,  Dittel,  and  Schede  have  employed 
the  perineal  route.  Villeneuve  reached  them  by  way  of  the  inguinal  region. 
The  curved  perineal  incision  of  Zuckerkandl  is  the  method  usually  preferred. 
H.  H.  Young  makes  a  suprapubic  incision,  strips  the  peritoneum  from  the 
bladder,  and  reaches  the  vesicles  from  behind.  He  calls  it  the  suprapubic- 
retrocystic-extraperitoneal  method  (H.  H.  Young,  in  "Annals  of  Surger}^, " 
Nov.,  1901). 

Acute  Prostatitis. — Acute  inflammation  of  the  prostate  gland  may 
be  caused  by  inflammation  in  adjacent  structures,  the  use  of  instruments  or 
irritant  applications  in  the  deep  urethra,  injur)'  by  a  passing  or  impacted 
calculus,  various  infectious  diseases,  a  stricture  of  the  urethra,  but  particularly 
by  gonorrhea.  The  gland  enlarges  greatly,  the  prostatic  fluid  exudes  mixed 
with  blood  and  pus,  and  the  gland-ducts  become  distended  with  pus.  A 
distinct  abscess  may  form.  The  orifices  of  the  ejaculatory  ducts  become 
distended  and  filled  with  pus,  and  the  seminal  vesicles  or  epididymis  may 
also  suffer.  An  abscess  is  liable  to  form  in  the  cellular  tissue  outside  of  the 
prostate. 

Symptoms. — A  feeling  of  weight,  fulness,  or  soreness  in  the  perineum;  a 
persistent  pain  at  the  neck  of  the  bladder;  frequent  micturition,  pain  being 
present  and  becoming  most  severe  as  the  last  drops  are  voided;  perineal 
tenderness;  painful  defecation;  and  bulging  of  anal  mucous  membrane.  If 
a  finger  is  introduced  into  the  rectum,  it  causes  severe  pain  and  palpates  the 
enlarged  and  tender  gland,  unless  the  outhnes  are  destroyed  by  periprostatitis, 
in  which  case  there  will  be  felt  a  large,  bogg}',  tender  mass.  (See  Henry 
Morris  on  "Injuries  and  Diseases  of  the  Genital  and  Urinar}'  Organs.") 
These  symptoms  are  accompanied  by  distinct  elevation  of  temperature. 
The  inflammation  may  abate  without  suppuration,  but,  as  a  rule,  pus  forms,  the 
temperature  becomes  characteristic,  the  pain  becomes  pulsatile,  micturition 
causes  agony,  the  inflammatory' mass  is  felt  per  rectum  to  be  softening,  and  some- 
times the  swollen  perineum  becomes  dusky  red.     Retention  of  urine  is  almost 


Prostatorrhea  137 1 

certain  to  occur.  The  abscess  may  rupture  into  the  urethra  or  the  rectum, 
or  may  diffuse  in  the  periprostatic  cellular  tissue  and  subsequently  may 
■open  in  the  perineum.  Spontaneous  evacuation  may  be  followed  by  recovery 
or  by  the  development  of  annoying  or  dangerous  complications. 

Treatment. — Keep  a  hot-water  bag  on  the  perineum  and  three  or  four 
times  a  day  use  rectal  injections  of  hot  water.  Place  the  patient  on  a  milk- 
diet.  Leech  the  perineum.  Give  suppositories  of  opium  and  belladonna, 
•and  also  suppositories  of  ichthyol,  and  administer  urotropin  by  the  mouth. 
At  the  first  sign  of  suppuration  make  a  curved  perineal  incision.  Reten- 
tion of  urine  is  relieved  by  a  soft  catheter. 

Chronic  Prostatitis. — May  arise  from  stricture,  venereal  excess, 
•chr«nic  cystitis,  or  stone  in  the  bladder,  but  gonorrhea  is  the  common  cause. 
The  prostate  is  usually,  but  not  always,  enlarged,  is  somewhat  softened,  and 
the  ducts  contain  pus  and  blood. 

Symptoms. — There  is  usually  a  mucopurulent  discharge  or  fluid  can  be 
obtained  by  massage  of  the  prostate.  There  is  a  feeling  of  weight  and  fulness 
in  the  perineum,  there  is  increased  frequency  of  micturition,  and  the  prostate 
is  very  sensitive  to  digital  pressure.  The  patients  are  neurotic,  frequently 
suffer  from  nocturnal  emissions,  and  have  but  feeble  power  of  erection.  The 
prostatic  urethra  is  extremely  hyperesthetic.  All  the  symptoms  are  aggra- 
vated by  worry,  sexual  excitement,  or  violent  exercise.  An  abscess  may  form 
and  rupture  into  the  urethra. 

Treatment. — Tonics  and  nutritious  food  are  essential.  Intravesical 
irrigations  with  nitrate  of  silver  solution  (i  :  8000)  do  good.  Massage  of 
the  prostate  is  useful.  Some  cases  are  benefited  by  touching  the  posterior 
urethra  through  a  urethroscope  tube  with  nitrate  of  silver  (3  grains  to  the 
ounce)  or  by  injecting  by  means  of  Ultzman's  syringe  a  few  drops  of  silver 
nitrate  solution  (5  grains  to  the  ounce).  Rectal  suppositories  of  ichthyol 
may  be  ordered.  Blistering  the  perineum  at  intervals  may  prove  of  service. 
At  intervals  of  three  or  four  days  a  full-sized  cold  steel  sound  should  be  gently 
introduced.     If  an  abscess  forms,  open  it  through  the  perineum. 

Prostatorrhea. — Just  as  overaction  of  the  glands  of  the  urethra  con- 
stitutes urethrorrhea,  so  overaction  of  the  glandular  apparatus  of  the  prostate 
gland  constitutes  prostatorrhea.  Prostatorrhea  is  not  inflammatory,  although 
the  prostate  and  posterior  urethra  are  often  congested,  and  the  latter  region 
is  usually  hyperesthetic.  In  some  cases  urethrorrhea  exists  with  prostator- 
rhea. Prostatorrhea  is  produced  by  sexual  excess,  masturbation,  ungratified 
sexual  desire,  and  riding  a  bicycle  with  an  improper  seat.  The  condition 
is  usually  accompanied  by  marked  neurasthenia,  and  may  be  associated  with 
spermatorrhea  and  impotence. 

The  patient  notices  a  milky  or  gray  discharge  after  straining  at  stool 
(defecation-spermatorrhea),  after  violent  exercise,  sexual  excitement,  or  a 
bicycle  ride.  The  discharge  also  gathers  in  the  urethra  during  sleep.  Ex- 
amination of  the  discharge  shows  it  to  be  prostatic  fluid,  although  spermato- 
zoids  are  sometimes  found.  It  is  not  purulent  and  contains  amyloid  corpus- 
cles. The  meatus  is  not  glued  up  in  the  morning,  and  the  linen  is  very  sHghtly 
stained.  The  urine  is  clear  and  contains  small  comma-shaped  hooks  (Chris- 
tian) .  Sexual  excitement  and  alcohol  do  not  appreciably  aggravate  the  con- 
-dition.     The  bladder  is  irritable,  and  there  are  frequency  of  micturition  and 


1372  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

often  some  pain  in  the  head  of  the  penis  at  the  termination  of  the  act.  Noc- 
turnal emissions  may  occur. 

Treatment. — The  patient  should  correct  bad  habits.  If  there  is  urethral 
hyperesthesia  or  prostatic  congestion,  irrigate  the  bladder  and  urethra  once  a 
day  with  a  solution  of  silver  nitrate  (i  :  4000),  and  every  fourth  or  fifth  day 
introduce  a  cold  sound.  In  some  cases  the  occasional  instillation  into  the 
prostatic  urethra  of  a  few  drops  of  a  i  per  cent,  solution  of  nitrate  of  silver 
does  good. 

For  the  irritable  bladder  give  hot  hip-baths  at  night.  The  following 
prescription  is  of  service:  gr.  xv  of  bromid  of  potassium,  |  dram  of  tincture 
of  hyoscyamus  in  J  ounce  of  cinnamon- water,  three  times  a  day.  Hot  enemata 
are  of  service. 

After  the  hyperesthesia  of  the  urethra  has  abated  and  nocturnal  emissions 
have  ceased,  the  neurasthenia  is  treated  by  cold  sponging  of  the  body  night 
and  morning,  the  continued  use,  at  intervals  of  several  days,  of  a  large-sized 
cold  sound,  irrigation  every  second  or  third  day  with  silver  nitrate  (i  :  4000)^ 
and  the  administration  of  strychnin  and  other  tonics. 

Hypertrophy  of  the  Prostate  Gland. — It  was  pointed  out  by 
Morgagni  that  in  old  men  difficulty  of  micturition  is  due  to  obstruction  by 
an  enlarged  prostate  gland.  Enlargement  of  the  prostate  gland  may  be 
brought  about  by  different  forms  of  growth.  It  is,  as  a  general  thing,  a 
senile  change,  occurring  only  after  the  age  of  fifty,  and  being  most  Hkely 
to  arise  after  the  attainment  of  sixty  years.  It  is  very  rare  for  enlargement 
of  the  prostate  to  cause  symptoms  long  before  the  age  of  fifty  or  to  begin  after 
the  age  of  seventy.  Sir  Henry  Thompson  maintained  that  34  per  cent,  of 
men  over  sixty  have  prostatic  h}-pertrophy,  but  that  only  half  of  them  have 
troublesome  S}Tnptoms.  According  to  Freyer,  33  per  cent,  of  all  men  past 
fifty-five  years  of  age  present  some  enlargement  of  the  prostate. 

There  are  some  that  oppose  the  view  that  prostatic  enlargement  is  essen- 
tially a  senile  change.  For  instance.  Dr.  L.  Bolton  Bangs  ("Jour,  of  Der- 
matol, and  Gen.-urin.  Dis.,"  March,  1901)  maintains  that  the  change  is 
not  senile;  that  it  really  begins  early  in  fife,  but  that  its  effects  do  not  become 
manifest  until  during  or  after  middle  age.  Lydston  asserts  that  it  begins 
during  the  third  decade  of  life,  but  does  not  attain  sufficient  size  to  cause 
symptoms  till  beyond  middle  fife.  Socin  and  Burckhardt,  as  a  result  of  300 
postmortem  examinations,  reached  the  following  conclusions:  Between  the 
ages  of  thirty-six  and  forty  the  gland  is  hypertrophied  in  13  per  cent,  of  cases, 
between  forty  and  fifty  in  25  per  cent.,  between  fifty  and  sixty  in  31  per 
cent.,  between  sixty  and  seventy  in  56  per  cent.,  between  seventy  and  eighty 
in  50  per  cent.,  between  eighty  and  ninety  in  54  per  cent.  Undoubtedly,  the 
enlargement  begins  long  before  it  occasions  sufficient  obstruction  to  induce 
symptoms,  and  the  growth  progresses  very  slowly.  Guyon  and  the  French 
school  maintain  that  hypertrophy  of  the  prostate  gland  is  always  the  result 
of  arteriosclerosis,  affecting  not  only  the  prostate,  but  also  the  entire  urinary 
tract.  The  hypertrophy  that  ensues  affects  the  bladder-walls  notably,  as 
well  as  the  prostate,  because  of  distinct  growth.  Caspar  has  apparently 
demonstrated  that  Guyon's  view  is  not  correct.  He  has  shown  that  in  many 
cases  there  is  no  sclerosis  of  the  prostatic  arteries,  and  that  frequently  there 
are  no  sclerotic  changes  in  other  portions   of   the  urinary  tract,     x^nother 


Hypertrophy  of  the  Prostate  Gland  1373 

important  point  made  by  Caspar  is  that  arteriosclerosis  tends  to  cause  degen- 
eration, and  not  h\'pertrophy. 

Some  think  that  sexual  excess  is  a  cause  of  prostatic  enlargement;  some 
assert  that  antecedent  gonorrhea  is  the  cause,  but  it  seems  very  improbable 
that  either  is  causal.  Belfield  blames  altered  testicular  secretion;  Hawley 
believes  the  cause  to  be  altered  prostatic  secretion  and  the  '"chemical  action 
of  pathologic  proteids  resulting  from  irregular  metabohsm  or  derived  from 
disintegration  of  the  secretion,  or  in  the  usual  action  of  tissue  enzymes" 
(G.  W.  Hawley,  in  "Annals  of  Surger}-, "  Nov.,  1903). 

In  the  h}'pertrophied  prostate  there  is  an  excessive  production  of  fibrous 
tissue  and  of  ill-formed  glandular  tissue,  the  mass  constituting  a  fibro-adenoma. 
Fibro-adenoma  is  the  common  cause  of  enlargement  (\\.  Bruce  Clarke). 
Typical  adenoma,  according  to  Albarran  and  Halle,  is  found  in  14  per  cent, 
of  the  cases  ("Ann.  des  Mai.  des  Org.  Gen.-Urin.,"  Feb.  and  March,  1900). 
Again,  in  not  a  few  prostates  there  is  no  real  enlargement,  but  there  is  an 
indurated  fibrous  mass  producing  obstruction.  Albarran  and  Halle  ("  An- 
nates des  Maladies  des  Organes  Genito-Urinaires,"  1898,  vol.  xvi)  point  out 
that  in  an  enlargement  of  the  prostate  different  elements  may  usually  be 
recognized:  soft  h\-pertrophy  of  the  gland;  indurated  enlargement  of  the 
glandular  elements;  fibrous  enlargement;  circumscribed  tumor-masses; 
■distinct  fibromata  or  myomata;  or  adenofibromyomata.  The  real  cause 
•of  the  various  forms  of  prostatic  enlargement  is  not  kno^^-n.  Nearly  10 
per  cent,  of  cases  are  cancerous  (Oraison),  and  adenoma  is  apt  to  be  trans- 
formed into  cancer. 

All  the  lobes  may  be  enlarged  equally;  all  may  be  enlarged  unequally;  the 
enlarged  gland  may  surround  the  prostatic  urethra  Hke  a  horse-collar;  or 
one  lobe  only  may  be  enlarged.  S^-mmetrical  enlargement  of  the  entire  gland 
is  not  so  apt  to  produce  s}Tnptoms  as  is  a  non-symmetrical  enlargement. 
In  some  cases  the  chief  enlargement  is  into  the  bladder;  in  others,  into  the 
urethra.  An  enlarged  prostate  frequently  shows  a  circular  groove  about  it, 
•due  to  the  constriction  exerted  by  the  rectovesical  fascia  at  the  vesical  neck. 

The  bridge  of  prostate  which  joins  the  two  lateral  lobes  behind  the  ure- 
thra is  kno^\-n  as  the  lobe  0}  Home  or  the  ^'middle  /obc,"  and  a  compara- 
tively trixial  enlargement  of  the  middle  lobe  may  cause  obstruction.  Pros- 
tatic h}-pertrophy  causes  a  narrowing  and  lengthening  of  the  urethra,  and 
gives  this  tube  a  tortuous  course.  The  opening  of  the  lu-ethra  into  the  bladder 
is  usually  pushed  to  a  higher  level,  and  there  forms  behind  it  a  pouch  in 
which  urine  collects.  The  urine  that  gathers  in  this  pouch  is  kno^ATi  as 
residual  urine.  It  cannot  be  voluntarily  expelled.  It  may,  therefore,  col- 
lect in  large  quantity,  and  it  is  likely  to  decompose,  producing  cystitis.  Resid- 
ual urine  strongly  favors  calculus  formation.  The  mechanical  resistance 
to  the  expelling  of  the  urine  causes  congestion  of  the  neck  of  the  bladder 
and  the  posterior  urethra  and  also  h}-pertrophy  of  the  muscles  of  the  bladder. 
In  consequence  of  the  h}'pertrophy  the  bladder  enlarges,  thickens,  and  becomes 
fasciculated.  \Mien  this  takes  place,  micturition  becomes  very  difficult 
and  sometimes  impossible.  Enlargement  of  the  middle  lobe  inevitably 
blocks  the  flow  of  urine  and  causes  great  distention  of  the  bladder.  In  hyper- 
trophy of  the  prostate  gland  the  ureters  and  the  renal  pelves  and  calyces 
may  distend  and  surgical  kidney  may  develop. 


1374         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

It  is  useful  to  divide,  as  does  Horwitz,  persons  with  prostatic  hypertrophy 
into  three  groups:  (i)  those  in  whom  there  is  no  obstruction  or  in  whom  the 
urinary  symptoms  are  very  trivial;  (2)  those  in  whom  there  are  residual  urine 
and  disturbances  of  urinary  function,  who  depend  upon  the  catheter  for 
relief,  but  who  do  very  well  by  this  method;  and  (3)  those  that  suffer  a  com- 
plete breakdown  during  the  period  in  which  the  catheter  is  depended  upon 
(Orville  Horwitz,  in  "Phila.  Med.  Jour.,"  Nov.  16,  1901). 

Symptoms. — In  go  per  cent,  of  the  cases  there  is  very  trivial  inconveni- 
ence, the  patient  merely  being  annoyed  somewhat  by  episodes  of  nocturnal  fre- 
quency of  micturition.  The  stream  of  urine  is  slow  to  start  and  falls  feebly 
from  the  end  of  the  penis.  In  some  cases  there  is  interruption  of  the  stream 
(stammering).  The  last  drops  fall  entirely  without  control.  If  the  patient 
becomes  chilled  or  worried,  or  indulges  inordinately  in  the  pleasures  of  the 
table  or  in  wine,  beer,  or  alcohoUc  liquors,  nocturnal  frequency  of  micturition 
becomes  for  a  short  time  most  harassing.  In  10  per  cent,  of  all  cases  the 
bladder  cannot  be  emptied  entirely,  and  residual  urine  collects.  Frequency 
of  micturition  comes  on,  particularly  at  night;  the  patient  has  to  get  up  often; 
the  bladder  never  feels  empty;  and  cystitis  is  apt  to  arise.  The  urine,  at  first 
acid  and  clear,  becomes  neutral  and  cloudy,  and  finally  ammoniacal  and 
turbid,  and  contains  bacteria,  mucopus,  precipitates  of  phosphates,  and 
blood.  Above  the  pubes  there  is  aching  pain,  soon  spreading  to  the  peri- 
neum, which  pain  is  increased  when  the  bladder  is  distended  and  during 
mictiirition.  The  rectum  becomes  irritable,  and  piles  form  or  prolapse  of 
the  mucous  membrane  occurs,  because  of  straining  in  micturition.  Attacks 
of  retention  of  urine  may  occur.  In  about  one-third  of  all  cases  we  can  make 
a  diagnosis  by  rectal  palpation.  In  enlargement  of  the  middle  lobe  alone 
or  in  pure  intravesical  enlargement  rectal  touch  will  fail  to  make  the  diag- 
nosis and  the  cystoscope  must  be  relied  upon.  The  bladder  becomes  thin 
and  distended,  or  hypertrophied,  rigid,  and  fasciculated.  In  rare  cases  true 
incontinence  is  caused  by  the  median  lobe  growing  toward  the  neck  of  the 
bladder  and  preventing  closure;  The  health  breaks  down  because  of  pain, 
restless  nights,  indigestion,  and  disorder  of  the  bowels.  The  kidneys  may 
become  involved  (inflammation  of  the  pelves  or  calyces,  or  surgical  kidney),, 
and  suppression  may  occur.  Septic  fever  may  arise.  Calculi  may  form  in 
the  bladder.  Death  is  due  to  exhaustion,  suppression  of  urine,  or  septic 
cystitis.  A  foul  catheter  is  the  usual  cause  of  septic  cystitis,  but  micro- 
organisms sometimes  enter  by  passing  along  the  urethral  mucous  membrane. 

A  patient  should  be  examined  by  rectal  touch,  by  a  sound,  and  by  a  cysto- 
scope, if  possible;  the  amount  of  residual  urine  must  be  determined,  and  the 
condition  of  the  urine  is  carefully  studied.  The  presence  or  absence  of 
stone  should  always  be  determined.  After  an  examination  by  instruments 
the  patient  must  remain  in  bed  for  twenty- four  hours. 

Treatment. — There  is  no  known  method  of  preventing  prostatic  hyper- 
trophy. Many  cases  of  enlargement  are  treated  by  regular  catheterization,  and 
if  this  is  conducted  with  careful  cleanliness,  if  the  patient  rigidly  adheres  to 
hygienic  rules,  he  may  be  kept  comfortable  for  a  considerable  time.  Alexander 
has  formulated  several  sound  rules  as  to  when  catheterization  is  the  proper 
treatment.  He  says,  if  the  patient  is  intelligent  and  dextrous,  if  cystitis  is  not 
severe,  if  the  amount  of  residual  urine  is  not  very  large,  if  obstruction  is  not 


Treatment  of  Hypertrophy  of  the  Prostate  Gland  1375 

great,  if  the  bladder  retains  considerable  expulsive  power,  and  if  catheteriza- 
tion is  easy  and  painless,  we  are  justified  in  relying  upon  this  simple  plan  of 
treatment.  Prevent  cystitis  by  emptying  the  bladder  each  evening  with  a 
coude  catheter.  If  there  is  trouble  in  passing  the  catheter,  strengthen  the  in- 
strument by  inserting  a  filiform  bougie  as  a  stylet  (Brinton).  It  is  very  seldom 
that  a  metal  instrument  is  used,  but  if  it  is  required,  a  catheter  with  a  large  curve 
is  employed.  If  a  soft  semisolid  instrument  can  be  passed,  teach  the  patient 
how  to  clean  it,  how  to  use  it,  and  how  to  keep  it,  but  never  permit  the  patient 
to  use  a  metal  instrument  himself.  A  dirty  instrument  may  cause  fatal 
infection.  It  is  true  that  some  people  use  dirty  instruments  for  long  per- 
iods without  trouble,  but  in  most  cases  there  will  be  trouble  if  it  is  attempted. 
It  is  absolutely  necessary  to  use  only  perfectly  aseptic  instruments.  Metal 
instruments  are  sterihzed  by  boihng  in  water.  Rubber  catheters  can  be 
cleansed  by  washing  with  soap  and  running  water  and  boihng.  Woven 
instruments  can  be  placed  in  a  glass  cyHnder,  the  bottom  of  which  is  like 
a  sieve.  This  jar  is  placed  for  twenty-four  hours  in  a  vessel  which  con- 
tains formahn.  The  vapor  of  formalin  is  an  excellent  germicide,  and  does 
not  injure  the  catheter.  After  steriUzation  the  instruments  are  kept  ready 
for  use  in  a  glass  cyUnder  which  contains  calcium  chlorid.*  Guyon  scrubs 
the  catheters  with  soap  and  water,  dries  them  outside  and  inside,  and  places 
them  in  a  sealed  jar,  and  exposes  them  to  the  vapor  of  sulphurous  acid  for 
forty-eight  hours.  If  there  are  three  ounces  of  residual  urine,  use  the  cathe- 
ter only  at  night.  If  there  are  six  ounces,  use  it  night  and  morning.  If 
there  are  more  than  six  ounces  of  residual  urine,  add  one  more  catheterization 
a  day  for  every  additional  two  ounces  present  until  the  catheter  is  used  six 
times  in  the  twenty-four  hours.  It  should  never  be  used  oftener  than  this. 
Gradual  dilatation  with  steel  sounds  is  of  benefit,  but  forcible  dilatation  is  not 
advisable.  The  sound  may  be  passed  once  a  week.  Tell  the  patient  to 
avoid  violent  exercise,  cold,  damp,  sexual  excitement,  and  the  use  of  alcoholic 
liquors;  prevent  constipation  and  indigestion,  and  direct  him  to  drink  milk 
and  plenty  of  water.  A  hot  hip-bath  at  night  adds  to  his  comfort.  Hot 
enemata  are  of  value.  If  a  large  quantity  of  residual  urine  exists,  or  if  cystitis 
begins,  wash  out  the  bladder  daily  with  boric-acid  solution,  or  normal  salt 
solution,  or  nitrate  of  silver  (from  i  :  10,000  to  i  :  2000),  and  give  urotropin 
or  salol  and  boric  acid  by  the  mouth  (Cystitis,  page  13 19).  In  some  severe 
cases,  if  a  large-sized  rubber  catheter  be  tied  in  the  bladder  for  a  few  days, 
great  reUef  is  obtained.  Retention  of  urine  can  be  reheved  by  the  introduc- 
tion of  a  coude  catheter  strengthened  with  a  whalebone.  In  exceptional 
cases  a  silver  instrument  \\ith  a  prostatic  curve  must  be  employed  or  aspiration 
must  be  practised.  Many  cases  occurring  among  well-to-do  people  can  be 
kept  comfortable  by  catheterization.  Some  surgeons  still  think  that  only  when 
this  fails  should  an  operation  be  performed.  Unfortunately,  sooner  or  later  the 
regular  use  of  the  catheter  will  cause  cystitis.  A  poor  man  cannot  give  the 
necessar}'  time  and  attention  to  make  catheter  Hfe  safe  and  operation  must  be 
thought  of  in  him  sooner  than  in  others.  If  the  symptoms  grow  constantly 
worse,  if  the  sufi'ering  becomes  severe,  if  the  patient  cannot  urinate  without  the 
use  of  an  instrument,  if  catheterization  is  painful  or  impossible,  if  the  patient 
is  too  careless  or  ignorant  to  trust  with  a  catheter,  if  only  a  catheter  of  very 
*R.  W.  Frank,  in  Berliner  klin.  Woch.,  No.  44,  1895. 


1376  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

small  size  can  be  introduced,  if  attacks  of  obstinate  retention  occur,  if  there  is 
persistent  or  recurring  cystitis  or  hematuria,  if  there  are  signs  of  beginning  in- 
fection of  the  kidney,  if  the  residual  urine  gradually  increases  in  amount,  the 
bladder  should  be  opened.  Do  not  postpone  operation  until  the  patient 
becomes  really  ill.  Give  paUiative  measures  a  reasonable  trial,  and  if  they 
fail,  operate.  Before  determining  upon  any  operation  make  a  cystoscopic 
examination.  This  is  particularly  valuable  before  a  Bottini  operation  and 
before  a  perineal  operation.  It  shows  us  the  condition  of  the  bladder;  the 
nature,  size,  and  situation  of  the  enlargement,  the  median  lobe  if  present, 
and  a  calculus  if  one  exists.  This  examination  may  determine  the  form 
of  operation  desirable.  Prostatectomy  is  not  to  be  regarded  as  a  trivial 
affair  certain  to  result  in  cure.  It  is  a  grave  procedure,  with  a  considerable 
mortality,  which  may  be  attended  by  disastrous  complications  and  from 
which  unfortunate  consequences  may  arise.  I  agree  with  James  E.  Moore 
that — "It  is  altogether  too  grave  an  operation  to  be  resorted  to  as  a  routine 
treatment  for  every  enlarged  prostate,  and  is  applicable  only  to  properly 
selected  cases."  The  operation  is  contraindicated  if  there  is  advanced 
disease  of  the  kidneys,  and  if  it  is  performed  in  such  a  case,  fatal  uremia  is 
to  be  expected.  Age  is  not  in  itself  a  contraindication  if  the  kidneys  and 
cardiovascular  system  are  sound.  An  occasional  sequel  of  prostatectomy  is 
incontinence  of  urine  due  to  injury  of  the  neck  of  the  bladder  or  to  the  nerves 
of  the  part.     A  usual  sequel  is  impotence. 

In  the  majority  of  cases  in  which  palliation  fails  the  operative  indication 
is  to  remove  an  obstructing  mass  and  depress  the  level  of  the  opening  from 
the  bladder  into  the  prostatic  urethra,  so  that  the  prostatic  pouch  is 
abolished  and  the  bladder  can  be  thoroughly  drained.  The  surgeon  chooses 
between  prostatotomy  and  prostatectomy.  Prostatotomy  is  usually  performed 
by  the  galvanocautery  (Bottini's  operation).  Prostatectomy  may  be  supra- 
pubic or  perineal,  and  the  latter  may  be  by  enucleation  without  the  aid  of 
sight  (as  in  the  operations  of  Xicoll  and  Alexander)  or  by  open  dissection 
(as  in  Young's  operation).  No  one  routine  plan  is  suitable  for  all  cases. 
The  patient  should  be  studied  and  the  operation  chosen  which  is  safest  and 
best  for  that  indindual  case.  The  surgeon  who  only  uses  one  method  must 
wrong  many  patients,  and  he  retains  consistency  at  the  expense  of  humanity. 
It  was  formerly  beheved  that  any  operation  of  total  prostatectomy  must  of 
necessity  produce  impotence.  This  we  now  know  need  not  be  the  case.  The 
suprapubic  operation  is  probably  less  likely  to  be  followed  by  this  than  is  the 
perineal,  as  it  usually  spares  the  ejaculatory  ducts.  Young's  perineal  opera- 
tion spares  the  ejaculatory  ducts.  Destruction  of  the  ejaculatory  ducts 
certainly  produces  sterihty  and  may,  but  does  not  of  necessity,  produce  impo- 
tence. Willy  Meyer  ("Med.  Record, "  Oct.  7,  1905)  points  out  that  impotence 
may  also  be  caused  by  damaging  important  ner\-es  or  blood-vessels  in  advan- 
cing through  the  perineum,  and  also  by  the  operation  producing  relaxation  of 
the  verumontanum  and  prostatic  urethra,  parts  necessary  in  the  reflex  for 
erection. 

The  perineal  operation  is  as  safe  as  the  suprapubic  or  safer,  and  can  be 
rapidly  performed.  It  is  the  desirable  route  when  the  gland  can  be  palpated 
per  rectum  and  does  not  mount  high  up  when  we  are  deaHng  with  the  early 
stages  of  soft  hypertrophy  (Willy  Meyer,  in  "Med.  Record,"  Oct.  7,  1905), 


Treatment  of  Hy[)ertrophy  of  the  Prostate  Gland  1377 

and  when  prolonged  drainage  is  required.  According  to  Francis  S.  Watson 
("Annals  of  Surgery,"  June,  1904),  the  mortality  in  203  cases  was  only 
2.9  per  cent.  In  563  cases  of  removal  through  the  perineum  by  dissection, 
the  mortality  was  5.5  per  cent.  Young's  cases  in  this  group  number  150 
and  his  mortality  was  4.6  per  cent.,  the  mortality  of  Hartman's  was  9  per  cent., 
of  Albarran,  4  per  cent.,  and  of  Murphy,  3.9  per  cent.  (Schachner,  in  "Annals 
of  Surgery,"  August,  1908).  In  190  cases  of  bHnd  enucleation  through  the 
perineum  the  mortality  was  4.7  per  cent.  (Schachner,  Ibid.). 

After  the  performance  of  the  perineal  operation  the  drainage  is  at  the  lowest 
part  of  the  bladder.  In  a  perineal  operation  every  effort  should  be  made  to  do 
as  little  damage  as  possible  to  the  urethra.  If  we  destroy  the  entire  pros- 
tatic urethra,  the  operation  becomes  easy  and  rapid  and  nature  rapidly 
repairs  it,  but  a  traumatic  stricture  may  follow  and  may  make  the  patient's 
condition  worse  than  at  first.  As  Moore  says,  we  must  destroy  a  portion  of  the 
floor  of  the  urethra,  but  we  can  preserve  the  roof  and  the  side  walls.  Another 
point  in  the  perineal  operation  is  to  avoid  injuring  the  rectum.  A  tear  may 
enter  the  rectum,  or,  even  if  the  gut  was  not  torn,  sloughing  of  the  rectum 
resulting  in  recto-urethral  fistula  may  occur.  The  rectum  may  be  opened 
because  the  surgeon  fails  to  stick  close  to  the  urethra  in  his  dissection,  and 
sloughing  may  be  due  to  an  injudicious  use  of  the  retractors.  If  the  rectum 
is  opened,  it  should  be  at  once  sutured  with  catgut.  In  most  cases  it  takes 
about  three  weeks  for  the  wound  in  the  perineum  to  heal,  and  in  some  few 
cases  a  perineal  urinary  fistula  is  established.  Urinary  incontinence  may 
follow  this  operation.  By  simply  incising  the  prostate  gland  the  floor  of  the 
urethra  may  be  lowered  to  the  level  of  the  floor  of  the  bladder.  Simple 
incision  of  the  prostate  in  this  manner,  or  by  Bottini's  method,  is  known  as 
prostatotomy.  The  mortality  is  small  and  the  relief  is  often  great.  Prosta- 
totomy  is  performed  on  old  and  exhausted  patients  with  damaged  kidneys. 
A  large  tube  should  be  worn  during  the  healing  of  the  wound. 

The  suprapubic  operation  is  easier  than  the  perineal;  it  is  less  safe;  it 
gives  excellent  results  if  temporary  drainage  only  is  needed.  According 
to  Watson  ("Annals  of  Surgery,"  June,  1904),  the  mortahty  in  69  cases  was 
8.6  per  cent.  Freyer  reports  600  cases  varying  in  age  from  forty-eight  to 
eighty-nine  years.  There  were  47  between  the  ages  of  eighty  and  eighty-nine, 
and  7  were  seventy-nine;  most  of  the  cases  had  been  entirely  dependent  on 
the  catheter  for  periods  up  to  twent}^-four  years.  "Nearly  all  were  in  broken 
health  and  many  apparently  dying  before  operation."  "Few  were  free  from 
one  or  more  grave  complications,  such  as  cystitis,  stone  in  the  bladder,  pyelitis, 
kidney  disease,  diabetes,  heart  disease,  chronic  bronchitis,  paralysis,  hernia; 
and  in  a  few  instances  there  was  malignant  disease  of  some  other  organ  than 
the  prostate"  (P.  J.  Freyer,  in  "Archives  Internationales  de  Chirurgie,"  vol. 
iv,  Fascic,  4,  1909).  In  these  600  cases  there  were  37  deaths  in  periods  from 
six  hours  to  thirty-seven  days  after  operation,  a  mortality  of  6.15  per  cent. 
It  is  indicated  in  rather  young  subjects  in  whom  we  greatly  fear  impotence;  in 
cases  in  which  the  gland  is  placed  high;  in  cases  in  which  the  gland  is  not 
palpable  per  rectum,  but  is  causing  serious  symptoms,  and  in  which  the  hyper- 
trophy is  recognized  by  the  cystoscope  (Meyer),  this  condition  exists  if  there 
is  a  middle  lobe ;  in  cases  in  which  cancer  exists ;  or  in  which  calculus  complicates 
the  case.  It  is  the  most  useful  operation  when  the  hypertrophy  is  very  large 
87 


1378  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

and  intravesical.  It  is  not  a  suitable  method  if  the  bladder  is  markedly  con- 
tracted or  if  the  belly-walls  are  very  thick.  If  prolonged  drainage  is  required, 
as  it  is  sure  to  be  in  cases  with  advanced  cystitis,  the  opening  is  better  placed 
in  the  perineal  operation.  If  when  a  suprapubic  operation  has  been  performed 
it  is  found  that  prolonged  drainage  is  indicated,  a  siphon  drain  (Fig.  786) 
is  used.  If  permanent  drainage  is  required  in  a  case,  the  suprapubic  method 
is  the  best.  After  a  suprapubic  cystotomy  has  been  performed  for  drainage, 
the  opening  may  be  kept  permanently  patent  by  the  retention  of  a  tube  (Hunter 
]VIcGuire's  operation).  It  is  only  in  very  advanced  cases  or  in  cancer  that 
permanent  suprapubic  drainage  is  employed.  After  making  a  suprapubic 
incision  the  floor  of  the  urethra  cannot  be  brought  level  \nth  the  floor  of  the 
bladder  by  a  simple  incision  of  the  prostate  through  this  incision;  it  can  be 
brought  level  only  by  the  performance  of  prostatectomy.  In  the  suprapubic 
operation  the  strictures  divided  are  less  important,  the  hemorrhage  is  less, 
and  the  drainage  is  better  than  in  the};erineal  operation.  Suprapubic  prosta- 
tectomy inflicts  injury  upon  the  bladder,  it  may  gravely  damage  the  sphincter 
of  the  bladder,  and  is  often  followed  by  inabilit}-  to  expel  urine  (John  B. 
Murphy,  "Jour.  Amer.  Med.  Assoc,"  March  29,  1902),  but  disturbance  of 
control  is  less  common  than  after  the  perineal  operation.  The  bladder-wall 
may  be  seriously  torn,  and  if  such  a  wound  should  be  inflicted,  it  ought  to  be 
sutured  \\ith  catgut.  In  this  operation,  if  the  bladder  is  contracted,  the 
surgeon  must  exercise  great  care  to  avoid  injuring  the  peritoneum.  The 
ureters  may  be  damaged  and  subsequently  become  obstructed  from  contrac- 
tion. If  death  occurs  after  prostatectomy  it  is  due  to  shock,  uremia,  sepsis,  or 
postoperative  compHcations,  usually  pulmonan,'.  Schachner  ("Annals  of  Sur- 
ger)', "  August,  1908)  uses  Watson's  figures  to  present  the  special  dangers  of 
each  operation.     The  table  is  as  follows: 

Per  cent. 

Bottini 2.7  ^ 

Perineal  operations 35.0  J-  Uremia  (or  renal  insufficiency). 

Suprapubic      "  34.0  J 

Bottini 52.0  1 

Perineal  operations 17.8  >  Sepsis. 

Suprapubic      "  8.6  J 

Bottini 5.0  ^ 

Perineal  operations 21.4  V  Shock. 

Suprapubic      "  30.0  j 

Bottini b.o  I  Postoperative  pulmonarv  com- 

Penneai  operations 17.8  r        r     ♦,-     ^ 

>  „  !_■        <i  1       plications. 

^  Suprapubic  22.0  J       ^ 

Freyer*s  Method  of  Suprapubic  Prostatectomy.— The  bladder  is 
washed  out  through  a  catheter  with  warm  boracic  acid  solurion  and  is  then 
filled  \\ith  the  solution.  The  nozzle  of  a  large  syringe  filled  with  fluid  is 
inserted  into  the  end  of  the  catheter.  This  keeps  the  bladder  fluid  from 
running  out  and  enables  the  surgeon  to  quickly  distend  the  viscus  more  if 
occasion  shall  arise.  The  bladder  is  opened  in  the  mid-hne  and  in  an  area 
free  from  veins.  The  incision  is  vertical,  is  made  toward  the  symphysis,  and 
is  about  I  inch  in  length  (it  can  be  enlarged  later  if  necessan,-) .  If  any  calculi 
are  found  they  are  at  once  removed.  A  finger  is  placed  in  the  rectum  to  raise 
up  the  prostate  and  keep  it  steady.     The  finger  of  the  other  hand  is  introduced 


Operations  for  Suprapubic  Prostatectomy  1379 

into  the  bladder,  and  by  means  of  the  finger  nail  the  mucous  membrane  is 
scratched  through  over  "the  most  prominent  portion  of  one  lateral  lobe,  or 
over  the  so-called  middle  lobe,  if  there  be  but  one  prominence"  (Freyer,  in 
"Archiv.  Internat.  de  Chir. "  Fascic.  4,  1909).  This  portion  of  the  gland  is 
only  covered  with  mucous  membrane,  and  when  this  is  scratched  through, 
the  true  prostatic  capsule  is  reached.  The  finger  is  kept  in  close  contact  \\-ith 
the  true  capsule  and  enucleates  the  gland  by  passing  first  posterior,  next 
outside,  and  finally  in  front  of  one  lateral  lobe. 

"The  finger  is  then  swept  in  a  circular  fashion  from  without  inward,  in 
front  of  and  to  the  inner  side  of  the  lobe,  detaching  this  from  the  urethra, 
which  is  felt  covering  the  catheter,  and  pushed  forward  tov/ard  the  symphysis 
between  the  lateral  lobes,  which  vail,  as  a  rule,  have  separated  along  their 
anterior  commissure  in  the  course  of  the  manipulations.  The  other  lobe  is 
attacked  and  treated  in  the  same  manner.  The  finger  is  next  pushed  well 
downward  behind  the  prostate  and  the  inferior  surface  of  the  gland  is  peeled 
off  the  triangular  ligament.  Wlien  the  prostate  is  felt  free  within  its  sheath 
and  separated  from  the  urethra,  with  the  finger  in  the  rectum,  aided  by  that 
in  the  bladder,  it  is  pushed  into  the  bladder  through  the  opening  in  the  mucous 
membrane,  which,  during  the  manipulations,  will  have  become  considerably 
enlarged"  (Freyer,  Ibid.).  The  prostate  is  removed  from  the  bladder  by 
forceps.  If  the  lobes  come  away  separately,  Freyer  believes  that  the  ejacula- 
tory  ducts  are  uninjured  and  remain  attached  to  the  urethra.  There  has 
been  an  active  controversy  as  to  whether  Freyer's  operation  does  or  does  not 
destroy  the  prostatic  urethra.  It  seems  certain  that  even  if  it  is  left  it  must 
slough  for  want  of  blood-supply.  In  my  operations  by  this  method  it  has 
come  away  with  the  prostate. 

In  Freyer's  earlier  operations  he  sought  to  leave  the  urethra  and  accom- 
panying structures  behind,  but  he  is  now  convinced  that  the  prostatic  urethra 
may  be  torn  or  removed  without  ill  results. 

McGill's  Operation  :  The  bladder  is  opened  by  a  suprapubic  incision, 
the  edges  of  the  cut  bladder  are  sutured  to  the  abdominal  wound  with  catgut, 
and  the  interior  of  the  viscus  is  carefully  explored  with  the  finger  and  by  sight, 
an  electric  light  being  used  for  illumination.  If  a  sessile  growth  exists, 
the  mucous  membrane  is  incised  and  the  growth  enucleated  with  finger  or 
a  curet.  A  pedunculated  growth  is  cut  away  with  sharp-edged  forceps.  If 
a  mass  projects  into  the  bladder,  an  incision  is  made  to  divide  it  into  two 
portions  and  each  half  is  enucleated.  Hemorrhage  is  arrested  by  irrigation 
with  hot  salt  solution  and  by  compression  with  gauze  pads.  In  some  cases  a 
tampon  must  be  inserted.  The  bladder  is  drained  for  several  days  or  a  num- 
ber of  days  by  a  siphon  (Fig.  786).  As  a  matter  of  fact,  a  dense  fibrous  pros- 
tate cannot  be  enucleated  and  can  be  removed  only  by  scissors  or  cutting 
forceps. 

Fuller's  Operation  :  Open  the  bladder  above  the  pubes;  have  an  assistant 
push  the  gland  up  by  means  of  a  fist  in  the  perineum.  The  gland  can  be 
lifted  by  two  fingers  in  the  rectum  (Guiteras).  The  surgeon  makes  a  small 
incision  through  the  mucous  membrane  over  the  prostate,  enucleates  the 
gland  by  means  of  the  finger,  and  drains  through  an  incision  in  the  mem- 
branous lurethraj  as  well  as  through  the  suprapubic  opening. 


1380  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Belfield's  Operation  :  Belfield  performs  suprapubic  cystotomy,  makes  a 
perineal  cut  to  enable  the  finger  to  approach  the  prostate,  pushes  the  prostate 
up  toward  the  bcUy,  and  enucleates  it  from  within  the  bladder. 

Perineal  Prostatectomy. — Perineal  prostatectomy  is  less  bloody  than 
suprapubic  prostatectomy.  The  sphincter  of  the  bladder  is  not  damaged,  the 
entire  prostate  can  be  brought  into  view  and  removed,  and  perfect  drainage 
is  obtainable  after  operation. 

Nicoll's  Operation :  Perform  suprapubic  cystotomy.  Then  incise  the 
perineum  down  to  the  prostate,  split  the  capsule  of  the  prostate,  insert  two 


Fig.  822.  Fig.  823. 

Figs.  822  and  823. — Showing  double-tube  drainage  for  suprapubic  operation.  Fig.  822 
was  taken  from  an  elevation  to  show  the  termination  of  the  drainage-tubes.  Fig.  823  shows 
tubes  enlarged  in  separate  view. 


fingers  of  the  left  hand  into  the  bladder,  and  push  the  prostate  into  the  per- 
ineum so  as  to  bring  it  within  reach.  Enucleate  the  gland  from  the  per- 
ineal wound  without  damaging  the  mucous  membrane  of  the  floor  of  the 
bladder. 

Alexander's  Operation  :  Alexander  makes  a  suprapubic  incision  and  uses 
it  for  the  same  purpose  as  does  Nicoll,  but  he  also  opens  the  membranous 
urethra  on  a  grooved  staff.  After  enucleating  the  gland  he  inserts  a  drainage- 
tube  through  the  incision  in  the  membranous  urethra.  In  a  very  thin  subject 
it  may  not  be  necessary  to  perform  suprapubic  cystotomy.  Alexander  has 
brought  the  gland  into  an  accessible  position  in  the  perineal  wound  by  supra- 
pubic pressure,  and  Guiteras  has  done  so  by  making  an  incision  in  the  linea 
alba  and  inserting  two  fingers  into  the  prevesical  space.  Syms  advocates 
opening  into  the  peritoneal  cavity,  inserting  the  hand,  and  pressing  the 
prostate  into  the  perineum  without  opening  the  bladder  above  the  pubes. 

Bryson's  Operation :  This  is  a  satisfactory  method  in  some  cases.  The 
bladder  is  irrigated  and  filled  with  warm  salt  solution.     A  grooved  staff  is  intro- 


Bottini's  Galvanocaustic  Prostatotomy  1381 

duced  and  a  median  perineal  section  is  made  to  open  the  urethra  just  in 
front  of  the  apex  of  the  prostate  gland.  The  knife  is  pushed  back  in  the 
groove  of  the  staff  sufficiently  far  to  incise  the  ring  at  the  apex  of  the  pros- 
tate; the  forefinger  is  passed  into  the  prostatic  urethra  and  the  staff  is  with- 
drawn. Then  a  short  tear  is  made  by  means  of  a  blunt  instrument  into 
the  mass  of  the  left  lobe  and  the  finger  is  introduced  and  enucleates  the  lobe. 
The  same  procedure  is  carried  out  on  the  right  lobe,  and,  finally,  if  necessary, 
on  the  middle  lobe.  If  the  middle  lobe  requires  removal,  but  cannot  be 
reached,  a  suprapubic  cut  is  made  into  the  cave  of  Retzius,  two  fingers  are 
inserted,  and  the  lobe  is  pushed  within  reach  of  the  finger  below.  A  large 
perineal  tube  is  introduced  for  drainage  and  bleeding  is  arrested  by  packing. 
Horwitz  also  introduces  a  catheter  and  ties  it  in  place. 

Young's  Operation:  This  surgeon  frequently  operates  under  spinal 
anesthesia.  He  places  the  patient  in  an  exaggerated  lithotomy  position 
and  introduces  a  sound.  In  thin  subjects  the  incision  is  in  the  raphe  and 
is  carried  close  to  the  anus;  in  short  individuals  the  incision  is  an  inverted  V- 
He  incises  the  recto-urethralis  muscle  transversely,  exposes  the  membranous 
urethra,  opens  it,  and  inserts  his  tractor  into  the  opening  in  the  urethra  (Fig.  828). 
The  tractor  is  turned  180°,  the  blades  are  opened,  and  traction  is  made.  The 
capsule  is  incised  on  each  side  of  the  ejaculatory  ducts  and  the  gland  is  removed 
by  blunt  dissection,  the  forceps  grasping  each  lobe  during  enucleation  (Fig.  829). 
Every  effort  is  made  to  save  the  urethra.  After  removing  the  lateral  lobes  the 
tractor  is  used  to  bring  a  middle  lobe,  if  one  exists,  into  the  wound,  and  it 
is  also  enucleated.     The  bladder  is  drained  for  about  one  week. 

Bottini's  Galvanocaustic  Prostatotomy. — Bottini,  of  Padua,  in  1874 
suggested  cauterizing  the  prostate  by  means  of  a  special  instrument.  He  sought 
to  burn  away  a  portion  of  the  gland  in  hope  that  the  contraction  of  the  scar 
would  cause  the  remainder  of  the  gland  to  shrink.  The  instrument  of  Bot- 
tini is  shaped  like  a  catheter,  and  carries  a  platinum  blade  which  is  heated 
by  an  electri"c  current.  Bottini's  early  instrument  was  not  satisfactory  and 
the  operation  never  became  popular  until  Freudenberg  improved  the  tools 
in  1897  (Fig,  824). 

Bottini's  galvanocaustic  operation  is  performed  as  follows:  The  bladder 
should  be  emptied,  irrigated,  and  distended  with  air,  and  the  posterior  urethra 
must  be  anesthetized  by  instillation  of  cocain  or  eucain.  The  current  is  tried 
to  see  how  many  seconds  it  requires  to  heat  the  blade  sufficiently.  The  cur- 
rent is  broken,  the  instrument  is  introduced,  the  cooling  current  is  set  in 
motion,  and  one  assistant  watches  this  and  nothing  else.  Turn  on  the  cur- 
rent. Wait  the  required  number  of  seconds  for  the  blade  to  become  red  hot 
(twelve  to  fifteen  seconds),  turn  the  screw  at  the  handle,  and  burn  a  groove 
in  the  prostate.  A  groove  should  be  burned  toward  the  rectum,  one  to  the 
side,  and,  if  it  is  thought  desirable,  one  to  the  opposite  side.  No  groove  should 
be  burned  toward  the  pubes.  When  a  groove  has  been  burned,  return  the 
blade  into  its  sheath,  increasing  the  current  while  doing  so  in  order  to  keep 
the  blade  from  adhering  to  the  tissue,  then  shut  off  the  current.  After  with- 
drawing the  instrument  it  is  not  necessary  to  introduce  and  retain  a  catheter. 
The  patient  is  confined  to  bed  only  twenty-four  hours,  there  is  rarely  bleeding 
or  fever,  and  the  results  are  good.  The  scars  contract  and  the  gland  atrophies. 
During  the  period  of  healing  a  steel  sound  should  be  passed  from  time  to 


1382  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

time  (Bangs).     It  is  alleged  that  fibrous  stricture  of  the  neck  of  the  bladder 
may  follow  in  some  cases.* 


Fig..824. — Young's  modification  of  Freudenberg's  instrument  for  prostatotomy  by  galvanocautery. 

Bottini's  operation  is  the  procedure  to  be  selected  for  a  sclerotic  prostate, 
and  for  hypertrophy  in  a  feeble  and  aged  individual  with  damaged  kidneys. 


Fig.  825. — Incisions  of  the  middle  lobe  (Young). 

It  is  not  probable  that  the  cautery  operation  will  replace  prostatectomy.     The 
best  instrument  is  Young's  modification  of  Freudenberg's  apparatus  (Fig. 


\ 


Fig.  826. — Different  incisions  of  prostate  gland  in  Bottini's  operation  (after  Young). 


824).     Figs.  825  and  826  show  various  methods  of  making  the  cuts  as  advised 
by  Hugh  H.  Young.     When  there  is  a  distinct  and  pedunculated  median  lobe, 

*  For  description  of  this  operation  see  Freudenberg,  in  Berliner  klin.  Worh.,  No.  46, 
1897;  and  Willy  Meyer,  in  Med.  Record  of  March  5,  1898,  and  May  12,  1900. 


Castration  and  Vasectomy 


^3^3 


Fi'e;.  S27.— Incising  the  middle  lobe  (Young). 


the  ordinary  operation  fails  entirely;  but,  as  Young  shows  (Figs.  825,  827), 

if  an  oblique  cut  is  made  on  each  side 
across  the  base,  this  lobe  will  drop  out 
of  the  way  and  quickly  atrophy. 

Castration  and  Vasectomy. — In  1886 
Sanitzin  demonstrated  clinically  the 
shrinking  of  a  large  prostate  after  double 
castration  (Hawley,  in  "  Annals  of  Sur- 
gery," Nov.,  1903).  In  1893  Ramm,  of 
Norway,  performed  double  castration  in 
order  to  cause  shrinking  of  an  enlarged 
prostate.  In  1893,  after  a  long  series  of 
careful  experiments,  J.  William  White 
recommended  the  operation  of  bilateral 
orchidectomy  for  the  treatment  of  pros- 
tatic hypertrophy.  He  proved  that 
removal  of  the  testicles  causes  a  rapid 
shrinking  in  an  enlarged  prostate. 
Much  of  this  shrinking  may  be  due  to  diminution  of  congestion  and 
edema,  but  true  atrophy  undoubtedly  occurs  in  the  glandular  elements. 
Very  remarkable  results  have  been  recorded.  In  some  cases  the  patients 
become  absolutely  comfortable  and  dis- 
pense entirely  with  the  catheter. 
Cystitis  ceases,  and  desire  to  urinate 
frequently  becomes  less  marked.  Uni- 
lateral orchidectomy  has  been  employed, 
but  it  is  not  satisfactory.  In  1894 
Mears  suggested  ligation  of  the  spermatic 
cord.  In  1895  Lauenstein  suggested  divi- 
sion of  the  spermatic  cord.  In  1896 
Tilden  Brown  suggested  ligation  of  the 
vas.  Reginald  Harrison  in  1896  ad- 
vised section  of  the  vas.  Lennander 
in  1897  proposed  exsection  of  the  vas 
deferens  (vasectomy).  It  is  slower  in  its 
results,  but  just  as  certain  as  castration. 
In  spite  of  the  great  simplicity  of  orchi- 
dectomy the  mortality  has  been  consider- 
able (from  II  to  18  per  cent.,  according  to 
some  authors.  Socin  and  Burckhardt  say 
16.2  per  cent.).  In  several  instances  men- 
tal disturbance  has  followed  the  operation. 
Castration  is  now  very  seldom  performed, 
as  vasectomy  is  just  as  useful  and  is  safer. 
Vasectomy  is  valueless  in  cases  of  fibroid 
prostate,  does  some  good  in  adenoma,  but  is  most  valuable  when  the  prostate 
is  generally  hypertrophied  and  prone  to  great  congestion,  causing  violent 
s)'Tnptoms.  The  testicle  does  not  atrophy  after  vasectomy,  mental  disturb- 
ance does   not  occur  because   the  internal   secretion  of   the  testicle  is  still 


Fig.  828.— Tractor  introduced  ;  blades 
separated  ;  traction  made,  exposing  poster- 
ior surface  of  prostate.  Incisions  in  cap- 
sule on  each  side  of  ejaculatory  ducts 
(Young). 


1384  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


furnished  to  the  organism,  and  impotence  may  not  develofj,  though  steriHty 
must. 

Oiher  Methods. — ^Among  other  operations  which  have  been  suggested  are: 
ligation  of  the  vascular  elements  of  the  cord;  resection  of  all  the  cord  ele- 
ments except  the  vas  and  its  arten'  and  vein  (aftgioneureciomy,  proposed  by 
Albarran  in  1897);  parenchymatous  injections  of  cocain  into  the  testicles;  and 
ligation  of  both  internal  iliac  arteries.  Angioneurectomy  has  a  mortality  of 
5.5  per  cent.  (Socin  and  Burckhardt). 

Results. — The  relative  merits  of  these  various  operations  alluded  to  above 
are  in  dispute.  It  is  certain  that  many  cases  of  prostatic  hypertrophy 
can  be  kept  comfortable  by  aseptic  catheterism.  If  this  procedure  fails,  oi 
for  other  reasons  must  be  abandoned,  or  if  the  surgeon  decides  not  to  employ  it, 
a  careful  study  of  the  case  should  be  made  before  selecting  a  special  operation. 
The  Bottini  operation  has  come  into  somewhat  extensive  use.  Some  would 
apply  it  to  almost  any  sort  of  case,  and  claim  that  the  operation  is  practically 
free  from  danger.  Meyer  uses  it  for  any  case  of  uncomplicated  hypertrophy, 
but  if  the  prostate  is  very  large,  ligates  the  vasa  deferentia  some  weeks  before 
cauterizing  the  prostate,  in  order  to  lessen  the  danger  of  thromboses. 

A  more  consen'ative  view 
is  that  of  Eugene  Fuller,  who 
doubts  the  permanence  of  the 
results  of  the  Bottini  operation, 
fears  that  stenosis  of  the  vesical 
neck  may  follow,  and  would 
restrict  the  operation  to  un- 
complicated cases,  not  of  a 
grave  character,  and  in  which 
the  bladder  has  not  been  ser- 
iously damaged.  It  is  the 
operation  of  choice  if  the  prosr 
tate  is  fibrous;  Honvitz  prefers 
it  ifthe  patient  is  old,  debilitated, 
or  the  victim  of  kidney  disease. 
Some  residual  urine  usually  re- 
mains after  a  Bottini  operation. 
In  over  10  per  cent,  of  cases  no 
benefit  follows.  Vasectomy  is 
used  for  an  engorged  and  gener- 
ally enlarged  prostate.  It  may  do  great  good  and  may  fail  completely.  If  the 
urine  is  extremely  foul,  some  operation  permitting  drainage  is  advisable.  In  an 
adenomatous  prostate  in  which  enucleation  is  easy  we  should  prefer  the  perineal 
method.  In  other  cases  in  which  it  is  probable  enucleation  will  be  hard ;  in 
cases  of  uncertain  diagnosis:  in  cases  in  which  a  calculus  may  exist;  and  in 
cases  in  which  the  middle  lobe  is  at  fault,  do  a  suprapubic  operation,  ahhough 
sometimes  a  perineal  incision  may  be  made,  and  a  cut  be  made  in  the  prostate 
to  bring  the  floor  of  the  urethra  level  with  the  trigone. 

In  old  men  with  great  obstruction  and  with  serious  disease  of  the  bladder 
and  involvement  of  the  kidneys,  and  in  individuals  with  prostatic  cancer,  per- 
manent suprapubic  drainage  is  sometimes  the  most  useful  procedure. 


Fig.  829. — Enucleation  of  lobes. 
(Voung). 


Forceps  in   position 


Malignant  Disease  of  the  Prostate  Gland  1385 

The  mortality  from  Bottini's  operation  is  over  5  {)er  cent.  Horwitz  col- 
lected 888  operations:  84.3  per  cent,  were  cured  or  improved;  10  per  cent, 
were  not  improved;  and  5.7  per  cent,  died  ("Phila.  Med.  Jour.,"  Nov.  16, 
1901).     Young  had  3  deaths  in  41  operations. 

Vasectomy  done  early  gives  a  mortality  of  from  3  to  5  per  cent.  If  per- 
formed later,  the  mortality  is  10  to  15  per  cent.  Socin  and  Burckhardt  estimate 
the  mortality  of  bilateral  vasectomy  as  8.3  per  cent.  The  mortality  of  bilateral 
orchidectomy  is  16.2  per  cent. 

The  mortality  of  prostatectomy  is  variously  estimated.  Freudenberg  col- 
lected 753  cases:  622  were  cured,  44  died,  and  87  were  not  improved. 

Guiteras  collected  152  cases  done  by  various  methods  ("Jour.  Amer.  Med. 
Assoc,"  Nov.  2,  1901).  Twenty-five  died.  Bangs  believes  that  the  mor- 
tality from  prostatectomy  should  not  be  above  8  per  cent.,  but  statistics  indi- 
cate that  it  is  from  10  to  15  per  cent,  in  most  hands.  W.  Bruce  Clarke  reports 
a  mortality  of  9  per  cent.  The  mortality  of  the  suprapubic  operation  is 
higher  than  that  of  the  perineal  operation.  Belfield  estimates  the  former  at 
16  per  cent,  and  the  latter  at  9  per  cent.  Watson  estimates  the  mortality  of 
the  former  as  8.6  per  cent,  and  of  the  latter  as  2.9  per  cent. 

The  earlier  the  operation  is  performed,  the  safer  it  is.  (See  "  The  Choice 
of  Method  in  Operating  Upon  the  Hypertrophied  Prostate,"  by  Willy  Meyer, 
in  "Med.  Record,"  Oct.  7,  1905;  "A  Critical  Review  of  the  Technic  of  Per- 
ineal Prostatectomy,"  by  Charles  Greene  Cumston,  in  "American  Medicine," 
August,  1906;  "The  Operative  Treatment  of  the  Hypertrophied  Prostate," 
by  Francis  S.  Watson,  "Annals  of  Surgery,"  June,  1904.) 

Malignant  Disease  of  the  Prostate  Gland.— Primary  malignant 
growths  of  the  prostate  are  not  infrequently  encountered,  but  secondary 
growths  are  much  more  rare  than  are  primary  growths.  When  malignant  dis- 
ease does  occur,  it  is  almost  always  cancerous.  Secondary  cancer  of  the  pros- 
tate finds  its  most  usual  antecedent  in  cancer  of  the  rectum.  Epithelioma 
does  not  occur.  Scirrhus  occasionally  occurs;  but  the  most  frequent  form  is 
encephaloid.  Round-celled,  spindle-celled,  or  mixed-celled  sarcoma  may 
develop.  Powers  says  there  have  been  but  31  authenticated  cases  of  primary 
sarcoma  reported  ("Annals  of  Surgery"  Jan.,  1908).  Sarcoma  is  most 
frequent  in  childhood.  It  grows  rapidly,  is  usually  soft,  and  causes  pain  in 
the  rectum  and  perineum  or  pubic  region,  but  early  in  the  case,  at  least,  there 
is  seldom  residual  urine  (Powers,  in  "Annals  of  Surger)'"  Jan.,  1908).  No 
real  cure  of  sarcoma  has  yet  been  reported. 

Carcinoma  of  the  prostate  may  occur  at  an  earlier  age  than  ordinary 
hypertrophv  of  the  prostate.  The  latter  does  not  become  evident  until  after 
the  age  of  fifty;  but  carcinoma  of  the  prostate  may  begin  at  any  time  after 
the  age  of  forty,  and  sarcoma  of  the  prostate  may  commence  in  early  youth. 

At  first  the  carcinomatous  growth  enlarges  slowly;  but  it  soon  begins  to 
grow  with  rapidity.  It  breaks  through  the  capsule  and  fungates  into  the 
bladder  or  into  the  urethra.  The  pelvic,  the  inguinal,  and  the  femoral  glands 
become  involved  early  in  the  course  of  the  disease.  It  is  not  usual  to  find 
great  obstruction  to  urination  or  to  the  passage  of  a  catheter  at  an  early  period, 
but  later  both  these  conditions  are  noted.  Early  in  the  case  there  is  pain  only 
when  obstruction  to  lu-ination  occurs;  later,  the  pain  in  the  neck  of  the  blad- 
der may  be  severe,  and  there  may  also  be  pain  in  the  loin  and  in  the  sciatic 


1386  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

nerves.  Hemorrhage  usually  occurs.  In  the  beginning  the  hemorrhage  is 
trivial  and  intermittent,  but  when  fungation  exists,  large  hemorrhages  gen- 
erally take  place.  The  blood  is  usually  mixed  with  urine,  but  there  is  some- 
times a  large  hemorrhage  unassociated  with  micturition.  The  urine  is  not 
likely  to  contain  pus  or  any  large  quantity  of  mucus  unless  the  bladder  is  in- 
volved in  the  growth. 

When  the  prostate  gland  is  felt  by  means  of  a  finger  in  the  patient's  rectvim, 
it  is  found  to  be  of  stony  hardness  and  to  be  firmly  anchored  in  place.  Regi- 
nald Harrison  points  out  that  an  ordinary  hypertrophied  gland  is  not  so  firmly 
anchored  as  a  carcinomatous  gland;  that  the  bowel  moves  over  it  with  free- 
dom; and  that,  although  it  is  firm  to  the  touch,  it  is  not  of  stony  hardness. 
The  patient  with  carcinoma  of  the  prostate  loses  flesh  rapidly  and  develops 
distinct  cachexia,  and  metastatic  deposits  are  likely  to  form  in  the  vertebral 
column,  in  the  kidneys,  and  in  other  organs  and  structures. 

In  making  a  diagnosis  Harrison  insists  upon  the  value  of  the  cystoscope. 
He  says  that  in  cancer  one  does  not  find  much  intravesical  projection,  and 
that  what  projection  there  is  is  uneven  and  irregular.  In  an  ordinary  adeno- 
matous prostate,  on  the  contrary,  the  surface  is  smooth  and  rounded  and 
projects  into  the  bladder. 

Treatment. — Radical  operation  is  out  of  the  question  in  these  cases. 
Permanent  suprapubic  drainage  is  made  in  most  instances,  and  usually  gives 
the  patient  great  relief.  (See  "Remarks  on  Cancer  of  the  Prostate,"  by 
Reginald  Harrison,  in  "Brit.  'Sled.  Jour."  of  July  4,  1903.) 

Tuberculosis  of  the  Prostate  Gland. — Tuberculosis  of  the  pros- 
tate is  rarely  primary.  It  is  usually  secondary  to  tuberculosis  of  the  kidney 
or  of  the  epididymis.  In  the  majority  of  cases  of  tuberculosis  of  the  prostate 
the  lungs  are  involved  in  a  tuberculous  process  when  the  patient  is  first 
seen  by  the  surgeon.  The  disease  appears  particularly  between  the  ages  of 
twenty  and  thirty  years,  but  it  may  attack  elderly  men  and  even  the  aged. 
It  begins  by  the  formation  of  a  number  of  tuberculous  nodules  in  the  imme- 
diate neighborhood  of  the  prostatic  tubules.  These  nodules  caseate  and  run 
together,  forming  cavities  and,  eventually,  tuberculous  abscesses,  which  are 
prone  to  rupture  into  the  urethra.  In  very  rare  instances  a  large  tubercu- 
lous abscess  ruptures  through  the  perineum,  into  the  rectum  or  into  the 
peritoneum. 

The  disease  occasionally  undergoes  spontaneous  cure,  through  fibrous- 
tissue  formation  or  calcification.  The  tuberculous  process  is  hable  to  spread 
to  the  seminal  vesicles,  the  bladder,  the  ureters,  and  possibly  the  peritoneum; 
and  in  some  cases  it  inaugurates  thrombophlebitis  and  pyemia. 

Symptoms. — The  patient  suffers  with  pain  during  micturition;  there  is 
frequent  micturition;  and  from  time  to  time  the  urine  contains  blood.  Attacks 
of  cystitis  take  place,  and  weakness  and  a  loss  of  flesh  are  greater  than  is  com- 
mensurate with  any  ordinary  inflammation.  Tuberculosis  of  the  prostate 
alone  is  said  not  to  cause  marked  hectic  fever;  but  when  adjacent  structures 
become  involved,  the  temperature  attains  a  high  level  and  becomes  charac- 
teristic. When  the  disease  has  advanced,  there  is  not  unusually  urinary  in- 
continence, on  account  of  the  involvement  of  the  circular  muscular  fibers 
about  the  neck  of  the  bladder.  Commonly,  there  is  a  mucopurulent  discharge, 
or  mucopurulent  matter  may  be  obtained  by  massaging  the  prostate.     This 


Retained  and  Misplaced  Testicle  1387 

matter  may  contain  tubercle  bacilli,  and  in  some  cases  the  urine  also  contains 
these  bacilli.  Early  in  the  course  of  the  case  rectal  examination  detects  some 
enlargement  of  the  gland,  many  nodules,  and  tenderness;  later  in  the  disease 
it  finds  marked  enlargement  and  areas  of  softening. 

Treatment. — Early  in  the  case  Senn  recommends  parenchymatous  in- 
jections of  iodoform  emulsion,  the  punctures  being  made  through  the  peri- 
neum. If  these  fail,  operation  must  be  considered.  When  one  takes  into 
account  how  rare  primary  tuberculosis  of  the  prostate  is,  one  is  impressed 
with  the  infrequency  with  which  a  radical  operation  should  be  attempted. 
If  there  is  absolutely  no  evidence  that  any  adjacent  organ  is  involved  or  that 
any  distant  focus  of  disease  exists,  it  is  justifiable  to  perform  perineal  pros- 
tatectomy. As  a  rule,  however,  the  only  surgical  operation  performed  con- 
sists in  making  a  curvilinear  incision  in  front  of  the  rectum,  which  exposes 
the  prostate,  and  permits  the  surgeon  to  open  and  curet  caseous  foci.  If  an 
abscess  forms,  it  should  be  evacuated  by  means  of  a  perineal  incision  and 
cavities  should  be  cureted  and  packed  with  iodoform  gauze. 

If  it  is  determined  that  no  operation  is  advisable,  antituberculous  treat- 
ment is  employed.  One  should  look  to  the  patient's  general  health,  administer 
urotropin,  and  a'^oid  using  instruments  as  much  as  possible;  because,  as  Sir 
Henry  Thompson  has  shown,  instrumentation  irritates  the  prostate,  causes  a 
great  deal  of  pain,  and  makes  the  disease  worse  in  every  case. 

Retained  and  Malplaced  Testicle. — In  i  person  of  1000  there  is  unde- 
scended or  ectopic  tesds.  The  testicle  may  be  arrested  in  its  passage  to  the 
scrotum  {cryptorchisni,  single  or  double) ;  it  may  remain  in  the  lumbar  region; 
it  may  reach  the  internal  abdominal  ring;  it  may  lodge  in  the  inguinal  canal; 
it  may  emerge  from  the  external  ring,  but  fail  to  enter  the  scrotum;  or  it  may 
pass  into  an  unnatural  position,  as  into  the  perineum  or  the  crural  canal 
{ectopia  of  the  testis) .  The  failure  of  descent  may  be  unilateral  or  bilateral,  but 
when  bilateral  the  degree  of  descent  is  seldom  the  same  on  the  two  sides.  The 
gland  maybe,  but  seldom  is,  functionally  active.  When  retained  in  the  abdomen 
it  never  has  the  power  of  spermatogenesis.  Before  puberty  the  testicle  is  usu- 
ally normal,  but  after  puberty  there  is  practically  always  more  or  less  atrophy. 
In  about  i  case  out  of  5  there  is  spermatogenesis.  A  retained  testicle  is  liable 
to  attacks  of  orchitis  and  may  become  tuberculous  or  sarcomatous.  In  most 
cases  there  is  neither  pain  nor  tenderness,  and  the  patient  presents  himself  for 
treatment  because  a  lump  has  appeared  in  the  groin.  In  some  cases  there 
are  sudden  attacks  of  violent  pain,  accom.panied  by  nausea  (Rawling,  on 
Incompletely  Descended  Testicle,  in  "Practitioner,"  August,  1908).  A  testicle 
in  the  inguinal  or  crural  canal  or  in  the  perineum  is  far  more  apt  to  become 
sarcomatous  than  is  one  retained  within  the  abdomen.  Over  10  per  cent,  of 
cases  of  sarcoma  of  the  testicle  are  in  undescended  glands.  In  80  per  cent,  of 
individuals  the  testicles  have  descended  at  birth ;  most  often  it  is  the  right  testicle 
which  fails  to  descend.  Sometimes  a  testicle  descends  after  being  retained  for 
months  or  even  years.  In  Keyes'  case  it  descended  in  the  thirtieth  year. 
Late  descent  usually  causes  hernia,  and  in  90  per  cent,  of  all  cases  hernia  exists. 
In  double  cryptorchism,  in  which  the  testicular  function  has  been  aboHshed, 
there  is  delayed  union  of  the  bony  epiphyses  and  epiphyseal  fractures  are 
common,  and  there  may  be  excessive  growth  of  long  bones.  The  same  ha- 
bility  is  noted  in  those  subjected  to  castration  in  infancy.      When  such  a 


1388  Diseases  and  Injuries  of  the  Genilo-urinary  Organs 

subject  reaches  manhood,  he  may  develop  some  disease  of  the  skeleton  which 
is  usually  seen  only  in  children  (Gross  and  Sencert,  "Rev.  de  Chir.,"  No.  11, 
1905).  In  operating  on  these  cases  we  usually  find  a  well-developed  guber- 
naculum  and  a  vaginal  tunic  extending  well  below  the  testicle. 

Treatment. — If  one  testicle  is  undescended  at  or  after  the  eighth  year  of  life 
and  before  puberty,  if  it  hes  in  the  canal,  and  if  the  other  testicle  is  sound, 
the  former  should  be  removed  if  it  is  found  impossible  to  draw  the  gland  into 
the  scrotum.  Both  testicles  should  not  be  removed  from  a  child:  one  should 
be  placed  within  the  abdomen.  I  would  do  this  in  order  to  have  the  child  cer- 
tainly enter  and  remain  in  the  masculine  groove.  Removal  of  both  is  per- 
missible in  an  adult,  because  he  has  definitely  become  and  will  remain  mascu- 
line, and  undescended  or  ectopic  testicles  in  an  adult  are  or  will  surely  become 
functionally  useless  and  menaces.  If  a  testicle  is  retained  in  the  abdomen 
it  should  not  be  operated  upon  unless  it  causes  trouble.  Always  try  to  get  a 
retained  gland  into  the  scrotum  before  the  age  of  puberty.  If  it  is  retained 
after  puberty,  it  will  be  almost  certain  to  be  functionally  useless.  An  ectopic 
testicle  should  be  restored  to  the  scrotum  if  possible;  if  not,  it  should  be  removed. 
Even  when  operation  is  performed  to  replace  the  testicle,  success  is  seldom  endur- 
ing. In  Rawling's  29  cases  only  4  were  permanently  successful.  Other  opera- 
tors, however,  claim  better  results.  For  instance,  Broca  reports  79  cases  traced 
from  one  to  six  years,  and  in  31  of  them  the  result  was  perfect  and  permanent. 
The  method  I  employ  is  that  advocated  by  Coley,  viz.,  Bassini's  incision 
through  the  aponeurosis,  separation  of  the  cord  from  the  peritoneum  (it  is 
usually  in  the  posterior  sac  wall) ;  removal  of  the  vaginal  process,  the  cremaster 
and  fibrous  adhesions  around  the  cord;  the  making  of  a  scrotal  pouch  by  the 
fingers,  closure  of  the  canal  as  in  hernia;  suturing  of  the  cord  to  the  pillars  of 
the  external  ring,  as  advocated  by  Dowd.  This  is  practically  Broca's  method. 
Bevan  operates  for  a  testicle  vdthin  the  canal  by  separating  and  di\nding  the 
vaginal  process,  removing  all  the  coverings  of  the  cord,  and  leaving  the  testicle 
suspended  by  the  vas  and  spermatic  vessels  only.  This  proceeding  gives  the 
testicle  a  very  wide  range  of  mobihty.  A  pocket  is  made  in  the  scrotum  by 
means  of  the  finger,  the  testicle  is  placed  in  the  pocket,  and  remains  there 
without  suturing.  The  canal  is  now  sutured  as  in  a  Bassini  operadon  without 
cord  transplantation.  There  is  a  certain  though  small  risk  of  gangrene  of 
the  testicle  after  Bevan's  operation.  I  beUeve  Bevan's  method  should  be  em- 
ployed in  the  more  severe  cases.  If  there  is  no  hernia,  operation  should  not  be 
performed  until  between  the  eighth  and  twelfth  years  of  life. 

Orchitis  is  inflammation  of  the  testicle.  Acute  orchitis  may  be  due  to 
cold,  wet,  traumatism  or  epididymitis,  gout,  mumps,  rheumatism,  or  a  specific 
fever.  The  testicle  is  round,  swollen,  tender,  and  very  painful,  the  scrotum 
is  red  and  swollen,  the  tunica  vaginalis  is  filled  with  fluid,  and  there  is  fever. 
Chronic  orchitis  results  from  the  acute  form  or  from  a  chronic  urethral  in- 
flammation, and  is  almost  always  combined  with  epididymitis. 

The  treatment  of  the  acute  form  consists  of  rest  in  bed  and  applications 
as  for  epididymitis  (page  1391).  The  chronic  form  requires  the  removal  of 
the  causative  lesion,  if  possible,  the  wearing  of  a  suspensory  bandage,  ap- 
plications of  ichthyol  or  mercurial  ointment,  and  the  administration  of  iodid 
of  potassium  by  the  mouth.  Strapping  with  zinc  oxid  adhesive  plaster  may 
do  good.     Castration  may  be  required. 


Tuberculosis  of  the  Testicle  1389 

Tuberculosis  of  the  testicle  may  perhaps  be  primary,  but  in  the  vast 
majority  of  cases  is  secondary  to  tuberculosis  of  the  prostate,  bladder,  or 
seminal  vesicles.  I  have  never  seen  a  case  I  was  certain  was  primar}\ 
As  Keyes  says  ("Annals  of  Surgery-"  June,  1907),  careful  examination  will 
show  one  of  three  conditions — tubercle  bacilli  in  urine,  indurations  in  the 
prostate,  and  vesicles  or  "a  distinct  haze  in  the  urine  due  to  prostatic  ca- 
tarrh." These  patients  are  nearly  always  sterile.  The  disease  may  be 
preceded  by  pulmonarj-  tuberculosis,  peritoneal  tuberculosis,  anal  fistula, 
renal  tuberculosis,  or  tuberculous  disease  of  bones  or  joints;  and  primary 
tuberculosis  of  the  testicle  may  be  followed  by  near  or  distant  tuberculous 
lesions.  In  some  cases  involvement  of  the  prostate  exists,  but  cannot  be 
detected  {latent  tiiherculosis  of  the  prostate) ;  in  other  cases  the  prostate  is  in  a 
state  of  subacute  inflammation.  The  epididymis  is  always  involved  before 
the  testicle  and  early  chronic  lesions  are  localized  there  for  some  time.  In 
most  cases  the  bacilh  reach  the  prostate  and  vesicles  by  way  of  the  blood,  and 
reach  the  epididymis  by  way  6f  the  vas  deferens,  the  lesions  of  the  prostate 
and  vesicles  developing  first  or  remaining  latent.  In  some  cases  tuberculosis 
of  the  kidney  or  bladder  is  followed  by  tuberculosis  of  the  testicle.  The 
spread  from  the  prostate,  vas,  or  bladder  is  by  epithelial  infection.  There  is 
no  e\-idence  confirmaton'  of  the  idea  of  ascending  infection  from  the  urethra. 
In  a  child  ^^'ith  an  open  vaginal  process,  tuberculous  peritonitis  may  directly 
cause  tuberculous  epididymitis.  The  disease  begins  in  one  testicle,  but  in 
the  vast  majorit}'  of  cases  the  other  testicle  becomes  involved  after  a  few  weeks 
or  months.  If  the  other  testicle  remains  free  for  three  years,  its  chance  of 
remaining  free  is  good.  If  but  one  epididymis  is  involved,  the  testicle  may  not 
be  affected  for  weeks  or  months.  Von  Bruns  says  that  in  18  per  cent,  of  such 
cases  the  testicle  is  not  involved  for  six  months;  in  40  per  cent.,  for  over  two 
months  ("Archiv.  f.  khn.  Chir., "  Bd.  63,  H.  4).  It  usually  comes  on  gradually, 
but  it  may  begin  acutely,  as  I  have  seen  in  two  instances  during  the  progress 
of  tuberculous  peritonitis.  An  acute  onset  or  an  acute  exacerbation  of  a 
chronic  case  usually  means  a  mixed  infection.  The  disease  may  follow  a  slight 
injur}-  or  inflammation,  and  is  most  common  in  young  men,  but  may  arise  at 
any  age.  The  causal  influence  of  antecedent  or  existing  gonorrhea  is  doubtful. 
Some  maintain  that  sexual  excess  predisposes.  There  is  often  a  family 
history  of  tuberculosis.  A  chronic  case  begins  by  swelHng  of  the  epididymis. 
Palpation  detects  one  or  two  or  several  rounded  nodules,  or  a  diffuse  hardening. 
In  the  latter  case  the  epididymis  is  much  enlarged,  and  there  is  usually  a  shght 
hydrocele.  Rectal  examination  commonly  detects  nodules  in  the  prostate 
and  vesicles.  In  a  few  cases  there  are  frequency  of  micturition,  tenesmus, 
hematuria,  and  seropurulent  fluid  can  be  massaged  from  the  vesicles  and 
prostate  and  milked  from  the  urethra.  In  some  cases  bacilli  are  found  in  the 
urine.  In  others  the  urine  is  hazy.  Sooner  or  later  nodules  appear  in  the 
testicle.  The  vas  is  always  swollen  and  may  or  may  not  be  palpable.  In 
an  acute  case  one  testicle  is  involved.  The  testicle  is  ver}'  painful  and  the 
epididymis  is  greatly  swollen  and  smooth.  The  testicle  quickly  swells,  there 
is  always  a  hydrocele,  and  the  scrotal  skin  becomes  reddened.  In  a  few  days 
the  acuteness  of  the  symptoms  subsides,  but  suppuration  shortly  occurs.  In 
any  case  of  tuberculosis  of  the  testicle  nodules  tend  to  soften  and  run  together. 


1390  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

After  a  time  the  skin  may  become  red  and  adherent,  give  way,  and  expose. 
a  caseous  breaking-down  epididymis  or  testicle.  Caseation  can  occur  without 
mixed  infection,  but  in  many  cases  where  softening  and  sinus  formation  occurs, 
there  is  mixed  infection.  The  duration  of  the  chsease  is  uncertain;  10  per 
cent,  of  the  100  cases  carefully  studied  by  Keyes  were  known  to  be  alive  ten 
years  after  the  beginning  of  the  trouble,  and  4  (and  not  one  of  them  had  been 
operated  upon)  seemed  free  from  tuberculous  lesions  anywhere.  One-third 
of  the  cases  that  suppurated  were  apparendy  well  after  three  years  ("Annals 
of  Surgery"  June,  1907).  Except  in  the  acute  cases,  the  testicle  is  only  sHghtly, 
if  at  all,  painful,  and  tenderness  is  trivial.     In  one-sixth  of  the  cases  a  small 


Fig.  S30. — Obstructive  hyperemia  for  the  testicles.  The  ends  of  the  elastic  tube  are  held 
by  the  patient,  crossed.  A  piece  of  tape  is  placed  beneath  to  be  tied  by  an  attendant  (Meyer 
and  Schmieden). 

hydrocele  forms.  In  a  questionable  case  the  tuberculin  test  should  be 
employed.  If  a  hydrocele  exists,  the  fluid  should  be  withdrawn  by  tapping 
and  cultures  be  made  from  it. 

Treatment. — Before  attempting  any  operation  try  Bier's  method.  The 
patient  is  placed  recumbent,  the  diseased  testicle  is  lifted  upward,  cotton 
batting  is  placed  around  the  neck  of  the  scrotum,  and  a  rubber  drainage-tube 
of  a  caHber  of  25  F.  is  wound  t\\'ice  around  and  fastened  with  a  string  or 
clamp.  If  both  testicles  are  diseased,  both  are  held  up  and  the  neck  of  the 
scrotum  is  embraced  by  the  tube  \\ath  the  required  firmness  (page  247)  The 
treatment  is  applied  for  two  or  three  hours  a  day  or  longer.  The  patient  had 
best  be  recumbent  during  the  application.  In  the  intervals  he  wears  a  sus- 
pensory and  gets  about.  During  the  use  of  Bier's  method  full  antituberculous 
treatment  is  required  (page  245).  If  a  cold  abscess  forms,  open  it  and  dress  it 
antiseptically.     If  Bier's  treatment  fails,  consider  the  addsability  of  operation. 


Epididymitis  1391 

An  acute  case  requires  unilateral  castration.  If,  in  a  chronic  case  the  disease 
is  limited  to  the  ei)ididymis  or  to  the  epididymis  and  vas,  resect  the  epididymis 
{epididymcctomy)  and  the  vas  deferens.  If  the  testicle  is  diseased,  orchidectomy 
is  performed.  It  was  long  believed  that  orchidectomy  was  useless  if  the  vesicles 
and  prostate  were  involved,  but  Koenig  and  others  maintain  that  vesicular 
and  prostatic  tuberculosis  improves  after  removing  the  diseased  testicle  or 
epididymis.  If  the  epididymis  of  each  testicle  is  involved,  bilateral  epididy- 
mcctomy should  be  performed.  When  both  testicles  are  diseased  and  other 
organs  and  structures  are  not  extensively  involved,  bilateral  orchidectomy  is 
performed  or,  better,  the  testicle  which  is  most  diseased  is  removed  and  the 
diseased  portion  of  the  other  is  extirpated.  Cumston  points  out  that  the  testicle 
may  be  diseased  and  yet  even  when  exposed  the  disease  not  be  detectable. 
Hence  in  doing  epididymectomy  he  splits  open  the  testicle  to  see  if  it  is  diseased. 
If  it  is  not  diseased  he  sutures  it  with  catgut  and  removes  the  epididymis. 
If  it  is  diseased,  he  considers  the  advisabihty  of  unilateral  orchidectomy 
(Charles  Greene  Cumston,  in  "Annals  of  Surgery"  June,  1909). 

In  association  with  and  after  operation  employ  antituberculous  remedies, 
order  a  nourishing  diet,  send  the  patient  to  a  good  climate,  and  insist  on  an 
open-air  life.  A  very  large  percentage  of  unilateral  cases  are  cured  by  opera- 
tion (over  40  per  cent.) .     Some  few  bilateral  cases  are  cured. 

Orchidectomy,  or  Castration  {Excision  of  a  Testicle) . — Bilateral  cas- 
tration should  never  be  performed  without  deliberate  consideration.  It  often 
produces  grave  mental  disorder.  This  is  in  part  the  result  of  the  depression 
attendant  on  knowing  that  the  glands  are  gone  and  in  part  in  the  loss  to  the 
organism  of  the  internal  secretion  of  the  testicle.  A  boy  castrated  before 
puberty  never  becomes  potent.  A  man  may  retain  potency  for  a  considerable 
time.  I  removed  a  tuberculous  kidney  from  a  man  who  had  been  castrated 
by  my  colleague.  Dr.  Horwitz,  two  years  before,  yet  he  was  still  able  to  have 
intercourse.  Unilateral  orchidectomy  does  not  make  a  man  either  sterile  or 
impotent  and  does  not  produce  mental  disturbance.  In  orchidectomy  an 
incision  is  made  over  the  cord,  commencing  just  outside  the  external  ring  and 
running  down  over  the  base  of  the  tumor.  Clamp  the  cord  and  divide  it 
near  to  the  ring,  remove  the  testicle,  ligate  the  spermatic  artery  alone,  and 
then  ligate  the  entire  thickness  of  the  cord.  The  cord  is  ligated  with  chromic 
gut.  The  skin  is  sutured  with  silkworm-gut.  Drainage  is  not  required.  It 
is  often  advisable  to  remove  a  considerable  amount  of  scrotal  skin. 

Epididymitis,  or  inflammation  of  the  epididymis,  is  usually  due  to 
inflammation  of  the  urethra.  It  is  apt  to  occur  in  the  stage  of  decline  of  a 
gonorrhea,  and  is  announced  by  a  complete  cessation  of  the  discharge.  It 
mav  result'  from  the  passage  of  a  urethral  instrument,  the  voiding  of  iirine 
which  contains  fragments  of  calculi,  or  as  a  complication  of  prostatic  hyper- 
trophy. Acute  epididymitis  is  characterized  by  swelling  about  the  testicle, 
pain  in  the.  groin,  and  tenderness  over  the  posterior  part  of  the  testicle.  The 
pain  becomes  acute,  swelling  rapidly  increases,  and  the  constitution  sym- 
pathizes. The  swelling  is  due  partly  to  engorgement  of  the  epididymis  and 
partly  to  fluid  in  the  tunica  vaginalis  (acute  hydrocele).  Chronic  epididymitis 
is  usually  linked  with  orchitis,  and  it  follows  an  acute  attack  or  a  chronic 
urethral  inflammation. 


1392  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Fig.  831.— Hydrocele  of  tunica  vaginalis  (Horwitz). 


Treatment  by  septic  puncture  with  a  tenotome,  if  fluctuation  is  marked, 
will  relieve  tension  and  pain.  Leeching  over  the  external  abdominal  ring, 
the  use  of  an  ice-bag,  elevation,  application  of  guaiacol,  and  administration  of 
laxatives  and  opium  constitute  the  usual  treatment  in  the  acute  stage.  Ap- 
plications of  guaiacol  over  the 
cord,  epididymis,  and  testicle 
seem  to  relieve  pain  and  dis- 
tinctly lessen  swelling.  Two 
applications  a  day  should  be 
made  for  one  week.  At  each 
application  paint  the  scrotum 
and  over  the  external  ring  with 
15  drops  of  guaiacol  in  i  dram 
of  glycerin  or  olive  oil.  Strap- 
ping is  employed  as  the  inflam- 
mation subsides.  The  treat- 
ment of  the  chronic  form  is 
the  same  as  that  for  chronic  or- 
chitis. 

Strangulation  of  the 
Cord  by  Axial  Rotation. — 
In  nearly  one-half  of  the  cases  the  testicle  is  undescended  or  only  partly  de- 
scended. In  every  case  there  is  a  long  mesorchium,  and  if  a  normal  testicle  is 
normally  placed,  torsion  of  the  cord  will  hardly  occur  (Chas.  L.  Scudder,  "  An- 
nalsof  Surgery,"  Aug.,  1901).  The  twistingmay  be  toward  the  right  or  toward 
the  left.  The  symptoms  arise  suddenly,  and  usually  during  exertion.  In  some 
cases  a  hernia  also  exists.  When  the  rotation  occurs,  the  testicle  swells, 
hemorrhages  take  place  into  it,  and  gangrene  may  occur.  If  the  cord  of  an 
undescended  or  partially  descended  testicle  twists,  swelling  and  tenderness 
are  noted  in  the  abdomen  or  the  groin.  If  the  swollen  testicle  is  in  the  scro- 
tum, the  gland  feels  nodular  and  the  epididymis  is  anterior.  The  symp- 
toms are  sudden  pain,  vomiting,  moderate  shock,  and  a  swelling  in  the  groin 
or  a  swollen  testicle  in  the  scrotum.  The  swelling  receives  no  impulse  on 
coughing.  The  symptoms  resemble  those  of  strangulated  hernia,  but  are 
less  violent,  and  the  bowels  are  not  obstructed. 

Treatment. — An  incision  should  be  made,  and  if  the  twisting  was  recent 
and  the  testicle  is  not  gangrenous,  untwist  and  fasten  the  testicle  to  the  scrotum 
by  a  catgut  stitch.  If  the  testicle  is  gangrenous,  remove  it.  Scudder  tells 
us  that  in  88  per  cent,  of  cases  the  testicle  is  found  to  be  gangrenous.  Ac- 
cording to  Scudder,  there  are  32  cases  on  record:  31  were  operated  upon  and 
I  was  not,  but  all  recovered;  in  3  the  testicle  sloughed  and  in  2  it  atrophied 
("Annals  of  Surgery,"  Aug.,  1901). 

Vaginal  hydrocele — chronic  hydrocele  (Figs.  831  and  833,  e)  is  a  col- 
lection of  fluid  in  the  tunica  vaginalis  testis.  An  enlargement  of  the  testis 
may  cause  it,  but  in  most  instances  the  cause  is  unknown  and  no  signs  of 
inflammation  exist.  The  fluid  is  albuminous,  but  it  does  not  coagulate  spon- 
taneously; it  is  thin,  straw-cok)red,  and  may  contain  crystals  of  cholesterin. 
The  testicle  is  at  the  lower  and  back  part  of  the  sac.  The  pyriform  mass 
fluctuates,  is  translucent,  grows  from  below  upward,  and  the  introduction  of 


Treatment  of  Vaginal  Hydrocele 


1393 


of  an  exploring-needlc  permits  the  yellow  lluid  to  flow  out.  Sometimes  a 
hydrocele  has  an  hour-glass  shape.  This  is  the  hydrocele  ''en  bissac"  of  the 
French.  In  this  condition  (Fig.  832)  two  cavities  exist,  usually  but  not  in- 
variably communicating.  The  constriction  between  the  cavides  is  due  to 
inflammatory  thickening. 


Fig.  832. 


-Hydrocele  "  en  bissac."      This  hydrocele  extends  up  the  coid  into  the  inguinal 
canal  and  to  the  internal  abdominal  ring  (Horwitz). 


Treatment. — Simply  tapping  the  sac  with  a  trocar  is  only  palliative; 
air  must  run  in  as  fluid  runs  out,  and  suppuration  may  occur,  which  will  be 
dangerous  without  drainage.  Never  tap  a  rigid  sac.  The  injection  of  irri- 
tants should  be  abandoned,  as  it  exposes  the  patient  to  .serious  danger  because 


Fig.  833. — Varieties  of  hydrocele:  a,  Congenital  ;  5,  infantile;  c,  funicular;  d,  encysted;  e, vaginal. 

of  inflammation  occurring  without  provision  for  drainage.  Hearn  incises  the 
sac,  dries  its  anterior  with  bits  of  gauze,  swabs  it  out  with  pure  carbolic  acid, 
packs  it  with  iodoform  gauze,  and  dresses  it  antiseptically.  The  packing  is 
removed  in  twenty-four  hours  and  the  wound  is  allowed  to  close.  In  most 
cases  I  prefer  this  method.  If  the  sac  is  rigid  and  will  not  collapse,  either 
stitch  it  to  the  skin  and  pack  it  or  excise  a  large  portion  of  its  parietal  layer 
and  insert  a  drainage-tube   (Volkmann's  operation).     It  has  recently  been 


1394  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

proposed  to  tap  the  sac  with  a  trocar  and  canula,  to  leave  the  canula  in 
place  as  a  drain  for  some  days,  and  to  dress  antiseptically. 

Longuet's  operation  is  easy  and  successful.  It  is  called  extraserous  trans- 
position of  the  testicle.  It  was  introduced  by  Longuet  in  1898  ("Progr^s 
Med.,"  Sept.  21,  1901).  A  local  anesthetic  is  injected  and  an  incision  two 
inches  in  length  is  made.  The  testicle  is  lifted  from  the  scrotum.  The  serous 
and  all  the  other  coats  except  the  skin  fall  together  behind  and  make  a  sheath 
for  the  cord.  One  catgut  suture  will  hold  them  behind  the  cord.  A  bed  is 
made  for  the  testicle  beneath  the  inner  edge  of  the  skin  wound,  by  tearing  with 
the  fingers.  The  testicle  is  rotated  on  its  long  axis  and  inserted  into  this  cav- 
ity. The  testicle  rests  against  the  scrotal  septum,  and  in  front  of  the  gland  is 
the  cord  covered  with  tunic.     The  skin  is  sutured  and  the  wound  is  dressed. 

Congenital  hydrocele  (Fig.  833,  a)  is  hydrocele  through  an  unclosed 
funicular  process  into  the  tunica  vaginalis.  If  the  pelvis  is  raised,  the  fluid 
runs  back  into  the  peritoneal  cavity,  from  which  it  originally  came.  The 
treatment  is  the  application  of  a  truss  to  obliterate  the  funicular  process. 

Infantile  hydrocele  (Fig.  833,  h)  is  a  collection  of  fluid  in  a  funicular 
process  and  the  tunica  vaginalis,  the  funicular  process  being  closed  above, 
but  not  below.  The  treatment  is  to  puncture  the  sac  and  to  scarify  the  sac- 
wall  with  a  needle. 

Encysted  Hydrocele  of  the  Cord  (Fig.  ^t,t,,  d).—ln  this  variety 
the  funicular  process  is  obliterated  above  and  below,  but  it  is  patent  between 
these  two  points  and  fluid  collects.  The  treatment  is  the  same  as  that  for 
infantile  hydrocele.     If  this  fails,  incise  and  pack. 

Funicular  Hydrocele  (Fig.  833,  c). — The  funicular  process  is  closed 
below,  but  is  open  above.  Raising  the  pelvis  causes  the  fluid  to  trickle  back 
into  the  peritoneal  cavity.     The  treatment  is  the  application  of  a  truss. 

Encysted  hydroceles  0}  the  testicles  and  oj  the  epididymis  may  occur. 
Diffused  hydrocele  of  the  cord  is  simply  edema  of  the  cord.  Hydrocele  of  a 
hernia  is  the  distention  of  a  hernial  sac  with  peritoneal  fluid. 

Hematocele  (Fig.  834). — Vaginal  hematocele  is  blood  in  the  tunica  vagin- 
alis, the  result  of  traumatism,  a  tumor,  or  the  tapping  of  a  hydrocele.  There  is 
a  p\Tiform  tumor,  which  fluctuates,  but  which  gradually  becomes  firmer;  the 
scrotum  is  livid,  and  the  testicle  is  below  and  posterior  to  the  tumor.  The 
encysted  form  of  hematocele  of  the  cord  is  a  hydrocele  of  the  cord  into  which 
bleeding  has  occurred.  The  diffused  form  is  due  to  extravasation  of  blood 
into  the  cellular  substance  of  the  cord.  Encysted  hematocele  of  the  testicle  is 
due  to  effusion  of  blood  into  an  encysted  hydrocele  of  the  testicle.  Paren- 
chymatous hematocele  is  extravasation  of  blood  into  the  substance  of  the  testicle. 

The  treatment  of  a  recent  case  of  vaginal  hematocele  is  to  put  the  patient 
to  bed,  support  the  scrotum,  and  apply  an  ice-bag  over  the  testicle.  If  the 
swefling  does  not  soon  abate,  incise,  irrigate,  and  pack. 

Varicocele  is  varicose  enlargement  of  the  veins  of  the  venous  plexus 
of  the  spermatic  cord.  The  veins  are  thickened,  lengthened,  dilated,  and 
convoluted.  The  assigned  causes  are  straining,  cough,  constipation,  and  an 
occupation  requiring  prolonged  standing.  Some  beheve  ungratified  sexual 
desire  is  a  cause.  Hereditary  predisposition  is  probable.  There  are  more 
left-sided  than  right-sided  varicoceles,  because  the  right  spermatic  vein  has 
valves  and  empties  into  the  vena  cava  at  an  acute  angle,  but  the  left  spermatic 


Varicocele 


1395 


vein  has  no  vaWes  (Brinton)  and  empties  into  the  left  renal  vein  at  a  right 
angle.  Varicocele  is  a  very  common  condition.  The  elder  Senn  found  it  in 
21  per  cent,  of  10,000  recruits.  An  irregular  sv^^elling  exists  in  the  scrotum 
and  extends  up  the  cord.  This  swelling  feels  like  "a  bag  of  earth-worms"; 
it  exhibits  a  slight  impulse  on  coughing;  the  scrotal  skin  and  cremaster  mus- 
cle are  attenuated;  the  testicle  lies  at  the  bottom  of  the  swelling  and  is  softer 
and  smaller  than  normal;  the  swelling  diminishes  on  lying  down  and  increases 
on  standing  or  on  making  pressure  over  the  external  ring.  The  scrotum  is 
pendulous  and  the  scrotal  skin  frequently  contains  varicose  veins.  The 
testicle  may  be  soft  and  shrunken.     There  is  usually  some  discomfort,  aching, 


Fig.  834.— Acute  hematocele  of  tunica  vaginalis  the  result  of  traumatism  (  iiurwitz). 


or  dragging  in  the  testicle  and  the  groin,  and  even  neuralgic  pain  in  the  cord. 
There  may  be  no  discomfort  of  any  sort.  A  large  varicocele  may  be  free  from 
discomfort  and  a  small  varicocele  may  produce  much  annoyance,  or  vice 
versd.  There  are  sometimes  mental  depression  and  hypochondriasis.  As  a 
man  reaches  middle  age  a  varicocele  usually  ceases  to  give  trouble. 

Treatment. — In  treating  varicocele,  reassure  the  patient:  tell  him  there 
is  no  real  danger  of  impotence;  order  cold  shower-baths,  correct  constipation 
and  indigestion,  give  occasional  tonics,  and  order  the  patient  to  wear  a  sus- 
pensory bandage.  If  the  testicle  becomes  much  atrophied,  if  the  pain  and 
the  dragging  are  annoying,  or  if  the  mind  is  much  depressed,  operate  (page 
462). 


1396 


Amputations 


XXXVII.  AMPUTATIONS. 

An  amputation  is  the  cutting  off  of  a  limb  or  a  portion  of  a  limb.  Re- 
moval of  a  limb  or  a  portion  of  a  limb  at  a  joint  is  known  as  "disarticulation." 
Amputation  may  be  necessary  because  of  the  existence  of  severe  injury,  of 
gangrene,  of  tumors,  of  intractable  disease  of  bones  or  joints,  of  ulcers  which 
will  not  heal,  of  traumatic  aneurysm,  etc.  A  re-amputation  may  be  required 
because  of  the  existence  of  a  defect  or  disease  in  the  stump. 

Classification. — Amputations  are  classified  as  follows  :  (i)  As  to 
time  of  operation  after  the  injury:  a  primary  amputation  is  performed  soon 
after  the  occurrence  of  the  accident — as  soon  as  the  sufferer  reacts  from  shock, 
and  before  he  develops  fever;  a  secondary  amputation  is  performed  some 
time  after  the  accident,   suppuration  having  supervened   (Stokes);  and  an 


Fig.  835. — Esmarch's  elastic  bandage. 


Fig.  836. — Application  of  tourniquet. 


intermediate  amputation  is  performed  during  the  existence  of  fever,  but  before 
the  development  of  suppuration.  (2)  As  to  the  situation,  where  the  bone  is 
divided  or  according  to  which  joint  is  cut  through.  (3)  As  to  the  form  and 
situation  of  the  flap. 

In  performing  an  amputation  maintain  rigid  asepsis;  completely  remove 
the  hopelessly  damaged  portion;  sacrifice  as  little  of  the  sound  tissue  as  possi- 
ble; prevent  hemorrhage  during  the  amputation,  and  carefully  arrest  it  after 
the  operation;  have  enough  sound  tissue  in  the  flap  to  cover  the  bone,  and 
enough  skin  to  cover  the  muscles;  and  secure  drainage  at  a  dependent  point. 

Hemorrhage  may  be  prevented  by  the  elastic  bandage  of  Esmarch  (Fig. 
835)-  Ordinarily  we  can  apply  this  bandage  from  the  periphery  to  well  above 
the  line  of  the  prospective  incision,  encircle  the  limb  with  an  elastic  band  (not 
the  thin  tube  shown  in  the  cut),  and  remove  the  bandage.  The  bandage 
and  band,  asepticized  before  using,  are  applied  to  the  limb,  which  has 
been  carefully  sterilized.     After  the  band  has  been  applied  the  limb  should 


Classification  of  Amputations 


1397 


not  freely  or  forcibly  be  moved,  because  of  the  danger  of  tearing  muscles  which 
are  firmly  fixed  by  the  com[)re.ssing  band.  When  elastic  compression  is  used 
in  an  operation  the  surgeon  should  be  very  careful  to  tie  every  visible  vessel. 
The  paralysis  of  the  small  vessels  induced  by  pressure  often  prevents  bleed- 
ing, and  unless  their  mouths  be  found  and  the  vessels  be  tied  reactionary^ 
hemorrhage  will  occur.  Reactionary  hemorrhage  is  the  great  danger  after 
the  use  of  the  Esmarch  bandage,  and  paralysis  or  sloughing  may  also  follow 


Fig.  S37. — Petit's  spiral  tourniquet. 


Fig.  838. — Charriere's  tourniquet. 


its  employment.  If  there  be  an  area  of  suppuration  or  of  gangrene  or  an 
extra -osseous  malignant  growth,  do  not  apply  the  bandage  as  directed  above. 
One  bandage  can  be  applied  from  the  periphery  to  near  the  lower  border 
of  the  area  of  growth  or  infection,  and  another,  from  near  the  upper  border 
of  this  area,  up  the  h'mb.  If  the  bandages  are  applied  in  this  manner  the 
contents  of  the  diseased  area  (tumor-cells  and  fluid  or  septic  products) 
are  not  squeezed  into  the  circulation.     In  cases  like  the  above  many  surgeons 


Fig-  839— Catliu.  knife,  and  saws  for  amputation. 

hold  the  extremity  in  a  vertical  position  for  five  minutes,  lightly  stroking  it 
toward  the  body  with  the  hand,  and  at  once  apply  the  constricting  band. 
As  a  matter  of  fact,  this  plan  satisfactorily  empties  the  hmb  of  blood,  and  it 
is  not  necessary  in  any  case  to  force  the  blood  out  by  elastic  compression. 
Some  surgeons  prefer  the  tourniquet.  Figs.  837  and  838  show  two  forms  of 
tourniquet.  To  apply  Petit's  tourniquet,  place  the  plates  in  contact,  apply 
a  small,  firm  compress  over  the  artery  and  a  broad  thick  compress  over  the 
outer  surface  of  the  limb,  buckle  the  tapes  around  the  hmb  so  that  the  plate 


1398 


Amputations 


Fig.  840 — Amputation  of  arm  by 
the  circular  method  (Druitt). 


is  over  the  broad  pad,  and  tighten  the  tourniquet  by  separating  the  plates 
with  the  screw  (Fig.  836).  When  a  tourniquet  is  applied  to  arrest  bleeding 
during  transportation,  bandage  the  limb,  sew  the  compress  pad  to  a  bandage, 
and  place  the  plates  of  the  instrument  over  the  pad.  Signorini's  horseshoe 
tourniquet  may  be  used  upon  the  brachial  artery.  In  hip-joint  and  shoulder- 
joint  disarticulations  Wyeth's  pins  are  passed,  and  after  the  limb  is  emptied 
of  blood  the  band  is  fastened  above  them.  These  pins  prevent  the  bands 
from  slipping. 

The  instruments  and  appliances  required  for  amputation  are  Esmarch's 
apparatus  or  tourniquet,  amputating  knives  (Fig.  839),  a  bone-knife,  scalpels, 
saws  (Fig.  839),  a  lion-jawed  forceps,  bone-cutting  forceps,  a  periosteum- 
elevator,  retractors  of  linen,  dissecting,  hemo- 
static, and  toothed  forceps,  a  tenaculum,  an 
aneurysm-needle,  a  probe,  scissors,  needles,  liga- 
tures, sutures  of  silkworm-gut,  dressings,  band- 
ages, and  solutions.  A  retractor  has  two  tails  for 
the  thigh  and  arm  and  three  tails  for  the  leg  and 
forearm:  it  is  made  by  taking  a  piece  of  muslin 
eight  inches  wide  and  twelve  inches  long  and 
cutting  tails  on  one  side  eight  inches  in  length. 
Methods  of  Amputating.— Transverse  Circular  Method  (Figs.  840 
and  841).^ — This  is  the  oldest  method  of  amputating.  The  common  circular  in- 
cision is  at  a  right  angle  to  the 
axis  of  the  limb.  Kocher  con- 
siders also  as  a  circular  incision 
an  oblique  cut  around  the  limb 
if  the  line  of  the  incision  "con- 
tinues in  one  direction ' '  (Koch- 
er's  "Text-Book  of  Operative 
Surgery,"  translated  by  Harold 
J.  Stiles) .  This  method  is  called 
the  oblique  circular  amputation. 
A  racket  incision  is  formed  by 
adding  a  longitudinal  cut  to  a 
transverse  circular  cut.  If  the 
edges  are  rounded,  the  lanceolate 
incision  is  formed.  Rectangular 
flaps  are  formed  when  two 
longitudinal  incisions  are  added 
to  a  transverse  circular  cut.  If 
the  corners  of  a  rectangular  flap 
are  trimmed,  rounded  flaps  are 
formed.  The  three  last-men- 
tioned plans  are  considered 
under  the  head  of  the  Modified 
Circular      Amputation      (page 

1399)- 

The   surgeon  should   stand 
to  the   right   of   the    limb    and   use   a    long   amputating    knife   which    cuts 


Fig.  841.— The  steps  of  a  transverse   circular  amputa- 
tion (Kocher). 


Modified  Circular  Method 


1399 


from  heel  to  point  (Fig.  840).  After  an  assistant  has  retracted  the 
skin  the  operator  divides  the  soft  parts  by  a  series  of  circular  cuts. 
He  does  not  cut  at  once  to  the  bone,  but  divides  the  skin  and  subcutaneous 
tissues.  At  the  retracted  edge  of  the  first  cut  the  superficial  muscles  are 
divided,  and  after  these  muscles  retract  the  deep  muscles  are  divided.  The 
periosteum  is  incised  with  a  bone-knife  and  pushed  up  with  an  elevator,  and 
after  the  application  of  the  retractors  the  bone  is  then  sawed,  the  saw  start- 
ing from  heel  to  point.     A  periosteal  flap  can  be  made  to  cover  the  end  of  the 


Fig.  842.— Circular  amputation  ;  dissecting  up  the  skin-flap  (Esmarch). 


bone,  but  it  is  unnecessary.  In  this  amputation  is  formed  a  cone  whose  apex 
is  the  bone  and  whose  base  is  the  skin-edge.  Figure  841,  from  Kocher, 
shows  the  steps  of  the  operation  and  the  shape  of  the  resulting  stump.  In 
one  form  of  circular  amputation  {amputation  a  la  manchette)  the  retracted 
skin  is  cut  by  a  circular  sweep  of  the  knife,  a  cuff  of  skin  and  subcutaneous 
tissue  is  freed  and  turned  up,  and  the  muscles  are  cut  circularly  at  the  edge 
of  the  turned-up  cut  (Fig.  842) .  The  pure  circular  amputation  is  performed 
on  the  arm  and  the  thigh;  the  amputation  a  la  manchette  is  performed 
chiefly  through  the  wrist  and  the  lower  forearm. 


Fig- 843. — Modified  circular  amputation  ;  skin-flaps  and  circular  cut  through  muscles  (Esmarch). 

If  there  is  more  sound  skin  upon  one  side  of  the  extremity  than  upon  the 
other,  the  transverse  circular  incision  sacrifices  more  of  the  hmb  than  is  neces- 
sary and  the  oblique  circular  is  preferable.  An  objection  to  the  transverse 
circular  incision  is  that  the  cicatrix  hes  directly  at  the  end  of  the  stump  and 
is  liable  to  cause  pain  when  subjected  to  pressure. 

Modified  Circular  Method. — In  this  operation  the  circular  skin-cut 
may  be  modified  by  making  a  vertical  incision  to  join  the  first  wound,  the 


1400 


Amputations 


muscles  being  cut  by  a  circular  sweep  (racket  incision)  or  by  making  two 
vertical  skin-incisions  (rectangular  flaps).  The  lanceolate  incision  is  made 
by  rounding  the  edges  of  the  flaps  which  result  from  a  racket  incision. 
Liston's  modification  consists  in  dissecting  up  two  short  semilunar  integu- 
mentary flaps  and  in  dividing  the  muscles  circularly  (Fig.  843).  This  is 
known  as  the  "mixed  method."  The  modified  circular  can  be  used  upon 
the  thigh,  the  leg,  the  arm,  and  the  forearm. 

Oblique  Circular  Method  (Elliptical  Method). — Mark  the  upper  and 
lower  ends  of   the  incision  as  shown  in  Fig.  844.      The  lowest  incision  is 

at  a  right  angle  to  the  cutaneous 
surface;  the  highest  incision  is  parallel 
to  the  cutaneous  surface  (Kocher). 
The  skin  and  fascia  are  divided  so 
that  an  oblique  incision  to  the  muscles 
surrounds  the  limb.  The  distal  ellip- 
tical portion  of  skin  is  picked  up  and 
drawn  toward  the  body  and  the  mus- 
cles'are  divided  to  the  bone,  the  knife 
being  held  transversely  (Fig.  844). 
Kocher  points  out  that  this  flap  in- 
creases in  thickness  toward  the  bone. 
The  rest  of  the  muscles  are  divided 
on  a  level  with  and  in  the  direction 
of  the  skin-edge.  The  periosteum  is 
cut  transversely  and  is  treated  as  in 
the  transverse  circular  operation.  The 
flap  of  muscle  and  integument  is 
brought  over  the  wound.  This 
method  stands  midway  between  the 
circular  operation  and  the  operation 
by  a  single  flap,  and  is  employed 
particularly  in  certain  disarticulations. 
Racket  Method. — (If  flaps  are 
rounded,  is  known  as  the  "oval"  or 
"lanceolate"  incision.)  In  an  oval 
amputation  the  incision  through  the 
skin  and  subcutaneous  tissue  is  an 
oval  with  a  pointed  end  or  a  triangle ; 
and  the  other  parts  down  to  the  bone 
are  cut  from  without  inward.  WTien 
a  longitudinal  incision  down  to  the 
bone  (Fig.  854,  a,  h)  extends  from  the  point  of  the  oval,  the  operation 
is  called  the  "racket"  amputation.  If  the  longitudinal  cut  joins  a  circular 
cut,  the  operation  is  known  as  a  T-amputation.  The  oval  or  racket 
operation  is  performed  at  the  metacarpophalangeal,  metatarsophalangeal, 
and  shoulder-joints;   the  T-operation  may  be  performed  at  the  hip-joint. 

Flap  Method. — A  flap  may  be  composed  of  5^/;?  only  or  of  both  skin 
and  muscle,  but  the  skin-flap  must  always  be  longer  than  the  muscle-flap,  so 
that  the  latter  will  be  covered  by  it.  A  flap  containing  much  muscle  heals 
badly,  but  the  best  flap  has  a  moderate  amount  of  muscle  (enough  skin  to 


Fig.  844.— The  early  steps  of  an  oblique  circular 
amputation  (Kocher). 


Fingers  and  Hand 


1 401 


Fig.  845. — Amputation  of  the  thigh  by 
transfixion  (Gross). 


cover  the  muscle  and  enough  muscle  to  cover  the  bone).     Flaps  may  be  single 

or  double.  Double  flaps  may  be  lateral  or 
antero- posterior,  square  or  \j -shaped,  equal  or 
unequal,  and  they  may  be  cut  by  transfixion 
(Fig.  845),  by  cutting  from  without  inward, 
by  dissection,  or  by  cutting  the  skin  from 
without  inward  and  the  muscles  by  trans- 
fixion. 

Completion    of    an    Amputation. — 

When  an  amputation  is  completed,  tie  the 
main  vessels,  pull  down  the  nerves  and  cut 
them  high  up,  smooth  the  flaps,  take  off  the 
constricting  band,  and  after  arresting  hemor- 
rhage apply  sutures.  In  some  cases  the  deep 
parts  are  stitched  with  a  continuous  catgut 
suture  and  the  superficial  parts  are  closed  with  silkworm-gut;  in  other  cases 
the  deep  parts  are  not  stitched  at  all,  the  skin  alone  being  sutured  with 
silkworm-gut.  Drainage-tubes  should  be  used  except  in  amputations  of  the 
fingers  and  toes. 

Special  Amputations. 

Fingers  and  Hand. — In  amputating  the  thumb  and  index-finger  save 
every  possible  scrap  of  tissue.  In  either  of  the  fingers,  if  it  be  necessary  to 
amputate  above  the  middle  of    the  middle  phalanx,  ^ 

the  attachment  of  the  flexor  tendons  will  be  cut  off 
and  the  finger  will  be  liable  to  project  directly  back- 
ward, so  that  it  is  better  with  these  fingers  either  to 
disarticulate  at  the  metacarpal  joints  or  to  stitch  the 
flexor  tendons  to  the  periosteum.  The  flexor  tendons 
have  fibrous  sheaths  extending  from  the  proximal  end  of  the  distal  phalanx 

to  the  metacarpophalangeal  articulations,  these 
sheaths  being  thin  and  collapsible  opposite  the 
joints,  but  being  thick  and  rigid  opposite  the 
shafts  of  the  bone.  The  fibrous  sheath  is  known 
as  the  theca,  and  when  it  is  cut  in  an  amputation 
it  should  be  closed,  otherwise  it  may  carry  infec- 
tion to  the  palm  of  the  hand.  The  theca  does 
not  exist  over  the  distal  phalanx,  and  it  is  not 
distinctly  visible  over  the  joint  between  the 
distal  and  middle  phalanges.  To  effect  closure 
over  the  shaft  of  a  bone,  strip  up  the  periosteum 
and  pass  catgut  sutures  vertically  through  the 
Fig.  847.-The  line  of  the  joints  theca  and  the  periosteum  (Treves).     In  ampu- 

in  the  flexed  position  of  the  finger:  ^^  ^^^^^  ^^   Esmarch 

a,   Extensor  longus  digitorum  ;  b,    '•"''  "  & 

interossei  and  lumbricais ;  c,  ex-  bandage  is  unnecessary,  though  pressure  may  be 
tensor  longus  digitorum  and  inter-  ^lade  upon  the  arteries  at  the  wrist.     Only  two 

ossei  :  p-,  interossei  and  lumbricais ;  ,  t       .  /^i  '^i 

/,  flexor  subiimis;  e,  flexor  pro-  or  three  ligatures  are  necessary.      Close  with   a 
fundus  (Kocher).  very  few  sutures,  so  as  to  favor  drainage  between 

the  threads. 
The  distal  phalanx  is  best  removed  by  a  long  palmar  flap  (Fig.  846,  a). 


Fig.  846.  — Amputation  of 
the  finger. 


I402 


Amputations 


The  palmar  flap  (a)  is  marked  out  by  cutting  through  the  slcin  and  subcu- 
taneous tissue.  The  incisions  are  next  carried  to  the  bone,  the  flap  is  dis- 
sected from  the  bone,  the  finger  is  strongly  flexed,  a  transverse  incision  (b)  is 
carried  across  the  dorsum  on  a  level  with  the  base  of  the  third  phalanx,  the 
soft  parts  are  pushed  back,  the  joint  is  opened,  the  lateral  ligaments  are  cut 
from  within  outward,  the  third  phalanx  is  forcibly  extended,  and  the  remain- 
ing structures  are  cut  from  below  upward.  Fig.  847  shows  the  lines  of  the 
joints  when  the  finger  is  flexed.  The  middle  phalanx  can  be  removed  by 
the  same  method  (c,  Fig.  846).  The  proximal  phalanx  can  be  removed  by  a 
long  palmar  flap  or  by  a  long  palmar  and  a  short  dorsal  flap  (d,  e.  Fig.  846). 
Disarticulation  at  a  metacarpophalangeal  joint  is  best  performed 
by  the  oval  method.  The  incision  upon  the  dorsum  (a)  is  begun  just  above 
the  head  of  the  metacarpal  bone, 
is  carried  down  to  beyond  the  base 
of  the  phalanx,  and  involves  the 
skin  only  (Figs.  848  and  849).    One 


Fig.  848. — A,  Disarticulation  of  a  metacarpo- 
phalangeal joint ;  c,  amputation  of  a  finger 
with  the  metacarpal  bone. 


Fig.  849.— Disarticulation  of  the  little  finger 
and  index  finger.  Disarticulation  of  the  ring 
finger  with  its  metacarpal  bone.  Disarticula- 
tion of  the  thumb  with  its  metacarpal  bone 
(Kocher). 


incision  sweeps  around  the  finger  at  the  level  of  the  web,  going  only  through 
the  skin  (b)  ;  the  finger  is  e.xtended  and  the  palmar  cut  is  carried  to  the 
bone;  each  lateral  incision  is  carried  to  the  bone  while  the  finger  is  bent  in 
the  opposite  direction,  the  flaps  are  dissected  back  to  the  joint,  the  finger 
is  strongly  extended,  the  joint  is  opened  from  the  palmar  side,  and  dis- 
articulation is  effected.  Cutting  off  the  head  of  the  metacarpal  bone 
improves  the  appearance  of  the  stump  but  weakens  the  hand,  hence  in  a 
workingman  it  must  not  be  done  unnecessarily.  If  it  is  necessary  to  remove 
a  metacarpal  bone,  the  incision  (c)  is  made  from  the  carpometacarpal  joint. 

Amputation  of  the  thumb  through  its  distal  or  proximal  phalanx  is 
performed  identically  as  is  an  amputation  of  a  finger.  Amputation  of  the 
thumb,  with  a  portion  or  the  whole  of  its  metacarpal  bone,  is  performed  by 
the  oval  or  racket  incision  (Fig.  849). 

Disarticulation  atthewrist=joint  can  be  done  by  the  obhque  circu- 
lar method  (Fig.  851)  or  by  a  double  flap.  In  the  double-flap  amputation  a 
dorsal  flap  is  made  by  carrying  a  semilunar  skin-incision  between  the  styloid 
processes;  the  skin  is  lifted,  the  wrist  is  forcibly  flexed,  the  joint  is  opened 


Amputation  through  the  Forearm 


1403 


Fig.  850 — Modified  circular  amputation 
of  the  forearm  (Bryant). 


by  a  transverse  cut,  and  a  long  semilunar  palmar  flap  which  includes  only  the 
skin  and  fascia  is  made  by  dissection.     Kocher  prefers  to  amputate  by   an 

oblique  incision.  The  lower  end  of  this  in- 
cision is  about  the  middle  of  the  palm  and 
the  upper  end  is  in  the  line  of  the  wrist-joint 
(Fig.  851).  The  hand  is  strongly  flexed,  the 
extensor  tendons  are  divided,  the  posterior 
ligament  of  the  joint  is  incised,  and  incisions 
below  the  styloid  processes  divide  the  lateral  ligaments  and  certain  tendons. 
The  flexor  tendons  are  separated  from  the  bone  and  are  divided  so  as  to 
remain  in  the  palmar  flap. 

Amputation  through  the  forearm  may  be  effected  by  the  circular 
method  (Fig.  851),  the  modified  circular,  or  the  flap  operation.  The  modified 
circular  is  an  excellent  plan.  A  semilunar  dorsal  skin-flap  and  a  semilunar 
skin-flap  on  the  flexor  surface  are  made.     The  flaps  are  raised,  the  muscles  are 


I' 'g- 851.— Disarticulation   of  the   middle  finger.      Disarticulation   at   the   wrist-joint.      Amputation 
through  the  forearm  by  the  oblique  circular  method  (Kocher). 

cut  circularly  (Fig.  850),  the  interosseous  space  is  cleared  with  the  knife,  a 
three-tailed  retractor  is  applied,  the  periosteum  is  pushed  up,  and  the  bones 
are  sawn  half  an  inch  above  the  flap.  In  sawing  the  bones,  start  the  saw 
upon  the  radius,  draw  it  from  heel  to  point,  make  a  furrow  on  the  radius  and 


Fig.  852. — Disarticulation  of  the  elbow-joint  by  the  oblique  circular  method  (Kocher). 


ulna,  and  saw  both  bones  at  the  same  time.     After  sawing,  cut  away  any 
irregular  edge  with  bone-pliers.     In  the  lower  third  Teale's  amputatiorf  mav 


I404 


Amputations 


be  done,  the  dorsal  flap  being  the  long  one.  In  Teale's  amputation  rectan- 
gular flaps  are  made.  The  long  flap  is  equal  in  width  and  length  to  one-half 
the  circumference  of  the  limb  at  the  point  where  it  is  to  be  sawn.  The  short 
flap  is  equal  in  width  to  the  long  flap,  but  is  only  one-fourth  its  length.  The 
two  longitudinal  cuts  are  at  first  taken  only  through  the  skin,  but  the  two 
transverse  cuts  go  at  once  to  the  bone.  The  flaps  are  dissected  up  from  the 
interosseous  membrane  and  the  bone.  In  the  middle  or  the  upper  third  of  a 
fleshy  arm  two  semilunar  skin-flaps  can  be  cut  from  without  inward,  and  the 
muscle  can  be  cut  by  transfixion. 

Disarticulation  at  the  elbow=joint  can  be  done  by  the  elHptical 
method  or  by  a  long  anterior  and  short  posterior  flap.  In  Kocher's  oblique 
operation  the  incision  begins  anteriorly  over  the  joint-line  and  ends  poste- 
riorly a  hand's  breadth  below  the  summit  of  the  olecranon  (Fig.  852) .  A  pos- 
terior flap  which  contains  the  integument,  insertion  of  the  triceps,  the  an- 
coneus, and  periosteum  is  dissected  up  until  the  posterior  surface  of  the 
humerus  is  reached.     The  joint  is  opened  anteriorly  by  a  transverse  incision, 


Fig.  853.— Use  of  Wyeth's  pins  in  amputation  at  the  shoulder-joint.      The  acromion  is  marked  by  a 

black  line  (Keen). 


and  the  radiohumeral  articulation  is  opened  from  without  inward  (Kocher). 
In  the  double  flap  operation  the  forearm  is  partly  flexed  and  a  skin-cut  marks 
out  a  long  anterior  flap,  the  knife  being  entered  opposite  the  external  condyle 
and  being  withdrawn  one  inch  below  the  internal  condyle.  The  muscles, 
which  are  bunched  forward,  are  cut  by  transfixion.  A  posterior  semilunar 
flap  is  made,  which  separates  the  attachments  of  the  radius,  the  ulna  is  cleared, 
and  the  triceps  is  cut  at  its  insertion  (Bell).  Gross  advocated  sawing  through 
the  olecranon  and  the  inner  trochlear  surface. 

Amputation  of  the  arm  is  best  performed  by  marking  out  with  a  knife 
two  equal  semilunar  anteroposterior  flaps,  the  first  cut  being  carried  through 
the  skin  alone,  the  muscles  being  then  transfixed  with  a  long  knife.  Teale's 
method  is  shown  in  Figs.  380  and  381.  The  circular  or  the  modified  circu- 
lar amputation  may  be  performed. 

Disarticulation  at  the  Shoulder=joint. — In  this  operation  some 
surgeons  use  Wyeth's  pins  to  hold  the  Esmarch  band  in  place.  The  an- 
terior pin  is  entered  at  the  middle  of  the  lower  margin  of  the  anterior  axillary 


Disarticulation  at  the  Shoulder-joint 


1405 


fold,  and  emerges  one  inch  within  the  tip  of  the  acromion.  The  posterior  pin 
is  entered  at  a  corresponding  point  on  the  posterior  axillary 
fold,  and  emerges  more  posteriorly  than  the  first  pin  and  an 
inch  within  the  tip  of  the  acromion.  After  the  extremity  has 
been  drained  of  blood  by  the  Esmarch  bandage  or  by  stroking 
and  a  vertical  position,  the  Esmarch  band  is  applied  above 
the  pins  (Fig.  853).  With  a  competent  assistant,  however, 
the  pins  are  not  necessary,  the  surgeon  divides  his  main  ves- 
sels as  the  last  step  of  the  operation,  and  the  assistant  controls 
them  before  they  are  cut  and  until  they  are  tied,  with  his 
thumbs  sHpped  back  of  the  bone. 

Larrey's  Operation. — In  this  method  of  shoulder-joint 
disarticulation  the  hmb  is  held  from  the  side  and  an  incision 
is  made  down  to  the  bone,  the  incision  beginning  just  below 
and  in  front  of  the  acromion  and  running  vertically  for  four  inches  down  the 
outer  surface  of  the  arm  (Fig.  854,  cl  b).  From  the  center  of  this  incision  an 
oval  incision  (c  d,  c  e)  is  carried  around  the  arm,  the  inner  aspect  of  the  oval 
reaching  as  low  as  the  lower  end  of  the  vertical  cut.  The  oval  incision  at  first 
involves  only  the  skin  and  subcutaneous  tissues.  The  anterior  structures  are 
divided  close  to  the  bone,  and  the  posterior  structures  are  next  cut.  To  disar- 
ticulate, cut  the  capsule  transversely  upon  the  head  of  the  bone;  while  the  arm 
is  rotated  outward  cut  the  subscapularis,  and  while  the  arm  is  rotated  inward 
cut  the  supraspinatus  and  infraspinatus  and  the  teres  minor.     Cut  away  any 


Fig.  854.— Ampu- 
tation at  the  shoul- 
der-joint :  a,  i>,  c,  d, 
e,  Larrey's  opera- 
tion ;  f,  g,  Dupuy- 
tren's  operation. 


Fig.  855. -Disarticulation  at  the  shoulder-joint 
by  Kocher's  method  (Kocher). 


Fig.  856.— Removal  of  the  entire    upper  ex- 
tremity (Kocher). 


tissue  holding  the  humerus  to  the  body,  hanging  nerves,  capsule-fragments,  and 
tissue-shreds,  insert  a  tube,  and  sew  up  the  wound  vertically.  Bell  advises  an 
oval  incision  with  a  racket  handle.  Spence  used  an  anterior  racket  incision. 
Kocher's  Operation. — Kocher  makes  an  anterior  lanceolate  incision 
(Fig.  855).  The  incision  begins  over  the  clavicle  just  external  to  the  coracoid 
process  of  the  scapula,  and  is  carried  downward,  dividing,  as  it  advances,  the 
anterior  fibers  of  the  deltoid  muscle.  "  Bleeding  vessels  and  the  cephalic  vein 
are  ligatured.     In  the  upper  part  of  the  wound  the  acromial  branches  of  the 


1406 


Amputations 


acromiothoracic  artery  are  also  ligatured.  The  knife  is  carried  down  to  the 
bone  at  the  edge  of  the  deltoid  (only  the  upper  fibers  of  which  have  been 
divided).  The  capsule  is  divided  over  the  lesser  tuberosity  and  the  bicipital 
groove.  The  periosteum,  the  insertions  of  the  subscapularis,  pectoralis 
major,  latissimus  dorsi,  and  teres  major  are  detached  along  with  the  capsule. 
The  capsule,  along  with  the  insertions  of  the  supraspinatus,  infraspinatus, 
and  teres  minor  muscles,  is  also  detached  from  the  upper  part  of  the  head 
and  from  the  great  tuberosity.  The  head  of  the  humerus  can  now  be  pro- 
truded from  the  wound.  In  cutting  down  over  the  surgical  neck  it  may  be 
necessary  to  ligature  the  circumflex  arteries;  in  any  case  the  anterior  vessel 
must  be  tied.  The  racket  incision  is  now  completed  by  dividing  the  skin 
circularly  at  the  level  of  the  axillary  folds.  The  vessels  and  nerves  are  then 
easily  isolated,  the  former  being  ligatured  and  the  latter  divided"  (Kocher's 
"Text-book  of  Operative  Surgery,"  translated  by  Harold  J-  Stiles).  Kocher 
cautions  us  to  avoid  the  circumflex  nerve  which  supplies  the  deltoid,  as  the 
deltoid  is  the  muscle  of  the  stump. 

Dupuytren's  Operation. — In  Dupuytren's  shoulder-joint  disarticulation 
a  U-shaped  flap  is  marked  out  by  a  skin-incision  (Fig.  854,  /,  g).  If  the  am- 
putation is  to  be  at  the  right  shoulder,  the  arm  is  carried  across  the  chest;  the 
knife  is  entered  at  the  root  of  the  acromion,  follows  the  margin  of  the  deltoid, 
and  is  withdrawn  at  the  coracoid  process,  the  arm  being  gradually  abducted 
and  pulled  off  from  the  chest.  If  the  left  shoulder  is  to  be  amputated,  the 
procedure  is  reversed  (Treves).  The  knife  next  cuts  through  the  deltoid 
and  raises  a  flap  composed  of  this  muscle,  the  shoulder-joint  is  exposed,  and 
disarticulation  is  effected  as  in  Larrey's  method.  The  knife  is  passed  down 
back  of  the  bone  and  a  short  internal  flap  is  cut. 

Lisfranc's  amputation  is  by  transfixion  with  the  formation  of  an  anterior 
and  a  posterior  flap,  and  can  be  performed  very  rapidly  by  a  skilful  surgeon. 
Amputation   of   the    Entire    Upper  Extremity.— Berger's  Am- 
putation.— The  Intcrscapido-thoracic  Amputation. — This  operation,  which 
is  an  amputation  above  the  shoulder-joint,  was  described  by  Berger  in  1887. 
By  it  are  removed  the  arm,  the  scapula,  and  a  por- 
tion of  or  the  entire  clavicle.     It  is  occasionally  em- 
ploved  in  cases  of  malignant  disease  and  of  severe  in- 
jury.    The  operation  is  attended  with  profuse  hemor- 
rhage, and  as  a  preliminary  the  subclavian  vessels 
should  be  ligated.     The  incisions  must  be  varied  ac- 
cording to  the  necessities  of  the  case.     In  this  opera- 
tion Berger  divides  the  clavicle  at  the  junction  of  its 
outer  and  middle  thirds,  and  resects  the  middle  third 
of  the  bone;  hgates  and  divides  the  subclavian  vessels; 
cuts  the  anterior  flap;  divides  the  brachial  ple.xus; 
marks  out  the  posterior  flap;  and  completes  the  opera- 
tion by  dividing  the  structures  which  hold  the  shoulder- 
blade  to  the  chest.     It  is  in  this  last  step  that  bleed- 
ing is  profuse.     Fig.  857  .shows  Berger's  incisions  for 
the  operation.     Fig  856  shows  Kocher's  incisions. 
The    usual     procedure    of    tying    the    third    part    of    the    subclavian 
artery    as    a   preliminary   measure    possesses  certain   disadvantages.      The 


Fig.  857. — Removal  of    the 
whole  upper  extremity. 


Disarticulation  at  the  Tarsometatarsal  Articulation 


1407 


Fig.  858 — Ampu- 
tation ot  the  toes 
with  and  without 
the  metatarsal 
bones. 


artery  is  very  deeply  situated  at  this  point,  is  in  close  relation  with  the 
pleura,  and  is  covered  to  a  considerable  extent  by  the  vein; 
and  the  phrenic  nerve  is  very  near.  Le  Conte  resects  the 
entire  clavicle  before  tying  the  vessels.  He  maintains 
that  then  one  of  two  courses  may  be  taken:  The  veins  may 
be  severed  first,  and  afterward  the  artery  may  be  exposed 
and  tied.  When  this  is  done,  the  amount  of  blood  remain- 
ing in  the  arm  is  lost.  The  procedure  that  he  selects  as 
the  best,  however,  is  to  expose  the  axillary  artery  as  high  up 
as  possible,  and  place  a  temporary  ligature  around  it;  then 
elevate  the  arm,  empty  it  of  blood,  place  a  permanent  liga- 
ture around  the  third  part  of  the  subclavian  artery,  and 
divide  the  artery  in  this  portion  of  its  course  (Robert  G. 
Le  Conte,  "  Annals  of  Surgery,"  Oct.,  1902).  If  the  scapula 
is  involved  in  the  tumor,  the  mortality  is  something  over  23 
per  cent.  (Berger, "  Revue  de  Chir.,"  Aug.,  1905). 

Amputation  of  the  Toes  and  the   Foot.— Only 

through  the  great  toe  is  partial  amputation  performed,  and  it  is 
effected  by  the  formation  of  a  long  plantar  flap,  just  as  a  long 
palmar  flap  is  formed  from  the  finger.  Amputation  at  the  metatarso-phalangeal 
joints  is  performed  by  an  oval  or  racket  incision  (Fig.  858,  c).  Amputation 
of  a  toe  with  remoA^al  of  its  metatarsal  bone  is  shown  in  Fig,  858  a  b  and  d  e. 
Disarticulation  at  the  Tarsometatarsal  Articulation.— Lis- 
iranc's  Operation  (after  Treves). — In  order  to  amputate  the  right  foot  by 
this  method  begin  an  incision  on  the  outer  border  of  the 
foot,  behind  the  tubercle  of  the  fifth  metatarsal  bone;  carry 
the  incision  forward  one  inch  and  sweep  it  across  the 
foot  half  an  inch  below  the  tarsometatarsal  articulations; 
bring  the  incision  to  the  inner  edge  of  the  foot,  half  an 
inch  in  front  of  the  articulation  of  the  tarsus  with  the 
first  metatarsal  bone,  and  carry  the  cut  straight  back 
along  the  inner  margin  of  the  foot  until  it  reaches  a  point 
three-fourths  of  an  inch  above  the  articulation  of  the 
metatarsal  bone  of  the  great  toe.  A  very  short  semilunar 
dorsal  skin-flap  is  thus  formed.  Fig.  864  shows  the  flaps 
as  cut  by  Kocher.  After  the  skin-flap  has  been  dissected 
back  for  a  quarter  of  an  inch  the  tendons  are  divided,  and 
the  flap,  which  now  contains  ah  the  soft  parts,  is  dissected 
back  to  above  the  joint.  A  long  plantar  flap  is  cut,  reach- 
ing from  the  origin  of  the  first  flap  to  the  necks  of  the  meta- 
tarsal bones.  The  skin-flap  is  dissected  up  until  the  hollow  behind  the  heads 
of  the  metatarsal  bones  is  reached,  when,  with  the  toes  in  extension,  the  tendons 
are  cut  across  and  a  flap  composed  of  all  the  soft  parts  is  dissected  up  to  above 
the  tarsometatarsal  joint.  Figs.  859  and  864  show  the  line  of  Lisfranc  at  the 
tarsometatarsal  articulation.  The  joint  is  opened  from  the  outer  side  accord- 
ing to  the  following  rule:  in  separating  the  fifth  metatarsal  direct  the  edge  of 
the  knife  toward  the  distal  end  of  the  first  metatarsal ;  in  separating  the  fourth 
metatarsal  direct  the  knife  toward  the  middle  of  the  first  metatarsal;  in  separat- 
ing the  third  metatarsal  carry  the  knife  almost  directly  across.  The  separa- 
tion is  facilitated  by  bending  down  the  front  of  the  foot,  and  at  the  same 
time   the  tendons  of  the  peroneus  brevis  and  tertius  are  divided.     ^'Jpen 


Fig.  8c;g.  —  Lines  in 
amputations  of  the  foot 
(Gross). 


I40S 


Amputations 


ihe  joint  between  the  first  metatarsal  and  the  inner  cuneiform  bone,  turning 
the  knife  toward  the  middle  of  the  shaft  of  the  fifth  metatarsal,  and  at  the 
same  time  divide  the  tibialis  anticus  muscle.  Treves  says  that  in  disarticula- 
tion of  the  second  metatarsal  the  knife  is  to  be  held  as  a  trocar,  it  is  to  be 
thrust  between  the  base  of  the  first  and  second  metatarsal  bones  until  the 
point  strikes  bone  (Fig.  860),  and  is  then  to  be  raised  to  a  perpendicular  and 


Fig.  860., — Lisfranc's  amputation — first  step 
in  disarticulating  the  second  metatarsal  bone 
(Guerin). 


Fig.  861. — Lisfranc's  amputation — second 
step  in  disarticulating  the  second  metatarsal 
bone  (Guerin). 


the  cut  is  to  be  made  toward  the  external  malleolus  to  sever  the  ligament  of 
Lisfranc  (Fig.  861).  Divide  any  remaining  ligaments,  and  also  the  tendon 
of  the  peroneus  longus  muscle.  The  skin-incisions  in  the  left  foot  are  begun 
on  the  inner  side,  and  in  disarticulating  the  tarsal  joint  of  the  great  toe  is  first 
opened.  Fig.  865  shows  the  parts  after  disarticulation  at  the  line  of  Lisfranc. 
Hey's  Operation. — In  Hey's  method  the  incision  is  practically  the  same 


Fig.  862 — Anterior    intertarsal     Fig.  863. — Chopart's  am- 
disarticulation  (Kocher).  putation. 


Fig.  864.— Lisfranc's    ampu- 
tation. 


as  that  for  Lisfranc's  amputation.     The  four  external  metatarsal  bones  are 
disarticulated,  but  the  first  metatarsal  is  removed  by  sawing  a  portion  of  the 


Subastragaloid  Disarticulation 


1409 


internal  cuneiform  bone.  Guerin  advised  sawing  all  the  bones  across.  Skey 
advised  the  division  of  the  head  of  the  second  metatarsal.  Fig.  859  shows 
the  line  of  Hev. 


Fig.  865.— The  parts  after  Lisfranc's  amputa- 
tion (Bernard  and  Huette). 


Fig.  866. — The  parts  after  amputation  by 
Chopart's  method  (Bernard  and  Huette). 


Anterior  Intertarsal  Disarticulation.— The  disarticulation  is  ef- 
fected between  the  three  cuneiform  bones  in  front  and  the  scaphoid  behind, 
and  the  cuboid  is  sawn  across.  The  incision  of  the  soft  parts  is  as  for  Lis- 
franc's amputation  (Fig.  862). 

Disarticulation  through  the  Middle  Tarsal  Joint.— Chopart's 
Operation  (Posterior  Intertarsal  Disarticulation). — Make  a  transverse  in- 
cision through  the  skin  of  the  instep,  two  inches  below  the  ankle-joint;  cut 
the  tendons  and  muscles,  expose  the  tarsus,  and  make  on  each  side  a  small 
longitudinal  incision  reaching  to  below  and  in  front  of  the  corresponding 
malleolus.  The  flap  thus  formed  is  retracted.  The  plantar  flap  is  made 
as  in  Lisfranc's  amputation.  The  flaps  as  made  by  Kocher  are  shown  in 
Fig.  863.  Open  the  astragaloscaphoid  joint,  then  the  calcaneocuboid 
joint,  and  disarticulate.  Figsj  859  and  863  show  the  line  of  Chopart. 
Fig.  866  shows  the  parts  after  Chopart's  disarticulation.  In  amputation 
through  the  tarsus,  Forbes,  of  Toledo,  advises  making  flaps  as  in  Chopart's 
amputation,  disarticulating  the  scaphoid  from  the  cuneiform  bones,  and 
sawing  through  the  cuboid.     Fig.  859  shoves  the  line  of  Forbes. 

Subastragaloid     Disarticulation. — A    circular    incision    is    carried 

around  the  foot  at  the  level 
of  the  middle  tarsal  joint  and 
a  racket  incision  is  added  to 
it  running  below  and  poste- 
rior to  the  tip  of  the  external 
malleolus  (Fig.  867).  "The 
joint  between  the  astragalus 
and  scaphoid  is  opened  upon 
the  dorsum,  without  open- 
ing the  calcaneocuboid  joint. 
A  narrow  knife  is  then 
passed  backward  and  slightly  upward  beneath  the  head  of  the  astragalus 
so  as  to  divide  the  strong  interosseous  ligament  between  it  and  the  os  calcis. 
The  soft  parts  are  then  dissected  off  the  os  calcis,  first  from  its  upper  surface, 
then  from  its  outer  and  under  surfaces,  and  lastly  from  its  inner  and  posterior 


Fig.  867.— Subastragaloid  disarticulation  (Kocher). 


I4I0 


Amputations 


surfaces.  The  greatest  difficulty  is  raet  with  at  the  inner  side  in  clearing 
tne  projecting  sustentaculum  tali"  (Kocher's  "Text-Book  of  Operative 
Surger}-."  translated  by  Harold  J.  Stiles). 

Disarticulation  at  the  Ankle=joint.— Syme's  Method.— The  foot 
is  held  at  a  right  angle  to  the  leg,  and  a  skin-incision  is  carried,  from  just 
below  the  external  malleolus,  straight  across  or  a  little  backward  across  the 
sole  to  a  corresponding  point  on  the  opposite  side.  Do  not  take  this  incision 
near  to  the  inner  malleolus,  as  to  do  so  will  endanger  the  posterior  tibial 
arter}-.  The  incision  is  carried  to  the  bone,  the  flap  being  pushed  back  and 
separated  from  the  bone  by  means  of  a  strong  knife  and  the  thumb-nail  until 
the  tuberosity  of  the  os  calcis  has  been  reached.  The  foot  is  now  extended 
and  a  transverse  cut  is  made  across  the  dorsum,  joining  the  two  ends  of  the 
first  incision;  the  ankle-joint  is  opened,  the  lateral  ligaments  are  cut,  disar- 
ticulation is  effected,  and  the  foot  is  finally  completely  removed  by  severing 
the  tendo  Achillis.  A  thin  piece  of  bone  including  both  malleoli  is  sawn 
from  the  tibia  and  fibula.  The  flap  is  perforated  posteriori}-  to  secure  drain- 
age (Fig.  381). 

Pirogoff's  Method. — Flex  the  foot  to  a  right  angle  with  the  leg.  "Make 
an  incision  from  the  tip  of  the  internal  malleolus  across  the  sole,  a 
little  in  front  of  the  long  axis  of  the  tibia,  to  a  point  in  front  of  the 
apex  of  the  external  malleolus  down  upon  the  bone."*  Dissect  the 
flap   backward   from   the   calcaneum   for  a    quarter    of    an    inch,    but    do 

not  dissect  the  flap  from 
the  posterior  portion  of 
the  OS  calcis.  Join  the 
e.xtremities  of  the  first  in- 
cision by  another  cut 
which  reaches  to  the 
bone,  and  which  is  "  half 
an  inch  in  front  of  the 
lower  extremity  of  the 
tibia"  (Bn-ant);  but  saw 
off  this  bony  projection 
obliquely  and  leave  it  ad- 
herent to  the  tissues.  The 
saw  is  used  after  disarticu- 
lation of  the  ankle-joint; 
it  is  passed  behind  the 
astragalus,  cutting  downward  and  fon\ard,  sawing  the  os  calcis  obliquely, 
and  lea\-ing  a  considerable  portion  in  place  in  the  flap.  The  lower  ends  of 
the  tibia  and  fibula  are  well  exposed  by  raising  the  anterior  flap  slightly;  the 
sawing  is  begun  anteriorly  just  above  the  articular  surface,  and  is  completed 
half  an  inch  above  the  articular  surface  posteriorly.  The  lines  a  and  h  (Fig. 
868)  show  the  sections  made  by  the  saw.  The  sawn  surface  of  the  os  calcis 
is  brought  into  contact  with  the  sawn  surfaces  of  the  tibia  and  fibula,  and  the 
flaps  are  sutured. 

Amputations  of  the  Leg. — The  so-called  "point  of  election"  is  at  the 

♦"Operative  Surgery,"  by  Joseph  D.  Brj-ant. 


Fig.  868. 


-Lines  of  section  of  the  os  calcis  and  the  bones  of  the 
leg  in  Pirogofi's  amputation. 


Amputations  of  the  Leg 


1411 


Fig.  869.  —Diagrammatic  representation 
ot  amputation  of  the  leg  after  the  method 
of  Bier. 


upper  part  of  the  middle  third  of  the  leg.     Seventy  years  ago  Listen  advised 

surgeons  not  to  amputate  in  the  lower 
third  of  the  leg  because  of  the  scantiness 
of  the  soft  parts,  because  the  stump  is  apt 
to  ulcerate,  and  because  it  is  uncomfort- 
able in  an  artificial  leg.  These  views 
have  been  much  modified.  The  ampu- 
tation near  the  ankle  is  safer  than  the 
amputation  near  the  knee,  and  artificial 
legs  are  now  made  which  may  be  worn 
with  comfort.  In  amputations  of  the  leg 
by  the  long  anterior  flap,  cut  through  the 
skin,  dissect  up  the  anterior  muscles  with 
the  flap,  and  cut  all  the  posterior  tissues 
with  a  single  transverse  sweep.  Amputation  by  the  rectangular  flap,  Teale's 
method,  is  ven,'  useful  (see  page  1404).  The  long  flap  is  anterior,  and  is  in 
length  and  breadth  equal  to  one-half  the  circumference  of  the  limb.  The 
short  flap  is  one-fourth  the  length  of  the  long  flap.  The  flaps  are  dissected 
up,  the  bones  are  sawn,  the  long  flap  is  turned  upon  itself,  and  its  edges  are 
sutured  to  the  edges  of  the  short  flap. 

Bier  suggests  a  plan  (Fig.  86g)  to  increase  the  supporting  power  of  the 
stump  after  a  leg-amputation.  After  the  wound  has  healed,  a  wedge-shaped 
piece  of  bone  is  removed  above  the  level  of  the  stump.  The  lower  extremity 
is  turned  forward  and  upward  through  an  arc  of  90  degrees,  and  unites  in  this 
position  (Zuckerkandl's  "Operative  Surger}-").  Thus  the  medullar}'  ca\dty 
is  closed  and  the  skin  which  must  bear  pressure  is  healthy 
and  free  from  cicatrices;  and  as  the  muscles  are  still  at- 
tached to  the  bone,  they  do  not  undergo  atrophy. 

Sedillot's  leg-amputation  (Fig.  870)  is  by  a  long  ex- 
ternal flap.  A  longitudinal  incision  is  made  along  the  inner 
edge  of  the  tibia,  the  tissues  are  drawn  toward  the  fibula,  a 
knife  is  introduced  and  passed  to  the  outer  edge  of  the  tibia, 
just  touching  the  fibula,  and  is  brought  out  posteriorly,  thus 
transfixing  the  calf-muscles  and  cutting  an  external  flap.  A 
convex  incision  is  made  on  the  inner  side,  the  bones  are 
cleared  and  are  sawn  one  inch  above  the  flaps,  half  an  inch 
more  being  taken  from  the  fibula  than  from  the  tibia,  and 
the  tibia  being  bevelled  anteriorly. 

Modified  Circular  Amputation  of  the  Leg. — Cut  semi- 
lunar skin-flaps,  lay  them  back,  and  cut  circularly  to  the 
bone  at  the  edge  of  the  tumed-up  flap.  Another  method  of 
modified  circular  amputation  is  by  adding  to  the  circular  cut 
a  vertical  incision  down  the  front  of  the  leg.  In  sawing  the 
bones  of  the  leg  the  surgeon,  who  stands  to  the  outer  side  of  the  right  leg  or 
to  the  inner  side  of  the  left  leg,  di\ides  the  fibula  first,  and  at  a  higher  level 
than  the  tibia,  and  bevels  the  anterior  surface  of  the  tibia.  In  sawing  the 
left  fibula  the  saw  points  to  the  floor;  in  sawing  the  right  fibula  it  points  to 
the  ceiling. 

Amputation  of  the  Leg  by  a  Long  Posterior  and  a  Short  Anterior 


Fig.  870.— Se- 
dillot's amputa- 
tion of  the  leg 
(Wyeth). 


I4I2 


Amputations 


Fig.  871. — Amputation  of  the  leg  by 
a  long  posterior  flap  (Gross). 


Flap. — In  this  operation  a  posterior  U-shaped  flap  is  made  equal  in  length 
and  breadth  to  the  diameter  of  the  limb.  The  skin-incision  is  begvm  one  inch 
below  the  point  where  the  bone  is  to  be  sawn,  and  behind  the  inner  edge  of 
the  tibia,  and  is  carried  to  a  point  posterior  to  the  peronei  muscles.     The 

gastrocnemius  muscle  is  divided  transversely  at 
the  level  of  the  flap,  the  soft  parts  on  either 
side  in  the  hne  of  the  flap  being  cut  to  the 
bone.  Through  these  vertical  cuts  the  muscles 
are  lifted  from  the  bones  and  are  divided 
through  their  lower  part  by  cutting  from  within 
outward.  The  anterior  flap  is  formed  by  mak- 
ing a  semilunar  skin-flap  and  by  cutting  the 
muscles  across  at  its  retracted  edge  (Fig.  871). 
Amputation  oj  the  leg  by  lateral  flaps  is  not  a  popular  operation,  as  it 
offers  too  much  encouragement  to  subsequent  protrusion  of  the  bone. 

Amputation  just  below  the  Knee. — The  seat  of  election  is  one  inch  below 
the  tuberosities.  No  muscle  is  needed  in  the  flap.  Cut  two  flaps  of  skin, 
equal  in  size  and  semilunar  in  shape,  these  flaps  beginning  anteriorly  two 
inches  below  the  tuberosity  of  the  tibia.  One  flap  is  antero-extemal  and  the 
other  is  postero-internal.  The  flaps  are  pulled  up,  the  anterior  muscles 
are  cut  as  high  up  as  possible,  and  the  posterior  muscles  are  cut  through  the 
middle  of  the  portion  exposed  (Bell).  The  bone  is  sawn  one  inch  below  the 
tuberosity. 

Disarticulation  of  the  Knee. — In  disarticulation  by  the  long  anterior 
flap,  make  a  long  anterior  skin-flap,  incise  the  ligament  of  the  patella,  turn  up 
a  flap  containing  the  patella,  open  the  joint,  and  complete  the  disarticulation 
by  cutting  from  within  outward  and  downward.  The  knee  may  be  disarticu- 
lated by  means  of  a  long  anterior  and  a  short  posterior  flap.  Kocher  prefers 
the  obHque  incision  (Fig.  872).     This  secures  an  anterior  flap.     The  leg  is  so 


Fig.  872.— Kocher's  oblique  incision  for  disarticulation  at  the  knee-joint  (Kocher). 


held  that  it  makes  an  angle  with  the  thigh  of  135  degrees  and  "the  inci- 
sion falls  in  the  continuation  of  the  long  axis  of  the  thigh"  (Kocher's  "Text- 
book of  Operative  Surgery,"  translated  by  Harold  J.  Stiles).  The  poste- 
rior part  of  the  incision  is  opposite  the  line  of  the  joint  and  the  anterior 
part  of  the  incision  ends  four  finger-breadths  below  the  tibial  tubercle. 
Amputation  through  the  Femoral  Condyles. — Syme's  Method  by  a 


Amputation  of  the  Tlii^h 


1413 


Long  Posterior  Flap. — Carry  a  skin-incision,  with  a  very  slight  downward 
curve  from  one  condyle  to  the  other,  across  the  middle  of  the  patella.  Cut 
down  to  the  bone,  retract  the  flap,  and  cut  the  quadriceps  above  the  patella. 
Insert  a  long  knife  at  one  angle  of  the  wound,  pass  it  back  of  the  femur,  and 
make  it  emerge  at  the  opposite  angle,  cutting  a  posterior  flap  eight  inches 
long.  Retract  the  posterior  flap,  clear  for  sawing,  and  section  the  condyles 
horizontally.  Carden  made  a  curved  section  of  the  condyles  at  their  widest 
part.     In  children  Buchanan  showed  that  we  can  easily  separate  the  lower 


Fig.  873. 


-Diagrammatic      representation 
Gritti's  operation. 


Fig.  874. — Diagrammatic  representation  of  Sa- 
banejeff's  operation. 


femoral  epiphysis.  In  Gritti's  supracondyloid  amputation  an  oblique  inci- 
sion is  made.  The  upper  end  of  the  incision  is  posterior  and  just  above  the 
condyles.  Its  lower  end  is  anterior  and  two  finger-breadths  below  the  patella 
(Kocher).  The  ligament  of  the  patella  is  cut,  the  flap  is  turned  up,  the  femur 
is  sawn  at  the  base  of  the  condyles,  the  articular  face  of  the  patella  is  sawn 
off,  and  the  sawn  patella  is  fastened  to  the  sawn  femur  and  the  flaps  are 
sutured  (Fig.  873).  Sabanejeff  makes  an  anterior  flap,  opens  the  knee- 
joint  from  behind,  saws  the  condyles  at  their  broadest  part,  takes  a  bone-flap 
from  the  anterior  portion  of  the  tibia  and  fastens  it  to  the  femur  (Fig.  874). 

Amputation  of  the  Thigh. — 
In  high  amputation  in  the  lower 
third  either  a  flap  or  a  circular 
operation  may  be  performed.  In 
a  double-flap  operation  a  semi- 
lunar skin-incision  should  be  made 
from  without  inward,  and  the 
muscles  should  be  cut  by  trans- 
fixion (Fig.  875).  In  the  lower 
third  Teale's  flap  or  the  long  an- 
terior flap  may  be  employed.  The 
amputation  by  a  long  anterior  flap 
consists  in  making  a  lengthy  skin- 
flap,  reflecting  it,  cutting  the  ante- 
rior structures  to  the  bone,  again 
entering  the  long  knife  at  one  angle  of  the  incision,  pushing  it  back  of  the 
femur,  bringing  it  out  at  the  outer  angle,  and  cutting  the  structures  behind 
the  bone  directly  backward.     Bell  amputates  by  a  long  anterior  semilunar 


Fig.  875.— Amputation  of  the  thigh  (Bryant). 


I4I4 


Amputations 


Fig.  876. — Pancoast's  aorta  tourniquet. 


flap  and  a  short  posterior  flap.     In  amputations  in  the  itpper  two-ihirds  of 

the  thigh  the  best  plan  is  to  mark  out 
equal  anterior  and  posterior  semilunar 
skin-flaps,  divide  the  skin  with  a  scalpel, 
enter  the  long  knife  at  one  angle  of  the 
anterior  flap,  bring  it  out  at  the  other 
angle,  and  cut  the  muscles  by  trans- 
fixion. Cut  the  posterior  flap  in  the 
same  manner.  Some  surgeons  prefer 
a  long  anterior  semilunar  flap  and  a 
short  posterior  semilunar  flap.  The 
pure  circular  amputation  is  not  adapted 
to  the  thigh. 

Disarticulation  at  the  Hip- joint. 
— Various  methods  have  been  em- 
ployed to  prevent  or  limit  hemorrhage 
during  this  formidable  operation. 
Abernethy  used  digital  compression  of 
the  external  iliac  artery  or  of  the  fe- 
moral artery.  This  is  an  extremely 
tiresome  procedure;  the  finger  is  liable 
to  slip;  and,  in  any  case,  compression  so  situated  fails  to  intercept  the  blood- 
current  in  a  number  of  large  vessels. 

Various  other  methods  have  been  em- 
ployed. It  was  formerly  the  custom  to  com- 
press the  aorta  by  means  of  an  abdominal 

compressor  (Figs.  876,  878).     A  tourniquet 

is  very    hkely  to  be    displaced   during   the 

operation.     The  intention  is  to  compress  the 

artery  against  the  spine,  but  in  effecting  this 

the  circulation  in  a  portion  of  the  intestine 

may  be  impaired.       In  any  case,  as   Senn 

says,  the  circulation  is  cut  off  from  half  the 

body,  and  the  patient  is  exposed  to   grave 

danger  from  "sudden  vascular  engorgement 

of     important     internal      organs"    (Senn), 

Again,  an  abdominal  compressor  of  this  sort 

does  not  arrest  venous  bleeding.     A  number 

of  years  ago  Davy  suggested  that  a  suita- 
ble cylindrical  piece  of  wood,  about  25  inches 

long,  and  shaped  like  a  cone  at  the  end, 

might  be  introduced   into   the   rectum  and 

used  to  compress   the  common  iliac  artery 

upon  the  pelvic  brim.      This  appliance  is 

known  as  Davy's  lever.     It  is  apt  to  slip, 

and  may  do  serious  damage  to  the  rectum. 

Some  surgeons  have  practised    prelimi- 
nary ligation  of  the  common  femoral  artery  or  of  the  external  iliac  artery, 

and  others  have  tied  the  vessels  while   making  the  flaps.     I  followed  this 


Fig.  877  —Posterior  flap  in  author's 
unusual  case  requiring  hip-joint  ampu- 
tation, a,  by  The  anterior  incision  ;  a, 
c,  d,  the  external  incision  and  the  be- 
ginning of  the  posterior  cut. 


Disarticulation  at  the  Hip-joint 


1415 


Fig.  878 — Voii  Esmaich's  aorta  tourniquet. 


plan  with  perfect  satisfaction  in  a  recent  case  of  sarcoma  of  the  femur  with  in- 
volvement of  the  ihac  glands.  If  any  form  of  compression  is  used,  that  rec- 
ommended by  Macewen,  of  Glasgow,  is  the  most  successful  and  satisfactory 
(Fig.  879).  The  weight  of  the  assistant's  body  is  thrown  upon  the  patient's 
aorta  by  the  right 
fist,  placed  slightly 
to  the  left  of  the 
umbihcus.  McBur- 
ney  has  suggested 
the  prevention  of 
bleeding  by  mak- 
ing a  small  abdomi- 
nal incision  and 
having  an  assistant 
make  direct  digital 
pressure  upon  the 
ihac  artery.  I  em- 
ployed McBurney's  method  in  a  recent  case  and  found  it  most 
satisfactory.  In  this  case  a  sarcoma  of  the  thigh  reached  up  so  far  that  no 
band  could  be  applied  above  it  and  I  was  obliged  to  make  the  posterior  flap 
shown  in  Fig.  877.      If  the  constricting  band  of  Esmarch  is  applied  by  the 

ordinary  method,  it  is  certain 
to  slip.  It  may  remain  in 
place  if  applied  as  a  figure  of 
eight  of  the  thigh  and  the  pel- 
vis, but  even  then  it  is  uncer- 
tain. 

The  most  satisfactory 
method  in  the  great  majority 
of  cases,  is  Wyeth's,  in  which 
the  constrictor  is  held  in  place 
by  the  preliminary  passage  of 
two  steel  pins.  Trendelen- 
burg's method  consisted  in 
passing  one  pin  and  winding 
an  elastic  tube  about  it. 
Wyeth  applied  the  principle 
and  greatly  improved  the 
method.  The  outer  pin  is  in- 
serted an  inch  and  a  half  be- 
low and  a  Httle  internal  to  the 
anterior  superior  spine  of  the 
iUum,  and  is  brought  out  just 
back  of  the  great  trochanter. 
The  inner  pin  is  entered  one 
inch  below  the  level  of  the  crotch  and  internal  to  the  saphenous  opening,  and  it 
emerges  an  inch  and  a  half  in  front  of  the  tuberosity  of  the  ischium.  A  sterile 
cork  is  pushed  on  the  end  of  each  pin,  to  save  the  surgeon  from  wounding 
himself  upon  the  sharp  points.     After  the  Umb  has  been  emptied  of  blood  by 


Fig.  S79.— Macewen's  method  for  compression  of  the  ab 
dominal  aorta  ("American  Text-Book  of  Surgery"). 


I4I6 


Amputations 


holding  it  in  a  vertical  position  for  five  minutes  and  stroking  it  from  the 
periphery  toward  the  body,  the  constricting  band  is  fastened  about  the  hmb 
above  the  pins. 


Fig.  880. — Amputation  at  the  hip-joint — Wyeth's  bloodless  method. 

In  the  bloodless  method  of  Wyeth  (Figs.  880,  881),  after  the  passage 
of  the  pins  and  the  apphcation  of  the  band  of  the  Esmarch  apparatus, 
the  amputation  is  proceeded  with      The  hip  is  brought  well  over  the  edge 


Fig.  881.— Wyeth's  bloodless  amputation  at  the  hip-joint.  Cuff  of  skin  and  subcutaneous  fat 
turned  back,  muscles  divided  at  level  of  small  trochanter,  bone  partly  stripped,  and  large  vessels  ex- 
posed for  deligation. 

of  the  table,  a  circular  incision  is  made  down  to  the  deep  fascia,  six  inches 
below  the  constricting  band,  and  is  joined  by  a  longitudinal  skin-cut 
reaching  from  the  band  to  the  level  of  the  circular  incision,  and  the  cuff  is 


Senn's  Bloodless  Method 


W-' 


i 


V 

/ 

/ 

/ 

/ 

/ 

i 

{i 

/ 

( 

i 

J 

Fig.  S82. —Senn's  method  of  performing  bloodless  amputation  at  the  hip-joint.  Dislocation  of 
head  of  femur  and  upper  portion  of  shaft  through  straight  external  incision.  Elastic  constrictors  in 
place,  the  anterior  one  tied  (Senn). 


*  "■"m.munii 


"■3*3{i«' 


Fig.  883. — Elastic  constriction  completed  by  constricting  the  posterior  segment  of  the  thigh.      Flaps 
formed,  including  all  the  tissues  down  to  the  muscles  (Senn). 


141 8 


Amputations 


reflected  to  the  level  of  the  lesser  trochanter.  The  muscles  are  cut  by  a 
circular  sweep  at  the  level  of  the  retracted  cuff,  the  capsule  of  the  hip-joint 
is  opened  freely,  the  cotyloid  ligament  is  cut  posteriorly,  the  thigh  is 
bent  upward,  forward,  and  inward  to  dislocate  the  head  of  the  bone, 
and,  using  the  thigh  as  a  handle,  the  round  ligament  is  incised  and  the  limb 
removed.  After  ligating  the  vessels  and  introducing  drainage-tubes  the  flaps 
are  sewn  together  vertically.  The  old  transfixion  operation  is  practically 
extinct.  A  "[-amputation  may  be  employed.  It  consists  of  an  external 
straight  incision  down  to  the  bone,  starting  over  the  great  trochanter,  down 
the  outer  side  of  the  limb,  and  a  circular  incision  through  the  skin  five  inches 
below  the  constricting  band,  the  muscles  being  cut  by  a  circular  sweep  at  the 
level  of  the  retracted  skin.     This  method  affords  easy  access  to  the  joint. 

The  bloodless  method  of  Wyeth,  as 
applied  to  the  hip-joint  and  shoulder- 
joint,  is  one  of  the  notable  modern 
advances  in  the  art  of  surgery. 

Senn's  Bloodless  Method.— The 
elder  Senn  has  devised  a  method  for 
preventing  hemorrhage  during  ampu- 
tations of  the  hip-joint.  He  makes  a 
straight  incision,  about  eight  inches  in 
length,  in  the  direction  of  the  long 
axis  of  the  femur  and  directly  over 
the  center  of  the  great  trochanter. 
This  incision  reaches  about  three 
inches  above  the  upper  margin  of  the 
great  trochanter.  The  muscular 
insertions  are  divided  close  to  the 
bone,  and  the  thigh  is  flexed, 
strongly  adducted,  and  rotated  in- 
ward. The  capsular  ligament  is  div- 
ided at  its  upper  and  posterior  aspect. 
While  the  thigli  is  brought  into  a  posi- 
tion of  slight  flexion,  the  remaining 
portion  of  the  capsular  ligament  is  cut. 
Then  the  thigh  is  dislocated  outward, 
and  the  ligamentum  teres  is  cut.  If 
this  cannot  be  accomplished,  the  head  of  the  bone  is  forcibly  dislocated  upon  the 
dorsum  of  the  ilium.  After  dislocating,  the  lesser  trochanter  and  the  upper 
part  of  the  femoral  shaft  are  cleared.  The  limb  is  now  brought  down  in  a 
straight  line  with  the  body,  the  thigh  is  slightly  flexed,  a  long  and  stout  pair 
of  forceps  is  inserted  into  the  wound  behind  the  femur  and  on  a  level  with 
the  normal  situation  of  the  lesser  trochanter,  and  the  instrument  is  pushed 
downward  and  inward,  two  inches  below  the  ramus  of  the  ischium  and  just 
behind  the  adductor  muscles.  As  soon  as  the  point  can  be  felt  under  the  skin, 
an  incision  two  inches  in  length  is  made  upon  it,  and  the  instrument  is  forced 
through  the  opening.  The  tunnel  in  the  tissues  is  enlarged  by  opening  the 
forceps.  A  piece  of  rubber  tubing  three-quarters  of  an  inch  in  diameter  and 
four  feet  in  length  is  caught  about  the  middle  with  the  forceps  and  is  with- 


Fig.  884.— Keen  and  DaCosta's  case  of  inter- 
ilio-abdominal  amputation.  The  shaded  por- 
tion of  the  bone  was  removed  ("International 
Clinics,"  vol.  iv,  13th  series). 


Hypertrophy  of  the  Breast  141 9 

drawn.  The  rubber  tube  is  cut  in  two  at  about  the  point  at  which  the  forceps 
have  held  it,  and  half  of  the  tube  is  used  to  constrict  the  anterior  segment  of 
the  thigh  (Fig.  882)  and  the  other  half  to  constrict  the  remaining  portion  of 
the  thigh  (Fig.  883)  Before  the  constricting  bands  are  tied  the  limb  is  held 
vertically  for  a  sufficient  length  of  time  to  make  it  practically  bloodless;  the 
amputation  is  then  completed  (Senn's  "Practical  Surgery"). 

Other  Methods.— John  G.Sheldon  ("Amer.  Med.,"  April  19,  1902)  has 
modified  Senn's  method  as  follows:  He  disarticulates  the  head  of  the  femur 
and  frees  the  upper  part  of  the  femur  from  its  attachments.  He  then  intro- 
duces a  pair  of  long,  stout  artery-forceps  behind  the  femur  and  clamps  the 
femoral  vessels.  He  forms  the  flap,  removes  the  limb,  and  ligates  the  ves- 
sels. In  this  operation  the  surgeon  can  work  rapidly  and  can  make  a  flap 
of  any  size  or  shape,  and  is  not  hindered  by  a  constriction  apparatus;  but  this 
method  does  not  cut  off  the  bleeding  from  the  obturator 
and  the  sciatic  arteries. 

Larrey  amputated  by  lateral  flaps,  and  Liston  by 
anteroposterior  flaps.  Forneaux  Jordan's  method  con- 
sists in  dividing  the  soft  parts  low  down,  tying  the  blood- 
vessels on  the  face  of  the  stump,  shelling  out  the  femur 
from  the  soft  parts,  and  disarticulating. 

Interilio-abdominal  Amputation. — This  very  for- 
midable operation  is  occasionally  performed  for  sarcoma 
of  the  ilium.  The  operation  was  first  performed  by 
Billroth  in  1891,  and  the  patient  died.  Dr.  Keen  and 
I  collected  19  cases,  including  i  of  our  own.  Five  of 
these  cases   recovered  (W.  W.  Keen  and  J.  Chalmers  r- '  00      t.' 

.  .    .  J       ^  Fig.  885.— K  e  e  n 

DaCosta,  in  "International  Clinics,"  vol.  iv,  13th  series),  and  DaCostas  method 
Our  patient  perished  in  thirty-three   hours  from  sup-      °f   interiUo-abdominai 

r       •  1      '^1  r  .1  ,  1-1        amputation  ("Jnterna- 

pression  ot  urme  and  with  gangrene  of  the  parts  supplied  yg^j^j  cunics,"  vol.  iv 
by  the  internal  iliac  artery.  In  some  cases  the  entire  13th  series). 
innominate  bone  has  been  removed,  in  others  portions 
of  it  have  been  left.  In  our  case  we  made  the  flap  shown  in  Fig.  885,  tied  the 
internal  iliac  artery  after  rolling  up  the  peritoneum,  but  spared  the  external 
iliac,  kept  the  femoral  in  the  flap,  and  sawed  through  the  bones  as  indicated  in 
Fig.  884),  leaving  in  place  the  portions  shown  in  white. 


XXXVIII,  DISEASES  OF  THE  MAMMARY  GLAND. 

Hypertrophy  of  the  Breast  (Fig.  886).— This  is  a  rare  condition.  It 
may  affect  one  breast  or  both.  It  is  most  apt  to  appear  at  the  age  of  puberty, 
but  it  may  appear  in  childhood,  adult  life,  or  old  age.  The  breast  may  attain 
enormous  size.  In  Porter's  case  the  breasts  of  a  woman  of  thirty-seven  were 
so  very  large  that  they  were  carried  hung  upon  a  frame  ("Boston  Med. 
and  Surg.  Jour.,"  March  3,  1892). 

These  very  large  breasts  are  not  composed  of  true  gland  tissue,  but  rather 
of  fat  and  connective  tissue  (Sheild).  Hypertrophy  may  also  occur  in  the 
male  breast.  In  some  cases  hypertrophy  occurs  so  rapidly  as  to  merit  the  name 
acute.     Such  cases  may  perhaps  be  sarcomatous. 


I420 


Diseases  of  the  Mammary  Gland 


Treatment. — Be  sure  it  is  hypertrophy  and  not  sarcoma,  adenoma,  or 
lipoma.  Try  recumbent  posture,  dry  diet,  pressure,  and  iodid  of  potash 
(Sheild).     If  these  means  fail,  amputation  is  the  only  resource. 

Mammillitis  and  Fissure. — The  nipple  may  inflame  as  a  result  of 
injury,  but  the  condition  is  rarely  encountered  except  in  a  woman  who  is 
nursing  a  baby.  It  is  most  common  after  a  first  pregnancy,  when  the  nipple 
is  deformed  or  when  the  skin  is  delicate.  The  nipple  is  slightly  injured  during 
nursing,  and  the  epithelium  is  macerated  by  the  milk  and  saliva.  If  the  in- 
flammation is  not  arrested,  a  spot  excoriates  or  an  irritable  ulcer  forms  (a 
fissure).  A  fissure  is  often  surrounded  by  an  area  of  acute  inflammation, 
and  nursing  causes  intense  agony.     Because  of  the  pain  the  mother  is  apt  to 

extend  the  intervals  between 
nursing,  and  as  a  consequence 
the  ijreasts  become  swollen 
with  retained  milk.  The  ul- 
cer not  unusually  bleeds  when 
the  breast  is  taken  by  the 
child.  Besides  the  facts  that 
a  fissure  causes  pain  to  the 
mother,  it  often  leads  to  grave 
trouble.  It  is  a  suppurating 
area,  and  as  such  may  lead  to 
abscess  of  the  mother's  breast, 
or  may  impair  the  health  of 
the  nursing  child. 

Prevention  of  Fissure. 
— During  pregnancy  the  nip- 
ples should  be  carefully  at- 
tended to.  They  should  be 
washed  often  in  sterile  water 
and  bathed  in  alcohol,  and  if 
retracted,  ought  to  be  drawn 
out  repeatedly.  During  the 
period  of  lactation  the  nipples 
are  washed  in  sterile  water, 
dried,  and  dusted  with  ber- 
ated talc  powder  as  soon  as 
an  act  of  nursing  is  completed.  Washing  the  nipples  regularly  with 
the  following  solution  tends  to  prevent  the  formation  of  a  fissure: 
iodid  of  mercury,  gr.  ij;  alcohol,  Siss;  glycerin  and  distilled  water, 
aa  a  pint  (Lepage).  If  a  small  abrasion  appears,  order  the  woman  to 
wear  a  nipple-shield  during  nursing,  and  after  each  act  of  nursing  to  wash 
the  part  with  hot  sterile  water,  dry,  and  dust  borated  talc  over  the  surface. 
If  a  fissure  forms,  wean  the  child  at  once,  and  dry  up  the  milk  in  both  breasts. 
It  is  useless  to  try  and  dry  it  up  in  one  breast.  Milk  may  be  dried  up  by 
applying  ointment  of  belladonna  locally,  and  administering  iodid  of  potassium 
internally;  by  strapping  the  breasts  with  adhesive  plaster  (Parker);  or  by 
applying  to  the  nipples  six  times  a  day  a  5  per  cent,  solution  of  cocain  in  equal 
parts  of  glycerin  and  water  (Joise).     The  fissure  is  not  treated  by  ointments. 


Fig.  886. — Hypertrophy  of  breast  (Hoiwitz). 


Acute  Abscess  of  the  Breast  142 1 

These  preparations  are  septic,  prevent  drainage,  and  aggravate  maceration. 
Wash  the  fissure  twice  a  day  with  peroxid  of  hydrogen,  dress  it  with  gauze 
wet  in  boric-acid  solution  (gr.  x  to  5j  of  water),  and  cover  the  dressing  with 
waxed  paper.     If  the  fissure  resists  treatment,  touch  it  with  lunar  caustic. 

Acute  Mastitis  ■  and  Abscess. — Acute  inflammation  of  the  breast,  as 
a  result  of  injury  of  the  breast  or  nipple,  may  occur  in  either  sex  at  any  time 
of  life.  Very  commonly  in  both  sexes  a  few  days  after  birth  the  breast  be- 
comes distended  with  a  material  which  in  reality  is  milk.  The  fluid  is  usually 
small  in  quantity.  The  process  is  physiological,  and,  as  a  rule,  ceases  spon- 
taneously (Guelhot).  If  it  hngers,  the  application  of  belladonna  ointment 
will  stop  secretion.  If  the  nurse  meddles  with  and  tries  to  squeeze  out  the 
fluid,  acute  mastitis  is  apt  to  arise  in  one  gland,  or  occasionally  in  both.  The 
skin  of  the  breast  reddens,  the  gland  swells  and  becomes  tender  and  painful, 
the  child  loses  its  appetite  and  becomes  feverish,  restless,  and  sleepless.  Such 
a  condition  is  treated  by  the  local  use  of  lead-water  and  laudanum.  If  pus 
forms,  the  local  signs  and  constitutional  symptoms  are  aggravated.  Evacuate 
the  pus,  dress  with  hot  antiseptic  fomentations,  and  be  sure  that  the  child 
is  well  nourished.     Tonics  and  stimulants  are  indicated. 

A  condition  identical  with  the  secretory  activity  of  the  glands  of  the  new- 
born may  occur  in  either  sex  at  puberty.  The  methods  of  treatment  are  the 
same  in  both  cases.  As  a  matter  of  fact,  rarely  more  than  one  lobule  at  this 
period  inflames,  and  suppuration  is  most  unusual. 

Mastitis  is  most  usually  met  with  in  a  woman  who  is  nursing  a  child,  and 
is  due  to  bacterial  infection.  Primipara  are  particularly  liable  to  develop 
mastitis.  So  are  women  with  deformed  nipples.  In  many  cases  an  abrasion 
of  the  nipple  exists,  and  through  this  breach  of  continuity  bacteria  gain 
entrance  to  the  breast-tissue.  The  abrasion  may  be  so  slight  that  it  can  only 
be  detected  when  the  nipple  is  examined  through  a  magnifying-glass  (Marma- 
duke  Sheild).  Streptococcic  infections  are  very  generally  due  to  inoculation 
of  a  fissure  of  the  nipple.  Bacteria  may  pass  up  the  milk-ducts,  coagu- 
lating the  milk  and  penetrating  through  the  walls  of  the  acini.  Staphylococci 
not  unusually  pursue  this  route  in  reaching  the  breast-tissue.  Occasionally 
causative  bacteria  reach  the  breast  through  the  arteries  (in  septicemia  and 
in  septic  wounds  of  the  genital  organs). 

Symptoms. — There  are  pain,  swelling,  and  tenderness  in  the  breast,  and 
in  most  cases  a  fissure  or  abrasion  exists.  There  is  a  febrile  condition.  Occa- 
sionally a  chill  ushers  in  the  attack. 

Treatment. — Order  the  patient  to  suspend  nursing.  The  physician  en- 
deavors to  arrest  the  secretion  of  milk.  Treat  the  nipple  as  advised  on 
page  1420.  Support  the  breast  and  apply  ichthyol  ointment  or  lead-water 
and  laudanum. 

Mastitis  may  undergo  resolution;  it  may  terminate  in  organization  and 
induration;  it  may  eventuate  in  suppuration. 

Acute  abscess  of  the  breast  follows  acute  mastitis.  There  may  be 
but  one  area  of  suppuration,  or  multiple  foci  may  exist,  which  eventually 
fuse.  The  symptoms  of  mastitis,  local  and  constitutional,  are  greatly  aggra- 
vated. After  a  time  the  skin  becomes  dusky  and  edematous.  The  axillary 
and  superficial  cervical  glands  enlarge.  The  abscess  will  eventually  open 
spontaneously  at  one  or  more  points,  leaving  branching  fistulas.     A  super- 


1422  Diseases  of  the  Mammary  Gland 

ficial  abscess  is  situated  just  beneath  the  nipple,  and  pus  may  flow  from  the 
nipple. 

An  intramammary  abscess  is  in  the  depths  of  the  gland.  There  are  often 
multiple  foci  of  suppuration.  Nodules  are  felt  in  the  gland,  pus  may  run  from 
the  nipple,  but  cutaneous  redness  is  late  in  appearing.' 

Retromammary  abscess  is  a  rather  rare  condition.  It  may  occur  alone 
or  be  associated  and  connected  with  an  area  of  intramammary  suppuration. 
It  may  result  from  metastasis  or  from  caries  of  a  rib.  The  breast  is  lifted  up 
by  the  fluid  beneath  it. 

Treatment. — Open  a  superficial  abscess  by  an  incision  radiating  from 
the  nipple.  Treat  as  any  other  acute  abscess.  An  intramammary  abscess 
should  be  opened  by  a  radiating  incision,  and  pockets  of  pus  should  be  broken 
into  with  the  finger.  An  examination  is  made  to  determine  if  a  retromammary 
abscess  also  exists.  If  this  is  found  to  be  the  case,  an  incision  is  made  at  the 
point  of  junction  of  the  thorax  and  mammary  gland,  and  at  the  lower  border 
of  the  gland.  The  gland  is  raised  from  the  chest-wall,  the  pus  evacuated, 
a  drainage-tube  is  inserted,  and  a  few  sutures  are  introduced.  If  retromam- 
mary abscess  exists  alone,  make  the  last-named  incision  in  the  first  place. 

Chronic  Mastitis. — This  condition  may  be  present  in  only  a  portion 
of  the  breast,  or  may  attack  many  lobules  (lobular  mastitis).  The  ordinary 
form  may  arise  after  weaning  a  child,  or  may  be  due  to  a  blow,  to  the  pressure 
of  corsets,  or  to  numerous  shght  traumatisms.  It  may  occur  in  the  young, 
the  middle  aged,  or  the  old.  The  patient  has  slight  pain  at  times  in  the 
gland.  Examination  detects  a  firm,  elastic  area,  which  is  somewhat  tender 
and  does  not  possess  distinct  margins.  The  skin  is  not  adherent  to  the 
mass  unless  suppuration  occurs.  If  the  mass  is  pressed  against  the  chest 
by  the  surgeon's  fingers,  it  becomes  evident  that  no  real  tumor  exists. 

Treatment. — Remove  any  cause  of  irritation.  Support  the  breast  in  a 
sling.  Apply  ichthyol  ointment.  During  the  night  employ  a  hot-water  bag. 
If  pus  forms,  treat  as  before  directed. 

Chronic  lobular  mastitis  is  a  condition  in  which  numerous  lobules 
become  indurated.  The  real  cause  of  this  condition  is  unknown.  It  may 
occur  at  any  age  after  puberty,  and  often  attacks  both  breasts.  Such  a 
breast  is  apt  to  be  painful,  especially  at  the  menstrual  periods;  it  feels  un- 
natural, solid,  and  careful  examination  detects  numerous  indurated  areas, 
each  of  which  is  of  small  size.  At  the  menstrual  period  the  breast  enlarges 
and  new  nodules  may  be  detected.  In  some  of  these  cases  violent  neuralgic 
pains  are  present  in  the  gland  (mastodynia).  Chronic  lobular  mastitis  is  apt 
to  lead  to  cyst-formation.  When  cysts  form  fluid  may  occasionally  discharge 
from  the  nipple. 

Treatment.' — Support  the  breast  and  apply  ichthyol  ointment  or  bella- 
donna ointment.  Examine  the  generative  organs  and  correct  any  existing 
abnormality.  Improve  the  general  health  by  good  food,  tonics,  and  open-air 
life.  In  cases  where  multiple  cysts  are  known  to  exist  the  question  of  treat- 
ment is  uncertain.  There  seems  to  be  little  doubt  that  such  cases  tend 
in  some  instances  to  eventuate  in  cancer.  I  believe  that  the  proper  treat- 
ment when  multiple  cysts  exist  is  extirpation  of  the  breast. 

Tuberculosis  of  the  Mammary  Gland.— Sir  Astley  Cooper,  in  1829, 
wrote  on  "scrofulous  swellings"  of  the  breast,  and  Velpeau  also  referred  to 


Cysts  and  Tumors  of  the  Nipple  1423 

them.  Nevertheless,  Virchow  in  his  treatise  on  tumors,  stated  that  the  mam- 
mar}'  gland  was  not  subject  to  tuberculosis.  Durbar  first  proved  the  existence 
of  the  condition  by  histologic  or  bacteriologic  observations.  Primary  tuber- 
culosis of  the  breast  is  a  rare  condition.  If  we  are  to  judge  from  English  and 
American  literature,  it  is  a  very  rare  condition,  and  only  about  40  cases  con- 
firmed by  bacteriologic  findings  and  histologic  study  have  been  reported. 
It  is  seldom  that  both  glands  are  involved.  Tuberculosis  of  the  breast  may  be 
secondary  to  tuberculosis  of  the  skin,  of  related  glands,  of  the  rijj,  etc.  It  may 
result  from  some  distant  tuberculous  lesion  of  bone,  of  joint,  of  lung,  etc.  It 
may  be  a  part  of  general  miliary  tuberculosis.  We  consider  here  primary 
or,  as  Geissler  named  it,  solitary  tuberculosis,  tuberculosis  apparently  limited 
to  the  breast  in  an  individual  free  from  evidences  of  antecedent  tuberculosis, 
and  of  tuberculosis  elsewhere.  It  occurs  usually  in  those  of  excellent  general 
health.  The  route  of  infection  may  be  by  the  blood,  by  the  lymph-ducts,  and 
perhaps  by  the  lymphatics  from  the  skin  or  nipple.  E.  M.  Von  Eberts  (in  "Am. 
Jour.  Med.  Sciences,"  July,  1909)  states  that  there  is  no  reported  case  before 
the  age  of  puberty,  that  the  most  advanced  case  reported  was  fifty-three  years 
of  age,  that  maturity  of  the  gland  and  lactation  predispose,  and  that  the  re- 
ported cases  show  the  proportion  of  the  married  to  the  unmarried  as  4  to  i.  It 
is  vastly  more  common  in  women  than  in  men.  In  many  cases  there  is  a  history 
of  antecedent  inflammation  or  abscess  during  lactation.  In  some  cases  there  is 
a  history  of  traumatism.  There  are  two  forms  of  the  condition,  and  in  each 
form,  sooner  or  later,  degeneration  occurs,  and  fistulae  from  a  cold  abscess 
arises  (page  178);  these  forms  are  nodular  and  confluent  (Von  Eberts,  Ibid.). 
In  the  nodular  form  a  nodule,  several  nodules,  or  many  nodules  arise  in  the 
glandular  tissue.  There  is  little  or  no  pain.  If  nodules  are  under  the  nipple 
retraction  may  occur.  The  condition  is  very  slow  in  progress  and  a  year  or 
several  years  may  elapse  before  degeneration  occurs.  Degeneration  results  in 
cold  abscess  (page  155)  or  fistula  formation.  Schley  has  pointed  out  that  cold 
abscess  is  a  termination  more  common  in  the  confluent  than  in  the  nodular 
type  ("Annals  of  Surgery,"  1903).  In  the  confluent  form  the  condition  de- 
velops much  more  rapidly,  is  associated  with  pain,  is  most  apt  to  arise  during 
lactation,  is  particularly  prone  to  abscess  and  fistula  formation,  and  is  liable  to 
acute  exacerbation  from  secondary  pyogenic  infection.  The  axillary  glands 
are  found  enlarged  in  three-fourths  of  all  cases  of  primary  tuberculosis.  Cases 
have  been  reported  of  carcinoma  and  adenoma  associated  \vith  tuberculosis. 

Treatment. — In  a  very  slowly  developing  nodular  case,  in  which  it  is 
certain  lactation  \vill  not  arise,  it  may  be  considered  proper  to  treat  the  condition 
with  tubercuHn,  etc.  (see  chapter  on  Tuberculosis).  In  the  confluent  form  and 
in  cases  of  the  nodular  form  in  which  tuberculin  treatment  has  failed,  or  in 
which  we  cannot  exclude  the  possibility  of  pregnancy,  the  breast  should  be 
removed  and  the  glands  and  fat  should  be  removed  from  the  axilla.  Most  of 
the  cases  recover  permanently  after  radical  operation  (see  Braendle,  of  Tubingen, 
in  Beit.  Z.  klin.  Chir.,  1906,  Bd.  i). 

Cysts  and  Tumors  of  the  Nipple. — Tumors  are  rare  in  the  nipple, 
but  do  sometimes  occur.  The  follo^\ing  growths  are  occasionally  seen : 
fibroma,  angeioma,  papilloma,  myxoma,  myoma,  and  epitheHoma.  Seba- 
ceous cysts  of  the  nipple  and  areola  are  not  very  unusual.  A  cancer  of  the 
nipple  may  be  a  primary  growth,  or   may  be  secondary  to   gland  cancer. 


1424  Diseases  of  the  Mammary  Gland 

Primary  epithelioma  of  the  nipple  presents  the  same  general  characters  as 
epithelioma  in  any  other  region.  It  begins  as  an  indurated  area  in  the  areola, 
or  an  excoriation  of  the  nipple.  Ulceration  soon  occurs.  The  ulcer  is  irregu- 
lar in  outline,  has  hard  edges,  and  furnishes  a  foul,  red,  sanious,  and  fetid 
discharge.  The  mammary  gland  becomes  infiltrated  at  an  early  period. 
The  subclavian  glands  enlarge,  and  later  the  axillary  glands.  Such  a 
growth  must  not  be  confounded  with  a  chancre  of  the  nipple. 

Treatment  oj  Tumors  oj  the  Nipple. — Innocent  tumors  are  to  be  excised 
and  the  breast  need  not  be  removed. 

Epithelioma  of  the  nipple  requires  the  complete  extirpation  of  the  breast, 
and  also  the  clearing  out  of  the  lymphatic  contents  of  the  axilla,  and  possibly 
of  the  subclavian  triangle. 

Paget's  Disease  of  the  .Nipple  (Malignant  Dermatitis). — This  con- 
dition is  a  chronic  inflammation  of  the  epithelial  layer  of  the  nipple  and 
areola  occurring  in  women  beyond  middle  life,  and  is  a  not  unusual  precursor 
of  epithelioma  of  the  nipple  and  of  duct  cancer.  Paget's  disease  is  not  a  simple 
eczema,  it  is  not  associated  with  the  usual  causes  and  attendants  of  eczema, 
either  local  or  constitutional,  and  is  not  cured  by  remedies  which  control 
the  ordinary  disease. 

The  diseased  area  is  raw  and  red,  and  from  it  exudes  copiously  a  thick, 
yellow  discharge.  In  some  cases  Paget's  disease  is  secondary  to  duct  cancer, 
auto-infection  of  the  nipple  having  been  effected  by  the  fluid  flowing  from 
the  ducts.  Investigations  have  shown  the  presence  of  psorosperms  in  areas 
of  Paget's  disease. 

Treatment  consists  in  removal  of  the  entire  breast  and  clearing  out  of 
the  axilla. 

Tumors  and  Cysts  of  the  .'Vlammary  Gland. — These  tumors  may 
be  innocent  or  malignant.  Tumors  may  occur  in  childhood  (angeioma, 
sarcoma,  fibro-adenoma) .  Malignant  tumors  are  very  rare  before  the  age  of 
twenty-five. 

Innocent  Tumors  of  the  Mammary  Gland. — The  innocent  tumors 
are:  Periductal  fibroma,  fihrocystadenoma,  papillary  cystadenoma,  simple 
adenoma,  periductal  fihromyxoma,  myxoma,  angioma,  lipoma,  and  enchondroma. 
It  is  maintained  by  most  authorities  that  any  innocent  tumor  of  the  gland 
may  and  often  does  become  mahgnant. 

Periductal  Fibroma,  Fibro-adenoma. — The  nomenclature  of  fibro- 
adenomatais  in  a  state  of  great  confusion.  The  name  fibro-adenoma  was  given 
by  Cornil  and  Ranvier  to  the  same  sort  of  growth  which  the  younger  Gross 
called  a  fibroma,  Billroth  an  adenofibroma,  and  Sir  Astley  Cooper  a  chronic 
mammary  tumor.  It  is  doubtful  if  a  pure  fibroma  ever  occurs  in  the  mammary 
gland.  A  fibro-adenoma  consists  of  acini  surrounded  by  fibrous  tissue. 
Each  of  these  structures  proliferates,  but  the  fibrous  tissue  does  so  much  more 
rapidly  than  the  glandular.  Bloodgood  says  ("Am.  Jour.  Med.  Sciences," 
Feb.,  1908)  "the  fibro-adenoma  microscopically  is  nothing  more  than  an 
encapsuled  area  of  normal  breast  tissue,  in  which  the  parenchyma,  in  the  early 
stage  of  the  tumor,  is  greater  in  amount  than  the  normal  breast.  Later  the 
parenchyma  undergoes  pressure  atrophy  and  the  tumor  may  become  cal- 
cified." A  growth  of  this  character  is  surrounded  by  a  capsule  and  is  movable. 
It  is  firm,  elastic,  lobulated,  superficially  situated,  and  of  slow  growth.     It  is 


Simple  Adenoma  1425 

unassociated  with  retracted  nipple,  glandular  enlargement,  adhesion  to  the 
skin,  or  cachexia,  and  may  (Kcur  at  any  age  up  to  fifty,  but  is  most  common 
between  twenty  and  thirty  (J.  Bland  Sutton).  Such  a  tumor  is  rarely  very 
painful,  l)Ut  it  may  be  tender  on  rough  handling  and  may  be  i)ainful  at  the 
menstrual  period.  As  a  rule,  there  is  but  one  of  these  tumors  in  a  mammary 
gland,  but  the  tumors  may  be  mulriple  in  one  gland,  or  one  may  exist  in  each 
gland.     It  is  not  very  common  for  sarcoma  or  carcinoma  to  arise. 

Periductal  Fibromyxoma. — It  is  most  common  in  young  women.  It  may 
be  multiple  in  one  breast  or  both.  It  is  an  encapsuled,  lobulated,  and  elastic 
growth,  which  is  seldom  painful,  usually  small,  and  often  remains  quiescent 
indefinitely  or  even  disappears.  It  may  enlarge  and  even  attain  a  large 
size.     When  it  enlarges  it  is  apt  to  become  cystic  and  sarcomatous. 

Treatment  of  Periductal  Fibroma  or  Fihro-adenoma. — Extirpation  of  the 
tumor.  A  tumor  known  to  be  innocent  may  be  removed  through  an  incision 
made  along  the  junction  of  the  mammary  gland  and  breast,  at  the  lower  mar- 
gin of  the  gland,  as  Thomas  proposed,  or,  better,  at  the  edge  of  the  outer  hemi- 
sphere, as  advocated  by  Warren  ("Annals  of  Surgery,"  June,  1907).  The  in- 
cision exposes  the  fibers  of  the  great  pectoral  muscle,  the  gland  is  raised  from 
the  muscle,  and  its  posterior  surface  exposed.  Any  growth  is  exposed  by  an 
incision  from  center  to  periphery  and  this  incision  is  exploratory.  Warren 
removes  an  innocent  tumor,  a  cyst,  or  cysts  by  a  V-shaped  incision,  the  apex 
of  the  V  being  at  the  center  of  the  gland,  and  he  wisely  insists  that  the  tumor 
is  not  to  be  dissected  out.  Several  radiating  incisions  may  be  necessary  to 
explore  a  cystic  breast.  The  V-shaped  space  from  which  the  tumor  or  cyst 
was  removed  is  closed  by  a  double  row  of  catgut  sutures.  Incisions  for 
exploration  seldom  need  to  t3e  closed  with  suture.  The  gland  is  sutured  to 
the  outer  edge  of  the  pectoral  fascia,  and  a  row  of  sutures  is  inserted  through 
the  deep  layer  of  the  superficial  fascia.  Warren  calls  this  operation  ''^plastic 
resection  of  the  breast."    It  leaves  the  patient  free  from  deformity. 

Fibrocystadenonia  or  cystic  adenoma  (adenocele)  is  a  rare  form  of 
slowly  growing  tumor,  which  is  apt  to  attain  a  large  size,  which  is  nodular  in 
outline,  hard  to  the  touch,  and  firmly  attached  to  the  mammary  gland,  but 
mobile  upon  the  chest.  A  cystic  adenoma  has  a  distinct  capsule.  This 
form  of  tumor  is  painless,  and  is  most  apt  to  occur  in  women  between  thirty 
and  forty  who  have  borne  children.  The  growth  is  adherent  to  the  skin,  but 
the  cutaneous  surface  is  not  discolored,  the  cutaneous  veins  are  not  distended, 
the  axillary  glands  are  not  enlarged,  and  the  nipple  is  not  retracted.  From 
the  walls  of  the  dilated  acini  papillomatous  growths  are  apt  to  arise  (intra- 
cystic  vegetations). 

Treatment. — Extirpation. 

Papillary  Cystadenoma. — This  condition  is  often  called  villous  papilloma 
or  duct  papilloma.  There  is  much  more  epithelial  proliferation  than  in  the 
fibrocystadenoma,  and  the  warty  masses  project  into  the  cyst  cavities.  These 
growths  are  firm,  grow  slowly  and  painlessly,  and  seldom  fluctuate.  They 
do  not  adhere  to  the  skin,  attain  a  large  size,  or  cause  glandular  enlargement. 
They  are  situated  near  or  under  the  nipple,  and  occur  particularly  in  middle 
life.     Discharge  of  bloody  fluid  from  the  nipple  is  a  common  symptom. 

Treatment. — Extirpation. 

Simple  Adenoma. — This  is  a  very  rare  tumor.  It  occurs  in  young  and 
90 


1426  Diseases  of  the  Mammary  Gland 

middle-aged  women.  It  is  soft,  nodular,  and  freely  movable.  It  doe?  not 
adhere  to  the  skin  and  does  not  cause  lymphatic  involvement.  It  consists 
of  glandular  acini  and  a  very  deUcate  stroma  of  connective  tissue.  It  tends 
to  become  cancerous. 

Treatment. — Extirpation. 

Myxoma  is  a  rare  tumor,  and  only  occurs  in  a  person  of  middle  age. 
The  growth  is  solitary,  is  soft,  may  be  round  or  lobulated,  and  occasionally 
tungates.  The  nipple  is  not  retracted,  the  superficial  veins  are  not  distended, 
and  the  axillary  glands  are  not  enlarged. 

Treatment. — Removal  of  the  mammar}-  gland. 

Angioma. — This  form  of  tumor  is  very  rare.  It  may  arise  secondarily 
to  a  nevus  of  the  skin  (Sutton).  The  diagnosis  of  angioma  of  the  skin  is 
readily  made.  In  a  cavernous  angioma  of  the  breast  it  will  be  found  that 
the  tumor  can  be  lessened  in  size  by  pressure,  and  will  be  increased  in  size 
by  coughing,  laughing,  and  holding  the  breath.  Pulsation  may  be  detected 
and  a  bruit  may  be  audible. 

Treatment. — For  treatment  of  nevus  see  page  361.  If  a  cavernous  angioma 
exists  in  the  mammary  gland,  it  will  be  necessar\'  to  extirj^ate  the  gland. 

Lipoma  and  eiicliondroma  occasionally  occur  in  the  breast. 

Cysts  of  the  Mammary  Gland. — Involution  cysts  (cystic  degenera- 
tion of  the  mamma)  occur  in  women  who  are  approaching  the  menopause. 
Thev  occur  earlier  in  those  who  are  sterile  than  in  those  who  have  borne 
children,  and  may  arise  after  chronic  mastitis.  The  parenchyma  of  the  gland 
undergoes  atrophic  change,  but  the  ducts  remain,  become  blocked  and  dilated. 
Numerous  small  cysts  form,  and  both  glands,  as  a  rule,  suffer.  \'illous 
growths  may  arise  in  the  walls  of  the  ducts.  In  some  cases  there  is  much 
white  fibrous  tissue  between  the  cysts  (cystic  fibroma). 

The  subjects  of  this  disease  are  often  nervous,  hysterical,  and  despondent. 
One  or  more  ill-defined  indurations  are  detected.  Frequently  there  is  a  history 
of  discharge  from  the  nipple  and  of  attacks  of  lancinating  pain  in  the  breast. 
Cvstic  breasts  are  dangerous,  because  the  intracystic  vegetations  are  liable  to 
eventuate  in  duct  cancer. 

Treatment. — In  such  cases,  after  confirming  the  diagnosis  by  an  exploratory 
incision,  remove  the  entire  breast  (Snow). 

Lacteal  cyst  (galactocele)  is  an  accumulation  of  milk  brought  about  by 
blocking  of  some  of  the  milk-ducts.  It  arises  soon  after  the  delivery  of  the 
child,  and  grows  rapidly.  A  large  quantity  of  milk  may  collect,  and  rupture 
of  the  cyst-walls  can  occur,  the  fluid  passing  into  the  glandular  connective 
tissue. 

A  galactocele  is  rounded,  fluctuates  distinctly,  and  increases  in  size  during 
nursing.  There  is  little  or  no  pain.  In  some  cases  the  contents  of  the  rvst 
coagulate  and  a  solid  mass  is  formed. 

Treatment. — Incision  and  drainage. 

Hydatid  cysts  are  rare,  but  do  occasionally  occur.  There  are  ^t,  positive 
cases  on  record  (Le  Conte,  in  "Amer.  Jour.  Med.  Sciences,"  Sept.,  1901). 
A  small,  hard,  movable,  and  painless  mass  appears  in  the  mammary  gland. 
Usually  it  gradually  increases  in  size,  but  it  may  grow  rapidly  for  a  time 
and  then  remain  apparently  almost  stationary  for  a  period.  If  rapid  growth 
takes  place  there  is  always  pain,  and  pain  is  usual  in  any  case  when  the  cyst 


Carcinoma  or  Cancer  of  Mammary  Gland  of  the  Female      1427 

attains  considerable  size.    Fluctuation  is  often  absent  and  crepitation  is  never 
obtained  (Le  Conte).     Suppuration  is  apt  to  occur  and  sinuses  may  form. 

Treatment. — A  small  and  recent  cyst  may  be  extirpated.  If  the  cyst  is. 
not  recent,  but  is  fairly  large  and  adherent,  incise,  evacuate,  and  pack  with 
gauze.  If  the  cyst  is  large  and  adherent,  but  is  surrounded  by  considera- 
ble breast-tissue,  partially  amputate  the  breast  (Le  Conte).  If  the  cyst  is 
large  and  the  breast  practically  destroyed,  or  if  the  nipple  adheres  to  the 
cyst,  remove  the  mammary  gland  (Le  Conte). 

Malignant  tumors  of  the  mammary  gland  arc  ten  times  more 
common  than  innocent  tumors.  We  should  regard  every  palpable  tumor  m 
the  gland  as  malignant  until  it  is  proved  to  be  innocent.  In  other  words,  we 
reverse  the  rule  of  jurisprudence.  We  regard  every  tumor  as  guilty  of  malig- 
nancy until  its  innocence  is  proved.  If  the  mistake  is  made  of  regarding  an 
innocent  tumor  as  malignant,  the  woman  loses  her  breast.  If  a  malignant 
tumor  is  regarded  as  innocent  the  woman  loses  her  life. 

Sarcoma. — Sarcoma  of  the  mammary  gland  is  a  very  rare  growth  (not  over 
3  per  cent,  of  breast  tumors).  It  may  occur  at  any  age  from  puberty  to  old 
age.  It  was  long  thought  to  be  most  common  from  twenty  to  thirty-five  years 
of  age,  but  Rodman's  investigations  show  that  one-half  the  cases  occur  in  the 
fifth  decade  of  Kfe  (Rodman  on  "Diseases  of  the  Breast").  The  growth 
may  be  composed  of  round  cells  or  spindle  cells;  both  varieties  may  be 
present,  and  myeloid  cells  may  be  found.  Circumscribed  sarcoma  arises 
usually  between  the  ages  of  twenty  and  thirty;  it  is  firm  to  the  touch,  as 
it  contains  much  fibrous  tissue,  is  painless,  does  not  grow  very  rapidly,  glands 
are  not  involved,  and  there  is  no  cachexia.  The  nipple  is  not  retracted. 
The  growth  may  adhere  to  the  skin.  It  is  composed  of  giant  cells  or  spindle 
cells,  and  rarely  returns  after  extirpation  of  the  breast. 

Diffused  sarcoma  is  composed  of  small  round  cells,  arises  in  the  center 
of  the  breast,  and  grows  with  great  rapidity.  It  is  most  commonly  met 
with  about  the  age  of  thirty-five,  and  a  history  of  injury  can  often  be  ehcited. 
The  tumor  is  soft,  some  parts  being  softer  than  others  because  of  cyst-forma- 
tion. It  is  usually  mobile  upon  the  thorax,  though  it  soon  becomes  adherent 
to  the  skin.  The  tumor  reaches  a  very  great  size,  and  soon  fun  gates  through 
the  skin.  There  is  little  or  no  pain.  The  cutaneous  veins  over  the  tumor 
are  distended,  the  nipple  is  not  retracted,  and  the  axillary  glands  are  not 
often  enlarged.     Diffuse  sarcoma  is  apt  to  recur  after  removal. 

Treatment. — Remove  the  breast,  and  if  the  muscles  of  the  chest-wall  are 
infiltrated,  remove  them.  The  axillary  glands  should  be  removed  whether 
or  not  they  are  enlarged.  Operation  will  not  cure  when  metastases  exist. 
If  the  case  is  inoperable,  we  can  try  the  use  of  Coley's  fluid.  If  the  toxins 
of  erysipelas  fail  to  arrest  the  progress  of  the  disease,  keep  the  patient  as 
comfortable  as  possible  by  the  administration  of  cocain  and  morphin. 

Endothelioma. — This  is  a  very  rare  tumor.  I  have  had  one  case  of  it. 
The  diagnosis  cannot  be  made  from  carcinoma. 

Treatment. — As  for  cancer. 

Carcinoma  or  Cancer  of  the  Mammary  Gland  of  the  Female  (Fig.  887) . 
— The  great  majority  of  mammary  tumors  belong  to  the  genus  carcinoma. 
Cancer  is  due  to  proliferation  of  the  epithelium  of  the  acini  (acinous  cancer) 
or  of  the  ducts  (duct  cancer). 


1428 


Diseases  of  the  Mammary  Gland 


Acinous  cancer  is  vastly  more  common  than  duct  cancer.  Usually  there 
is  much  connective  tissue  and  but  little  parenchyma  in  the  growth  (scirrhus 
cancer).  In  some  cases  there  is  little  connective  tissue  and  much  paren- 
chyma (encephaloid  or  medullary  cancer).  If  colloid  degeneration  of  the 
parenchyma  or  stroma  occurs,  the  growth  is  spoken  of  as  colloid  cancer. 

Scirrhus,  the  common  form  of  acinous  cancer,  is  almost  as  hard  as  stone. 
On  section  it  is  concave,  and  Sutton  says  "resembles  an  unripe  pear."  The 
tumor  is  without  a  capsule,  and  the  epithelial  cells  are  surrounded  by  masses 
of  fibrous  tissue.     Portions  of  tissue,  even  some  distance  away  from  the 


Fig.  887.— Scirrhus  rarcinoma  (J.  Collins  Warren). 


tumor,  contain  foci  of  ])rolifcrating  embryonic  epithelial  cells.  In  atrophic 
or  withering  scirrhus  the  fibrous  stroma  contracts  and  epithelial  cells  undergo 
fatty  degeneration  (Senn). 

Halsted  in  1898  described  adenocarcinoma.  It  is  the  initial  movement 
in  the  direction  of  unrestrained  epithelial  proliferation,  and  secdons  of  the 
tumor  show  the  formation  of  tubular  acini.  The  most  characteristic  sections 
resemble  adenoma.  Adenocarcinoma  is  not  the  common  form  of  breast 
cancer.     In  the  common  forms  the  proliferating  epitheHum  attains  no  resem- 


Carcinoma  or  Cancer  of  Mammary  Gland  of  the  Female     1429 

blance  to  glandular  structure,  but  multiplies  irregularly  in  connective-dssue 
spaces  or  lymph-spaces. 

Causes  and  Symptoms. — Scirrhus  is  more  common  among  women  who 
have  borne  children  than  among  those  who  have  not.  Heredity  is  mani- 
fest in  only  about  10  per  cent,  of  cases.  The  younger  Gross  found  it 
in  I  case  out  of  9.  Trauma  has  no  apparent  influence  in  producing  cancer. 
The  disease  is  rare  before  the  age  of  thirty-five,  and  is  most  common  between 
forty-five  and  fifty.  The  author  operated  for  scirrhus  of  the  breast  on  a 
woman  only  twenty-seven  years  of  age.  Henry  saw  a  woman  of  twenty-one 
with  cancer.     It  is  frequently  met  with  in  the  aged.     These  tumors  are  rare 


Fig.  888. — Carcinoma  of  right  breast.     Lesion  first  noticed  six  months  before  photograph  was 

made. 

in  the  negro  race.  A  hard  nodule  is  found  in  the  breast,  usually  under  the 
nipple,  but  possibly  far  away  from  it.  The  growth  is  nodular,  and  is  immo- 
bile from  the  beginning.  In  a  large,  fat  breast  there  is  often  a  deceptive 
sense  of  mobility,  because  some  of  the  breast-tissue  moves  with  the  tumor. 
The  cancer  may  have  been  present  for  a  considerable  time  before  being 
discovered.  Sometimes  wide-spread  lesions  develop  from  a  small  or  an  un- 
discovered breast  cancer  (pleural  effusion,  enlarged  glands  of  the  neck,  dis- 
ease of  the  spinal  cord,  bones  of  skull  and  brain).  In  obscure  lesions  of  bones 
and  viscera  examine  the  mammary  glands,  because  the  trouble  might  be  due 
to  metastasis  from  an  undiscovered  carcinoma  of  the  breast.  What  Osier 
calls  mastitis  carcinomata  is  a  wide-spread  regional  metastasis,  affecting  one  or 
both  breasts  and  beyond  them,  and  which  attains  a  considerable  size  in  a  very 
few  months.  The  breast  soon  liecomes  enormous  and  brawny,  the  skin  is  in- 
filtrated, there  are  no  nodules,  the  glands  above  the  clavicle  usually  enlarge, 
and  the  arm  may  swell.  Metastases  may  occur  within  the  chest,  either  by 
lymph  regurgitation  from  the  axillary  and  subclavian  glands,  or  directly 
through  the  chest  walls  to  pleura  and  lung  or  to  mediastinal  glands.     Retrac- 


I430 


Diseases  of  the  Mammary  Gland 


tion  of  the  nipple  is  present  in  over  one-half  of  the  cases.  It  occurs  when  the 
growth  is  near  the  nipple,  and  is  due  to  the  contracting  fibrous  tissues  of  the 
tumor  puUing  on  the  milk-ducts.  If  the  growth  is  far  away  from  the  nipple, 
a  dimple  is  apt  to  form  on  the  skin  of  the  breast  because  of  the  puUing  upon 
the  suspensory  fibers. 

Glandular  enlargement  in  the  axilla  soon  follows  the  appearance  of  a 
scirrhus;  the  glands  become  very  hard  and  adherent.  In  over  60  per  cent, 
of  persons  the  glands  of  the  axilla  are  feh  to  be  enlarged  when  the  patient 
first  comes  for  treatment.  Because  the  surgeon  cannot  feel  enlarged  glands 
is  no  proof  that  there  are  none.  As  a  matter  of  fact,  the  glands  are  usually 
involved  within  two  months  of  the  beginning  of  the  disease,  but  the  involve- 
ment can  rarely  be  detected  externally  until  months  later.     Enlargement  of 


Fig.  SS9. — Recurient  carcinoma.      Cancer  en  cuirasse. 


the  axillary  glands  is  followed  by  enlargement  of  the  glands  in  the  posterior 
cervical  triangle  and  in  the  mediastinum.  Herbert  Snow  has  shown  that 
the  blocking  of  the  axillary  glands  often  leads  to  regurgitation  of  lymph  con- 
taining cancer-cells,  the  cells  being  thus  deposited  in  the  head  of  the  humerus 
and  the  thymus  gland.  Cells  in  the  th}Tnus,  after  a  time,  cause  a  projection 
of  the  sternum  (the  sternal  symptom).  \\*hen  the  axillary  lymphatics  are 
extensively  involved,  the  arm  swells  from  obstruction  to  the  lymph-flow  (lymph- 
edema) or  pressure  upon  the  vein.  The  tumor  usually  grows  rather  slowly 
unless  lactation  is  established;  then  it  grows  rapidly.  As  it  grows  it  infiltrates 
adjacent  structures  (the  pectoral  fascia,  pectoral  muscles,  subcutaneous  cel- 
lular tissue, and  skin).  \\'hen  the  skin  is  destroyed,  an  ulcer  forms,  and  around 
this  ulcer  the  skin  becomes  red  and  filled  with  cancerous  nodules,  which  feel 


Carcinoma  or  Cancer  of  Mammary  Gland  of  the  Female     1431 

like  shot  in  the  skin.     Metastases  are  apt  to  occur  into  the  bones,  liver,  brain, 
pleura,  spine,  thymus  gland,  and  rarely  the  eye. 

Pain  is  usually  present  in  scirrhous  carcinoma.      It  is  lancinating  and 
neuralgic  in  character,  and  not  brought  on  or  increased  by  handling.     It 


Fig.  890. — Recurrent  carcinoma  of  the  breast. 

ceases  if  colloid  degeneration  begins.  The  general  health  is  usually  unim- 
paired until  ulceration  takes  place,  when  cachexia  arises.  The  cancer  en 
cuirasse  of  Velpeau  is  a  condition  in  which  the  lymphatic  vessels  of  the  skin 
are  extensively  invaded,  the  growth  itself  being  adherent  to  the  wall  of  the 


Fig.  891. — Ulcerating  scirrhous  carcinoma. 


thorax.     In  this  condition  the  chest-wall  is  fixed,  respiration  is  difficult,  and 
the  temperature  is  commonly  somewhat  elevated. 

In  atrophic  or  withering  scirrhus  the  contraction  is  so  great  that  it  seems 
as  though  the  mammary  gland  had  been  removed.  The  duration  of  scirrhus, 
when  left  to  run  its  course,  varies,  but  the  disease  generally  produces  death 


1432  Diseases  of  the  Mammary  Gland 

within  two  and  a  half  years.  Occasionally  it  causes  death  within  a  year.  In 
atrophic  scirrhus  the  patient  may  live  for  many  years. 

Duct  cancer  is  not  a  common  growth.  It  arises  from  the  duct-walls  in 
conditions  of  cystic  degeneration  of  the  mammary  gland.  The  tumor  is 
softer  than  the  acinous  growth  and  is  not  nodular.  There  is  no  pain,  no 
retraction  of  the  nipple,  no  skin  dimple.  Serous  or  bloody  fluid  may  often 
be  squeezed  from  the  nipple.  A  duct  cancer  grows  and  infiltrates  less  rapidly, 
and  involves  adjacent  glands  later  than  does  an  acinous  growth. 

Cancer  of  the  Male  Breast. — This  condition  is  seldom  met  with,  though 
I  beheve  it  to  be  more  common  than  is  generally  supposed.  I  have  seen  3 
cases  within  the  last  ten  years.  Each  patient  was  in  the  early  forties;  neither 
complained  of  pain.  In  one,  the  breast  had  been  extremely  large  from  early 
years.  In  each  case  the  growth  was  indurated,  but  in  neither  was  there  any 
retraction  of  the  nipple.  The  condition  in  each  patient  was  scirrhous  carci- 
noma. Warfield  has  collected  32  cases  from  literature  and  has  added  5  others 
("Bull,  of  Johns  Hopkins  Hosp.,"  Oct.,  1901).  The  patients  were  between 
forty  and  seventy  years  of  age;  8  gave  a  history  of  injury;  in  9  cases  there 
was  pain,  and  in  12  the  nipple  was  retracted.  Palermo  has  collected  750 
cases  of  tumor  of  the  male  breast  ("  Semaine  ]Medicale,"  May  20,  1908) 
and  649  of  them  were  cancerous. 

Treatment  of  Carcinoma  of  the  Mammary  Gland. — The  treatment  is 
early  and  thorough  operation;  the  earUer  and  the  more  thorough,  the  better. 
The  older  surgeons  operated  simply  to  prolong  hfe  a  few  months;  the  modem 
surgeon  operates  with  the  hope  of  curing  the  patient.  The  mortaht}'  of  the 
operation  is  surprisingly  small.  It  is  certainly  under  2  per  cent.  Rodman's 
statistics  (2133  operations  performed  since  1893  by  twent}'-one  American  sur- 
geons) show  a  mortahty  of  less  than  i  per  cent.  I  have  personally  lost  4  patients 
in  over  200  operations.  In  1878  Billroth's  statistics  showed  only  8  cures  in 
143  cases.  In  1896  W.  Watson  Cheyne  reported  12  cures  out  of  21  cases 
(57  per  cent.).  His  cases  now  show  54.8  per  cent,  alive  and  well  from  six  to 
thirteen  years  after  operation.  Depage's  statistics  show  that  48  per  cent,  of 
cases  passed  the  three-year  limit  ("  Presse  Medicale,"  Oct.  21,  1908).  Green- 
ough,  Simmons,  and  Bumey  consider  320  cases  operated  upon  radically 
(".\nnals  of  Surger)', "  July,  1907);  88  cases  passed  the  three-year  hmit. 
Bloodgood  ("Am.  Jour.  Aled.  Sciences,"  Feb.,  1908)  sets  forth  Halsted's 
statistics: 

"The  statistics  in  Halsted's  clinic  up  to  the  present  time  show  that  among 
210  cases,  in  which  three  years  or  more  have  passed  since  the  operation,  42  per 
cent,  are  apparently  well.  If  we  consider  the  cases  in  which  the  axillar}' 
glands,  studied  microscopically,  showed  no  e^•idence  of  metastasis,  61  cases, 
or  85  per  cent.,  are  well.  In  cases  in  which  the  axillary  glands  showed  metas- 
tasis (no),  30  per  cent,  remained  free  from  recurrence  for  three  years.  WTien 
the  glands  in  the  neck  showed  metastasis  (40  cases),  only  10  per  cent,  remained 
well  for  three  years.  In  all  of  these  groups  metastasis  has  been  observed  after 
an  interval  of  three  years  of  apparent  cure.  Such  late  metastasis  may  take 
place  up  to  eight  years  after  operation.  Excluding  these  cases  of  late  recur- 
rence, the  definitely  cured  in  these  three  groups  is  reduced  to  75,  24,  and  7  per 
cent,  respectively,  or,  for  all  cases  together,  35  per  cent.  I  have  not  time  to  give 
the  facts,  but  there  is  endence  to  indicate  that  when  the  microscope  fails  to 


Treatment  of  Carcinoma  of  the  Mammary  Gland  1433 

demonstrate  metastatic  cancer  cells  in  the  lymphatic  glands  in  the  axilla,  this 
is  not  a  positive  proof  that  metastasis  has  not  taken  place,  and  for  this  reason 
and  others,  which  space  prevents  me  from  stating,  there  should  be  no  restriction 
in  the  complete  operation  for  carcinoma  of  the  breast."  It  will  be  observed 
that  of  these  40  cases,  with  involvement  of  neck  and  axilla,  only  4  passed  the 
three-year  hmit.  If  they  had  not  been  operated  upon,  statistics  would  have 
been  bettered.  The  surgeon  who  would  not  operate  on  such  cases  would  have 
a  higher  percentage  of  cures  for  his  statistics,  but  he  would  have  sacrificed  to 
statistical  glory  these  4  cases.  If  there  is  the  slightest  doubt  of  the  diagnosis, 
make  an  exploratory  incision  before  making  the  incisions  for  the  removal  of 
the  breast  (see  Dawbarn's  remarks  on  the  deceptive  signs  given  by  thick-walled 
abscesses  in  the  "Annals  of  Surgery,"  March,  1908),  If  the  mass  proves 
to  be  cancer,  I  always  pack  in  a  piece  of  gauze  just  wTung  out  of  boiling  water 
and  go  on  at  once  with  the  removal  of  the  breast.  As  Dawbam  shows,  this 
method  seals  up  the  open  mouths  of  lymphatics.  A  radical  operation  should 
remove  the  breast  and  much  of  the  skin  above  it,  the  pectoral  fascia,  the 
pectoral  muscles,  the  fat  and  glands  of  the  axilla,  and  the  fascia  over  the 
serratus  magnus.  As  Cheyne  says,  remove  all  the  glands  along  the  axillary 
vein  and  lift  up  the  vein  at  the  apex  of  the  axilla  and  remove  the  glands  and 
fat  behind  it.  The  sheath  of  the  vein  should  always  be  removed.  Cheyne 
points  out  that  the  hne  of  spread  must  be  traced  upward  along  the  vessels  and 
nen-es  and  downward  along  the  external  respiratory  nerv^e  of  Eell  ("Lancet," 
March  12,  1904).  If  three  years  after  an  operation  there  has  been  no  return, 
we  regard  the  case  as  cured  (Volkmann's  Umit).  As  a  matter  of  fact,  recur- 
rences are  noted  after  five  years,  and  this  limit  should  be  used  instead  of  three 
years.  It  is  true  that  80  per  cent,  of  those  passing  the  three-year  Hmit  remain 
free  from  recurrence.  Over  90  per  cent,  of  those  passing  the  five-year  limit 
remain  free.  Coley  reported  65  cases  of  recurrence — 15  per  cent,  recurred 
after  three  years  and  6  per  cent,  after  fourteen  years.  Ransohofif  collected 
10  cases  of  recurrence  during  the  seventh  and  eighth  years,  2  each  after  the 
ninth,  tenth,  eleventh,  twelfth,  and  fifteenth  years,  and  i  each  after,  at  various 
inten'als,  from  fifteen  to  t\vent}'-five  years.  ^lartin  suggests  that  these  later 
so-called  recurrences  are  really  new  growths  in  persons  predisposed  to  cancer 
("Annals  of  Surger)^, "  Oct.,  1908).  Certain  cases  are  unsuited  for  a  radical 
operation:  cases  in  which  metastases  exist;  cases  of  cancer  en  cidrasse;  cases 
where  axillar}^  involvement  is  very  great.  Che}Tie  would  also  rule  out  cases 
where  large  glands  may  be  felt  above  the  clavicle,  belie\ing  that  in  such  cases 
the  mediastinal  glands  must  be  cancerous.* 

Hoisted' s  Operation. — Halsted  performs  a  very  radical  operation.  He 
removes  suspected  tissue  in  one  piece,  and  thus  prevents  carcinoma  cells  fall- 
ing into  the  wound,  for  it  is  well  known  that  if  such  cells  should  fall  into  the 
wound  they  may  grow  just  as  may  a  graft  of  healthy  epitheHum.  The  neck, 
shoulder,  the  arm  to  the  elbow,  the  entire  surface  of  the  chest  down  to  the 
waist,  both  breasts,  the  axilla,  the  side  and  the  back  of  the  diseased  side  must 
be  sterilized.  It  is  necessar}-  to  have,  besides  scalpels  and  the  ordinary  instru- 
ments for  an  operation,  a  great  number  of  hemostatic  forceps  (80  to  100). 
Place  the  patient  recumbent,  with  a  sand-pillow  under  the  shoulder  of  the 
affected  side.  The  shoulder  is  right  at  the  edge  of  the  bed,  and  a  nurse  holds 
*See  "  Objects  and  Limits  of  Operation  for  Cancer,"  by  W.  Watson  Che\Tie. 


f434 


Diseases  of  the  Mammary  Gland 


the  arm  from  the  side.  Hals  ted  describes  his  operation  as  follows:*  The 
skin-incision  is  made  as  shown  in  Fig.  892,  and  is  carried  at  once  through  the 
fat.  The  triangular  skin-flap  (a,  b,  c)  is  turned  down.  The  costal  insertions 
of  the  great  pectoral  muscle  and  the  muscle  are  spht  between  the  clavicle  and 


r^' 


J 


Fig.  892. — Halsted's  operation  for  carcinoma  of  the  breast  ;  the  first  incision. 


costal  portions  and  up  to  a  point  opposite  to  the  scalene  tubercle,  and  at  this 
point  the  clavicular  portion  of  the  muscle  and  the  tissue  overlying  it  are  cut 
through  close  to  the  clavicle,  and  the  apex  of  the  axilla  is  at  once  exposed. 
The  cellular  tissue  under  the  clavicular  portion  of  the  muscle  is  dissected 
from  the  muscle,  and  the  splitting  of  the  muscle  is  continued  on  to  the  humerus. 


r 


C!  n 


Fig.  893. — Halsted's  operation  for  carcinoma  of  the  breast ;  the  mass  turned  down. 

The  part  of  the  muscle  to  be  removed  is  cut  through  close  to  its  humeral  in- 
sertion. The  whole  mass  circumscribed  by  the  first  incision  (skin,  breast, 
areolar  tissue,  and  fat)  is  raised  with  considerable  force  in  order  to  put  the 
submuscular  fascia  on  the  stretch  as  it  is  stripped  from  the  thorax  close  to  the 
*  Johns  Hopkins  Hosp.  Reports,  vol.  iv;  Annals  of  Surgery,  Nov.,  1S94. 


Treatment  of  Carcinoma  of  the  Mammary  Gland  1435 


ribs.  It  is  well  to  include  the  deHcate  sheath  of  the  pectoralis  minor  muscle. 
The  lower  and  outer  boundary  of  the  lesser  pectoral  having  been  passed  and 
exposed,  the  muscle  is  cut  at  a  right  angle  to  its  fibers  and  a  little  below  the 
middle.  The  tissue  over  the  pectoralis  minor  muscle  near  its  coracoid  inser- 
tion is  divided  as  far  out  as  possible,  and  is  then  reflected  inward  to  prepare 
for  the  reflection  upward  of  this  part  of  the  minor  muscle.  The  upper  por- 
tion of  the  minor  muscle  is  retracted  upward.  Some  surgeons  do  not  remove 
the  lesser  pectoral  muscle.  I  believe  it  should  be  removed,  because  the  axilla 
can  then  be  more  easily  and  rapidly  cleared.  The  removal  of  the  muscle 
does  not  impair  arm  movements,  and  its  retention  leads  to  the  formation,  when 
healing  is  complete,  of  a  cord-like  band  in  front  of  the  axilla.  (See  Douglas 
Drew,  in  "Brit.  Med.  Jour.,"  May  17,  1902.)  The  small  blood-vessels 
under  the  minor  muscle  are  carefully  separated  from  it,  are  dissected  out 
very  clear,  and  are  ligated  close  to  the  axillary  vessels.  Having  exposed  the 
subclavian  vein  at  the  highest  possible  point  below  the  clavicle,  the  contents  of 
the  axilla  are  dissected  away  with  a  sharp  knife  and  the  vein  and  its  branches 
are  stripped  absolutely  clean.  The  loose  tissue  about  the  artery  and  the 
nerves  should  also  be  removed.  When  the  vessels  are  cleared,  the  axillary 
contents  are  rapidly  stripped  from  the  inner  walls 
of  the  axilla  and  the  lateral  wall  of  the  thorax 
(Fig.  893) .  The  fascia  which  binds  the  mass 
to  the  chest  is  cut  close  to  the  ribs  and  the  ser- 
ratus  magnus  muscle.  Just  before  reaching  the 
junction  of  the  posterior  and  lateral  walls  of  the 
axilla  an  assistant  draws  the  triangular  flap  of 
skin  outward  in  order  to  spread  out  the  tissue 
which  lies  upon  the  subscapularis,  teres  major, 
and  latissimus  dorsi  muscles.  The  operatoi 
cleans  the  posterior  wall  of  the  axilla  from 
within  outward.  The  subscapular  vessels  are 
clearly  exposed,  and  are  caught  before  they  are 
cut.  In  some  cases  the  subscapular  ner\^es  are 
removed,  in  others  they  are  permitted  to  remain. 
Having  passed  these  nerv^es,  the  mass  is  turned 
back  into  its  normal  position  and  severed  from 
the  body  of  the  patient  by  a  stroke  of  the  knife 
from  b  to  c,  repeating  the  first  cut  through  the 
skin.  Every  bleeding  point,  however  small,  is 
tied  with  fine  silk.     From  60  to  100  Ugatures  or  even  more  may  be  required. 

After  the  completion  of  the  operation  the  wound  into  the  axilla  is  closed 
with  a  subcuticular  stitch  of  silver  wire;  if  a  cut  has  been  carried  above  the 
clavicle,  it  is  closed  in  the  same  manner,  and  the  edges  of  the  elliptical  opening 
are  brought  nearer  together  by  a  purse-string  subcuticular  stitch.  Thiersch 
grafts  cut  from  the  patient's  thigh  are  used  to  cover  the  gap.  Silver-foil  is 
placed  over  the  wound,  this  is  covered  with  gauze,  bandages  are  applied,  and 
the  dressing  is  overlaid  by  a  plaster-of-Paris  bandage,  which  includes  the 
head,  neck,  chest,  and  arm.  The  area  from  which  grafts  were  taken  is  dressed 
with  sterile  gauze  or  an  ointment  containing  boric  acid. 

Formerly  I  did  not  open  the  subclavian  triangle.     I  believed  that  these 


Fig.  894. — The  younger  Senn's 
incision  for  amputation  of  the 
breast. 


1436 


Diseases  of  the  Mammary  Gland 


glands  were  involved  only  from  the  axillary  lymphatics,  that  v^hen  they  were 
involved  the  mediastinal  glands  were  sure  to  be  affected  (the  route  to  them 
being  more  direct)  and  operation  was  certain  to  be  useless.  When  the  sub- 
clavian glands  are  involved  from  the  axillary  lymphatics  this  is  true,  but  in 
some  cases  they  are  involved  by  way  of  the  direct  lymph  paths  from  the  mam- 
mary gland.  In  such  a  case  the  mediastinal  glands  may  be  free,  and  cleaning 
out  the  subclavian  triangle  may  save  the  padent.  I  always  open  the  subclavian 
triangle  and  clear  out  fat  and  glands  if  no  glands  or  only  a  few  small  glands 
were  palpable  before  operation.  If  there  is  a  large  glandular  mass  in  the 
triangle,  operation  is  useless.  I  always  open  the  triangle  if  the  tumor  of  the 
mammary  gland  is  in  the  upper  hemisphere,  or  if  I  discover  enlarged  glands 
at  the  apex  of  the  axilla,  whether  there  are  or  are  not  small  palpable  glands 
above  the  clavicle. 

The  Younger  Sennas  Incision. — A  very  useful  incision  is  that  described 
by  the  younger  Senn,  and  shown  in  Fig.  894.  The  breast  is  circumscribed 
by  two  curviHnear  incisions  which  meet  above,  at  the  border  of  the  great 


Fig.  895. — Jabez  N.  Jackson's  incision 
for  removal  of  the  mammary  gland. 


Method    of    approximating    flaps    after 
breast  amputation. 


pectoral  muscle.  The  incision  is  continued  a  little  internal  to  the  outer  border 
of  the  muscle  to  about  i  inch  above  the  apex  of  the  axilla,  when  it  is  curved 
outward  in  the  deltoid  region,  and  terminates  at  the  level  of  the  apex  of  the 
axilla.  The  breast  is  removed  from  the  wall  of  the  chest,  and  is  then  sus- 
pended by  axillary  glands  and  fat,  which  are  removed  en  masse*  This 
incision  gives  a  free  exposure,  opens  the  axilla  from  in  front,  enables  the  surgeon 
quickly  to  locate  and  freely  expose  the  axillary  vein,  and  the  resulting  scar 
does  not  materially  limit  the  motions  of  the  arm. 

Jackson's  Incision  (Jabez  N.  Jackson,  "Jour  Am.  Med.  Assoc,"  March  5, 
1906)  is  shown  in  Fig.  895.  The  axilla  is  entered  from  above,  a  quadrilateral 
flap  of  skin  is  raised,  and  is  subsequently  pulled  down  to  and  inclosing  the 
wound  (Fig.  896). 

Warren's  incision  is- shown  in  Fig.  897.  It  enables  the  surgeon  to  close  the 
wound. 

*See  the  younger  Senn  in  Jour.  Amer.  Med.  Assoc,  May  27,  1899. 


Treatment  of  Carcinoma  of  the  Mammary  Gland  1437 


Willy  Meyer's  Operation  ("Jour.  Amer.  ^led.  Assoc,"  July  29,  1905). — 
For  the  last  three  years  I  have  been  performing  the  operation  devised  by 
Willy  Meyer.  I  consider  it  a  most  excel- 
lent procedure,  with  distinct  points  of 
superiority  over  other  plans.  We  owe  to 
Gerster  the  principal  of  opening  the  axilla 
in  the  beginning  of  the  operation  in  order 
to  prevent  the  diffusion  of  cancer  cells 
and  so  diminish  the  chance  of  rapid  re- 
currence. Gerster's  paper  was  pubHshed 
in  the  "American  Jour,  of  Med.  Sciences" 
in  1888.  The  younger  Gross,  in  his  later 
years,  used  to  open  the  axilla  first  when 
there  was  an  axillary  mass,  but  he  did  it 
in  order  to  determine  in  the  beginning 
of  the  operation  if  the  axillary  mass  was 
really  removable.  Willy  ]Meyer  empha-  Fig.  897 
sizes  the  value  of  his  procedure  in  lessen- 
ing hemorrhage.     In  Meyer's   operation 

two  flaps  are  formed  by  the  skin-incision  (Fig.  898) — a  lower  and  an  upper 
flap.  The  incision  for  the  formation  of  the  lower  flap  begins  at  the  point 
of  insertion  of   the  great  pectoral  muscle  on  the  humerus,  and  is  carried 


. — W'.irrcn'^  incision  for  removal 
of  the  mammary  gland. 


Fig.  8q8.— Willy  Meyer's  operation  for  carcinc 


oreast.    Skin  incision  as  practised  since  1898. 


downward  and  inward  h  inch  above  the  border  of  the  muscle  and  parallel 
to  it.     When   the   incision   reaches    the    base   of    the    mammary  gland,  it 


1438 


Diseases  of  the  Mammary  Gland 


is  carried  along  the  lower  margin  of  the  gland,  and  it  ends  over  the  ster- 
num, a  little  beyond  the  mid-Hne  (Fig.  898) .  The  lower  flap  is  separated  and 
turned  down,  a  quantity  of  subcutaneous  fat  being  allowed  to  remain  attached 
to  the  breast.  This  turning  down  is  carried  to  the  border  of  the  latissimus 
dorsi  muscle,  to  the  axillary  cavity,  and  to  the  chest-wall.  Meyer  then  directs 
that  the  border  of  the  latissimus  dorsi  be  followed  down  to  the  serratus  anticus 
major,  and  upward  to  the  mass  of  fat  that  enters  the  bicipital  sulcus  of  the 
arm.  The  fat  is  removed  from  the  anterior  border  of  the  muscle  by  blunt 
dissection.     This  anterior  lower  wound  is  then  packed  with  gauze. 

The  surgeon  next  forms  the  upper  flap  by  uniting  the  inner  and  outer  ends 
of  the  first  incision  with  another  incision  carried  along  the  upper  margin  of 
the  breast  (Fig.  898).     In  this  flap,  as  in  the  other,  the  surgeon  leaves  as 


Fig.  8gQ.— Willy  Meyer's  operation  for  carcinoma  of  the  breast.     Insertion  of  pectoralis  major  muscle 
exposed.     Operator's  left  index-finger  encircling  its  tendon. 

much  subcutaneous  fat  adhering  to  the  breast  as  he  can  spare  without  in- 
ducing the  danger  of  skin-necrosis.  This  upper  flap  is  raised  progressively 
until  the  cephalic  vein  is  reached  and  there  is  exposure  of  the  lower  surface 
of  the  clavicle  with  the  sternoclavicular  articulation.  Meyer  directs  that  the 
tissues  covering  this  articulation  shall  not  be  disturbed. 

After  the  formation  of  these  two  flaps  the  next  step  in  the  operation  is  the 
division  of  the  tendons  of  the  two  pectoral  muscles  and  the  exposure  of  the 
axillary  and  subclavian  veins.  Meyer  advises  that  the  cephalic  vein  be  fol- 
lowed up  until  the  insertion  of  the  great  pectoral  muscle  into  the  humerus  is 
found.     The  tendon  is  fully  exposed,  care  being  taken  to  bare  it  of  axillary 


Treatment  of  Carcinoma  of  the  Mammary  Gland 


1439 


fat.  The  arm  is  then  carried  a  Httle  nearer  to  the  side  to  relax  the  great  pec- 
toral muscle.  This  tendon  is  cut  off  close  to  the  humerus  (Fig.  899).  The 
muscle  is  pulled  downward  and  inward  and  is  loosened  from  the  cephalic 
vein.  It  is  then  cut  off  near  the  lower  border  of  the  clavicle  and  the  sterno- 
clavicular articulation.  It  is  necessary  to  divide  the  nerves  that  enter  the  pec- 
toral muscle,  and  all  the  vessels  that  come  into  view  are  divided  between  twc 
clamps  and  tied. 

The  next  step  is  to  divide  the  tendon  of  the  lesser  pectoral  muscle  near  the 
coracoid  process  (Fig.  900).  Just  beneath  this  tendon  lies  the  subclavian 
vein.  The  surgeon  now  makes  a  transverse  division  of  the  fascia  over  the 
axilla,  and  thus  exposes  the  axillary  and  subclavian  veins  (Fig.  901). 

Meyer's  third  step  is  to  split  the  axillary  fat  over  the  upper  portion  of  the 
latissimus  dorsi  up  to  the  axillary  vein,  "thus  dividing  it  from  the  mass  of  fat 
that  enters  the  sulcus  bicipitalis  brachii." 

Next,  the  axillary  and  the  subclavian  veins  are  followed  up  to  where  the 


Fig.  900.— \Villy  Meyer's  operation  for  carcinoma  of  the  breast.  Finger  under  tendon  of  pectoralis 
minor  muscle.  Above,  cut  surface  of  clavicular  portion  of  pectoralis  major  parallel  to  clavicle  is  vis- 
ible (in  the  living,  the  belly  of  the  pectoralis  major  is  not  so  thoroughly  detached  from  that  of  the 
pectoralis  minor.    It  is  done  here  to  show  the  latter's  tendon). 

subclavian  passes  below  the  clavicle,  and  every  vessel  that  evidently  must  be 
cut  is  divided  between  two  ligatures  and  tied.  This  procedure  saves  a  great 
amount  of  hemorrhage.  Meyer  directs  us  to  be  careful  to  preserve  the  two 
superior  subscapular  nerves,  although  the  third  subscapular  must  be  sacrificed. 
The  next  step  in  the  operation  is  to  have  the  assistant  hold  up  the  mass  of 
partly  loosened  tissues  without  pulling  upon  them;  for  if  he  does  pull  upon 
them,  Meyer  truly  says,  he  is  apt  to  tear  off  pieces  of  periosteum  or  perichon- 


I440 


Diseases  of  the  Mammary  Gland 


drium;  and  such  bare  spots  are  liable  to  become  necrotic.  The  surgeon  now 
cuts  to  the  wall  of  the  chest,  being  careful  not  to  damage  the  great  serratus 
muscle.  Meyer  cautions  us  at  this  step  to  hold  the  blade  of  the  knife  horizon- 
tal; that  is,  "perpendicularly  toward  the  thorax."  "If  he  (the  surgeon) 
should  not  thus  turn  the  blade  of  his  knife,  but  cut  perpendicularly  downward 
toward  the  subscapular  muscle,  he  would  enter  the  fat  covering  and  enveloping 
the  nerves  and  blood-vessels  of  this  region,  thus  running  the  risk  of  unneces- 
sarily causing  considerable  hemorrhage  and  of  injuring  the  subscapular 
nerves.  In  the  general  run  of  cases  this  region  need  not  be  explored;  only  in 
very  advanced  cases  did  I  find  a  few  injected  glands  in  this  area." 

The  pectoralis  major  muscle  is  now  divided  close  to  the  wall  of  the  chest, 
the  cuts  being  parallel  to  the  ribs,  and  almost  level  with  them;  and  the  mass 
being  gently  drawn  toward  the  sternum.     By  watching  carefully,  one  may 


Fig.  901.— Willy  Meyer's  operation  for  carcinnn,  :  '  breast.  Subclavian  and  axillary  veins 
fully  exposed.  So  far,  glands  and  fat  tissue  not  removed;  smaller  vessels  still  in  connection  with 
main  trunks.    Finger  under  fat  toward  sulcus  bicipltalis,  its  nail  resting  on  axillary  vein. 

see  the  perforating  arteries  and  veins  drawn  out  by  traction  Ijefore  cutting 
them,  and  may  usually  catch  each  of  them  with  two  clamps  and  divide  be- 
tween the  clamps.  If  this  is  impossible,  they  are  divided  and  quickly  picked 
up.  The  last  tissue  that  holds  the  mass  to  the  chest-wall  is  composed  of  the 
muscle-fibers  from  over  the  sternum.  These  are  divided  close  to  the  sternum 
fFig.  902).  The  final  steps  consist  in  tying  all  blood-vessels,  draining,  and 
suturing  the  wound.     The  draining   is   done  through  a  perforation  in  the 


Treatment  of  Carcinoma  of  the  Mammary  Gland  1441 

posterior  flap.     It  may  be  tubal  or  by  gauze.     Gauze  has  the  advantage  of 
restraining  oozing  of  blood. 

This  operation  has  noteworthy  merits.  It  can  be  performed  far  more 
rapidly  than  can  any  other  method  that  I  have  ever  employed.  The  loss  of 
blood  is  comparatively  trivial,  because  in  this  operation  the  chief  blood- 
vessels are  divided  close  to  the  axillary  artery  and  tied.  In  removing  the  mass 
from  the  chest-wall  there  is  httle  bleeding,  except  what  comes  from  the  per- 
forating vessels,  hemorrhage  from  the  branches  of  the  axillary  being  entirely 
absent;  and  even  many  of  these  perforating  vessels  are  tied  before  being 
divided.     We  are  far  less  apt  by  this  method  than  by  the    usual  plan   to 


Fig.  902. -Willy  Meyer's  operation   for  carcinoma  of  the  breast. 

ready  to  be  cut  off. 


Pedicle  of  mass  over  sternum 


milk  lymph-containing  cancer  cells  into  the  wound,  or  in  aberrant  directions 
through  the  lymphatics.  As  Dawbarn  says,  the  squeezing  "of  the  breast  by 
the  retractors  during  its  oblation,  as  also  its  handling  when  separated,  save 
for  its  attachments  to  the  armpit, "  are  real  dangers  and  may  be  responsible 
for  rapid  recurrence  of  the  growth  ("Annals  of  Surgery,"  March,  1908). 
The  drain  is  removed  in  from  thirty-six  to  forty-eight  hours.  The  patient 
is  placed  in  a  sitting  posture  on  emerging  from  ether  and  is  allowed  out  of 
bed  on  the  fourth  or  fifth  day. 

Dressing  and  After-treatment. — The  dressing  must  be  wide  and  ample. 

Fluffed  up  gauze  is  pushed  into  the  axilla  to  obhterate  the  dead  space  and  the 

arm  is  bound  to  the  side  for  forty-eight  hours,  when  the  binding  is  removed, 

the  extremity  is  placed  on  a  pillow,  and  is  moved  a  little  more  each  day.     If 

91 


1442  Diseases  of  the  IMammary  Gland 

the  incision  was  placed  well  above  the  axillary  border  the  mobility  of  the  arm 
will  be  such  that  in  two  weeks  the  patient  can  place  the  hand  on  the  back  of 
the  head.  Some  surgeons  place  the  arm  at  once  after  the  operation  in  abduc- 
tion (upon  a  pillow  or  a  triangular  spMnt  which  rests  upon  the  side).  This 
is  unnecessary  if  the  incision  does  not  run  into  the  arm  and  in  front  and  above 
the  anterior  axillary  margin.  If  the  old  incision  in  the  axilla  is  made  early, 
abduction  and  all  other  plans  vaW  fail  to  prevent  limitation  of  movement. 

Inoperable  Malignant  Diseases  of  the  Breast.— This  term  im- 
plies that  a  radical  operation  looking  to  cure  is  impossible.  The  conditions  in 
which  it  is  impossible  have  already  been  specified  (page  1432).  Even  if  the 
case  is  judged  inoperable  from  the  radical  standpoint,  it  may  be  wise  to  re- 
move the  mammary  gland,  in  order  to  free  the  patient  from  a  hideous,  ulcer- 
ating area,  violent  pain,  and  harassing  hemorrhage. 

It  has  been  suggested  that  some  cases  inoperable  by  ordinary  methods  may 
be  subjected  to  removal  of  the  entire  upper  extremity  or  to  disarticulation  at 
the  shoulder-joint  with  some  prospect  of  cure.  My  own  view,  however,  is  that 
when  a  case  has  advanced  so  far  that  it  is  not  amenable  to  ordinary  operative 
treatment,  neither  of  the  above-mentioned  procedures  offers  any  reasonable 
chance  of  success.  If  the  pain  is  extremely  violent  in  an  inoperable  case, 
the  surgeon  may  relieve  it  by  dividing  the  brachial  plexus,  or  perhaps  by 
disarticulating  at  the  shoulder-joint. 

An  inoperable  case  may  be  greatly  improved — for  a  time,  at  least — by  the 
use  of  the  :v-rays ;  and  even  when  the  condition  is  not  benefited  in  other  ways, 
this  new  force  sometimes  mitigates  or  greatly  relieves  the  pain. 

Beatson's  Operation,  or  Double  Oophorectomy. — It  has  been  pointed 
cut  by  this  surgeon  that  there  is  a  certain  similarity  between  the  formation  of 
cancer  in  the  mammary  gland  and  the  process  of  lactation.  In  each  there  is 
an  enormous  production  of  embryonal  epitheHal  cells;  but  in  lactation  the 
epithelial  cells  undergo  fatty  degeneration,  and  in  cancer-formation  they  do 
not  do  so,  but  penetrate  into  the  tubules  and  the  acini  and  infiltrate  the  gland- 
structure.  Beatson  further  points  out  that  when  a  lactating  cow  is  spayed, 
it  continues  to  give  milk  indefinitely.  This  seems  to  indicate  that  removing 
the  ovaries  favors  the  fatty  degeneration  of  the  epithehal  cells.  This  operation 
has  been  performed  in  cases  of  inoperable  carcinoma  of  the  breast,  in  the  hope 
of  bringing  about  degeneration  in  the  tumor-mass.  In  the  great  majority 
of  cases  it  fails  utterly;  but  now  and  then  it  secures  a  notable  improvement, 
and  in  a  very  few  cases  cure  seems  to  have  been  obtained.  Abbe  obtained 
an  apparent  cure  in  two  patients.  It  was  at  first  thought  that  the  operation 
would  be  apphcable  only  to  persons  that  have  not  passed  the  menopause, 
but  one  of  Abbe's  patients  was  over  seventy  years  of  age.  Buthn,  however, 
says  that  there  is  no  genuine  cure  seemed  by  this  operation  on  record.  My 
o%\Ti  view  is  that  the  procedure  offers  but  Little  prospect  of  success,  but  that, 
as  it  does  ofi"er  some,  the  exact  facts  should  be  placed  before  the  patient,  and 
she  should  be  permitted  to  choose  whether  or  not  she  wishes  the  operation 
performed.  The  operation  is  not  to  be  considered,  however,  if  visceral  de- 
posits exist. 


The  Rontgen  or  X-rays  1443 


XXXIX.     SKIAGRAPHY     OR     RONTQENOQRAPHY     (THE     EM= 

PLOYMENT   OF   THE   X=RAYS).     THE    FIN5EN    LIGHT; 

BECQUEREL'S  RAY5;   RADIUM  RAYS. 

The  Rontgen  or  X=Rays. — The  cathode  rays  were  discovered  by 
Hittorf,  in  1869,  while  passing  an  induction  current  through  a  vacuum  tube. 
Crookes,  of  London,  greatly  improved  the  vacuum  tube,  and  obtained  a 
rarefaction  which  left  in  the  tube  but  one-millionth  of  an  atmosphere. 
This  last-named  obser^-er  found  that  when  an  interrupted  current  of  high 
potential  is  passed  through  a  vacuum  which  is  nearly  perfect,  fluorescence 
takes  place.  In  a  Crookes  tube-  the  positive  electrode  is  placed  at  some 
indifferent  point,  and  the  current  ixom  the  negative  electrode  flows  not  to  the 
positive,  but  directly  to  the  wall  of  the  tube  opposite  the  cathode,  and  at  this 
point  the  phosphorescent  glow  ^s  detected. 

In  1895  Rontgen,  of  Wiirzlurg,  while  making  a  study  of  cathode  rays  as 
developed  in  Crookes  tubes,  discovered  the  energ)'  which  he  named  the 
5c-rays.  Ro'.cgen  showed  that  at  the  wall  of  the  Crookes  tube  opposite  the 
negative  ekctrode  a  new  and  hitherto  unknown  energy  is  generated.  Be- 
cause of  the  imcertain  character  of  this  energy  he  gave  to  its  manifestation  the 
name  of  the  :\;-rays  or  unknown  rays. 

The  -c-rays  are  invisible ;  cannot  be  deflected,  refracted,  or  concentrated;  are 
not  influenced  by  the  magnet,  and  produce  none  of  the  ordinarily  recognized 
effects  of  heat.  The  rays  cannot  be  polarized,  travel  with  the  velocity  of  light, 
and  cause  fluorescence  in  certain  substances,  notably  in  the  tungstate  of 
calcium  (Edison) ,  platinocyanid  of  barium  (Rontgen),  and  the  platinocyanid  of 
potassium.  They  have  a  marvellous  power  of  penetration.  Freund  says  ("  Ra- 
dium Therapy"),  "Speaking  broadly  one  may  say  that  the  lighter  the  specific 
gravity  of  a  body  the  more  transparent  is  it  to  a:-rays.  On  the  other  hand, 
a  body's  opacity-  for  the  rays  increases  with  its  densit}',  though  not  in  the  same 
proportion."  "V.  Xovak  and  O.  Sule,  also  VoUer  and  Walter,  proved  that  the 
transparency  of  a  body  to  x-rays  depends  less  upon  its  densit}^  than  upon  its 
atomic  weight." 

The  ic-rays  in  their  action  on  photographic  plates  or  films  exhibit  actinic 
effects.  If,  therefore,  an  object  whose  component  parts  are  of  unequal 
density — e.  g.,  the  hand — is  placed  on  a  phonographic  plate  protected  from 
ordinary  Ught,  and  exposed  to  the  action  of  .r-rays,  the  plate  when  developed 
by  photographic  methods  \yi\\  exhibit  a  picture  of  the  shadows  cast  by  the  sev- 
eral parts  of  the  object.  Such  a  picture  is  known  as  a  skiagraph,  radiograph, 
or  a  Rontgenograph.  Similar  shadows  will  be  seen  on  a  fluorescent  screen  if 
the  object  is  between  an  excited  rc-ray  tube  and  the  screen.  The  portion  of 
the  screen  free  from  shadow  glows  with  fluorescence.  Such  a  screen  is  known 
as  a  fluoroscope  or  Rontgenoscope. 

The  real  nature  of  the  rays  remains  unkno^vn.  They  resemble  the  ultra- 
\iolet  and  Becquerel  rays  in  their  action  on  a  charged  electroscope  and  in 
producing  fluorescence  in  certain  substances,  but  the  latter  have  not  the  pene- 
trating power  of  the  former.  Many  theories  have  been  advanced,  but  the  most 
acceptable  has  been  on  the  electromagnetic  theory  of  Ught.     The  difference 


1444  Skiagraphy  or  Rontgenography 

between  the  Rontgen  rays  and  a  beam  of  sodium  Hght  is  said  to  be  that  the 
thickness  of  the  Rontgen  ray  pulse  is  very  small  compared  with  the  wave  length 
of  sodium  light,  and  that  in  the  Rontgen  rays  there  is  not  that  regular  periodic 
character  which  occurs  in  a  train  of  waves  of  constant  wave  length  (J.  J. 
Thompson). 

Solid  bodies  which  are  struck  by  the  x-rays  emit  new  rays  having  similar 
properties  (Sagnac),  known  as  secondary  rays,  and  less  powerful  than  the 
primary  rays. 

For  practical  purposes  we  may  consider  that  the  A-rays  have  penetrating 
and  actinic  properties. 

For  the  production  of  the  Rontgen  rays  the  essential  is  to  have  an  electric 
current  pass  through  a  Crookes  tube  of  rather  high  vacuum.  The  state 
or  degree  of  vacuum  controls  the  nature  of  the  rays.  A  tube  of  low  vacuum 
will  emit  soft  rays  of  low  penetrating  power,  while  the  rays  from  a  tube  of  high 
vacuum  will  penetrate  even  pure  sheet  lead.  The  vacuum  of  a  given  tube  does 
not  remain  constant  with  use,  the  tendency  being  for  the  vacuum  to  become 
higher.  Some  get  so  high  that  they  cannot  be  used.  All  modem  tubes  have 
some  de\ice  by  means  of  which  the  vacuum  may  be  regulated  and  controlled. 

The  soft  rays  are  rich  in  actinic  value,  but  because  of  their  feeble  penetrat- 
ing qualities  are  of  use  only  in  treating  superficial  conditions,  or  for  the  Ront- 
genography of  thin  parts,  and  where  much  contrast  of  shadows  is  desired.  On 
the  other  hand,  in  deep  and  dense  parts  satisfactory  results  can  only  be  ob- 
tained with  hard  rays.  In  the  hands  of  the  experienced  operator  the  quahty 
of  the  rays  is  adapted  to  the  condition. 

To  excite  the  Crookes  tube  or,  as  it  is  more  commonly  called,  the  x-Ta.y 
tube  it  is  necessary  to  have  an  electric  apparatus  capable  of  dehvering  a  cur- 
rent of  high  tension  and  as  far  as  possible  unidirectional.  Rontgen  used  the 
induction-coil  of  Ruhmkorflf.  The  fundamental  parts  of  an  induction-coil  are  a 
primary  ^\'inding,  which  receives  and  stores  up  the  electricity  from  its  origin  or 
from  its  source  of  supply,  an  interrupter,  to  make  and  break  the  current,  and  a 
secondary  \\'inding,  which  receives  the  current  and  delivers  it  to  a  negative  and  a 
positive  pole.  Wires  carried  from  these  poles  to  their  respective  terminals  on 
the.T-ray  tube  \\'ill  complete  the  circuit. 

A  static  machine  is  frequently  used  to  excite  Crookes  tubes,  but  only 
the  most  powerful  are  of  practical  value  in  x-ray  work.  The  most  recent  and 
powerful  apparatus  is  the  Rontgen  transformer,  invented  by  Snook,  of  Phila- 
delphia. The  first  machine  of  this  type  was  installed  in  Jefferson  Hospital 
in  June,  1907,  and  this  tj^DC  is  now  internationally  accepted  as  the  best. 
Many  of  the  German  firms  are  making  a  more  or  less  exact  copy  of  the 
Snook  apparatus.  This  apparatus  is  an  epoch-making  advance  in  the  con- 
struction of  the  Rontgen  transformer. 

The  induction-coil  is  the  most  widely  used  apparatus,  but  it  possesses 
many  disadvantages,  the  chief  of  which  is  that  its  output  is  not  constantly 
unidirectional.  The  static  machine  delivers  a  current  of  ideal  qualit}', 
but  one  lacking  in  quantity.  The  Rontgen  transformer  has  none  of  the  dis- 
advantages of  the  induction-coil,  is  capable  of  an  enormous  output  of  a  current 
free  from  inverse  discharge,  and  in  qualit)'  approaching  that  of  the  static  cur- 
rent. The  most  satisfactory  source  of  current  is  the  ordinary  electric-lighting 
circuit. 


Physiologic  Effects  of  the  Rontgen  Rays  1445 

Physiologic  Effects  of  the  Rontgen  Rays. — Clinical  observations  have 
determined  that  in  small  or  moderate  intensity  the  Rontgen  rays  act  as  a 
stimulant  to  cell-growth  and  metabolism,  while  prolonged  radiation  produces 
cell  destruction. 

Histologic  study  shows  that  the  cellular  elements  of  the  integument  are 
first  affected,  and  that  only  after  repeated  or  j)rolonged  exposures  are  the  normal 
connective-tissue  elements  acted  upon  noticeably. 

Cell  degeneration  occurs  and  is  followed  by  inflammatory  changes  in  the 
surrounding  tissues,  notably  in  the  blood-vessels. 

After  sufficient  irradiation  this  process  will  go  on  to  endarteritis  and 
necrosis. 

The  cause  of  these  tissue  changes  under  x-ray  exposure  has  been  variously 
conjectured,  viz. :  liberation  of  ozone  in  the  tissues  (Tesla) ;  interference  with 
cellular  nutrition  caused  by  static  electric  currents  "induced  by  the  introduc- 
tion of  the  patient's  tissues  into  the  high  potential  induction-field  surrounding 
the  tube"  (Leonard);  the  destruction  of  the  nerve  supply  of  the  tissue  (Hop- 
kins); irritation  of  the  peripheral  extremities  of  the  sensory  nerves,  causing 
vasomotor  paralysis  (Rudis-Jicinsky) ;  "no  doubt  there  is  some  chemic 
action  which  causes  metabolic  disturbances"  (Beck);  "the  effects  of  :x:-rays 
upon  tissues  and  upon  substances  sensitive  to  x-rays  are  due  to  actinic  proper- 
ties of  the  same  character  as  those  of  light"  (Pusey). 

It  is  now  generally  admitted  that  the  rays  themselves  are  responsible  for 
the  tissue  changes,  and  not  some  external  agent,  such  as  electric  discharges. 

The  earhest  noticeable  effect  of  exposure  to  x-rays  is  a  tanning  of  the  skin  in 
dark  people  or  reddening  of  the  skin  in  blondes.  Ormsby  has  noted  this 
analogy  between  the  action  of  x-rays  and  the  sun  rays. 

Glandular  structures  undergo  atrophic  changes  after  repeated  exposures. 
Its  action  on  the  nervous  mechanism  is  more  difficult  to  understand,  but  that 
it  has  anodyne  effects  in  certain  painful  conditions  is  beyond  question.  There 
is  also  testimony,  but  not  certain  evidence,  that  the  x-rays  have  an  inhibitory 
influence  on  the  sympathetic  nervous  system.  It  has  occurred  that  a  small 
ureteral  calculus,  lodged  in  the  lower  end  of  one  ureter  for  a  long  period,  has 
passed  into  the  bladder  within  a  few  days  after  x-ray  examination. 

The  influence  of  Rontgen  rays  is  in  many  cases  distinctly  inhibitory 
to  the  growth  of  bacteria. 

The  untoward  effects  from  overexposure  to  the  x-rays  may  range  from 
falling  out  of  the  hair  or  slight  irritation  of  the  skin  to  the  production  of 
steriUty,  extensive  sloughing  or  even  chronic  non-heaHng  and  painful  ulcers, 
cancer,  and  death.  These  affects  may  be  acute  or  chronic.  The  patient  is 
more  apt  to  develop  acute  conditions,  while  the  operator  or  investigator  is 
constantly  in  danger  of  the  remote  or  chronic  lesions. 

The  so-called  x-ray  bum  is  not  a  burn,  but  a  dermatitis  or  a  gangrenous 
process.  A  burn  results  from  heat,  begins  on  the  surface  and  at  once,  is  ac- 
companied by  pain  from  the  moment  of  its  origin,  and  is  followed  by  inflamma- 
tion starting  from  the  surface  burnt.  An  x-ray  burn  does  not  come  in  evi- 
dence for  several  days  or  for  a  longer  time  after  the  application  of  the  cause, 
and  the  inflammation  begins  in  the  skin  rather  than  upon  its  surface.  So 
called  x-ray  bums  may  be  classified  by  stages  or  degrees.  In  a  bum  of  the 
first  degree  the  skin  is  hyperemic,  more  or  less  tender,  and  may  itch  or  bum. 


1446  Skiagraphy  or  Rontgenography 

there  is  increased  pigment  formation  and  the  outer  layer  of  the  skin  will  ''pull 
off"  as  in  sunburn.  It  may  develop  any  time  after  a  few  days,  but  usually 
does  so  in  from  ten  to  twenty.  Such  a  condition  is  popularly  known  as  a 
"reaction."  No  treatment  is  required  for  dermatitis  of  this  degree,  unless  there 
is  severe  itching  or  burning,  when  we  may  use  the  following  preparation  advised 
by  Dr.  Martin  F.  Engman  ("Interstate  Med.  Jour.,"  July,  1903):  It  con- 
sists of  12  drams  of  boric  acid,  i  ounce  of  zinc  oxid,  i  ounce  of  starch,  i 
ounce  of  subnitrate  of  bismuth,  i  ounce  of  olive  oil,  3  ounces  of  lime-water,  3 
ounces  of  lanolin,  and  1 2  drams  of  rose-water.  The  powder  is  rubbed  in  a 
mortar,  the  lanoHn  is  added.  The  oUve  oil  and  lime-water,  mixed,  are  slowly 
added  to  the  powder  and  lanolin.  The  mixture  is  stirred,  the  rose-water  is 
added,  and  the  preparation  is  beaten  into  a  creamy  paste.  If  itching  is 
severe,  i  to  2  per  cent,  of  carbolic  acid  is  added.  The  paste  is  spread  on 
several  thicknesses  of  gauze  and  the  gauze  is  covered  with  a  rubber  dam. 

In  an  ".r-ray  burn"  of  the  second  degree  the  condition  becomes  more 
painful,  vesicles  or  even  bullae  are  formed,  there  is  swelling,  and  if  the 
blisters  are  opened  the  denuded  cutis  will  weep  and  is  sensitive  to  touch  and 
to  direct  contact  vidth  air. 

This  condition  requires  Uttle  treatment  beyond  aseptic  attention  and 
protection  from  further  exposure  to  :x;-ray  or  air. 

The  ":x;-ray  burn"  of  the  third  degree  involves  all  the  layers  of  the  skin  and 
more  or  less  of  the  underlying  tissue.  In  an  area  of  sloughing  the  slough  is 
white,  adherent,  tough,  and  stringy.  Hopkins  calls  the  process  "white  gan- 
grene" (G.  G.  Hopkins,  "Phila.  Med.  Jour.,"  Jan.  6,  1900).  The  pain  is 
excruciating  and  constant,  seeming  as  if  "red-hot  coals  were  held  against  the 
body."  Sloughing  may  continue  for  weeks  or  months,  and  the  exudate  is 
profuse  and  irritating.  The  process  may  eventuate  in  gangrene  of  a  limb  or 
large  area.  Such  ulcers  require  months  to  heal,  if  they  heal  at  all,  and  are 
not  improved  by  the  treatment  which  relieves  ordinary  burns.  Excision  with 
subsequent  skin-grafting  or  amputation  may  be  necessary.  In  the  early  stages 
alkaline  astringents  give  the  best  results,  e.  g.,  a  mixture  composed  of  2  drams 
each  of  zinc  oxid  and  bismuth  subnitrate,  ^  fluidram  each  of  hquor  potassa 
and  liquor  plumbi  subacetatis,  2  drams  of  glycerin,  and  sufficient  lime-water 
to  make  6  fluidounces. 

This  mixture  may  be  applied  twice  daily  and  will  relieve  much  of  the  itch- 
ing and  burning  as  well  as  control  the  exudate.  It  should  be  appHed  over  a 
considerable  area  surrounding  the  seat  of  inflammation.  Ointments  should 
not  be  used  to  relieve  pain.  Leonard  considers  them  conducive  to  malignant 
changes 

In  extensive  ulceration  the  wound  must  be  kept  as  clean-  as  possible  and 
free  from  irritants.  When  sloughing  ceases  and  granulation  tissue  forms, 
mild  stimulants  may  be  applied. 

The  patient's  general  health  should  be  improved  in  every  possible  manner. 

Skin-grafting  is  not  usually  successful  vidthout  excision  of  the  floor  of  the 
ulcer,  but  should  be  tried.  In  spite  of  all  treatment  the  condition  may  remain 
a  chronic  ulcer  and  be  subject  to  malignant  change. 

Sometimes  the  results  of  an  x-ray  burn  may  be  most  serious.  In  a  case 
reported  by  J.  P.  Tuttle  it  became  necessary  to  amputate  the  thigh  ("Med. 
Record,"  May  5,  1898). 


The  Uses  of  the  Rontgen  Rays  1447 

The  chronic  "A--ray  burn"  or  chronic  .^-ray  dermatitis  is  seen  among  operators 
or  men  working  more  or  less  constantly  with  the  rays.  The  onset  is  very 
insidious.  Ulcers  may  not  form  for  a  year  or  more.  The  earliest  signs  of 
trouble  are  brittleness  of  the  finger-nails  and  itching  about  the  matrices. 
Scratches  on  the  fingers  heal  sluggishly.  The  skin  atrophies,  telangiectases 
form,  vesicles  appear  and  disappear,  keratoses  develop,  fall  off,  and  return. 
Small  ulcers  start  and  gradually  heal,  reappear,  become  more  extensive,  pain- 
ful, and  sluggish.  The  finger-nails  drop  off,  leave  sensitive  surfaces,  and 
grow  again  indifferently  or  in  a  misshapen  condition. 

If  exposure  is  continued  the  ulceration  advances,  and  the  tendons  and  even 
phalanges  may  slough  away.  Usually  when  ulceration  of  this  kind  has  started, 
the  damage  is  irreparable  except  through  amputation  or  excision,  with,  of 
course,  absolute  protection  from  further  exposure. 

These  lesions  are  most  common  on  the  hands,  but  may  occur  elsewhere. 

That  malignant  changes  take  place  in  chronic  .T-ray  lesions  has  been  de- 
finitely shown  clinically  and  by  the  microscope.  Porter,  of  Boston,  has  made 
an  extensive  study  of  these  lesions,  and  emphasizes  the  importance  either  of 
excision  and  skin-grafting  or  amputation  as  methods  of  treatment. 

His  results  are  excellent.  PaUiative  treatment  should  be  Hmited  to  cleanli- 
ness and  care. 

Sterilization  of  either  sex  by  use  of  the  ^c-ray  is  possible  and  should  be 
guarded  against. 

Can  the  x-rays  cause  death?  The  x-rays  do  not  cause  death  directly,  but 
may  inaugurate  a  lesion  which  eventually  causes  death.  Death  may  follow 
a  burn  without  being  directly  due  to  it.  Carcinomata  have  developed  in 
chronic  x-ray  lesions  and  produced  death;  4  fatal  cases  have  been  reported 
in  the  United  States  from  multiple  carcinomata  following  chronic  x-ray  der- 
matitis (C.  A.  Porter  and  C.  J.  White,  paper  before  the  American  Surg.  Assoc, 
in  1907). 

Unnecessary  exposure  to  x-rays  is  to  be  avoided.  The  operator  should 
remain  as  far  away  from  the  excited  tube  as  possible,  and  have  between  it 
and  him  a  lead  screen  no  less  than  \  inch  in  thickness  and  of  dimensions 
sufficient  to  protect  his  entire  person.  The  patient  is  to  be  protected 
from  undue  irradiation  by  means  of  lead-glass  or  lead-covered  tube-holders 
and  lead  diaphragms.  In  the  treatment  of  lesions  beneath  the  skin  some  form 
of  filter  should  be  used  over  the  exposed  area.  Sheet  aluminium  is  commonly 
used.    Pfahler  has  suggested  the  use  of  sole  leather. 

The  function  of  the  filter  is  to  absorb  the  soft  rays,  which  would  be  otherwise 
taken  up  by  the  skin  and  would  irritate  that  structure.  With  proper  care  pa- 
tients may  be  treated  safely  and  frequently  over  a  long  period  of  time. 

The  Uses  of  the  Rontgen  Rays. — In  the  hands  of  trained  and  experienced 
workers  this  agent  is  a  most  valuable  aid  in  nearly  all  branches  of  medicine 
and  surgery;  whereas,  in  the  hands  of  the  untaught  and  inexperienced,  it 
may  lead  to  grave  error  in  diagnosis,  and  is,  even  at  the  present  day,  fraught 
with  all  the  dangers  of  its  early  use.  The  general  practitioner  should  not  at- 
tempt its  use  without  first  having  had  practical  training. 

For  diagnostic  purposes  studies  may  be  made  by  means  of  the  fluoro- 
scope  or  by  making  Rontgenographs  (skiagraphs,  radiographs). 

Edison's  fluoroscope  consists  of  four  sides  of  a  box,  one  end  being  open  and 


1448  Skiagraphy  or  Rontgenography 

made  to  fit  tightly  over  the  observer's  eyes,  the  other  end  being  closed  with 
cardboard  made  fluorescent  by  smearing  it  vi^ith  mucilage,  and  before  the  muci- 
lage is  quite  dry  sprinkling  it  with  crystals  of  tungstate  of  calcium.  If  it  is 
desired  to  examine  the  hand  with  a  fluoroscope,  the  extremity  is  held  opposite 
an  excited  Crookes  tube  and  from  6  to  10  inches  away  from  it;  the  end  of  the 
fluoroscope,  which  is  covered  with  fluorescent  paper,  is  placed  near  the  surface 
of  the  hand  which  is  away  from  the  tube,  and  the  observer  looks  through  the 
other  end  of  the  instrument.  The  flesh  seems  but  a  dim  haze,  and  the  shadows 
of  the  bones  are  distinctly  outHned.  The  fluoroscope  is  of  advantage  in  the 
examination  of  the  movable  organs  of  the  chest  and  abdomen.  This  method, 
except  with  special  forms  of  apparatus,  endangers  both  the  patient  and  opera- 
tor. It  was  used  extensively  in  the  pioneer  days  and  caused  the  vast  majority 
of  injuries  to  the  early  workers. 

Rontgenographic  technic  has  been  wonderfully  developed  in  the  last  few 
years.  This  method  has  the  advantage  of  safety  to  patient  and  operator, 
as  well  as  permanency  of  record.  With  the  most  improved  apparatus  a 
Rontgenograph  of  any  portion  of  an  averaged  sized  person  can  easily  be  made 
with  an  exposure  of  five  seconds  or  less,  so  that  the  motion  of  breathing  need 
not  interfere  as  it  did  in  former  years.  Children  are  skiagraphed  by  in- 
stantaneous exposure  and  seldom  require  an  anesthetic.  It  is  the  most  valu- 
able agent  we  have  for  the  study  of  bone  conditions.  In  fractures  the  rays 
enable  us  to  determine  the  nature  of  the  injury,  the  amount  of  splintering,  the 
existence  of  impaction,  the  question  whether  or  not  the  fragments  are  in  contact 
or  can  be  brought  in  contact,  the  direction  of  the  fine  of  fracture,  the  variety 
of  deformity,  the  existence  of  more  than  one  fracture,  the  presence  of  epiphy- 
seal separation  or  dislocation  alone  or  with  a  fracture,  the  existence  of  an 
ununited  fracture,  the  presence  of  callus,  and  if  the  splints  are  holding  the 
fragments  in  apposition.  By  means  of  stereoscopic  Rontgenographs  fractures 
of  any  part  of  the  skull  can  be  detected;  and  the  actual  relations  of  the  parts 
in  fracture  or  dislocation  of  the  hip,  pelvis,  or  shoulder  can  be  determined. 

Fractures  of  the  spine  in  the  lower  dorsal  region  are  difficult  to  demonstrate 
in  stout  persons.  In  bone  disease  the  experienced  Rontgenologist  can  greatly 
aid  the  surgeon  in  making  a  differential  diagnosis.  The  dissolved  appearance 
of  the  bone  in  myeloid  sarcoma  without  evidence  of  demarcation  differs  from 
the  tuberculous  bone,  which  presents  a  picture  of  impoverishment  of  mineral 
matter,  but  with  more  or  less  distinctly  outHned  foci  of  destruction.  Bone 
atrophy  due  to  pressure  or  disuse  presents  still  another  picture.  Chronic 
periostitis,  osteoperiostitis,  necrosis,  chronic  osteomyeHtis,  and  osteosclerosis  cast 
shadows  more  or  less  characteristic.  Bone-cysts,  giant-cell  sarcoma,  osteoma, 
and  osteophytes  show  clearly.  Conditions  about  the  joints,  such  as  arthritis 
deformans,  ossifying  bursitis,  and  foreign  substances  within  the  joints,  the 
character  of  deformity  and  whether  due  to  disease  or  congenital  defect  can  be 
determined.  The  bone  changes  of  rickets  and  scurvy  appear  in  distinguishable 
manner. 

Pathologic  processes  in  the  accessory  sinuses  of  the  skull  and  in  the  mastoid 
cells  are  capable  of  detection,  and  the  condition  as  well  as  position  of  the  teeth 
can  be  shown  with  great  clearness. 

Intrathoracic  conditions  from  very  early  tuberculous  deposit  in  the  lungs  to 
generaUzed  involvement;  thickened  pleura;  extensive  effusion;  cavity  forma- 


The  Uses  of  the  Rontgen  Rays  1449 

tion;  consolidation,  the  excursus  and  relations  of  the  diaphragm  (Williams' 
sign)  to  fixation  of  this  organ;  from  the  normal  heart  to  all  sorts  of  variations  in 
size,  shape,  and  position;  dilated  aorta;  aneurysm;  the  presence  of  enlarged 
mediastinal  or  peribronchial  glands;  and  tumors  of  this  region,  can  be  studied 
to  great  advantage  in  connection  with  physical  and  clinical  findings. 

Through  the  painstaking  and  untiring  efforts  largely  of  Rieder,  Holz- 
knecht,  and  Jonas  abroad,  and  of  Hulst,  Pfahler,  and  Leonard  in  America 
much  has  been  made  practical  in  the  diagnosis  of  disease  of  the  alimentary 
canal.  By  means  of  the  technic  they  have  developed  the  Rontgenologist  can 
demonstrate  constriction,  dilatation,  diverticulum,  and  often  tumors  involving 
the  esophagus;  the  size,  position,  shape,  motor  activity  of  the  stomach;  hour- 
glass contraction,  invasion  in  the  walls  by  irregular  indentations  of  malignant 
growths,  often  the  probe-like  opening  through  a  pyloric  stenosis,  and  occa- 
sionally the  presence  of  ulcer  of  the  stomach.  We  can  determine  the  char- 
acter of  peristaltic  function  in  the  small  intestine  or  obstruction  of  the  small 
intestine,  and  in  addition,  the  presence  or  absence  of  ptosis,  dilatation,  or 
contraction  of  the  large  intestine. 

In  a  study  of  the  urinary  organs  the  Rontgenologist  should  be  able  to  deter- 
mine the  size  and  position  of  the  kidneys  in  a  normal  subject  weighing  160 
pounds  or  less.  In  larger  persons  only  the  best  skiagraphs  will  show  the  out- 
hne  of  the  kidneys.  In  patients  under  160  pounds  renal  calculi  from  the  size 
of  a  No.  2  shot  to  the  largest  found,  whether  single  or  multiple,  in  one  kidney 
or  both,  and  relatively  their  situation  in  the  kidneys  (except  in  stones  composed 
of  pure  uric  acid)  can  be  determined  in  Rontgenographs  of  the  best  quality. 
One  can  frequently  aid  in  the  diagnosis  of  movable  kidney,  tuberculosis  of  the 
kidney,  advanced  pyelitis  and  pyonephrosis  or  hydronephrosis,  although  in 
these  conditions  the  rc-ray  e\idence  is  purely  corroborative  of  other  clinical 
findings.  Ureteral  calculi  are  subject  to  the  same  display  as  renal  calculi. 
The  course  of  the  ureters  can  be  sho\^^l  clearly  if  ureteral  catheters  styleted 
with  fine  fuse  wire  are  passed  from  the  bladder  to  the  kidney.  This  is  of  value 
when  in  the  region  of  the  lower  end  of  the  ureters  there  appears  a  shadow 
of  a  foreign  body  which  may  be  cast  by  a  ureteral  calculus,  a  small  deposit  of 
bone  in  some  of  the  pelvic  Ugaments,  a  phlebolith,  calcareous  gland,  an 
appendoUth,  or,  in  the  female,  calcareous  deposits  in  the  mucous  membrane 
of  the  vagina  or  in  the  tubes.  The  ureteral  stone  is  never  round;  it  is 
oval  or  irregularly  oblong.  In  the  portion  of  the  ureter  overlying  the  sacro- 
ihac  joint  it  is  possible  that  even  a  small  phosphatic  or  oxalate  stone  may 
escape  detection.  In  doubtful  cases  the  ureters  should  be  catheterized.  Stone 
in  the  bladder  is  usually  well  shown,  but  here  one  is  more  apt  to  encounter  pure 
uric  acid  calculi.  The  Rontgen  method  is  particularly  valuable  in  disclosing 
the  presence  of  a  stone  encysted  in  the  mucous  membrane  of  the  bladder,  or 
when,  because  of  disease  of  the  prostate,  instrumentation  is  very  painful  or 
contraindicated.  The  Rontgenologist  should  never  say  that  a  stone  does 
not  exist,  especially  in  the  bladder.  An  absolutely  necessary  procedure, 
prior  to  study  of  the  urinary  organs,  is  to  have  the  patient  thoroughly  purged 
and  the  stomach  empty.  The  stomach  usually  lies  over  the  left  kidney,  the 
hepatic  flexure  of  the  colon  overlies  the  region  of  the  right  kidney,  and  the  ure- 
ters are  throughout  their  course  in  a  position  to  be  obscured  by  intestinal 
contents.     Hardened  feces  in  the  rectum  may  be  mistaken  for  vesical  calculi. 


1450  Skiagraphy  or  Rontgenography 

The  Hver  and  spleen  offer  but  Httle  field  for  useful  study.  Enlargement 
may  be  seen.  Biliary  calculi  are  not  often  seen  in  the  a:-ray  negative,  because 
they  are  lacking  in  density  and  are  surrounded  by  thick  structures.  One  can- 
not make  a  negative  diagnosis  of  biliary  calculus  by  means  of  the  x-ray.  Chronic 
discharging  sinuses  may  be  outlined  and  studied  after  they  have  been  injected 
with  bismuth  paste.  This  study  is  best  made  by  means  of  stereoscopic  nega- 
tives. In  advanced  atheroma  the  outlines  of  the  arteries  of  the  extremities  are 
seen  in  the  Rontgenograph. 

Localization  of  Foreign  Bodies. — Metallic  bodies,  such  as  bullets,  pieces 
of  steel  or  iron,  coins,  pins,  needles,  tin,  zinc,  brass,  etc.,  can  be  detected  in  any 
portion  of  the  body  and  accurately  localized.  Fragments  of  stone,  granite,, 
marble,  and  lead-glass  can  be  skiagraphed  except  when  very  small  and  deeply 
situated.  Drainage-tubes  and  iodoform  gauze  can  be  found  if  lost  in  a  sinus 
or  cavity.     Anthracite  coal,  glass  other  than  lead-glass,  or  spHnters  of  wood  are 


Fig.  903. — Gunshot- wound  of  the  lung.  Rib  resection  for  secondary  hemorrhage  into  the 
pleural  sac  ten  days  after  the  injury  ;  bullet  not  removed.  Hemorrhage  arrested  by  packing 
with  gauze.     Skiagraph  taken  three  months  afterward  shows  the  bullet  (author's  case). 

diihcult  to  detect  unless  they  are  of  considerable  thickness,  are  not  superim- 
posed by  bone,  and  are  imbedded  in  thin  structures  so  that  the  foreign  body 
can  be  brought  close  to  the  sensitive  plate.  When  the  fingers  are  the  seat  of 
injury,  anteroposterior  and  lateral  views  are  sufficient.  When  in  the  esoph- 
agus, trachea,  or  bronchi  the  fluoroscope  should  be  used  for  differentiation, 
after  which  a  skiagraph  will  assist. 

Foreign  bodies  elsewhere  should  be  localized,  either  by  stereoscopic  Ront- 
genographs  if  near  a  joint  or  in  close  relation  to  some  bony  surgical  guide. 
(See  stereoscopic  skiagraph,  Fig.  904,  of  bullet  in  a  shoulder  case  of  mine, 
where  the  bullet  lay  in  close  relation  to  the  anterior  surface  of  the  glenoid 
process,  and  on  a  line  perpendicularly  below  the  coracoid  process.  This 
bullet  was  removed  with  ease.) 

Pieces  of  needle  in  the  palm  of  the  hand  or  soft  parts  near  the  surface  are 
best  localized  stereoscopically  when  a  definite  relation  between  some  known 


Localizatio:.  of  Foreign  Bodies  1451 

surface  mark  and  the  foreign  body  can  be  determined.  A  thin  coating  of 
bismuth  on  the  palm  of  the  hand  will  cause  every  line  in  the  skin  to  show  on  the 
skiagraph.  When  the  foreign  body  is  deeply  situated  and  not  in  close  reladon 
to  a  surgical  guide,  some  method  of  localization  must  be  used  to  indicate  the 
depth  and  direction  from  a  known  point  on  the  surface  in  which  the  body 
lies.  All  localizing  methods  are  based  upon  displacement  of  the  foreign  body 
shadow  by  making  two  or  more  exposures  ^vith  the  .v-ray  tube  in  different  and 
known  positions,  while  the  part  containing  the  foreign  body  and  sensitive  plate 
remain  in  one  position.     This  has  been  called  the  triangulation  method. 

Mackenzie-Davidson  first  used  the  cross-threads,  from  the  known  positions 
of  the  focus  point  of  the  .v-ray  tube  to  their  respective  shadows  on  the  negative, 
the  crossing  of  the  threads  representing  the  position  of  the  foreign  body  in 
relation  to  the  sensitive  plate  and  focus  tube.     Measurements  were  then  made 


Fig.  904. — Bullet  localized  by  means  of  stereoscope.      RLinoved. 

from  some  point  on  the  skin  of  the  patient  that  had  registered  with  a  known 
position  on  the  negative.  The  Rontgenologist  could  then  say  that  the  foreign 
body  lay  perpendicularly  beneath  a  certain  point  to  a  definite  depth.  Nearly 
all  the  modern  localizing  schemes  are  modifications  of  this  general  plan,  and 
diff'er  mainly  in  the  manner  of  determining  the  position  of  the  focus  point  of  the 
5c-ray  tube. 

A  foreign  body,  unless  it  be  large,  may  easily  lie  to  one  side  of  an 
imaginary  line  as  drawn  by  the  scalpel  to  the  depth  of  2  or  more 
inches;  again  a  change  in  position  of  the  patient  will  alter  the  relation  of  the 
foreign  body  to  a  perpendicular  line  from  the  indicated  surface  point.  A 
modification  of  the  Mackenzie-Davidson  scheme  was  devised  by  Snook. 
Manges  improved  the  apparatus  by  limiting  the  possibility  of  error,  and  in 
using  it  as  a  guide  during  the  surgical  operation.  With  this  apparatus  all 
relations  between  the  patient,  foreign  body,  source  of  x-rays,  and  sensitive 


1452 


Skiagraphy  or  Rontgenography 


plate  are  obtained,  maintained,  and  regained  with  ease  and  mechanical  ac- 
curacy. 

The  localizer  is  a  detachable  part  of  the  tube  carriage  of  the  Rontgen- 
ographic  table,  and  consists  of  a  metal  frame  having  two  upright  bars  connected 
near  their  top  by  a  horizontal  bar  and  at  the  bottom  by  a  cur\ed  bar.  The 
upper  bar  is  deeply  notched  to  a  scale  of  inches  on  each  side  of  its  center. 
To  the  cuned  bar  are  attached  four  adjustable  clamps  and  rods,  three  of  which 
are  used  to  estabUsh  a  relation  between  the  localizer  and  the  patient,  the  fourth 
to  indicate  the  depth  and  direction  of  the  foreign  body.  The  fourth  rod  can 
be  moved  through  a  sleeve  in  the  direction  of  its  long  axis,  and  can  be  held  at 
the  desired  depth  by  a  collar  and  set-screw  attachment.  The  horizontal  bar 
Df  the  tube  carriage  is  graduated  on  one  side  to  correspond  with  the  notches 


Fig.  905. — Modified  Mackenzie- Davidson  localizer. 


on  the  cross-bar  of  the  localizer.  The  focus  point  on  the  target  of  the  tube 
(the  source  of  the  rays)  is  accurately  determined  by  sighting  from  cross  Unes 
on  one  side  of  the  lead-glass  tube  shield  to  cross  Unes  on  the  opposite  of  the 
shield,  and  is  exactly  6  inches  above  the  level  of  the  notched  bar  of  the  local- 
izer. The  relation  between  the  focus  point  and  the  sensitive  plate  is  obtained 
by  means  of  a  clamp  on  the  edge  of  the  table.  This  clamp  has  two  flat  metallic 
arms  projecting  over  the  sensitive  plate  and  a  fixed  rod  externally,  against  which 
the  upright  bar  of  the  carriage  rests. 

In  making  the  locaHzation  the  patient  is  placed  on  the  table  as  if  for  surgical 
operation.  A  sensitive  plate,  loX  12  or  1 1  X  14,  is  put  under  the  part  containing 
the  foreign  body,  the  tube  clamp  appUed,  and  the  tube  carriage,  localizer, 
and  tube  are  adjusted  and  leveled.     Three  of  the  adjustable  rods  of  the  local- 


Localization  of  Foreign  Bodies  1453 

izer  are  made  to  touch  the  surface  of  the  patient  at  as  widely  separated  points 
as  possible,  in  which  positions  they  are  tightly  clamped.  These  three  spots 
are  touched  with  silver  nitrate. 

After  all  adjustments  are  examined,  and  the  height  of  the  tube  from  the 
plate  noted,  the  carriage  cross-bar  is  elevated  and  the  localizer  removed.  By 
lowering  the  tube-carrier  to  6  inches  below  its  original  position,  the  focus  point 
of  the  tube  vnW  be  at  the  level  formerly  occupied  by  the  cross-bar  of  the  local- 
izer, and  if  the  carriage  cross-bar  is  shifted  to  a  definite  distance  to  one  side  of 
zero,  the  focus-point  will  be  in  the  corresponding  position  held  before  by  a 
notch  on  the  cross-bar  of  the  localizer.  After  carefully  adjusting  the  tube- 
holder  an  exposure  is  made.     The  carriage  is  then  shifted  to  the  opposite  side 


Fig.  906. — Bullet  localized  by  method  described  in  the  text.     Removed. 

of  zero  in  the  same  extent  and  manner,  and  a  second  exposure  made.  The 
patient  is  removed,  the  plate  developed,  and  tracings  of  the  shadows  of  the 
foreign  body  and  arms  of  the  table  clamp  made  on  paper.  This  tracing  is  taken 
to  the  table  and  put  in  relation  \\-ith  the  table  clamp.  The  localizer  is  then 
made  to  occupy  its  original  position,  and  threads  are  carried  from  the  notches 
on  its  cross-bar  to  the  tracings  of  the  foreign-body  shadows.  At  the  crossing 
of  these  threads  is  the  position  of  the  foreign  body  in  relation  to  the  localizer. 
The  point  of  the  fourth  adjustable  rod  can  be  made  to  touch  the  cross-threads 
from  any  direction.  If  the  Rontgenologist  cannot  determine  the  best  direc- 
tion for  incision,  he  may  consult  the  surgeon,  and  when  this  is  known,  the  point 
of  the  rod  is  made  to  touch  the  crossing  of  the  threads,  and  its  collar  and  set- 
screw  fixed. 


1454  Skiagraphy  or  Rontgenography 

At  the  operation  for  removal  of  the  foreign  body  the  locaUzer  is  sterilized 
and  appHed  to  the  patient,  preferably  by  the  Rontgenologist,  if  he  has  had 
sufficient  surgical  training  to  render  his  assistance  of  value  from  the  standpoint 
of  surgical  technic ;  or  he  may  thoroughly  instruct  the  surgeon  in  the  manip- 
ulation of  the  apparatus.  The  following  precautions  are  to  be  observed: 
First,  the  localizer  must  be  handled  carefully  to  prevent  displacement  of  the 
rods;  and  second,  the  patient  should  be  placed  on  the  operating  table  in  about 
the  position  he  occupied  on  the  Rontgenographic  table,  so  that  the  three 
marked  spots  on  the  skin  receive  the  three  fixed  points  of  the  localizer.  With 
the  apparatus  in  position,  the  indicating  rod  is  placed  in  its  carrier  or  sleeve, 
and  when  its  point  touches  the  skin  the  long  axis  of  the  rod  indicates  the  direc- 
tion of  incision,  while  the  distance  between  the  collar  on  the  rod  and  the  sleeve 
shows  the  depth  at  which  the  foreign  body  lies.  During  the  course  of  the  opera- 
tion the  locaUzer  should  be  repeatedly  applied,  so  that  excessive  manipulation 
of  the  tissues  may  be  avoided. 

The  determination  of  the  localization  of  pieces  of  metal,  glass,  or  other 
substances  in  the  eye  or  immediately  adjacent  structures  by  means  of  the 
Rontgen  rays  requires  that  the  shadow  of  the  foreign  body,  as  shown  on  the 
radiograph,  be  studied  in  relation  to  the  shadow  of  one  or  more  opaque  objects 
of  known  position.  Dr.  William  M.  Sweet  has  designed  a  localizing  apparatus 
which  consists  of  two  ball-pointed  indicating  rods,  one  opposite  the  center  of 
the  cornea  and  the- other  situated  at  a  known  distances  from  the  first  to  the 
temporal  side.  The  patient  is  in  the  recumbent  posture,  with  the  photographic 
plate  to  the  side  of  the  head  corresponding  with  the  injured  eye.  Two  nega- 
tives are  made,  one  with  the  tube  horizontal  or  nearly  so  with  the  plane  of  the 
two  indicating  rods,  and  the  other  at  any  distance  below  this  plane.  A  special 
chart  is  employed,  containing  a  section  of  the  normal  adult  eyeball,  and  Hnes 
are  drawn  indicating  the  planes  of  shadow  at  the  two  exposures.  Where  these 
planes  cross  is  the  position  of  the  foreign  body  in  relation  to  the  structures  of 
the  eyeball  and  orbit. 

The  accuracy  of  this  method  of  locaUzation  has  been  fully  demonstrated 
by  its  author  and  other  x-ray  workers,  but  the  student  found  considerable 
difficulty  in  understanding  the  Hnes  to  be  drawn  upon  the  chart  to  represent  the 
planes  of  shadow  at  the  two  exposures,  so  that  Dr.  Sweet  has  recently  de- 
signed an  entirely-  new  apparatus,  in  which  a  single  indicator  is  employed. 
As  shown  in  the  illustration  (Fig.  907)  the  tube-holder,  indicating-ball,  and 
plate-holder  are  upon  a  movable  stage,  and  the  tube  is  in  a  fixed  carrier,  so 
that  the  angle  of  the  rays  with  the  eyeball  and  the  distance  of  the  tube  from 
the  plate  are  always  the  same.  A  telescope  and  reflecting  mirror  permit 
the  observer  to  adjust  the  instrument  until  the  image  of  a  cross-wire  in  the 
tube  is  in  direct  contact  with  the  lateral  image  of  the  summit  of  the  cornea. 
After  this  adjustment  is  made,  the  indicating-ball  is  exactly  10  millimeters 
from  the  center  of  the  cornea. 

The  patient  fixes  with  the  good  eye  upon  a  circular  mirror  placed  12  inches 
above  the  injured  eye,  so  that  there  is  no  movement  of  the  eye  during  exposure, 
and  the  visual  line  of  the  injured  eye  is  parallel  with  the  plate.  The  two 
exposures  are  made  upon  one  plate,  one  with  the  tube  in  the  zero  position  of  the 
apparatus,  so  that  the  rays  pass  in  a  direction  corresponding  with  the  horizon- 
tal plane  of  the  eyeball;  and  the  second  exposure  with  the  tube  at  its  farthest 


Localization  of  Foreign  Bodies 


1455 


])oint  on  the  graduated  rod  to  the  right  or  left  of  the  first  position,  depending 
upon  which  eye  is  to  be  examined.  Two  metal  shutters  are  used  to  uncover 
any  desired  portion  of  the  photographic  plate. 

Since  the  relative  position  of  the  tube  in  reference  to  the  indicating-ball  and 
the  photographic  plate  remains  fixed  and  known,  the  direction  of  the  rays  in 
]3assing  through  the  eyeball  follows  a  definite  course,  which  is  the  same  for  the 
two  separate  exposures.  Lines  have,  therefore,  been  drawn  upon  the  localiz- 
ing chart  to  indicate  the  direction  of  the  rays  at  the  two  exposures,  each  line 
with  the  required  amount  of  divergence  to  represent  rays  coming  from  a  point 


Fig.  907. Sweet's  apparatus  for  locating  foreign  bodies  in  the  eyeball  and  orbit.* 

the  distance  of  the  tube  from  the  photographic  plate.  After  development 
the  photographic  plate  is  placed  in  a  frame  containing  cross  lines  indicating  the 
focal  coordinates  of  the  rays.  The  radiograph  is  moved  until  the  shadow  of 
the  indicating-ball  is  in  apposition  with  a  spot  representing  the  indicating-ball 
on  the  key-plate.  A  reading  is  then  made  of  both  the  vertical  and  horizontal 
coordinate  lines  which  pass  through  the  shadow  of  the  body  on  the  radiograph, 
and  this  is  transferred  to  the  corresponding  lines  on  the  locaHzation  chart. 
Three  readings  are  taken,  and  after  having  been  transferred  to  the  chart,  the 
point  of  crossing  of  the  several  fines  indicates  the  location  of  the  foreign  body 
in  the  eyeball  or  orbit. 

The  accuracy  of  the  locaHzation  depends  only  upon  the  care  with  which 
the  operator  adjusts  the  indicating-ball  opposite  the  center  of  the  cornea  and 
*  Transactions  of  the  American  Ophthalmological  Society,  1909. 


1456  Skiagraphy  or  Rontgenography 

at  a  definite  and  fixed  distance  from  it.  After  the  exposures  are  made  and  the 
plate  developed,  the  determination  of  the  situation  of  the  foreign  body  is 
simply  a  question  of  reading  from  a  key-plate  and  transferring  these  readings 
to  a  localization  chart. 

The  x-Rays  in  the  Treatment  of  Diseases. — It  may  be  said  that 
the  beneficial  results  obtained  through  the  use  of  .v-rays  is  in  direct  propor- 
tion to  the  skill  of  the  Rontgenologist.  No  two  Crookes  tubes  are  alike 
in  their  behavior,  they  vary  widely  from  day  to  day,  and  even  during  one 
operation. 

Unfortunately  there  is  no  accurate  method  of  computing  dosage  either  in 
quahty  or  quantity.  The  quality  of  rays  may  be  fairly  well  estimated  by 
determining  the  electric  resistance  the  tube  manifests.  Tubes  of  high  vacuum 
offer  great  resistance,  and  emit  hard  or  highly  penetrating  rays,  while  tubes  of 
lower  vacuum  offer  less  resistance  to  the  passage  of  the  electric  current  and 
emit  softer  rays.  The  quantity  of  a  certain  quality  of  rays  may  be  roughly 
estimated  by  the  amount  of  current  passing  through  a  tube  of  known  vacuum 
in  a  definite  period  of  time.  The  instrument  commonly  used  in  this  country 
for  this  purpose  is  known  as  the  miUiamperemeter,  the  standard  of  measure- 
ment of  electric  units.  In  Europe  the  physiochemic  properties  of  the  rays 
are  more  in  vogue  as  a  means  of  measurement  of  dosage.  In  the  United 
States  most  Rontgenologists  give  repeated  short  exposures,  while  abroad  the 
,  tendency  is  to  use  infrequent  but  powerful  applications  of  the  rays. 

In  any  case,  ability  gained  by  experience  is  essential  for  the  proper 
selection  and  control  of  the  Crookes  tube  in  the  treatment  of  a  given  condition. 

The  effects  of  :r-rays  which  offer  possibiUties  of  therapeutic  appHcation  are, 
according  to  Pusey,  as  follows  ("  The  Rontgen  rays  in  Therapeutics  and  Diag- 
nosis," Pusey-Caldwell) :  (i)  "Their  effect  in  causing  atrophy  of  the  append- 
ages of  the  skin;  (2)  their  destructive  action  upon  organisms  in  living  tissues; 
(3)  their  stimulative  action  upon  the  metabohsm  of  tissues;  (4)  their  power 
of  destroying  certain  pathologic  tissues;  (5)  their  anodyne  effect."  A 
qualitative  generahzation  may  be  made,  /.  e.,  superficial  diseases  should  be 
treated  in  most  instances  with  tubes  of  low  vacuum,  while  deeper-seated  lesions 
should  be  exposed  to  the  rays  from  tubes  of  higher  vacuum.  Quantitatively, 
for  causing  atrophy  of  the  skin  appendages,  stimulating  action  upon  metabohsm, 
and  for  the  rehef  of  pain  in  other  than  mahgnant  conditions,  mild  apphca- 
tions  or  short  exposures  should  be  given;  on  the  other  hand,  for  destructive 
action  maximum  exposures  are  demanded. 

In  diseases  of  the  skin  the  surrounding  healthy  parts  are  to  be  protected 
from  the  action  of  the  rays  by  means  of  sheet-lead,  while  the  diseased  portion 
is  directly  exposed.  In  treating  lesions  beneath  the  surface  it  may  be  necessary 
to  expose  an  area  beyond  the  evident  Hmits  of  the  disease,  but  all  overlying 
healthy  skin  must  be  protected  from  the  non-penetrating  rays  by  a  filter  such 
as  aluminum  or  leather. 

Because  of  the  possible  untoward  effects  of  exposure  to  .v-rays,  diseased  con- 
ditions amenable  to  other  forms  of  treatment  should  not  be  treated  by  the  rays 
except  "as  a  last  resort."  It  is  strikingly  true,  however,  that  the  most  signal 
results  of  x-ray  therapy  are  obtained  in  conditions  that  are  frequently  incurable 
by  other  means.  Many  of  the  chronic  diseases  of  the  skin  that  yield  but 
slowly  to  medication  will  be  found  safely  and  promptly  amenable  to  .v-ray 


The  .r-Rays  in  the  Treatment  of  Diseases  1457 

txealment.  Among  these  diseases  are  acne,  eczema,  lupus  vulgaris,  lupus 
erythematosis,  and  psoriasis. 

The  treatment  is  also  beneficial  in  tinea  tonsurans,  favus,  sycosis,  alopecia 
areata,  hypertrichosis,  and  prurigo. 

In  the  treatment  of  maUgnant  growths  the  Ronlgen  rays  find  their  greatest 
field  of  therapeutic  usefulness.  With  improved  technic,  jjermitting  of  massive 
doses  of  the  rays  vdth  safety  to  overlying  and  adjacent  healthy  tissue,  the 
results  are  far  more  favorable  than  in  the  earher  x-ray  days. 

In  superficial  epithelioma,  rodent  ulcer,  and  Marjolin's  ulcer,  without 
glandular  involvement,  cure  is  the  rule,  recurrence  is  becoming  less  frecjuent 
and  is  amenable  to  cure,  and  the  cosmetic  effect  is  good. 

When  deeper  structures  are  invaded  by  carcinoma  cure  becomes  less 
frequent  and  recurrence  more  frequent  in  direct  proportion  to  the  depth  of 
the  lesion  and  the  degree  of  glandular  involvement.  Even  in  advanced  cases, 
however,  for  instance  when  the  entire  contents  of  an  orbit  are  involved,  large 
portions  of  the  nasal  structure  destroyed,  or  extensive  areas  of  subcutaneous 
tissue  the  seat  of  foul  and  painful  ulceration,  and  where  operative  interference 
is  contraindicated,  the  x-rays  relieve  pain  and  decrease  discharge.  Some 
reach  a  stage  of  improvement  where  surgical  procedure  may  be  instituted 
with  hope  of  success,  and  in  a  few  actual  cures  result  from  x-ray  treatment 
alone. 

Epitheliomata  involving  mucous  membranes,  particularly  of  the  lower  hp, 
anus,  or  vagina,  should  not  be  treated  by  x-ray  until  after  surgical  methods 
have  been  exhausted.  The  rays  are  used  to  prevent  recurrence  after  oper- 
ation. The  reason  why  the  rays  should  be  regarded  as  a  last  resource  in 
these  cases  is  that  mucous  membranes  are  very  susceptible  to  the  action  of  the 
rays  and  are  as  apt  to  be  destroyed  as  are  the  cancers.  Further,  in  the  lower 
lip,  glandular  involvement  is  almost  sure  to  exist.  All  forms  of  carcinoma 
with  glandular  involvement,  if  operable,  should  be  subjected  to  radical  surgical 
extirpation,  and  the  rays  should  be  used  only  as  a  prophylactic  measure  against 
recurrence. 

It  is  difficult  to  determine  the  value  of  x-rays  in  this  capacity,  but  theoretic- 
ally they  should  Ije  of  use. 

All  cases  of  primary  inoperable  carcinoma,  regardless  of  situation,  extent 
of  involvement,  or  cause  lor  being  inoperable,  should  be  exposed  to  vigorous 
irradiation.  Likewise,  all  recurrences  after  operative  procedure  is  prohibited 
ought  to  be  afforded  the  possible  benefits  of  x-ray  treatment. 

In  sarcoma  the  results  are  becoming  more  favorable  also,  but  this  form  of 
treatment  is  by  no  means  on  a  basis  of  success  that  it  may  interfere  with  or 
supersede  surgical  methods.  It  is  a  fact,  however,  that  in  some  cases  in  which 
operation  was  not  agreed  to  by  the  patient  or  parents,  or  in  which  the  con- 
dition was  deemed  by  the  surgeon  to  be  inoperable,  surprising  results  have 
been  obtained  with  the  Rontgen  rays  alone  or  in  connection  with  the  use  of 
Coley  toxins.  I  know  of  a  case  of  rapidly  growing  periosteal  sarcoma  of  the 
humerus  in  a  young  girl,  the  onset  of  which  was  so  rapid  that  the  mass  was 
considered  to  be  a  subperiosteal  abscess,  but  which  was  proved  by  x-ray  ex- 
amination and  later  by  incision  to  be  sarcoma,  that  has  remained  well  eighteen 
months  after  treatment  by  .r-ray  and  Coley  toxins  at  first,  and  later  by  x-ray 
alone.  The  arm  is  strong  and  useful,  and  the  girl  is  robust.  At  the  site  of 
92 


1458  Skiagraphy  or  Rontgenography 

origin  there  remains  a  spur  of  bone  which  is  about  i  inch  long,  ^  inch  in 
thickness,  and  has  a  density  equal  to  that  of  the  densest  portion  of  the  humerus. 
Isolated  cases  of  inoperable  retroperitoneal  sarcoma,  fibrosarcoma  of  the 
uterus,  and  other  deep-seated  tumors,  cHnically  or  after  exploratory  opera- 
tion considered  sarcoma,  have  been  reported  as  greatly  benefited,  controlled, 
or  cured. 

Good  results  in  .r-ray  treatment  of  inoperable  sarcoma  are  obtained  only 
with  the  best  apparatus.  In  the  deep-seated  growths  hard,  penetrating  rays 
in  maximum  quantity  are  demanded.  The  treatment  must  extend  over  a 
period  of  months,  so  that  great  care  and  skill  is  required.  There  is  little 
reason  to  believe  that  .x-rays  cause  metastatic  involvement  in  other  parts. 

Tuberculous  sinuses  that  are  not  deep  seated  are  frequently  quickly  bene- 
fited, and  old  tuberculous  glands  in  which  ulceration  has  recurred  after  opera- 
tion should  always  receive  the  x-ray  treatment,  as  some  remarkable  results  have 
been  obtained. 

Of  late  years  exophthalmic  goiter  has  been  treated  more  or  less  successfully 
with  Rontgen  rays.  It  is  distinctly  of  value  in  many  cases  that  are  not  operable 
or  amenable  to  other  forms  of  treatment.  The  Mayos  use  the  rays  for  a 
time  before  operating.  Many  of  the  distressing  nervous  symptoms  are  re- 
lieved, the  pulse-rate  is  materially  lowered,  and  changes  favorable  to  future 
operation  take  place  in  the  gland  and  its  capsule.  Dr.  Alanges,  the  Ront- 
genologist at  Jefferson  College  Hospital,  in  an  extreme  case  of  exophthalmic 
goiter,  has  obtained  a  remarkably  good  result  from  .r-ray  treatment,  so  far 
as  reUef  of  the  nervous  symptoms,  tachycardia,  and  improvement  of  the  gen- 
eral health  of  the  patient  are  concerned.  There  is  not  a  marked  diminution 
in  the  size  of  the  goiter,  but  the  exophthalmus  is  distinctly  less.  The  patient 
has  been  following  her  occupation  as  a  weaver  without  inconvenience  for 
nearly  a  year. 

Here  again  more  data  is  to  be  desired  before  other  methods  of  treating 
this  disease,  especially  surger\',  are  to  be  replaced  by  Rontgenization.  These 
rays  are  perhaps  the  most  valuable  therapeutic  agent  we  have  in  the  treatment 
of  myelogenic  or  splenomedullary  leukemia  and  lymphatic  leukemia.  Since 
Senn's  report  some  years  ago  this  plan  of  treatment  has  been  widely  used  in 
connection  with  other  remedies.  A  spleen  of  enormous  size  \vill  sometimes 
go  back  to  normal,  high  leukocyte  counts  disappear,  red  cells  and  hemoglobin 
increase,  and  the  general  health  of  the  patient  improves.  Stengel  and  Pan- 
coast  have  decidedly  improved  the  technic  of  :r-ray  treatment  in  their  system- 
atic exposures  of  the  bony  skeleton,  particularly  the  long  bones,  with  com- 
paratively Httle  irradiation  of  the  spleen  until  late  in  the  course  of  treatment. 

Very  advanced  cases  are  apt  to  impro\'e  greatly  for  a  time,  but  even  in 
the  early  cases  recurrence  usually  appears  sooner  or  later,  and  becomes  less 
responsive  to  treatment.  Life  may  be  prolonged  for  many  years,  but  perma- 
nent cure  is  rare. 

Chronic  suppurating  sinuses  sometimes  heal  under  the  influence  of  these 
rays,  and  varicose  ulcers  are  benefited  by  moderate  exposure.  The  pain  in 
rheumatic  affections  and  neuralgias  is  often  greatly  reheved. 


The  Finsen  Light,  Becquerel's  Rays,  Radium  Rays  1459 


THE  FINSEN  LIGHT. 

It  is  known  that  below  the  spectrum  of  white  light  are  heat  rays  and  above 
the  spectrum  of  white  light  are  short  violet,  actinic,  or  chemical  rays.  The 
short  violet,  with  the  indigo  rays  and  blue  rays,  constitute  the  Finsen  light. 
Ultraviolet  rays  cause  an  electrified  body  to  discharge,  excite  fluorescence  in 
certain  substances,  affect  a  photographic  plate,  and  are  bactericidal  but  have 
little  power  of  penetrating  tissues  and,  it  is  said,  do  not  inflame  tissues.  Ultra- 
violet rays  pass  readily  through  rock  salt  or  ice,  which  will  not  transmit  heat-rays. 

Finsen  taught  us  to  use  these  rays  therapeutically.  He  first  obtained 
the  rays  from  sunUght,  intercepting  the  heat-rays  by  ice  or  rock  crystals. 
Later  he  obtained  them  from  the  arc  Ught. 

Blood  in  part  prevents  the  passage  of  the  Finsen  light,  hence  in  using 
the  light  we  must  make  the  area  on  which  the  rays  are  to  act  nearly  bloodless. 
This  is  done  by  pressing  firmly  upon  the  part  with  a  rock  crystal  through 
which  water'passes.  The  rays  pass  through  the  crystal  and  the  water  ab- 
sorbs the  heat-rays.     The  rays  are  especially  serviceable  in  lupus. 

BECQUEREL'S  RAYS. 

Becquerel  discovered  in  1896  that  uranium  and  some  of  its  compounds  give 
off  a  radiation  similar  to  but  much  weaker  than  the  x-rays.  Among  these 
radiant  substances  are  pitchblende,  radium,  and  uranium.  These  rays  are 
luminous,  actinic,  and  skiagraphic  (McFarland),  and  may  produce,  by  prolonged 
action,  dermatitis  similar  to  an  x-ray  dermatitis. 

RADIUM  RAYS. 

Monsieur  and  Madame  Currie,  after  prolonged  research,  found  that  thorium 
and  certain  ores  of  thorium  and  uranium  (pitchblende)  are  radio-active,  pitch- 
blende being  more  strongly  so  than  uranium  itself.  The  conclusion  was  that 
pitchblende  contained  a  strongly  radio-active  element  and  that  it  was  not 
uranium.  In  1903  they  discovered  the  sources  of  radio-activity  to  be  two 
hitherto  unknown  elements,  radium  and  polonium  (see  Dawson  Turner  in 
"Brit.  Med.  Jour.,"  Dec.  12,  1903). 

Turner  tells  us  (Ibid.)  that  radium  gives  off  a  radio-active  emanation  and 
three  kinds  of  rays  (alpha-rays,  beta-rays,  and  gamma-rays).  It  also  emits 
heat,  and  is  itself  at  a  higher  temperature  than  the  medium  in  which  it  rests. 
The  emanation  from  radium  is  a  luminous  gas,  which  can  be  condensed  by 
great  cold,  and  which  imparts  radio-activity  to  certain  bodies.  It  is  to  this 
gas  that  most  of  the  curative  effects  of  radium  can  be  attributed. 

Alpha-rays  consist  of  a  stream  of  positively  charged  gaseous  particles.  Tur- 
ner points  out  that  these  particles  are  each  about  twice  the  size  of  a  hydrogen 
atom,  travel  at  a  velocity  of  20,000  miles  a  second,  and  have  Httle  power  of 
penetration.  In  fact,  the  pentrating  power  of  the  alpha-rays  is  so  sHght  that 
they  do  not  pass  through  the  glass  of  a  tube  (Robert  Abbe  in  "  Med.  Record, " 
Oct.  12,  1907).  The  beta-rays  consist  of  particles  each  being  joVir  the  size  of 
a  hydrogen  atom  and  being  strongly  actinic.  These  rays  are  said  by  Turner  to 
resemble  cathode  rays  and  to  be  far  more  penetrating  than  alpha-rays.  Gamma- 
rays  resemble  x-rays  and  have  great  penetrating  power  (Dawson  Turner, 


1460  Radium  Rays 

in  "Brit.  Med.  Jour.,"  Dec.  12,  1903).  It  is  probable  that  radium  also 
generates  or  helps  to  generate  a  gas  called  helium,  which  has  no  action  on 
tissues. 

The  actions  of  radium  are  extraordinary.  A  man  entirely  blind  cannot 
perceive  light  when  radium  is  brought  near  him,  but  one  not  quite  but  almost 
blind  can,  and  one  quite  blind  to  form  l)ut  with  retention  of  some  light  percep- 
tion can  actually  see  the  shapes  of  objects  near  a  screen  rendered  luminous 
by  radium  (Turner) .  Turner  tells  us  that  a  man  retaining  vision,  who  covers 
his  eyes,  can  detect  radium  held  in  a  box  behind  his  head.  If  dry  seeds  before 
planting  are  exposed  to  radium  rays  sprouting  will  be  retarded  in  proportion 
to  the  time  of  exposure.  When  meal  worms  are  exposed  to  the  rays  "they  go 
on  living  as  meal  worms,  'veritable  Methuselahs,'  as  it  has  been  said,  while 
their  sisters  and  brothers,  unradiumized,  progress  for  generations,  completing 
several  cycles  of  beetles,  eggs,  meal  worms,  etc."  (Abbe,  Ibid.).  Radium  rays 
are  germicidal,  but  act  very  slowly  and  feebly.  Skiagraphs  can  be  taken  with 
the  rays.  Water  and  other  materials  may  be  rendered  radio-active  by 
exposure  to  radium  rays.  Probably  certain  natural  waters  have  subtle  powers 
due  to  radio-activity.  On  the  tissues  radium  may  act  to  produce  a  retro- 
gressive effect;  may  increase  self -digestion;  may  cause  irritation  and 
inflammation,  and  so  block  blood-vessels.  Severe  reaction  may  result  in 
ulceration.  Sometimes  a  spreading  eruption,  like  that  of  scarlet  fever,  follows 
overaction.  Abbe  says  that  when  an  ulcerated  surface  is  treated  or  when  a 
tube  of  radium  is  inserted  in  a  wound  for  twenty-four  hours,  a  "specific 
toxemia"  frequently  arises.  "The  symptoms  will  be  headache,  chill,  general 
aching,  coated  tongue,  fever  up  to  from  103°  to  106°  F.,  and  an  occasional 
rash-like  scarlatina"  (Abbe,  in  "Med.  Record,"  Oct.  12,  1907).  Some  hold 
that  radium  acts  similarly  to  the  .v-rays  and  that  the  ;c-rays  can  do  anything 
radium  can  do.  Most  observers  beheve  that  the  radium  rays  have  a  specific 
action  and  can  accomplish  things  impossible  to  the  .v-rays. 

Radium  therapy  is  assuming  a  high  degree  of  importance.  How  great 
its  future  is  to  be  we  can  only  guess.  Sir  Frederick  Treves  bids  us  be  cau- 
tious in  our  estimates,  although  he  thinks  there  may  be  a  great  future  for 
radium  therapy  in  surgery  ("Brit.  Med.  Jour.,"  Jan.  30,  1909).  It  has 
cured  many  surface  carcinomata  and  sarcomata,  keloids,  angeiomata,  moles, 
pigmented  moles,  and  warts.  It  is  particularly  valuable  in  lesions  about 
the  face  when  it  is  desirable  to  avoid  scars;  in  lesions  of  the  nostril,  mouth,  and 
other  cavities.  It  has  been  used  most  advantageously  for  epithelioma  of  the 
eyelid  (see  the  striking  cases  reported  by  Abbe,  in  "Med.  Record,"  Oct.  12, 
1907).  When  treating  a  surface  lesion  the  rays  are  obtained  from  radium 
bromid,  which  material  is  kept  in  a  hermetically  sealed  glass  tube.  In  a  deep- 
seated  tumor  an  incision  may  be  made  and  a  tube  of  radium  bromid  be  inserted  in 
the  wound  and  allowed  to  remain  for  some  hours  or  a  number  of  hours.  At- 
tempts are  being  made  to  treat  internal  conditions  by  the  inhalation  of  radium 
emanations  or  by  the  administration  of  materials  which  have  been  rendered 
radio-active  and  contain,  so  to  speak,  radium  emanations  in  solution.  Radio- 
active w'ater  has  been  tried  for  cancer  of  the  stomach.  It  is  extraordinary  how 
even  very  brief  applications  may  be  followed  by  notable  changes.  In  one  of 
Abbe's  cases  an  epithelioma  of  the  forehead  disappeared  after  one  exposure  of 
an  hour's  duration.     Another  on  the  side  of  the  nose  disappeared  in  four  weeks 


Effects  Produced  by  Lightning  1461 

after  one  exposure  of  an  hour's  duration.  A  cancer  involving  one-third  of  the 
upper  eyeUd  entirely  disa])peared  in  two  weeks  after  three  five-minute  expos- 
ures. After  an  exposure  no  changes  are  apparent  for  several  days  or  a  week. 
The  skin  at  the  site  of  application  then  begins  to  burn  and  itch  and  becomes 
reddened.     The  irritation  endures  for  about  two  weeks. 

Confusion  has  arisen  because  of  the  varying  strengths  and  amounts  used 
by  different  operators.  Bromid  of  radium  is  the  salt  usually  employed. 
Abbe  takes  as  a  standard  10  mgr.  of  bromid  of  radium  and  tests  other  specimens 
by  this  (see  his  method  of  testing  in  previously  quoted  article) .  He  calls  the 
10  mgr.  of  strong  German  bromid  of  radium  "the  working  unit."  In  malig- 
nant disease  the  best  results  have  followed  one  hour's  exhibition  of  the  "working 
unit"  to  small  growths  and  three  or  four  hours  to  large  growths,  "with  an 
interval  of  one  month  for  study  of  the  effect"  (Abbe,  Ibid.).  Ischemia 
favors  powerful  action  of  radium  rays. 


XL.  INJURIES    BY    ELECTRICITY. 

Effects  Produced  by  Lightning. — Every  year  in  the  United  States 
about  224  persons  are  killed  by  lightning  (McAdie).  An  individual  may  be 
struck  directly  or  he  may  be  shocked  by  the  lightning  having  struck  a  near- 
by object.  A  person  can  be  struck  while  in  a  room,  but  there  is  more  danger 
when  exposed,  especially  in  the  open  country.  To  be  under  a  single  tree  or 
under  a  tree  at  the  margin  of  a  forest  during  a  thunder-storm  is  dangerous, 
but  to  be  in  a  wood  or  under  a  hedge  is  reasonably  safe.  The  oak  is  struck 
more  often  and  the  beech  less  often  than  other  trees  (Professor  McAdie, 
quoted  in  "Draper's  Legal  Medicine").  It  is  not  safe  during  a  thunder- 
storm to  stand  by  a  chimney  or  fireplace,  in  an  open  doorway,  or  close  to 
cattle  (Professor  McAdie,  Ibid.).  One  should  not  use  a  telephone  or 
ring  a  bell  during  a  storm.  It  is  unwise  to  run,  as  the  current  of  air 
thus  created  is  a  danger.  Telegraph  posts  should  be  avoided.  A  pool 
of  water  is  a  dangerous  neighbor.  Horses  and  other  animals  should  be 
given  a  wide  berth.  The  victim  of  lightning  may  be  killed  instantly.  The 
body  may  show  no  mark,  but  there  are  usually  burns.  Burns  may  be 
superficial  or  a  large  area  (as  a  Hmb)  may  be  carbonized.  Death  is  the 
fate  of  over  one-third  of  those  struck.  Tidy  states  that  out  of  54  cases, 
21  died  and  33  recovered.  Recovery  may  follow  even  when  there  has  been 
severe  burning.  Post-mortem  examination  may  fail  to  reveal  a  lesion,  but  in 
many  cases  severe  burns  are  discovered;  in  some  there  are  laceration  of  tissue, 
crushing  of  bones,  and  fearful  injury.  Bums  are  especially  apt  to  occur  at 
the  points  where  the  current  entered  and  emerged.  The  clothes  are  usually 
singed  or  torn,  shoes  are  especially  apt  to  be  torn  apart  or  destroyed.  Yet 
a  man  may  be  burned  or  killed  and  the  clothing  be  undamaged,  or  the  under- 
clothing may  be  destroyed  and  the  outer  garments  escape  uninjured.  A 
person's  clothing  may  be  destroyed,  he  may  be  left  naked,  and  yet  he  may  not 
be  injured.  Clothing  may  be  cast  far  off,  and  in  some  cases  is  said  to  have 
utterly  disappeared.  The  typical  lightning-marks  are  arborescent  tracings, 
representing  the  course  of  bood-vessels,  produced  by  disorganization  and 


1462  Injuries  by  Electricity 

efifusion  of  blood  as  the  fluid  travels  through  it.  Occasionally  metal  objects, 
such  as  buttons,  knives,  money,  keys,  etc.,  are  fused,  and  spread  as  a  metallic 
film  over  a  considerable  portion  of  the  surface  of  the  body.  Bichat  stated 
that  in  death  from  lightning  rigor  mortis  does  not  occur.  This  statement  is 
now  known  to  be  an  error  (see  the  3  cases  reported  by  M.  Tourdes).  As 
a  rule,  there  are  early  but  perhaps  brief  rigor  mortis,  retained  fluidity  of  blood, 
and  distention  of  the  brain  with  venous  blood.  Putrefaction  is  early  and 
rapid.  A  man  killed  by  lightning  may  remain  in  the  exact  attitude  in  which 
he  was  struck  dead.  He  may  not  be  disfigured,  his  clothing  may  be  intact, 
and  yet,  almost  at  a  touch,  he  may  crumble  to  ashes  because  the  body  was 
practically  incinerated  (see  the  apparently  authentic  cases  quoted  by  Flam- 
marion  in  "Thunder  and  Lightning").  In  most  cases  killed  the  body  shows 
burns.  The  cause  of  death  by  lightning  was  supposed  by  Hunter  to  be 
destruction  of  muscular  contractility,  and  by  Richardson  the  resolution  of 
the  blood  into  gases.  It  is  asserted  that  some  deaths  are  due  to  actual  dis- 
organization of  vital  structure  and  that  others  are  due  to  shock  or  inhibition. 
Spitzka  believes  that  death  from  electric  shock  is  due  to  asphyxia,  to  paralysis 
of  the  heart  with  fibrillary  contractions  of  that  organ,  or  to  a  combination  of 
these  conditions.  An  individual  struck  by  lightning  may  recover  even  when 
heis apparentlydesid.  Sestier  collected  reports  of  77  persons  struck  by  lightning; 
7  of  them  were  apparently  dead  for  a  number  of  hours,  but  finally  reacted.* 
Brouardel  says  in  such  cases  the  death-like  state  may  be  ascribed  to  inhibition, 
caused  by  a  maximum  degree  of  stimulus. f  When  death  from  lightning  is 
not  immediate,  the  condition  may  be  as  above  outlined,  the  individual  being 
apparently  dead,  without  obvious  respiration  or  pulse.  He  may  be  insensible, 
with  slow  and  labored  respiration,  a  weak  and  irregular  pulse,  and  dilated 
pupils,  and  may  remain  in  this  condition  for  a  few  minutes  or  for  several  hours. 
The  above  condition  is  not  to  be  distinguished  from  severe  concussion  of  the 
brain.  Every  individual  suffering  from  the  effects  of  lightning  should  have 
his  entire  body  carefully  examined  to  see  if  physical  injuries  exist  (fractures, 
wounds,  burns,  ecchymoses,  arborescent  tracings).  The  consequences  of 
lightning-stroke  are  many  and  various.  There  may  be  rapid  and  complete 
recovery,  gradual  recovery,  traumatic  neurasthenia,  sloughing  bums,  partial 
paralysis,  which  is  usually  recovered  from  (Nothnagel),  but  which  may  be 
permanent;  hysteria,  blindness,  change  of  character,  and  actual  insanity. 

Treatment. — Do  not  pronounce  a  person  dead  until  a  thorough  attempt 
at  resuscitation  has  been  made.  Raise  the  head  a  little,  draw  the  tongue 
forward,  make  artificial  respiration,  occasionally  tickle  the  epiglottis,  apply 
external  heat,  massage  over  the  heart,  and,  if  the  means  are  at  hand  and  the 
man  is  apparently  dead  or  all  but  dead,  throw  salt  solution  and  adrenalin  into 
a  large  artery  and  toward  the  heart,  as  advised  by  Crile  and  Dolley  (page  467). 
Do  not  give  alcoholic  stimulants.  If  the  respiration  is  feeble,  make  tongue 
traction  and  employ  artificial  respiration.  Apply  the  stream  of  a  warm  douche 
to  the  head,  rub  the  Hmbs  vdth  mustard,  put  a  mustard  plaster  over  the  heart 
and  another  to  the  back  of  the  neck,  wrap  the  individual  in  hot  blankets,  give 
enemata  of  hot  saline  fluid,  and  strj'chnin  hj'podermatically.     In  some  cases 

*  Sestier,  "  De  la  Foudre,"  Paris,  1866.  Quoted  by  Brouardel  in  his  lectures  upon 
"Death  and  Sudden  Death." 

fBenham's  translation  of  Brouardel's  lectures  upon  "Death  and  Sudden  Death." 


Effects  of  Artificial  Currents  1463 

venesection  has  seemed  to  be  of  benefit.  Lumbur  puncture  may  be  tried. 
When  the  individual  reacts,  treat  any  existing  condition  symptomatically, 
and  treat  particular  physical  injuries  according  to  their  character. 

Effects  of  Artificial  Currents. — Individuals  may  receive  dangerous 
or  fatal  shocks  by  contact  with  wires  carrying  a  powerful  electric  current,  by 
contact  with  a  dynamo,  or  with  some  metal  object  which  has  become  accidentally 
charged  by  a  powerful  current.  The  shock  may  be  from  contact  with  both 
poles  of  a  circuit  (while  standing  on  the  ground  and  touching  one  pole  of  a 
"grounded"  circuit);  when  actual  contact  has  not  occurred,  but  a  person  has 
been  very  close  to  a  high-tension  current  and  the  current  has  jumped  an  inch 
or  several  inches  through  the  air;  when  a  person  insolated  from  the  ground 
grasps  the  conductor  with  both  hands  (Spitzka,  Journal  Med.  Soc.  of  New 
Jersey,  1909).  Workmen  for  electric  companies,  pedestrians  in  the  streets  of 
a  city  which  is  lighted  by  electricity  or  in  which  trolley  cars  are  employed, 
roofers,  and  firemen  are  liable  to  be  injured  by  electricity.  During  many 
fires  in  cities  five  electric  wires  fall  and  charge  the  rails  of  a  street-car  track, 
the  iron  of  a  hook-and-ladder  truck,  water-tower,  or  a  fire-escape.  Firemen 
who  come  in  contact  with  such  charged  materials  are  shocked.  I  have  seen 
dozens  of  men  thus  shocked,  but  have  as  yet  seen  no  fatal  case.  There  are 
enormous  differences  in  individual  resistance  and  susceptibility.  Spitzka  points 
out  that  in  one  case  death  followed  a  shock  of  65  volts,  and  others  have 
survived  shocks  of  many  thousand  volts.  The  amount  of  current  the  indi- 
vidual gets  from  the  circuit  is  influenced  by  the  tension  of  the  current;  the 
ground  he  stands  on  (metal  floors  and  wet  floors  are  most  dangerous) ;  the 
area  of  contact  (limited  area  of  contact  means  serious  burning  and  less 
general  shock,  broad  area  means  little  or  no  burning  and  severe  shock) ;  the 
nature  of  the  tissue  (the  thick  palm  offers  less  resistance  than  the  lip  and  the 
more  callus  the  palm  of  the  hand  the  greater  the  resistance) ,  and  the  duration 
of  the  contact.  An  alternating  current  is  decidedly  more  dangerous  than  a 
continuous  current  of  equal  strength.  The  constant  current  causes  a  shock 
only  as  the  circuit  is  opened  and  closed.  While  the  current  is  passing  con- 
tinuously there  is  no  shock,  although  dreadful  bums  may  be  caused  at  this  time. 
The  alternating  current  causes  rapidly  repeated  violent  shocks.  The  arc  light 
is  either  an  alternating  or  a  direct  current.  "  Low-tension  currents  with  30  to 
150  alternations  are  more  dangerous  to  the  heart  than  if  of  more  than  500  fre- 
quency. Greater  frequencies,  as  in  Tesla's  currents,  are  practically  harmless  " 
(Spitzka,  Ibid.) .  An  artificial  current  acts  like  lightning.  It  may  produce 
instant  death,  it  may  produce  unconsciousness,  delirium,  stertorous  respi- 
ration, Cheyne-Stokes'  breathing,  or  clonic  spasms.  Its  effects  can  be  often 
recovered  from.  Not  unusually  the  victim  is  apparently  dead,  but  subse- 
quently recovers.  D 'Arson val  reports  the  case  of  a  man  who  was  appar- 
ently killed  by  the  passage  of  4500  volts.  No  attempt  at  resuscitation  was 
made  for  one-half  hour,  and  yet  he  recovered  when  artificial  respiration 
was  employed.  Donnellan  reports  a  case  of  recovery  after  the  passage  of 
1000  volts.  SHght  shocks  may  cause  temporary  numbness  and  even  motor 
paralysis.  An  electric  shock  frequently  causes  bums  or  ecchymoses  and, 
occasionally,  wounds.  Wounds  caused  by  electricity  bleed  profusely  and 
are  apt  to  slough.  Spitzka,  Ibid.,  sets  forth  the  effects  of  electric  shock  as 
follows: 


1464  Injuries  by  Electricity 

"  I.  Local  Signs: 

(a)  Bums  of  the  skin  and  hair. 
{h)  Puncture  and  rupture  of  tissues, 
(c)  Superficial  necroses. 

{d)  Metallic  im|)regnation  of  the  surface  tissues. 
(e)  Hemorrhages. 

(/)  Edema,  erythemas,  'lightning'  figures. 
"  II.  General  Effects: 

(a)  Loss  or  consciousness  and  of  nerve-functions  generally. 

(b)  Paralyses  or  spasms  of  muscles. 

(c)  Disturbances  of  respiration  and  cardiac  action;  high  temperature. 
"Later.  Affections  of  the  bowel  activity:  meteorism,  constipation,  albu- 
minuria, icterus,  incontinence  or  retention  of  urine,  bloody  urine,  arterial 
rigor  or  spasms  of  arterioles,  acute  edema  of  various  parts  (joints) ;  eye- 
symptoms  of  various  kinds:  blinding,  conjunctivitis,  keratitis,  iritis,  cataract, 
dislocation  of  lens,  etc.;  ear-symptoms:  rupture  of  t}^mpanic  membranes, 
deafness,  bleeding,  epistaxis;  thermal  symptoms:  usually  a  rise  of  temperature 
to  ^8°  to  39°  C,  amnesia,  neuritis,  etc." 

If  death  occurs  it  is  due  to  asphyxia,  to  cardiac  paralysis  with  fibrillary 
contractions  of  the  heart,  or  to  both  conditions  (Spitzka,  Ibid.).  An  electric 
hum  looks  like  a  blackened  crust;  it  is  surrounded  by  pale  skin,  and  for  twenty- 
four  hours  remains  dry,  when  inflammatory  oozing  begins  and  the  skin  around 
it  reddens.  These  bums  are  seldom  as  painful  as  ordinar}'  bums,  but 
sometimes  cause  severe  pain,  and  recovery  requires  a  long  time.  When 
inflammation  begins  and  suppuration  occurs,  tissue  is  extensively  destroyed; 
tendons,  bones,  and  joints  may  suffer;  some  portions  become  deeply  excavated, 
and  other  portions  show  dry  adherent  masses  of  dead  and  d}'ing  tissue,  and  a 
bum  which  was  at  first  small  may  be  followed  by  a  large  area  of  moist  gan- 
grene;* lack  of  tissue-resistance,  due  to  trophic  disturbance,  is  largely  respon- 
sible for  the  progress  of  the  sloughing.  Even  an  apparently  trivial  burn  may 
be  followed  by  extensive  sloughing. 

Treatment. — If  a  person  is  in  contact  with  a  live  wire,  the  first  thing  to  do 
is,  if  possible,  to  shut  off  the  current.  If  it  is  not  possible  to  shut  oft"  the  cur- 
rent, catch  a  portion  of  the  clothing  of  the  victim  and  pull  him  away  from  the 
wire,  but  do  not  touch  his  body  with  the  bare  hand.  If  a  pair  of  rubber 
gloves  can  be  obtained,  the  subject  can  be  moved  with  impunity  and  the  wires 
can  be  safely  cut.  If  it  is  not  possible  to  drag  a  person  away  from  electric 
wires,  an  individual  can  wrap  his  hands  in  dry  woolen  material  and  safely  lift 
the  portion  of  the  body  in  contact  with  earth  or  wire,  and  thus  break  the 
circuit  and  permit  of  removal  of  the  body.f  A  dry  cloth  can  be  pushed  between 
the  body  and  the  ground,  and  the  body  can  then  be  removed  from  the  wires. 
It  may  be  possible  to  push  the  wires  away  by  means  of  a  dr\'  piece  of  wood, 
or  to  cut  them  with  shears  which  have  wooden  handles  and  which  are  perfectly 
dry,  or  to  push  or  draw  the  body  away  from  the  wire  by  the  employment  of 
sticks  of  dry  wood.  Spitzka  warns  us  to  be  careful  in  using  shears  "as  the 
momentary  arc  formed  between  the  separated  ends  may  blind  the  rescuers." 

*  See  the  article  by  N.  W.  Sharpe  on  "  Peculiarities  and  Treatment  of  Electrical  In- 
juries," in  Phila.  Med.  Jour.,  Jan.  29,  1898. 

t  See  the  directions  in  Med.  Record,  Dec.  28,  1895,  from  Med.  Press. 


Effects  of  Artificial  Currents  1465 

Treat  the  general  condition  in  the  manner  set  forth  in  the  article  on  Light- 
ning-stroke (i)age  1462).  Raise  the  head  a  little,  apply  external  heat,  draw 
the  tongue  forward,  and  at  once  make  artificial  respiration.  Occasionally 
tickle  the  epiglottis  with  the  finger.  Massage  over  the  heart  region.  If 
facilities  are  at  hand  and  the  victim  is  ap[)arently  dead,  inject  at  once  adrenalin 
and  salt  solution  into  a  large  artery  (page  467).  While  any  heart  action 
remains  there  is  a  chance  of  resuscitation.  When  heart  action  and  respiration 
are  present  the  prognosis  is  good.  Very  severe  burns  may  be  caused.  The 
author  has  dressed  a  number  of  electric  bums  with  hot  fomentations  of  salt 
solution  during  the  first  few  days.  This  facilitates  the  separation  of  the 
sloughs  and  seems  to  aid  the  weakened  tissues  in  resisting  microbic  invasion; 
after  sloughs  separate,  the  part  is  dressed  with  dry  sterile  gauze.  Antiseptic 
dressings  can  be  used  from  the  beginning,  but  they  often  fail  entirely  to  arrest 
the  sloughing.  Iodoform  produces  much  irritation  and  should  not  be 
employed.  Ointments  are  ver}'  unsatisfactory.  When  the  dressings  are 
changed,  the  part  should  not  be  washed  \\ith  corrosive  sublimate,  as  this  agent 
produces  irritation;  peroxid  of  hydrogen  should  be  employed,  followed  by 
warm  normal  salt  solution.  Sharpe  removes  sloughs  by  applying  the  following 
mixture:  2  parts  of  scale  pepsin,  i  part  of  hydrochloric  acid,  U.  S.  P.,  120 
parts  of  distilled  water.  This  mixture  is  washed  off  after  two  hours  with 
peroxid  of  hydrogen.  The  same  surgeon  treats  necrosis  of  bone  by  injecting 
every  few  hours  a  3  per  cent,  solution  of  hydrochloric  acid,  using  every  second 
day  the  pepsin  solution,  and  when  necrotic  areas  come  away,  packing  with 
gauze.  W^hen  repair  begins,  the  raw  surface  should  be  covered  with  silver-foil. 
Skin-grafting  by  Reverdin's  method  or  Thiersch's  method  is  rarely  successful. 
In  some  regions  it  is  possible  to  slide  a  large  flap  in  place  to  cover  a  granulating 
area  which  will  not  heal.  In  a  very  severe  case  amputation  or  resection  may 
be  necessar}\ 

In  New  York  and  New  Jersey  and  several  other  states  electricity  is  em- 
ployed to  execute  criminals  convicted  of  capital  offenses.  The  infliction  of  death 
by  electricity  is  popularly  spoken  of  as  electrocution.  It  is  beyond  doubt,  in  the 
words  of  my  colleague,  Dr.  Spitzka,  "the  most  humane  method  of  executing 
criminals."  The  first  electrocution  in  New  York  was  in  Auburn  Prison  in 
i8go,  and  since  then  over  100  criminals  have  been  executed  by  electricity 
in  New  York  state  alone.  Dr.  Spitzka  has  witnessed  36  electrocutions  and 
made  autopsies  on  27  of  the  \ictims  ("Journal  Med.  Soc.  of  New  Jersey," 
1909).  The  apparatus  used  is  "an  alternating  dynamo  capable  of  generating 
2000  volts,  a  'death-chair'  with  adjustable  head-rest,  binding  straps,  and  ad- 
justable electrodes.  (At  Trenton  a  2400-volt  current  is  taken  from  the  public 
service  wire  and  lowered  to  the  desired  tension  by  a  rheostat.)  "  The  notch 
bound  to  control  the  current  is  in  the  death-chamber  and  the  dynamo  is  in 
another  apartment,  communication  l^eing  had  by  electric  signals.  The 
prisoner  (usually  without  fetters)  walks  in  when  ever}'thing  is  ready  and  sits 
down  in  the  chair,  and  his  arms,  legs,  head,  and  chest  are  strapped  to  the  chair. 
An  electrode  moist  with  salt  solution  is  fastened  to  the  head  and  another  to 
the  calf  of  the  leg.     The  head  need  not  be  shaved. 

"The  application  of  the  current  is  usually  as  follows:  The  contact  is 
made  vpith  a  high  potential — 1800  volts — for  five  to  seven  seconds,  reduced 
to  200  to  250  volts  until  a  half  minute  has  elapsed;  raised  to  high  voltage  for 


1466  Injuries  by  Electricity 

three  to  five  seconds;  again  reduced  to  low  voltage  until  one  minute  has 
elapsed,  when  it  is  again  raised  to  the  high  voltage  for  a  few  seconds,  and  the 
contact  is  broken.  The  ammeter  usually  shows  that  from  7  to  10  amperes 
have  passed  through  the  criminal's  body. 

"  A  second  or  even  a  third  brief  contact  is  sometimes  made,  partly  as  a 
precautionary  measure,  but  more  to  completely  abolish  reflexes  in  the  dead 
body. 

"  The  time  consumed  by  the  strapping-in  process  is  usually  about  forty-five 
seconds  and  the  first  contact  is  made  a  few  seconds  later.  In  all,  about  sixty 
to  seventy  seconds  elapse  from  the  moment  the  convict  leaves  his  cell  until 
he  is  shocked  to  death"  (Spitzka,  Ibid.). 

After  electrocution  the  temperature  of  the  body  rises  and  may  reach 
129.5°  F.  Dr.  Spitzka  finds  that  after  removing  the  brain  the  temperature 
in  the  vertebral  canal  is  often  over  120°  F.  The  brain  shows  capillary  hemor- 
rhages, arterial  anemia,  and  venous  congestion.  In  some  of  Spitzka's  cases 
sections  of  the  pons,  oblongata,  and  spinal  cord  showed  areas  resembling  gaseous 
emphysema,  which  were  perhaps  caused  by  "electrolytic  liberation  of  gas." 

In  electrocution  there  is  no  pain,  consciousness  is  at  once  abolished, 
death  is  certain,  and  resuscitation  is  impossible.  The  lurid  stories  about 
criminals  being  killed  by  the  necropsy  and  not  by  the  electric  current  are 
nonsense. 


INDEX 


Abbe's  method  of  lateral  intestinal 
anastomosis,  1104 
operation  for  esophageal  stric- 
tvire,  929 
of    intracranial    neurectomy, 
784 
Abdomen,  contusion  of,  muscular 
rupture  from,  937 
desmoid  tumor  of,  351 
diseases  and  injuries  of,  936 
gunshot-wounds  of,  947 
operations  on,  1048 
Abdominal  actinomycosis,  311 
aorta,  compression  of.  446 
ligation,  498 

Macewen's  method  of   com- 
pressing, 141 5 
hernia,  1 123.     See  also  Hernj'a. 
nephrectomy,  1293 
operations  in  insanity,  841 

thrombosis  after,  202 
pads,  Ashton's,  preparation  of, 

section,  1048 

after-treatment,  1053 

control  of  hemorrhage  in,  454 

ligation  of  iliac  arteries  after, 
494 

suture  of  wound  after,  1052 

toilet    of    peritoneum    after, 
1051 
wall,  contusion,  without  injury 
of  viscera,  936 

wounds  of,  945 
Abernethy's    method    of    ligating 
external  iliac  artery,  495 

of  preventing  hemorrhage  in 
amputation     of     hip-joint, 
1414 
Abscess,  137 
acute,  142,  144 

in  various  regions,  145 
alveolar,  148 

treatment  of,  151 
appendiceal,  146,  988 

treatment  of,  152,  1059 
axillary,  147 
Bezold's,  822 

treatment  of,  153 
Brodie's,  144,  504 
caseous,  144 

cerebral,  from  ear  disease,  822 
cheesy,  144 
chronic,  144,  155.  160 
circumscribed,  142,  144 
cold,  144,  155 

large,  treatment  of,  166 
congestive,  144,  155 
consecutive,  144 
critical,  144 
deep,  144 

Hilton's  method  of  opening, 
154 

of  neck,  146 

treatment  of,  153 
diagnosis  of,  149 
diathetic.  144 
diffused,  144 
dorsal,  tuberculous,  162 

treatment  of,  167 
embolic,  144,  213 
emphysematous,  144 
encysted,  144 
epiploic,  949 


Abscess,  extradural,  823 
fecal,  144 
follicular,  144 
forms  of,  144 
gravitative,  144 
healing  of,  143 
hematic,  144 
hypostatic.  144 
iliac,  tuberculous,  162 
intramammary,  1422 
ischiorectal,  148,  1168 

treatment  of,  152 
lumbar,  tuberculous,  162 

treatment  of,  167 
lymphatic,  144,  155 
marginal,  144 
metastatic,  144,  213 
migrating,  155 
milk,  144 
mushroom,  820 
of  antrum  of  Highmore,  148,  881 

treatment.  152 
of  bone,  chronic,  504 

tuberculous,  treatment  of,  165 
of  brain,  145,  819 

treatment,  152 
of  breast,  148,  142 1 

treatment,  152 

tuberculous,  163 
treatment,  166 
of  frontal  sinus,  882 
of  groin,  149 
of  hip,  634 

of  joints,  tuberculous,  162 
of  kidney,  1284 
of  larynx,  148 

treatment.  153 
of  liver,  146,  1017 

pyemic,  10 17 

treatment  of,  102 1 

traumatic,  10 17 
treatment  of,  102 1 

treatment,  151 

tropical,  144,  1018 
of  lung,  147,  898 

pneumotomy  for,  908 

treatment,  151 

Tuffier's  method  of  exploring 
for,  go8 
of   lymphatic   glands,   tubercu- 
lous, treatment  of,  165 
of  mediastinum,  147 

treatment,  151 

tuberculous,  162 

treatment,  166 

of  neck,  deep,  146 

tuberculous,  162 
of  popliteal  space,  149 
of  prostate.  148 

in  gonorrhea,  treatment,  1350 

treatment,  153 
of  rib,  tuberculous,  162 

treatment  of,  166 
of  scalp,  791 
of  spine,  864 
of  spleen.  1047 
orbital,  149 

treatment  of,  152 
ossifluent,  144 
Paget's,  144,  253 
palmar,  149,  735 
pelvirectal,  1168 
pericystic,  1028 
perigastric,  957 

1467 


•  Abscess,  perinephric,  147,  1285 

treatment  of,  152 
peri-urethral,      in      gonorrhea, 
1341 
treatment,  1350 
pointing  of,  140,  143 
postpharyngeal,       tuberculous, 
161 
treatment  of,  167 
prognosis  of,  150 
psoas,  144 

tuberculous,  162 
treatment  of,  166 
pyemic,  144 
residual,  144,  157 
rest  in,  97 

retromammary,  1422 
retropharyngeal,  acute,  147 

treatment  of,  152 

tuberculous,  161 
retrorectal,  1168 
scrofulous,  155 
secondary,  213 
shirt-stud,  154,  159 

treatment  of,  163 
spontaneous  evacuation,  143 
stercoraceous,  144 
strumous,  144,  155 
subdiaphragmatic,  147 
subphrenic,  147,  890,  1012 

treatment  of,  151 
superficial,  144 

treatment  of,  153 
sympathetic,  144 
syphilitic,  144 
thecal,  144,  735,  739 
treatment  of,  150 
tropical,  144,  1018 
tuberculous,  144,  153 

age  occurring,  156 

albuminoid  disease  from,  i6o 

amyloid  disease  from,  160 

contents  of,  156 

diagnosis  of,  160 

formation  of,  156 

in  various  regions,  161 

lardaceous  disease  from.  160 

of    considerable    size,    treat- 
ment, 163 

of  head  of  bone,  161 

prognosis  of,  160 

results  of,  160 

secondary  infection  with  ba- 
cilli    of,    suppuration 
from,  157 
with   bacteria  of,  putre- 
faction from,  158 

signs  of,  158 

situation  of,  156 

small   superficial,   treatment, 
163 

symptoms  of,  158 

terminations  of,  157 

treatment  of,  163 
general,  165 

wall  of,  156 

waxy  disease  from,  160 
tympanitic,  144 
urinary,  144 
verminous,  144 
von  Bezold's,  149 
wandering,  144,  155 
Absence,     congenital,     of     gall- 
bladder, H13 


1468 


Index 


Absence  of  thyroid  gland,  1226 
Absorbent  cotton,  sterile,  prepara- 
tion of,  75 
wool  as  dressing,  76 
Absorptive  power  of  stomach,  test- 
ing, q66 
Accessory  adrenals,  375 
A.  C.  E.  mixture,  1204 
Acetabulum,  fractures  of,  552 

of  brim,  592 
Acetanilid,  .51 

Acetonuria  after  anesthesia,  1202 
Achard    and  Castaign's   test    for 
excretory   capacity  of  kidneys, 
1271 
Achillodynia,  355  , 

Acid  intoxication  after  anesthesia, 

1202 
Acidosis  after  anesthesia,  1202 
Acne,  syphilitic,  321 
Aconite  in  inflammation,  109 
Acromegaly,  515 
Acromion,  fractures  of,  558 
Actinomyces,  300 
Actinomycosis,  309 
abdominal,  311 
cutaneous,  310 
of  bone,  311,  500 
of  brain,  826 
ray-fungus  as  cause,  18 
treatment  of,  311 
Actol,  32 

Acupressure  in  hemorrhage,  445 
Acupuncture  in  aneurysm,  429 
Adams's  operation  of  osteotomy, 
700 
saw,  698 
Adenitis,  cervical,  tuberculous,  253 

tuberculous,  253 
Adenocarcinoma   389 

of  breast,  1428 
Adenocele  of  breast,  1425 
Adenoma,  377 
cystic,  377 

of  breast,  1425 
of  brain,  827 
of  breast,  1425 
of  mucous  membranes,  377 
of  prostate,  377 
of  thyroid  gland,  377 
Adherent  tongue,  921 
Adhesion-dyspepsia,  963 
Adhesions,  perigastric,  963 
Adrenal  rests,  375 

tumors,  374 
Adrenalin  chlorid  in  shock,  264 
Adrenals,  accessory,  375 
Agglutination  test  in  diagnosis  of 

tuberculosis,  243 
Agglutinins,  38 

Agnew's    operation    for    webbed 
lingers,  755 
splint  in  transverse  fracture  of 

patella,  613 
treatment  of  fracture  of  femur 
at  upper  third,  603 
Agraphia,  831 
Air-embolism,  208 
Airol,  32 

Air-passages,  foreign  bodies  in,  883 

Air-pressure,  positive  or  negative, 

intrathoracic  operations  under, 

901 

Air-resistance,    influence    of,    on 

projectiles,  288 
Albert's  disease,  355,  741 
Albuminoid   disease   from   tuber- 
culous abscess,  160 
Albuminous  expectoration,  904 
Albuminuria  in  tertiary  syphilis, 
327 
obstructing  repair,  120 
of  secondary  syphilis,  323 
Alcohol,  29 

and  chloroform  anesthesia,  1204 
in  neuralgia  of  fifth  nerve,  780 
Alcoholic  coma,  803 
Alden   and   Allen's   treatment    of 
pyogenic  arthritis,  644 


Aleppo  boils,  1223 
Alexander's  method  of  diagnosing 
rupture  of  bladder,  1312 
of     perineal     prostatectomy, 
1380 
Alexin,  38 
Alimentary  canal,  tuberculosis  of, 

251 
Alkaloids,  poisonous,  3O 
Allen    and    Alden's   treatment   of 

pyogenic  arthritis,  644 
Allingham's  method  of  intestinal 
anastomosis,  1098 
operation  for  piles,  1177 
AUis's  ether-inhaler,  1193 
method  of  nerve-suture,  776 
operation  in  pulmonary  tuber- 
culosis, 901 
sign  in  intracapsular  fracture  of 
femur,  591 
in    traumatic    dislocation    of 
femur,  688 
treatment     of     dislocation     of 
femur    into    obturator 
foramen,  690 
upon    dorsum    of    ilium, 

690 
with     catching     up     of 
sciatic  nerve,  691 
of  head  of  femur  with  frac- 
ture of  shaft,  692 
of  elbow  injuries,  571 
Almen's  test  for  hematuria,  1265 
Alopecia,  syphilitic,  322 
Alpha-rays,  1459 
Alveolar  abscess,  148 

treatment,  isi 
Amboceptor,  329 
American  bandage  of  foot,  1252 
Amputation,  1396 
4  la  manchette,  1399 
at  ankle,  1410 
Pirogoff's,  1410 
Syme's,  1410 
at  elbow,  1404 
at  forearm,  1403 
at  hip- joint,  1414 
at  knee,  1412 
at    metacarpophalangeal    joint, 

1402 
at  middle  tarsal  joint,  1409 
at  shoulder,  1404 
Dupuytren's,  1406 
Kocher's,  1405 
Larrey's,  1405 
Lisfranc's,  1406 
at  tarsus,  1409 
at  wrist,  1402 
Bell's,  of  thigh,  1413 
Bergcr's,    of    upper    extremity, 

1406 
Bier's,  of  leg,  141 1 
Chopart's,  of  foot,  1409 
circular,  1398 
classification,  1396 
completion  of,  1401 
elliptical  method,  1400 
flap,  method,  1400 
for  gangrene,  rules,  198 
Forbes's,  at  tarsus,  1409 
Gritti's  supracondyloid,  1413 
hemorrhage  in,  1396 
Hey's,  of  foot,  1408 
in  gunshot-wounds,  284 
interilio-abdominal,  1419 
intertarsal,  anterior,  1409 

posterior,  1409 
Jordan's,  of  hip-joint,  1419 
Kocher's,  of  knee,  1412 

of  upper  extremity,  1406 
lanceolate  incision,  1398,  1400 
Larrey's,  of  hip-joint,  1419 
Le  Conte's,  of  upper  extremity, 

1407 
Lisfranc  s,  of  foot,  1407 
Liston's,  of  hip-joint,  1419 
methods  of,  1398 
mixed  method,  1400 
modified  circular,  1399 


Amputation,      oblique      circular, 
1398,  1400 

of  arm,  1404 

of  fingers,  1401 

of  foot,  1407 

of  hand,  1401 

of  hip-joint,  Jordan's,  1419 
Larrey's,  1419 
Liston's,  1419 
Senn's,  1418 
Sheldon's,  1419 
VVyeth's,  1416 

of  leg,  1410 

below  knee,  1412 
by  lateral  flaps,  1412      * 
by  long  anterior  flap,  141 1 
by  long  posterior  and    short 

anterior  flap,  141 1 
by  rectangular  flap,  14H 
modified  circular,  141 1 
point  of  election,  1410 

of  penis,  1369 

of  thigh,  1413 

by  transfixion,  1401 

of  thumb,  1402 

of  toes,  1407 

of  upper  extremity,  1405 

oval,  1400 

racket,  1400 

rectangular  flaps,  1398 

rounded  flaps,  1398 

Sabanejeff's,   through     femoral 
condyles,  1413 

Sedillot's,  of  leg,  141 1 

Senn's,  of  hip-joint,  1418 

Sheldon's,  of  hip-joint,  1419 

special,  i4oi_ 

subastragaloid,  1409 

Syme's,  through  femoral  con- 
dyles, 1412 

T-,  of  hip-joint,  1418 

Teale's,  of  leg,  141 1 

transverse  circular,  1398 

Wyeth's,  of  hip- joint,  1416 
Amyelia,  852 
Amyloform,  32 
Amyloid  disease  from  tuberculous 

abscess,  160 
Anastomosis,   aneurysm    by,   360, 

415,  432 
arteriovenous,    for     obhterative 
endarteritis,  414 
for  transfusion  of  blood,  464 
facio-accessory,  784 
faciohypoglossal,  784 
intestinal,  Allingham's  method, 
1008 
by  Murphy's  button,  109S 
Connell's  method,  1100 
consideration     of      methods, 

1 106 
end-to-side,  1003 
Halsted's  method,  iioo 
Harris's  method,  1098 
Kocher's  method,  1098 
Laplace's  forceps  for,  iioo 
lateral,  1093,  1102 
Abbe's  method,  1104 
Halsted's  method,  1104 
Horsley's  method,  1 105 
Laplace's  forceps  for,  1105 
>Ioynihan's  method,  1106 
with  rings,  1103 
Maunsell's  method,  1096 
Moynihan's  method,  1099 
O'Hara's  forceps  for,  iioi 
Robson's  method,  1098 
Senn's  method,  1093,  iioo 
with  Prank's  coupler,  1096 
of  nerves,  776 
Anatomical  snuff-box,  472 

tubercle,  250 
Anderson's     method     of     tendon- 
lengthening,  750 
Anel's  operation  for  aneurysm,  422 
Anesthesia,  1187 

acetonuria  after,  1202 

acid  intoxication  after,  1202 

acidosis  after,  1202 


Index 


1469 


Aneslhcsia,  after-effects,  1201 

backache  after,  1201 

closure    of    epiglottis   in,    treat- 
ment, 1199 

cyanosis  in,  1 197 
treatment  of,  11 98 

death-rate,  1 1S7 

delayed  ijoisoninj;  after,  1202 

edema  of  lungs  in,     treatment, 
1199 

forgetting  to  breathe  in,  1108 

heart  massage  in  collapse  dur- 
ing, 1 198 

local,  12 10 

preparation  of  patient,  1187 

primary,  1204 

reaction  from,  1200 

renal  complications  after,  1202 

respiratory  disorders  after,  1201 

shock  in,  treatment,  1197 

spinal,  1 2 14 

swallowing  tongue  in,  1197 
treatment,  T199 

syncope  in,  treatment,  1197 

treatment      of      complications, 

vomiting  in,  1201 

treatment,  1197 
urine  after,  1202 
Anesthetic  successions,  1208 
Aneurysm,  414 
acute,  415 

Anel's  ofjeration  for,  422 
Antylus's  operation  for,  421 
arteriovenous,  415 

treatment  of,  430 
Brasdor's  operation  for,  424 
by  anastomosis,  360,  415.  432 
capillary,  416 
Carnot's  solution  in,  420 
causes,  417 
circumscribed,  415 
cirsoid,  360,  432 
consecutive,  414 
constituent  parts,  417 
Corradi's  operation  for,  429 
cylindrical,  415 
diagnosis,  419 
diffuse,  414 

traumatic,  414,  430 
dissecting,  415 
embolic,  416 
false,  414 
forms  of,  414 
fusiform,  414 
gelatin  treatment,  420 
Halsted's  oi^eration  for.  426 
Hunter's  operation  for,  422 
Lister's  tourniquet  in,  421 
Matas's  operation  for,  424 
miliary,  4:6 
needle,  Dupuytren's,  470 

Saviard's,  470 
of  bone,  415 
Pott's,  431 

Reid's  treatment,  421 
rest  in,  97 
ruptured,  414,  416 
sacculated,  415 
secondary,  416 
Shekelton's,  415 
spontaneous,  415,  416 
strongylus  armatus  as  cause,  417 
Syme's  operation  for,  422 
symptoms,  417 
traumatic,  415 
treatment,  419 

after  operation,  428 

by  acupuncture,  429 

by  amputiition,  428 

by  distal  ligation,  423 

by  electrolysis,  428 

by  extirpation,  422 

by       injecting       coagulating 
agents,  428 

by  introduction  of  wire,  429 

by  ligature  and  sutures,  421 

by  manipulation,  42S 

by  pressure,  421 


Aneurysm,    treatment,    following 
wound   of    healthy  artery, 
430 
oi^erative,  421 
true,  414 
tubulated,  414 
Tuffnell's  compress  in,  421 

treatment  of,  419 
varicose,  431 

symptoms  of,  432 
treatment  of,  432 
verminous,  416 
Wardrop's  oj^ration  for,  424 
Aneurysmal  varix,  431 
Aneurysmorrhaphy,  424 
Angeiosarcoma,  369 
Angina,  Ludwig's,  196 
Angioma,  359 
capillary,  359 
cavernous,  360 
of  brain,  826 
of  breast,  1426 
plexiform,  360 
simple,  359 
Angioneurectomy,  1384 
Angiosa^roma  of  brain,  826 
Angle's  bands,  546 
Animal  inoculations  in  diagnosis 

of  tuberculosis,  243 
Ankle-joint,      disarticulation      at, 
1410 
disease,  640 
excision  of,  717 

Hancock's  method,  718 
traumatic  dislocation,  696.     See 
also    Dislocation,     traumalir, 
of  ankle-joint. 
tuberculosis  of,  640 
Ankyloglossia,  congenital,  921 
Ankylosis,  659 

Baer's  treatment,  662 
bony,  659 
complete,  659 
extra-articular,  659 
treatment  of,  663 
false,  6s9 

after  fractures  of  elbow,  572 
faulty,  of  hip-joint,   osteotomy 
for,  700 
of  knee-joint,  osteotomy  for, 
701 
fibrous,  659 

Hugier    and     Murphy's     treat- 
ment, 662 
incomplete,  659 
intra-articular,  659 
treatment  of,  660 
true,  659 

after  fractures  of  elbow,  572 
Anosacral  cysts,  853 
Antemortem  tlirombus,  200 
Anthrax,  301 
bacillus  of,  51 
benign,  1223 
carbuncle,  302 
edema,  302,  303 
external,  302 
forms  of,  303 
Sclavo's  serum  in,  304 
Antibodies,  38 
bacteriolytic,  38 
lytic,  38 
Antigens,  39 

Antigonococcic  serum,'i358 
Antinosin,  31 
Antisepsis,  55 

dry,  57 
Antiseptic,  chemical,  25 

fomentation    in    inflammation, 

105 
gauze,  preparation,  75 
Antitoxin  serum  in  tetanus,  225, 

227 
Antitoxins,  39,  42 
Antrum  of  Highmore,  abscess  of, 
148 
treatment,  152 
inflammation,  88 1 
Siircoma  of,  363,  366 


Antyllus's  operation  for  aneurysm, 

421 
Anus,  artificial,  978 
making  of,  i  no 
diseases  and  injuries,  ri6o 
examination  of,  1161 
fissure  of,  1172 
fistula  of,  1 169 

fecal  incontinence  after  oper- 
ation for,  treatment,  1171 
gonorrhea  of,  1354 
imperforate,  1 169 
prolapse  of,  11 78 
pruritus  of,  1171 
tumors  of,  benign,  1180 
Aorta,  abdominal,  compression  of, 
446 
ligation  of,  498 
Macewen's   methcxl   of   com- 
pressing, 141S 
Apathetic  shock,  262 
Aphasia,  motor,  831 
Aplastic  lymph,  88 
Apoplexy,  coma  of,  803 
Appendiceal  abscess,  146,  988 
treatment,  152,  1059 
colic,  986,  987,  988 
lithiasis,  986 
Appendicitis,  983 

Barker's  operation  for,  1057 
Batde's  incision  in,  1055 
blood-count  in  diagnosis  of,  995 
catarrhal,  987 
Davis's  incision  in,  1055 
Dawbam's  operation  for,  1058 
diagnosis,  993 

differential,  993 
etiology,  985 
forms  of,  987 
fulminating,  987 
gangrenous,  988 
hematuria  in,  994 
hepatic  infection  after,  992 
in  children,  996 

treatment,  1000 
in  pregnancy,  996 
treatment,  1000 
infection  after,  992 
McBumey's  incision  in,  1054 
interval  operation  in,  1059 
point  in,  984,  990 
rule  in,  999 
obi  iterative,  988 
operation  for,  1054 

mortality  after,  1060 
Parker's  incision  in,  1059 
pathology,  985 
prognosis,  991 
recurrent,  987 
simple  parietal,  987 
stercoral,  986 
suppurative,  987 
symptoms  and  signs,  988 
terminations,  991 
thrombosis  in,  202 
traumatic,  986 
treatment,  997 
tuberculous,  996 
treatment  of,  1000 
Appendicostomy,  Weir's,  1061 
Arachnitis,  817 
Ardor  urinse  in  gonorrhea,  1340 

treatment,  1349 
Argonin  in  acute  gonorrhea,  1346 
ArgjTol,  32 

in  acute  gonorrhea,  1347,  1348 
Aristol,  31 
Arm,  amputation  of,  1404 

lawn-tennis,  732 
Amot's  method  of  skin-grafting, 

1261 
Arrow -wounds,  277 
Arterial    hemorrhage,    rules    for 
arresting,  450 
piles,  1175 


saline  fluid  in  arteries,  467 
centripetiil,  in  shock,  265 


147° 


Index 


Arteriocapillary  fibrosis,  412 
Arteriorrhaphy,  440 

Bickham's  method,  443 
Glutk's  method,  443 
Halsted's  method,  444 
Lexer's  method,  444 
Murphy's  method,  443 
Salomoni        and        TomaseUi's 
method,  443 
Arteriosclerosis,  412 
Arteriovenous     anastomosis     for 
obliterative        endarteritis, 
414 
for  transfusion  of  blood,  464 
aneurysm,  415 
treatment,  430 
Arteritis,  acute,  411 

Ford's  treatment,  412 
chronic,  412 

treatment  of,  413 
Arthrectomy,  709.     See  also  Era- 

sion. 
Arthritis,  625,  628 
acute  infantile,  S'z 
rheumatic,  648 
suppurative,  644 
chronic  rheumatic,  648 
deformans,  650 
gonorrhe.d,  645 

treatment  of,  1358 
gouty,  650 
hemophilic,  469 
infective,  643 
neuropathic,  652 
non-tuberculous,  642 
ossificans,  659 
pneumococcus,  647 
pyogenic,  644 
rheumatoid,  650 
syphilitic,  322 
traumatic,  643 
tuberculous,  628 

fistula  in,   Beck's   treatment, 

631 
gelatiniform  degeneration  in, 

629 
treatment  of,  630 
typhoid,  64s 
Arthropathie  deformant,  338 
Arthrojjathy,  tiibetic,  652 
Artlirospores,  23 
Arthrotomy  in  pyogenic  arthritis, 

644 
Artificial  anus,  978 
making  of,  11 10 
respiration,  1199 

Laborde's  method,  1199 

Sylvester's  method,  1200 

Asch   tube   in    fractures   of   nasal 

bones,  540 
Ascites    from    hepatic     cirrhosis, 

surgical  treatment,  1108 
Ascococci,  20 
Asepsis,  55 

dry,  57 
Aseptic  agents,  25 
fever,  123 

gauze,  preparation  of,  75 
peritonitis,  1002 
pus,  138 

traumatic  fever,  134 
Ashhurst's  method  of  excision  of 

knee- joint,  717 
Ashton's   abdominal   pads,   prep- 
aration, 75 
Asphyxia,  traumatic,  888 
Aspiration,  003 
of  joints,  707 
Aspirator  and  injector,  708 
Astragalectomy,  719 
Barker's  method,  719 
by  subperiosteal  plan,  719 
in  talipes,  758 
Astragalus,  traumatic  dislocation, 
697 
forward  or  backward,  697 
lateral  and  rotary,  697 
Astringent  injection  in  acute  gon- 
orrhea, 1346 


Astringents  in  inflammation,  103 
Atheroma,  412,  413 
Atony  of  bladder,  1312 
Atro])hy  of  bone,  500 

of  muscles,  727 
ischemic,  728 

of  thyroid  gland,  1226 
Atropin  in  shock,  265 
Attacks  of  stone,  1314 
Auditory    nerve,    division   of,    for 

tinnitus  aurium,  784 
Auricle,  cancer  of,  386 
Autogenous  vaccine,  45 
Auto-intoxication,  37 
Autotoxins,  22 

Autotransfusion  in  shock,  266 
Avulsion  of  limb,  275 

of  scalp,  275 

of  spine  of  tibia,  618 
Axillary  abscess,  147 

artery,  ligation  of,  476 


Babinski's  reflex,  854 

Bacelli's  treatment  of  tetanus,  228 

Bacillus,  20 

aerogenes  capsulatus  of  Welch, 

53 
anthracis,  51 
branching,  21 
coli  communis,  52 
colon,  48,  52 
comma,  20 
dichotomy,  21 
Eberth's,  53 
Frankel's,  52 
Koch's,  51,  231 

circuit  as  proof  of  cause  of  dis- 
ease, 35 
leptothrix  forms,  21 
mallei,  52 

ccdematis  maligni,  52 
of  anthrax,  51 
of  Escherich,  52 
of  glanders,  52 
of  malignant  edema,  52 
of  Neisser,  49 
of  Nicolaier,  50 
of  tetanus,  50,  221 
pseudodichotomy,  21 
pyocyaneus,  48 
pyogenes  fetidus,  48 
rest,  236 

tuberculosis,  51,  231 
distribution,  232 
extracellular  poisons,  235 
in  blood,  in  diagnosis,  243 
intracellular  poisons,  235 
products,  235 
resistance,  237 
typhoid,  53 
Back,  strains  of,  732 
Backache  after  anesthesia,  120 1 
Bacteria,  19 
aerobic,  24 
amotile,  20 
anaerobic,  24 
capsule,  19 
cell,  19 

chemical  composition,  23 
distribution,  34 
efifect  of  bacteria  on,  24 
of  cold  on,  24 
of  heat  on,  24 
of  motion  on,  24 
of  radium  on,  24 
of  sunlight  on,  24 
of  A-rays  on,  24 
forms,  20 
in  fission,  21 
in  segmentation,  21 
latent,  25 
life-conditions,  23 
motile,  19,  20 
multii)lication,    21 
non-pathogenic,  19 
parasitic,  19         • 
pathogenic,  19 

action  on  tissues,  36 


Bacteria  pus,  46 
putrefactive,  19,  54 
pyogenic,  46 
saprophytic,  19 
special  surgical,  46 
Bacterial  carrier,  37 

vaccines,  treatment  of  infec  tion 
by,  45 
Bacteriology,  17 
Bacteriolytic  antibodies,  38 
Bacterium  coli  commune,  52 
drumstick,  23 
facultative -aerobic,  24 
obligate-aerobic,  24 
typhi,  53 
Baer's     treatment    of     ankylosis, 

662 
Balanitis  in  gonorrhea,  1341 

treatment,  1349 
Balanoposthitis  in  gonorrhea,  1341 

treatment,  1349 
Bald  patch,  321 

Ballance's   method   of  division  of 
auditory  nerve,  784 
mushroom  abscess,  820 
Ballooning  rectum,  1164 
Ball-valve  gallstones,  1034 
Balsams  in  acute  gonorrhea  1346 
Band  roller,  Halsted's,  428 
Bandage,  79,  1250 

American,  of  foot,  1252 

Barton's,  1253 

Borsch's,  of  eye,  1253 

circular,  1250 

crossed,  of  angle  of  jaw,  1254 

of  both  eyes,  1253 
demi-gauntlet,  12  51 
Desault's,  1256 
Esmarch's  elastic,  1306 
figure-of-eight,  1250 
of  breast,  1257 
of  elbow,  1255 
of  eyes,  1253 
of  jaw  and  occiput,  1253 
of  neck  and  axilla,  1256 
of  shoulders,  1255 
of  thigh  and  pelvis.  1255 
French,  of  foot,  1252 
gauntlet,  1251 
Gibson's,  1253 
Hamilton's,  545 
handkerchief,  1257 
Alartin's,  in  ulcer,  172 
oblique,  ,of  jaw,  1254 
of  foot,  1252 

covering  heel,  1252 
not  covering  heel,  1252 
plaster-of-Paris,  J  2  58 
recurrent,  of  head,  1257 

of  stump,  1257 
Ribbail's,  1252 

Scudder's,  in  fractures  of  ana- 
tomical neck  of  humerus, 
560 
of  shaft  of  humerus,  564 
Selva's,  of  thumb,  1251 
silicate  of  sodium,  1258 
spica,  1250 
of  groin,  1255 
of  instep,  1252 
of  shoulder,  1255 
of  thumb,  1251 
spiral,  1250 
of  fingers,  1251 
of  foot,  covering  heel,  1252 
of  palm  or  dorsum  of  hand, 

1251 
reversed,  of  lovier  extremity, 
1252 
of  upper  extremity,  1250 
T-,  of  perineum,  1257 
Velpeau's,  1255 

in  fracture  of  clavicle,  556 
Barker's    method    of    astragalec- 
tomy, 719 
of  excision  of  hip-joint,  715 
of  osteotomy  in  talipes  equi- 
novarus,  702 
operation  for  appendicitis,  1057 


Index 


1471 


Barker's  operation  for  dislocation 
of   semilunar   cartilages  of 
knee-joint,  723 
for    transverse    fractures    of 
patella,  615 
point,  789 

sharp-edged     irrigating     curet, 
164 
Barlow's  disease,  259 
Barton's  bandage,  1253 

fracture,  582 
Basedowitied  goiter,  1230 
Basedow's  disease,  1234 
Basin,  dressing,  77 
Bassini's    operation    for    oblique 
inguinal  hernia,  1131 
for  undescended  testicle,  1388 
Bath,  hot-water,  in  inflammation, 

106 
Battle's  incision   in   appendicitis, 
1055 
sign  in  fractures  of  base  of  skull, 
811 
Bauer's   method   of    positive   air- 
pressure,  902 
Beads,  rachitic,  256 
Beatson's    operation     of    oopho- 
rectomy, 391,  1442 
Bechterew's  disease,  866 
Beck's  operation  for  hypospadias, 
1365 
treatment  of  empyema,  892 
of  fistula  in  tuberculous  ar- 
thritis, 631 
Becquerel's  rays,  1459 
Bed-sores,  176,  iSo,  195 

Charcot's.  195 
Bees,  stings  of,  298 
Belfield's   method   of   suprapubic 

prostatectomy,  1380 
Bell's  amputation  of  thigh,  1413 
induction    balance    in   locating 
bullet,  283 
Bennett's  fracture,  587 

operation  for  varix  of  leg,  462 
Bergenhem's    operation    for    ex- 
strophy of  bladder,  13 10 
Berger's     amputation     of     upper 

extremity,  1406 
Berg's  operation  for  exstrophy  of 

bladder,  1309 
Berry's  operation  for  cleft  palate, 

91? 
Bertonier's  treatment  of  injuries  of 
elbow-joint  in  young  children, 
572 
Beta-rays,  1459 
P-eucain  anesthesia,  12 12 
Sevan's  incision    for    surgery   of 
bile-tracts,  11 13 
operation  for  undescended  tes- 
ticle, 1388 
Beyea's  operation  for  gastroptosis, 

1091 
Bezold's  abscess,  822 

treatment,  153 
Biceps    flexor    cubiti    or    tendon, 
rupture  of,  732 
long  head,  dislocation  of,  734 
rupture  of,  733 
Bichat's  tissure,  786 
Bichlorid  of  methylene  anesthesia, 

120S 
Bickham's    method    of    arterior- 

rhaphy,  443 
Bier's  amputation  of  leg,  1411 
hyperemia    in    tuberculosis    of 

testicle.  1390 
hyperemic  treatment  of  inflam- 
mation, 116 
treatment  of  tuberculosis,  249 
Bigelow's  evacuator,  1326 
ligament,  6S9 
lithotrite,  1327 

operation  of  litholopaxy,  1325 
Bigg's  apparatus  for  bunion,  748 
Bile-ducts,  1014 

catarrhal  inflammation,  1024 


Bile-ducts,    croupous    inflamma- 
tion, 1025 

incision    for    operations    upon, 
1113 

rupture  of,  945 

suppurative  inflammation,  1025 
Biliary    fistula    after    cholecystos- 

tomy,  1 1 16 
Billroth's  method  of  gastro-enter- 
ostomy,  1076 
of  pylorectomy,  1067 
Bilocular  stomach,  964 
Bircher's   method   of   gastroplica- 

tion,  1089 
Birth  palsy,  brachial,  767 

operation  for,  786 
Bismuth  subgallate,  32 

subiodid,  32 
Bismuth-vaselin    paste    in    fistula 

in  tuberculous  arthritis,  631 
Bites  and  stings  of  insects,  298 

of  centipedes.  299  ^ 

of  cobra,  300 

of  leech,  hemorrhage  from,  con- 
trol of,  455 

of  poisonous  lizard,  301 
spider,  298 

of  rattlesnake,  300 

of  scorpion.  298 

of  snakes,  299 

of  tarantula.  298 
Black  gonorrhea,  1339 

sarcoma,  369 
Bladder,  atony  of,  1312 

Brown's    method    of    injecting 
air  into,  1324 

calculus  in,  rest  in,  97 

cancer  of,  1320 

chronic  catarrh,  1318 

congenital  defects,  1309 

contusions  of,  13 10 

cystoscopic  examination,  1297 

diseases  and  injuries,  1306,  13 10 

exstrophy  of,  1309 

female  growths  in,  1332 

hemorrhage  from,  1268 
control  of,  456 

hernia  of,  11 58 

inflammation  of,  13 16.   See  also 
Cystitis. 

injury  of,  in  operating  for  in- 
guinal hernia,  1127 

neck  of,  inflammation,  pain  in, 
91 

nervousness,  1269 

operations  on.  1322 

rupture  of,  13 10 

stone  in,   13 13.     See  also  Cal- 
culus in  bladder. 

tumors  of,  1320 

ulcer  of,  1320 

wounds  of,  13 10 
Blake's  method  of  preparing  sil- 

verized  catgut,  71 
Blandin     and     Xuhn's     mucous 

glands,  922 
Blank-cartridge  wounds,  279 
Blastomycetes  dermatitis,  18 
Blastomycosis,  312 

cutaneous,  312 

systematic,  312 
Bleeders,  468 

Bleeding   from   kidney-substance, 
1265 

from  pelvis  of  kidney,  1265 

from  ureter,  1265 

in  inflammation,  97,  108 
Blind  boil,  1223 

Blister  fluid  from  suspected  tuber- 
culosis,    injecting     tuberculous 

animal  with,  243 
Blistering   in  diagnosis  of  tuber- 
culosis, 243 
Blisters  in  inflammation,  108 
Blood  changes  in  cancer,  386 

cryoscopy  of,  1271 

loss  of,  434.     See  also  Hemor- 
rhage. 

plaques  in  inflammation,  85 


Blood,  transfusion  of,  463 
Brewer's  method,  465 
Crile's  operation,  464 
in  sh<ick,  265 

tubercle  bacilli  in,  in  diagnosis 
of  tuberculosis,  243 
Blood-clot,  healing  by,  123 
Blood-count   in   diagnosis  of  ap- 
pendicitis, 995 
Blood-cyst,  260 

Bloodgood's    operation    for    vari- 
cocele, 462 
Bloofl -supply,   cutting  off,   in  in- 
flammation, 99 
Blood-vessels,  repair  of,  132 

tuberculosis  of,  251 
Bloody  urine,  1264 
Blue   ointment   in    inflammation, 
104 

pus,  140 
Bodine's     method     of     inguinal 

colostomy,  11 12 
Boeckman's  method  of  preparing 

catgut,  71 
Boil,  1222 

blind,  1223 

gum-,  148 
Boiled  water,  29 
Boiling  water,  34 
Boils,  Aleppo,  1223 

endemic,  of  tropics,  1223 
Boldt's  operating  table,  59,  60 
Bond's  splint  in  Colles's  fracture, 

584 
Bone,  abscess  of,  chronic,  504 
tuberculous,      treatment     of, 
.   165 

actinomycosis  of,  311,  500 

aneurysm  of,  415 

atrophy  of,  500 

cystoma  of,  500 

cysts  of,  SCO 

diseases  of,  500 
typhoid,  508 

excision  of,  708 

felon,  739 

fissure  of,  519 

head  of,  tuberculous  abscess  of, 
161 

hypertrophy  of,  500 

inflammation  of,  501 

necrosis  of,  502,  506,  506.     See 
also  Necrosis  oj  bane. 

node  of,  503 

operations  on,  698 

repair  of,  132 

syphilis  of,  322 

syphilitic  affections,  322 

tertiary  syphilis  of,  326 

transplantation  of,  704 

tuberculosis  of,  252,  501 

tumors  of,  500 
Bone-cavities,    bone-grafting    for, 

,  Sio. 

decalcified  bone-chips  for,  509 

Dressman's  treatment,  509 

Xeuber's  treatment,  509 

Schede's  treatment,  509 

Schleich's  treatment,  509 

Senn's  treatment,  509 

treatment,  509 

von    Mosetig-Moorhof's    treat- 
ment, 509 
Bone-chips,  decalcified,  for  bone- 
cavities,  509 

Senn's  decalcified,  78 
Bone-grafting,  704 

for  bone-cavities,  510 
Borsch's  eye-bandage,  1253 
Bottini's     method     of     galvano- 
caustic    prostatotomy, 
1381 
Young's       modification, 
1382 
Bougie,  esophageal,  928 
Bougie-a-boule,  1351 
Bov-ine  tuberculosis,  232 
Bow-legs,  756 
Boyer's  cyst,  744 


1472 


Index 


Brachial   artery,   compression   of, 
446 
ligation  of,  475 
birth  palsy,  767 

operation  for,  786 
plexus,  evulsion  of,  766 
Braided  silk,  73 
Brain,  abscess  of,  145,  810 
treatment,  152 
actinomycosis  of,  826 
adenoma  of,  827 
angioma  of,  826 
angiosarcoma  of,  826 
bulging  of,  834 
carcinoma  of,  827 
cholesteatoma  of,  827 
compression  of,  800 

treatment.  804 
concussion  of,  797 
contusion  of,  797 
cysts  of,  827 

diseases  and  malformations,  793 
from  suppurative  ear  disease, 
822 
dura  mater,  hematoma  of,  817 
enchondroma  of,  827 
endothelioma  of,  826 
fibroma  of,  827 
fungus  of,  816 
glioma  of,  826 
hernia  of,  815 
laceration  of,  797 
neuroma  of,  827 
operations  on,  842 

technique,  845 
osteoma  of,  827 
pearl  tumor  of,  827 
prolapse  of,  815 
psammoma  of,  826 
repair  of,  129 
sarcoma  of,  826 
sinus  of,  rupture,  806 
syphilis  of,  328 
syphiloma  of.  826 
traumatic  inflammation,  817 
tuberculoma  of,  826 
tuberculosis  of,  252 
tuberculous  gumma  of,  826 
tumors  of,  825 

consecutive  bulging  in,  834 
Cushing's  decompression 

operation  in,  835 
decompression  operation  for, 

.  83s.  850 
diagnosis,  829 
gummatous,  826 
initial  bulging  in,  834 
palliative  trephining  in,  835 
symptoms,  S27 
treatment,  833 
tuberculous,  826 
two-stage  operation,  834 
water  on,  819 
woimds  of,  812 

from  revolver  bullets,  814 
in  war,  813 
Brainard's  drills,  704 
Brain-areas,  localization  of,  Kron- 

lein's  method,  789 
Brain-matter  in  tetanus,  228 
Brain-sand  tumor,  352 
Branchial  cysts,  395 
fistula,  395 
complete,  395 
incomplete,  395 
sinus",  305 
Brandt's    operation    of    stoniach- 

reeting  for  dilatation,  1090 
Brasdor's  operation  for  aneurysm, 

423 
Brass  wire,  preparation  of,  74 
Brauer's    method    of    cardiolysis, 

461 
Braun's   method  of  gastro-enter- 

ostomy,  108 1 
Breast,  abscess  of,  148,  142 1 
treatment,  152 
tuberculous,  163 
treatment,  166 


Breast,  adenocarcinoma  of,  1428      ' 
adenocele  of,  1425 
adenoma  of,  1425 
angioma  of,  1426 
cancer     of,      1427.     See     also 

Cancer  oj  breast. 
cystadenoma  of,  1425 
cystic  adenoma,  1425 
degeneration,  1426 
fibroma,  1426 
cysts  of,  1424,  1426 
diseases  of.  1419 
enchondroma  of,  1426 
endothelioma  of.  1427 
fibro-adenoma  of,  1424 
fibrocystiidenoma  of,  1425 
fibroma  of,  1424 
fibromyxoma  of,  1425 
figure-of-eight  bandage,  1257 
fissure  of,  1420 

prevention.  1420 
hydatid  cysts,  1426 
hypertrophy  of.  1419 
inflammation  of,  142 1 
inoperable    malignant   diseases. 

1442 
involution  cysts,  1426 
lacteal  cysts,  1426 
lipoma  of,  1426 
myxoma  of,  1426 
plastic    resection    for    fibroma, 

1425 
sarcoma  of,  1427 
scirrhus  of,  1428 

atrophic  or  withering.  143 1 
tuberculosis  of.  250,  1422 
confluent.  1423 
ncxiular,  1423 
tumors  of,  1424 
malignant.  1427 
Brewer's  method  of  transfusion  of 
blood,  465 
tubes,  464 
Brick's  pile  clamp,  11 76 
Bright's    disease,    operation    for, 

1288 
Brisement  force  in  ankylosis,  661 
Broca's  operation  for  undescended 

testicle,  1388 
Brodie's  abscess,  144,  504 

joint.  653 
Bronchi,  foreign  bodies  in,  884 
Bronchocele.  1229 
Bronze  wire,  preparation  of,  74 
Brophy's  operation  for  cleft  palate. 

918 
Brown's  cystoscope,  1299 
cystoscopic  table,  1301 
method    of    injecting    air    into 
bladder,  1324 
Bruises,  perineal,  1332 
Brush-bum,  274 

Bryant's  extension  in  fractures  of 
shaft  of  femur  in  children,  606 
method  of  colopexy,  11 79 
splint  in  Pott's  fracture.  622 
treatment  of  fracture  of  femur 

just  above  condyles.  609 
triangle,  591 
Bryson's      method      of      perineal 

prostatectomy,  1380 
Bubo  in  chancroid.  1366 

in  gonorrhea,  treatment,  1350 
indolent,  317 
pyogenic,  149 
syphilitic,  317 
Bubonulus  in  gonorrhea,  134 1 
Buck's  apparatus  in  intracapsular 

fracture  of  femur,  593 
Budding  fungi.  18 
Buechner's   treatment  of  delayed 

union  in  fractures.  538 
Buerger's  test  of  patency  of  deep 

veins,  413 
Buffy  coat  of  inflammation,  94 
Bulging  of  brain.  .S34 
Bullet.     See  also  Projectiles. 
Dumdum,  290 
explosive,  290 


Bullet,  fluoroscope  in  locating,  28 ; 
induction   balance   in   locating, 

283 
Krag-Jorgensen,  287 
mushroom,  290 
skiagraph  in  locating,  284 
Springfield.  287 
Bullet-forceps,  284 
Bullet-probe,  Fluhrer's,  283 
Lilienthal's,  283 
Nelaton's,  284 
Senn's,  283,  815 
Bunion,  747 

Bigg's  apparatus  for,  748 
Mayo's  operation  for,  748 
Bums  and  scalds,  12 17 
of  epiglottis,  1220 
of  esophagus,  932,  1220 
of  glottis.  1220 
of  pharynx.  1220 
of  tongue,  1220 
picric  acid  treatment,  12 19 
treatment,  12 18 
brush,  274 
electric,  1464 
«-ray,  1445,  1446,  1447 
Burrs,  Hudson's,  843 
Bursa,  diseases  and  injuries,  726 
retrocalcaneal,  exostoses  of,  355 
Bursitis,  741 
acute,  741 
chronic,  741,  742 
gluteal,  742 
iliac,  742 
iliopsoas,  742 
retrocalcaneal,  741 
subacromial.  744 

Codman's  treatment,  747 
Dawbarn's  sign  in,  745 
Monk's  treatment,  746 
treatment,  744,  747 
Butcher's   method   of   excision  of 
metatarsal  i)one  of  great  toe,  710 
Button  suture,  274 


Cachexia,  cancerous,  346.  370 
in  sarcoma,  346 
of  malignant  disease,  346 
strumipriva,  1226 
Calcium   chlorid   in   hemorrhage, 

449 
Calculus  in  bladder,  1313 
attacks  of,  13 14 
crushing,  1325 
in  children,  1315 
in  female,  1315,  1330 
mulberry.  1313 
treatment,  13 16 
in  ureter,  1283 
pancreatic,  1044 
renal,  1281 

operation  for,  1291 
pain  of,  91 
sound,  Thompson's,  13 14 
urethral,  treatment  of.  1308 
vesical,  rest  in,  97 
Callender's  strain-fracture,  519 
Callus,  central,  530 
definitive.  530 
ensheathing,  530 
formation  of,  530 
intermediate,  530 
permanent,  530 
provisional,  530 
temporary.  530 
Calmette's  antivenene  serum,  301 
Calomel  ointment  in  syphilis,  330 
Calor  cum  tumore  et  dolore,  90 
Camphor  in  clironic  ulcer  of  leg, 

171 
Cancer,  378 

i  deux,  345,  387 
biologic  theory,  382 
blood  changes  in,  385 
cachexia  in,  346,  379 
causes  of,  380 
chimney-sweeps',  386 
(       classification  of,  386 


Index 


1473 


Cancer,  colloid,  380 
conjugal,  345 
contact,  344,  387 
paralTm  workers',  386 
dissemination  of,  385 
distribution  of,  383 
emboli,  385 

en  cuirasse,  386,  1431.  1433 
encephaloid,  389 
endothelial,  370 
extension  of,  384 
glandular,  380 
hematoid,  380 
hereditary  intluence,  383 
houses,  343,  384 
immunity  to,  342 
increase  of,  382 
influence  of  diet,  384 
irritation  as  cause,  3S0 
lymphatic  involvement,  384,  385 
medullary,  389 
melanotic,  387,  389 
metastasis  in,  38s 
mouse,  382 
of  auricle,  386 
of  bladder,  1320 
of  brain,  827 
of  breast,  1427 
acinous,  142S 
Beatson's  operation   in,    391, 

1442 
causes  and  symptoms,  1429 
dressing  and  after-treatment 

after  operation  for,  1441 
duct,  1432 

Halsted's  operation,  1433 
hard,  1428 
in  male.  1432 
Jackson's  operation,  1436 
Meyer's  operation,  1437 
oophorectomy  in,  391,  1442 
Senn's  operation,  1436 
sternal  symptom,  1430 
treatment,  390,  1432 
Warren's  operation,  1436 
of  esophagus,  930 
treatment,  300 
of  gall-bladder,  1037 
of  intestine,  983 
treatment,  390 
of  lip,  919 

Grant's   operation   for,    390, 
919 
of  liver,  1015 
of  nipple,  1423 
of  penis,  1368 

treatment,  390 
of  prostate,  1385 
of  pylorus,  treatment,  390 
of  rectum,  1182 

Cripp's  operation,  1185 
Kraske's  operation,  1185 
palliative  colostomy  in,  1185 
Quenu-Mayo  operation,  1186 
rest  in,  97 

treatment,  390,  1183 
Weir's  operation,  1186 
of  stomach,  950 

coffee-ground  vomit  in,  951 
Ewald's  test-breakfast  in,  951 
treatment,  052 
of  thyroid  gland,  1227,  1228 
of  tongue,  922 

complete  removal  of  tongue 

in,  92  s 
Kocher's  operation  for,  925 
partial  removal  of  tongue  in, 

924 
treatment,  390 

Whitehead's    operation     for, 
926 
parasitic  theory,  381 
precancerous  stage,  380 
recurrence    of,    after    operative 

removal,  384 
regions,  384 
scirrhous,  389 
secondary  growths,  385 
serum  reaction  in,  380 

93 


Cancer,    spontaneous    disappear- 
ance, 385 
telangiectatic,  389 
Thiersch's  hypothesis,  381 
transplantation  of,  344 
treatment  of,  390 
.v-rays  in,  301,  MS" 
Cancerous  cirrhosis  of  liver,  lOis 

ulcer,  true,  387 
Cancroid,  388 

ulcer,  173 
Cancrum  oris,  192 
Caimon-balls,  wounds  by,  284 
Cannula  a  chemise,  456 
Capillary  aneurysm,  416 
angioma,  359 
drains,  77 
fracture,  siQ 

hemorrhage,  control  of,  454 
hemorrhoids,  11 75 
Capsule  of  bacteria,  19 
Capsulorrhaphy   in  habitual   dis 

location  of  humerus,  680 
Caput  medusa;,  400 
succedaneum,  790 
Carbolic  acid,  28 
gangrene,  197 
in  piles,  11 76 
in  tetanus,  228 
poisoning,  28 
Carboluria,  28 

Carbuncle,  149,  1223  I 

anthrax,  302  ; 

of  lip,  921 
treatment,  1225 
Carcinoma,  378.     See  also  Camer. 
Cardiolysis,  461 

Brauer's  method,  461 
Delorme's  method,  461 
Cargile  membrane,  76 
Caries,  502,  505 

excision  of  rib  in,  720 
necrotica,  505 

of     lumbar     and     last     dorsal 
vertebrae,  Treves's  operation 
for,  707 
sicca,  50s 
spinal,  861 

treatment,  864 
strumous,  502,  505 
tuberculous,  502,  505 
CiU-not's  solution  in  aneurysm,  421 
Carotid  artery,  common,  ligation 
of,  483 
external,  ligation  of,  484 
preliminary  closure,  721 
by     median     incision, 

721 
Weber's  incision,  721 
internal,  ligation  of,  485 
triangle,  inferior,  482 
superior,  482 
Carpal  bones,   traumatic   disloca- 
tion, 684 
scaphoid,  fractures,  586 
Carpus,  fractures  of,  585 
Carrying    angle    in    fractures    of 

humerus,  566,  5^7 
Cartilages,    costal,    fractures    of, 

549 
Malgaigne's  treatment.  550 
traumatic  dislocation,  686 
fioaring,  663 
inflammation  of,  87 
laryngeal,  fractures  of.  547 
loose,  in  osteo-arthritis,  651 
repair  in,  127 

semilunar,  inflammation  of,  626 
of      knee-joint,      dislocation. 
Barker's  operation,  723 
traumatic  dislocation,  694 
Castration,  1391 

for    hypertrophy    of     prostate, 

'383     .     .   , 
Cataplasm  m  mflammation,  106 
Catarrh,  chronic,  of  bladder,  1318 

urethral,  1342 
suppurative,     of     gall-bladder, 

1026 


Catarrh,  venereal,  1339 
Catarrhal  apiiendicitis,  987 
cholecystitis,  T024 
gonorrhea,  1341 

treatment,  1346 
inflammation,  87,  88 

of     gall-bladder     and     bile- 
ducts,  1024 
Catgut,  60 

chromicized,  preparation  of,  72 
method  of  tying,  72 
preparation      of,      Boeckrnan's 
method,  71 
boiling  in  alcohol,  70 
Claudius'  method,  71 

Salkindsohn's    modifica- 
tion, 71 
corrosive   sublimate   method, 

cumol  method,  70 
dry  heat  method,  71 
formalin  method,  71 
Johnston's  method,  72 
Kroniij's  method,  70 
Senn's  method,  71 
silverized,    Blake's    method    of 
preparing,  71 
Cathcart  drainage,  1325 
Catheter,  English,  1309 
French,  1308 
Gouley's,  1307 
Mercier's,  1308 
Nelaton's,  1307 
ureteral,  steriliziition  of,  1300 
urethral,  disinfection  of,  i.',o5 
Catheterization    in    prostatic    hy- 
pertrophy, 1374 
ureteral,  practical  value,  1304 
Cathelerizing  cystoscopes,  1298 
Cathode  rays,  1443 
i    Cauterization  in  inflammation,  108 
Cautery,    actual,   in   hemorrhage, 

'  449 

Corrigan,  m  mflammation,  108 

Paquelin,  449 
Celiotomy,  1048 
Cell,  epithelioid,  229 

of  bacteria,  19 
Cell-division,  127 

direct,  127 

indirect,  127 
Cell-proliferation  in  inflammation, 

8s 
Cellulitis,  215.  218 

crab,  214 

diffused,  141 

gangrenous,  219 
Celluloid  thread,  74 

preparation  of,  74 
Cementome,  355 
Centipedes,  bites  of,  298 
Centripetal  arterial  transfusion  m 

shock,  265 
Cephalhematoma,  791 
Ceph.alic  tetanus,  223 
Cephalocele,  793 

frontal,  793 

occipital,  793 

Robson's  treatment,  795 
Cephalodynia,  726 
Cerebellar  tumors,  decompression 

operation  for,  835,  850 
Cerebellitis,  817 
Cerebellum,  tumors  of,  832 
Cerebral  abscess  from  ear  disease, 
822 

concussion,  rest  in,  97 

hemorrhage,  806 

irritability,  799 

sinus,  hemorrhage  from,  control 
of,  453 

tetanus,  223 

tumors,  decompression    opera- 
tion for,  835,  850 
Cerebritis.  817 

Cerebrospinal  fluid,  bacteriology, 
879 
chemistry,  879 
cytodiagnosis,  879 


1474 


Index 


Cervical  adenitis,  tuberculous,  253 
fistula,  complete  median,  922 

median,  922 
lymphadenitis,  tuberculous,  253 
lymph-glands,    tuberculosis   of, 

253 
rib,  857 

method  of  removing,  720 
Chain  coccus,  48 
Chalk-stone,  650 
Chancre,  315 

and  chancroid,  mixed  infection, 

316 
diagnosis,  316 
Hunterian,  315 
redux,  317 
relapsing,  317 
soft,  1366 
Chancroid,  1366 
and   chancre,    mixed   infection, 
316 
Charbon,  301 

Charcot's  acute  bed-sores,  195 
disease,  652 
fever,  1034 

steeple  chart  of,  1035 
joint,  652 
Charriere's  splint,  686 

tourniquet,  1597 
Chemiotaxis,  negative,  20,  41,  84 

positive,  20,  41,  84 
Chest,  concussion  of,  894 
contusions  of,  894 

treatment,  895 
diseases  and  injuries,  888 
tapping  of,  003 
wounds  of,  894-  896 
Chiene's  method  of    finding  Ro- 
lando's fissure,  787 
Chilblain,  1221 
Chimney-sweeps'  cancer.  386 
Chinese  pox,  314 
Chlorid  of  ethyl  anesthesia,  1205 
for  freezing  anesthesia,  1211 
Chloroform,     administration     of, 
1191 
and  oxygen  anesthesia,  1193 
anesthesia,  1190,  1196 
followed  by  ether,  1028 
Chloroma,  367 
Choked  disk,  801 

as  symptom  of  brain-tumors, 
828 
Cholangitis.  1035 
infective,  1028 
suppurative.  1028,  1029 
Cholecystectomy,  1117 
for  gall-stones,  1037 
Cholecystendysis    for    gall-stones, 

1037 
Cholecystenterostomy,  1 1 16 
for  gall-stones.  1037 
Murphy's  method,  1117 
Cholecystitis,  1022 

acute  phlegmonous.  1027 
bacteriology  of,  1022 
catarrhal,  1024 
simple  suppurative,  1026 
typhoid,  1029 
Cholecystostomy,  1115 
biliary  fistula  after,  11 16 
for  gall-stones,  11 15 
Cholecystotomy,  1115 
ideal,  1 1 16 

for  gall-stones,  1037 
Choledochoduodenostomy,     inter- 
nal, 1 12 1 
Choledocho-enterostomy  for  gall- 
stones, 1037 
Choledocholithotrity      for      gall- 
stones, 1037 
Choledochostomy,  1120 

for  gall-stones,  1037 
Choledochotomy,  11 18 
for  gall-stones,  1037 
retroduodenal,  1121 
Cholelithiasis,  1030 
Cholesteatoma,  352 
of  brain,  827 


Chondroma,  353 

Chondrosarcoma,  370 

Chopart's    amputation    of    foot, 

1409 
Chordee  in  gonorrhea,  1340,  1341 

treatment.  1349 
Christian's     treatment     of     acute 

gonorrhea,,  1347 
Chromicized  catgut,  preparation, 

72 
Chvostek's  sign,  1243 
Chyle  cysts,  398 
Cicatrices,  125 
vicious,  126 
Cicatricial  tissue,  124 
Cicatrization,  125 
Circulation.  retardaUon  of,  in  in- 
flammation, 81 
Circumcision  in  phimosis,  136S 
Cirrhosis,  cancerous,  of  liver,  10 15 
Cirsoid  aneurysm,  360,  415,  432 
Clamp  and  cautery  operation  in 

piles,  1 1 76 
Clap,  1339 
Claret  stains.  360 
Claudius'     metliod    of    preparing 
catgut,  71 
Salkindsohn's    modifica- 
tion, 71 
Clavicle,  excision  of,  719 
fractures  of.  554 

at  acromial  end,  557 
at  shaft,  554 
at  sternal  end,  557 
Fox's  apparatus.  555 
Moore's  dressing  in,  556 
SajTe's  dressing  for,  556 
\'elpeau's  bandage  in,  556 
gumma  of,  325 
traumatic  dislocations,  670 

Rhoad's  apparatus  for,  670 
Clavus,  1225 
Claw-hand,  770 
Cleft  palate,  910 

Berry's  operation.  917 
Brophy's  operation,  918 
Fergusson's  operation,  918 
operation  for,  912 
Cloaca,  507 
Cloquet's    tabatiere    anatomique, 

472 
Clostridium,  23 
Clot,  active,  416 
external,  434 
internal,  434 
passive,  417 
Clove-hitch  knot,  678 
Clover's  ether -inhaler,  1194 
Club-foot.  757.     See  also  Talipes. 
Club-hand,  756 
CoBgulable  lymph,  121 
Cobra,  bite  of,  300 
Cocain    hydrochlorate,    hypoder- 
matic injection.  12 11 
Cocainization  of  nerve-trunk,  1212 

of  spinal  cord,  1214 
Cocain-poisoning,  fever  of,  136 
Coccus,  20 
chain.  48 
F'ehleisen's,  49 
plate,  20 
pyogenic,  21 
wool-sac,  20 
Coccygodynia,  554 
Coccyx,  fractures  of.  554 
Cock's    method  of    reducing  dis- 
located humerus.  678 
operation    of    perineal    section, 
136s 
Codman's     treatment     of     sub- 
acromial bursitis,  747 
Coffee-ground  vomit,  951 
Cohnheim's    inclusion    theory    of 

tumors,  341 
Coin-catcher,  928 
Cold  abscess,  144,  15s 

large,  treatment  of,  166 
effects  of,  1220 
on  bacteria,  24 


Cold,  exposure  to,  treatment,  1221 
gangrene,  180 
in  inflammation,  99 
Coley's    dressing    in    oblique    in- 
guinal hernia,  1133 
fluid  in  sarcoma,  373 
operation  for  undescended  tes- 
ticle, 1388 
Colic,  appendicular,  986,  987,  988 
in  gall-stones,  1033 
nephritic,  1282 
Collapse,  262 
Collar-bone,  fractures  of,  554.  See 

also  Clavicle. 
CoUargolum,  32 
Colles's  fracture,  581 

Bond's  splint  in,  583 
Le\is's  treatment,  583 
Maisonneuve's   symptom    in, 

583 
Moore's  treatment.  584 
Pilcher's  treatment.  584 
Roberts's  splint  in.  584 
Storp's  treatment,  585 
law  in  syphilis,  313 
Colley's  operation  in  \'olkmann's 

contracture,  731 
Collin's  apparatus   for   salt   solu 

tion,  466 
Collins'    incision    for    surgery   of 

bile-tracts,  11 14 
Collodion,  iodoform,  76 
Colloidal  silver,  32 
Colon  bacillus,  48,  52 

congenital  idiopathic  dilatation, 
1000 
Colopexy  in  rectal  prolapse.  1180 
Colostomy.  11 10 
inguinal.  11 10 

Bodine's  method,  11 12 
Maydl's  method,  mo 
lumbar,  11 12 

palliative,  in  cancer  of  rectum, 
ii8s 
Colubrine  venom,  299 
Columnae  adiposae,  1223 
Coma,  alcoholic,  803 

determination  of  cause.  S02 
diabetic,  189,  804 
hysterical,  803 
of  apoplexy,  803 
of  opium-poisoning,  804 
of  uremia,  803 
post-epileptic,  803 
Comma  bacillus,  20 
Complement.  329 
Compound  ganglion,  737,  738 
Compression  in  epididymitis,  103 
in  erysipelas.  103 
in  fractures,  103 
in  hemorrhage.  445 
in  inflammation,  103 

of  joint,  103 
in  lymphadenitis,  103 
in  ulcers,  103 
of  spinal  cord.  870 
Concussion,  cerebral,  rest  in.  97 
of  brain,  797 
of  chest,  894 
of  spinal  cord,  869 
Condyles,     femoral,     amputation 

through,  1412 
Condyloma,  321 

flat,  321 
Congestion  by  recoil,  904 
of  thjToid  gland,  1227 
Cormective-tissue      tumors,      in- 
nocent, 347 
malignant,  363 
Connell's     method    of     intestinal 
anastomosis,  iioo 
suture.  1063 
Constipation  of  appendix,  987 
Constitution,  lymphatic,  240 
Contact  cancer,  344,  387 
Continuous  suture,  272 
Contraction,  Dupuytren's,  754 
Keen's  operation  for,  754 
Lexer's  operation  for,  754 


Index 


1475 


Contractions  of  muscles,  734 
Contracture,  Volkmann's,  728 
Collcy's  oijeration  for,  7,51 
Jones's  treatment,  730 
Contused  wounds,  274 
Contusions,  250 
of  abdomen,  muscular  rupture 

from,  037 
of  abdominal  wall  without  in- 
jury of  viscera,  936 
of  bladder,  13 10 
of  brain,  707 
of  chest,  804 

treatment,  805 
of  head,  797 
of  lunR,  805 
of  musdes,  731 
of  nerves,  77"; 
of  spinal  cord,  869 
symptoms  of,  260 
treatment  of,  2(10 
wind,  from  projectiles,  294 
Cook's  speculum,  1163 
Cooper's  hemiotome,  11 50 

method  of  reducing  dislocated 
humerus,  677 
dislocation    of   radius   and 
ulna,  681 
operation  for  ligating  abdomi- 
nal aorta,  498 
rule  in  old   traumatic   disloca- 
tions, 668 
treatment    of    traumatic    dislo- 
cations of  lower  jaw,  669 
Copper  wire,  preparation  of,  74 
Coracoid  process,  fractures,  558 
Com,  1225 

Cornea,  inflammation  of,  86 
Corneal  corpuscles,  87 
Coming's   method   of    preventing 

nerve  regeneration,  777 
Corona  veneris,  320 
Corpus  striatum,  tumors  of,  832 
Corpuscles,  corneal,  87 
educated,  42 

third,  in  inflammation,  85 
Corradi's  operation  for  aneurysm, 

429 
Corrigan  cautery  in  inflammation, 

108 
Corrosive  sublimate,  26 

in  acute  gonorrhea,  1344 
method  of  preparing  catgut, 

poisoning,  27 
Cortical  motor  area,  lesions  in,  830 
Costal  cartilages,  fractures,  549 

traumatic  dislocation,  686 
Costotome,  720 

Cotton,    sterile    absorbent,    prep- 
aration of,  75 
Coup  de  fouet,  733 
Courvoisier's   law    in   gall-stones, 

Cowperitis  in  gonorrhea,  1341 
treatment,  1350 

Coxa  valga,  762 

Galeazzi's  treatment,  763 
vara,  762 

Coxalgia,  pain  of,  91 

Coxitis,  633 

Crab  cellulitis,  214 

Crampton's  line,  495 

Cranial  pneumatocele,  792 

Cranioschisis,  794 

Craniotabes,  256 

Craniotomy,  linear,  849 

Crede's  ointment  of  silver,  32 

Creolin,  29 

Crepitus  in  fractures,  526 

Crequy's  plan  of  removing  for- 
eign bodies  from  esophagus, 
934 

Cretinism,  1227 

Crile's    method    of    injection    of 
saline  solution  and  adren- 
alin, 468 
of  transfusion  of  blood,  464 
rubber  suit  in  shock,  264 


Cripp's  operation  for  rectal  cancer, 

ii8s 
Crises,  Dietl's,  1274 
Crookes'  lube,  1443 
Crossed  paralysis,  832 
Croupous  inflammation,  87,  88 
of     gall-bladder     and     bile- 
ducts,   I02S 
Crucial    ligaments   of   knee,   rup- 
ture, 658 
Crushing  vesical  calculi,  1325 
Cryoscopy,  12  71 
Cryptitis,  1181 
Cryptorchism,  1387 
Crypts    of    ^lorgagni,    inflamma- 
tion, 1 181 
Cuirass  cancer,  386,  1431,  1433 
Culminating  point  of  bullet,  289 
Cumol  methofl  of  preparation  of 

catgut,  70 
Cupping  in  inflammation,  98 
Cups,  dry,  99 

wet,  00 
Curling's  ulcer,  177,  979,  12 18 
Curvature,  spinal,  858.     See  also 

Spinal  curvature. 
Cushing's    decompression    opera- 
tion in  tumors  of  brain,  83s, 
850 

electrode,  847 

method    of   decompressive    tre- 
phining, 850 
of    osteoplastic    resection    of 

skull,  843 
of     removal     of     Gasserian 
ganglion,  783 

right-angled  suture,  1062 

treatment  of  hydrocephalus,  797 
Cut  throat,  882 
Cyanid  gauze,  preparation,  75 
Cyanosis  in  anesthesia,  1197 

treatment,  1198 
Cylindrical-celled        epithelioma, 

387 
Cylindroma,  370 
Cyrtometer,  Horsley's,  789 
Cystadenoma  of  breast,  1425 
Cystic  adenoma  of  breast,  1425 

degeneration  of  breast,  1426 

fibroma  of  breast,  1426 

tumors,  multilocular,  355 
Cysticotomy,  1037 
Cystitis,  1316 

acute,  1317 

chronic,  1318 

tuberculous,  1318 

in  gonorrhea,  treatment,  1350 

rest  in,  97 

treatment,  1319 
Cystocele,  11 24 
Cystoma,  391,  396 

atheromatous,  392,  394 

mesoblastic,  392 

mucous,  392 

of  bone,  500 

traumatic  epithelial,  392 

varieties  of,  392 
Cystoscope,  1297 

Brown's,  1299 

catheterizing,  1298 

collection  of  urine  by,  1303 

operative,  1304 

removal  of,  1303 

sterilization  of,  1300 

universal,  1299 
Cystoscopic  table.  Brown's,  1301 
Cystoscopy,  1297 

contraindications  to,  1300 

location  of  interureteral  bar  in, 
1301 
of  ureteral  orifices  in,  1302 

practical  value,  1304 

technic,  1300 
Cystotomy,  1330 

median,  1332 

suprapubic,  1331 
Cysts,  396,  410 

anosacral,  853 

blood-,  260 


Cysts,  Boyer's,  744 

branchial,  395 

chyle,  398 

dentigerous,  355 

dermoid,  394 

sequestration,  394 

from  softening,  398 

hydatid,  399 
of  breast,  1426 
of  liver,  1016 

involution,  of  breast,  1426 

lacteal,  397 

of  breast,  1426 

milk,  397 

mucous,  397 
of  mouth,  922 

of  bone,  500 

of  brain,  827 

of  breast,  1424,  1426 

of  incisive  gland,  922 

of  liver,  1015 

of  mesentery,  948 

of  nipple,  1423 

of  omentum,  948 

of    sinus    pocuiaris,    treatment, 
1308 

of  vitello-intestinal  duct,  398 

oil,  397 

pancreatic,  1044 

parasitic,  399 

retention-,  396 

salivary,  397 

sebaceous,  396 

solitary,  354 

subhyoid,  922 

thyroglossal,  922 

thyrolingual,  922 

traumatic  epithelial,  394 

tubulo-,  398 

urachal,  398 
Cytodiagnosis     of     cerebrospinal 

fluid,  879 
Czerny-Lembert  suture,  1062 
Czemy's      method     of     tendon- 
lengthening,  750 


Da  Costa's    method    of    bowel- 
identification,  942 
modification    of    Senn's   opera- 
tion for  fixing  kidney,  1293 

Dactylitis   in   hereditary   syphilis, 
338 
tertiary,  326 

Dalton's  formula  in  acute  gonor- 
rhea, 1345 

Dangerous  area,  791 

Danger-zone  of  projectiles,  289 

Davis's    incision   in    appendicitis, 
1055 

Davy's  director,  702 
lever,  446,  1414 

Dawbam's  operation  for  appendi- 
citis, 1058 
for  sarcoma  of  tonsil,  372 
sign  in  subacromial  bursitis,  745 

De  Guise's  operation  for  salivary 
fistula,  909 

Dead  space,  56 

Deafness,  word-,  832 

Death  by  inhibition,  262 

Deaver's   operation   for   appendi- 
ceal abscess,  1060 

Decollenient  of  parietal  pleura  in 
abscess,  908 

Decompressive    trephining,    835, 
850 

Decortication,    pulmonary,    Fow- 
ler's operation,  907 

Decubital  gangrene,  180,  195 

Decubitus,  176,  180,  195 

Defecation-spermatorrhea,  1371 

Defensive  proteid,  38 

Deformity,  silver-fork,  582 

Degeneration,    cystic,    of    breast, 
1426 
gelatiniform,  in  tuberculous  ar- 
thritis, 629 
of  muscles,  727 


1476 


Index 


Degeneration,  pulpy,  of  synovial 

membrane,  253,  626,  628 
Delirious  shock,  263 
D  lorme's  method  of  cardiolysis, 
461 

treatment  of  ununited  fractures, 
530 
Delusions,  hypochondriacal,  oper- 
ative treatment,  840 
Demarcation,  line  of,  181,  182 
Dental  nerve,  inferior,  neurectomy 

of,  779 
Dentigerous  cysts,  355 
Deodorizer,  26 
Depage's   operation   for   enterop- 

tosis,  1002 
Depression-fracture,  519 
Dermatitis  gangraenosa  infantum, 
180 

malignant,  of  nipple,  1424 

venenata,  1222 

ar-ray,  1445,  1446,  1447 
Dermatol,  32 

Dermoid    associated    with    sacro- 
coccygeal region,  1160 

cyst,  394 

sequestration,  394 

sublingual,  922 
Desault's  bandage,  1256 

sign  in  intracapsular  fracture  of 
femur,  591 
Diabetes  obstructing  repair,  120 
Diabetic  coma,  804 
Diabetics,  operations  on,  190 
Diaphragm,  eventration  of,  1159 

rupture  of,  805 
Diaphragmatic  hernia,  1158 
Diastasis,  521 

Diathesis,  hemorrhagic,  467 
Dichotomy  of  bacilli,  21 
Diday's    operation     for     webbed 

finders,  75s 
Dietl's  crises,  1274 
Diffenbach's     treatment     of     old 

traumatic  dislocations,  668 
Digestive    tract,    upper,    diseases 

and  injuries,  908 
Digits,  supernumerary,  755 
Dilatation,   congenital   idiopathic, 
of  colon,  1000 

digital,  of  pylorus,  for  cicatricial 
stenosis,  1063 

of  stomach,  acute,  966 

Brandt's  operation  for,  logo 
chronic,  965 
Dimple,  j  ost-anal,  853 
Diphtheritic  inflammation,  87,  88 
Diplococcus,  20 

pneumoniae,  52 
Disarticulation,     anterior     inter- 
tarsal,  1409 

at  ankle-joint,  1410 

at  elbow-joint,  1404 

at  hip-joint,  1414 

at    metacarpophalangeal    joint, 
1402 

at  middle  tarsal  joint,  1409 

at  shoulder-joint,  1404 

at  tarsometatarsal  articulation, 
1407 

at  wrist-joint,  1402 

of  knee,  1412 

posterior  intertarsal,  1400 

subastragaloid,  1409 
Discission    of   pulmonary   pleura, 

Ransohoff's  operation,  908 
Disease  production,  35 
Disinfectant,  26 
Disinfection,  26 

of  mucous  membranes,  68 
Dislocation.  664 

congenital,  665 

consecutive,  665 

in  typhoid  fever,  665 

Monteggia's,  691 

Nelaton's,  696 

occurring  with  fractures,  535 

of     hip,     congenital,     Hoffa's 
operation,  724 


Dislocation    of    hip,    congenital, 
Lorenz's         bloodless 
method   of    reduction, 
723 
operation,  725 
operation  for,  723 
of  kidney,  1273 
of  latissimus  dorsi.  734 
of  long  head  of  biceps,  734 
of  muscles,  734 
of  semilunar  cartilages  of  knee. 

Barker's  operation,  723 
of  spine,  871 
of  tendons,  734 
of  ulnar  nerve  at  elbow.  774 
pathological,  665 
spontaneous,  665 
traumatic,  664 

at  inferior  radio-ulnar  articu- 
lations, 61S4 
at  metacarpophalangeal  artic- 
ulations, 685 
joint  of  thumb,  685 
at  superior  tibiofibular  artic- 
ulation, 695 
causes,  665 
compound,  668 
diagnosis,  667 
of  ankle-joint.  696 
anteroposterior,  696 
lateral,  696 
upward,  696 
of  astragalus,  697 

forward  or  backward,  697 
lateral  and  rotary,  697 
of  carpal  bones,  684 
of  clavicle,  670 

Rhoad's  apparatus  for,  670 
of  elbow-joint,  680 
of  femur,  687 

AUis's  sign  in,  688 

anomalous,  691 

into  obturator  foramen,  690 

into  sciatic  notch,  689 

of  head,   with  fracture  of 

shaft,  692 
upon  dorsum  of  ilium,  688 
upon  pubis,  691 
with  catching  up  of  sciatic 
nerve   during   reduction, 
691 
with    fracture   of   shaft   of 
bone,  692 
of  fibula,  695 

of   hip-joint,    687.     See   also 
Dislocation,    traumatic,    oj 
jemur. 
of   humerus,    672.     See   also 
Humerus,   traumatic:  dislo- 
cation. 
of  knee,  692 
backward,  692 
fomard,  692 
inward,  693 
outward,  693 
of  lower  jaw,  668 

Cooper's  treatment,  669 
Nelaton's  treatment,  669 
of  metacarpal  bones,  685 
of  metatarsal  bones,  698 
of  patella,  693 
edgewise,  604 
inward,  693 
outward,  693 
of  pelvis,  686 
of  phalanges,  686,  698 
of  radius,  682 

and  ulna,  681 
of  ribs  and  costal  cartilages, 

686 
of  scapula,  672 
of    semilunar     cartilages    of 

knee-joint,  694 
of    shoulder-joint,    672.     See 
also    Humerus,    traumatic 
dislocation. 
of  sternum,  686 
of  tarsal  bones,  698 
of  ulna,  682 


Dislocation,   traumatic,  of    ulna, 
682 
2and  radius,  681 
of  wrist,  683 
old,  668 

Cooper's  rule  in.  668 
Diffenbach's  treatment.  668 
Lister's  treatment.  668 
pathological  conditions,  666 
recent,  667 
.  subastragaloid,  697 

I  symptoms,  666 

treatment,  667 
Displacement    in    plastic  surgery, 

1260 
Dissection-wounds,  297 
Diver  goiter,  1230 
Diverticulum,  Meckel's,  970 
hernia  of,  11 58 
intestinal    obstruction    from. 
969 
of  esophagus.  932 
pharyngeal,  305 
Divulsion  in  rectal  stricture.  1182 

of  uretlira  for  stricture,  1361 
Dorsal  abscess,  tuberculous.  162 

treatment  of.  167 
Dorsalis  pedis  artery,  ligation.  488 
,    Douche  in  inflammation,  104 
I        Scotch,  in  inflammation,  104 
I    Dowd  and  McBumey's  fracture- 
hook,  536 
Dowd's  operation  for  undescended 

testicle.  1388 
Downes's  method  of  electrohemo- 
stasis.  450 
suture,  1062 
Doyen's  vasotribe,  440 
I    Drainage,  76 

Cathcart,  1325 
of  hepatic  duct,  11 18 
of  pus,  77 
of  woimds,  268 
Drainage-tubes,  77 
Drains,  capillary,  77 
Dressing  basin,  77 
Dressings,  75 
change  of,  77 
fixed,  1258 

silicate  of  sodium,  1258 
Dressman's    treatment    of    bone- 

ca\nties,  509 
Drop-finger,  756 
Dropsy,  626 
Drummond    and    Morison's   epi- 

plopexy,  1 108 
Drumstick  bacterium,  23 
Dugas's    sign    in    dislocation    of 
shoulder-joint,  674 
I    Dumdum  bullet.  290 
i    Dunham's   treatment  of  fracures 
of  shaft  of  femur  in  children,  606 
Duodenocholedochotomy,  1121 

for  gall-stones,  1037 
Duodenostomy,  1091 
Duodenum,  peptic  ulcer.  970 
Dupuytren's  amputation  at  shoul- 
der-joint, 1406 
aneurysm  needles.  470 
contraction,  754 

Keen's  operation  for,  754 
Lexer's  operation  for,  754 
fracture,  696 

splint  in  Pott's  fracture,  621 
suture,  1062 
Duret's  operation  for  gastroptosis, 

1090 
Dyspepsia,  adhesion-,  963 


Ear  disease,  cerebral  abscess  from, 
822 
suppurative,      brain     disease 
from,  822 
hemorrhage    from,    control    of 

45.S 
syphilitic  affections.  322 
Eberth's  bacillus,  Si 
Ecchondroses,  353 


Index 


1477 


Ecchymosis,  260 
Ecchymotic  mask,  888 
Ecthym:i,  gangrenous,  180 

syphilitic,  ,521 
Ectopia  of  testicle,  1387 

vesicae,  1300 
Eczema  complicating  ulcer,  treat- 
ment, 171 
Eczema tous  urethritis,  1338 
Edebohls's    method    of    nephrot- 
omy,  I2QO 
operation  for  chronic  nephritis, 
1289 
for  movable  kidney,  1278 
Edema,  anthrax,  302,  303 
in  fractures,  535 
malignant,  207 

bacillus  of,  52 
of  glottis,  K82 
of  larynx,  882 

of   lungs    in    anesthesia,    treat- 
ment, IIQ9 
Edison's  fluoroscope,  1447 
Educated  corpuscle,  42 
Effusion,     pericardial,     operation 
for,  459 
pleuritic,  889 
purulent,  142 
Ehrlich's  theory  of  mechanism  of 

immunity,  30 
Elbow,    figure-of-eight    bandage, 
1255 
miners',  747 
Elbow-joint,     disarticulation     at, 
1404 
disease,  642 
excision  of.  712 

fractures    in    or    near,    Allis's 
treatment,  571 
false  ankylosis  after,  572 
in  young  children,   Berto- 
mier's        treatment, 
572 
treatment,  572 
Jones's  dressing  for,  571 
Frazier's         modifica- 
tion, 571 
prognosis,  569 
Roberts's  treatment,  572 
treatment,  569 
true  ankylosis  after.  572 
traumatic  dislocations,  6S0 
tuberculosis  of,  642 
Electric  bum,  1464 
Electricity,  effects  of  artificial  cur- 
rents, 1463 
injuries  by,  1461 
Electrocution,  1465 
Electrode,  Cushing's,  847 
Electrohemostasis,  Downes's 

method,  450 
Skene's  method,  450 
Electrolysis  in  aneurysm,  428 
Elephantiasis.  1247 

spurious,  1247 
Elevation  in  hemorrhage,  445 
Embolic  aneurysm,  416 
Embolism,  203 
air-,  208 
fat-,  205 

occluding  pulmonary,  897 
of  mesenteric  arteries,  205 
vessels,  intestinal  obstruction 
from,  971 
pulmonary,  205 
symptoms,  204 
treatment  of,  205 
Embolus,  203 
aseptic,  203 
bland,  203 
cancer,  385 
infectious,  203 
septic,  203 
simple,  203 
toxic,  203 
Embryonic  tissue  in  inflammation, 

86  " 
Emergencies,  intra-abdominal,  di- 
agnosis of,  936 


Emotional  fever,  136 
Emphysema,  cellular,  548 

gangrenous,  185,  297 
Emprosthotonos,  222 
Empyema    149,  890 

acute,  H90 

Heck's  treatment,  892 

chronic,  X91 

closed,  891 

double,  891 

excision  of  rib  in,  720 

netessitiitus,  800 

of  antrum  of  Highmore,  148 

of     gall-bladder,     1023,     1026, 

I03S 
acute,  1027 
recurrent,  1027 
of  mastoid,  822 
open,  891 
partial,  890 
pulsating,  890 
total,  890 
treatment  of,  891 
Encephalitis,  817,  818 

chronic,  818 
Encephalocele,  794 
Encephaloid  cancer,  389 
Enchondroma,  353 
of  brain,  827 
of  breast,  1426 
Endarteritis,  chronic,  412 
obliterative,  413 

arteriovenous  anastomosis  for, 
414 
treatment  of,  413 
End-bulb,  129 

Endo-aneurysmorrhaphy,   obliter- 
ative,   without    arterioplasty, 
424 
with     complete      arterioplasty, 

425 
with  partial  arterioplasty,  425 
Endocarditis,    gonorrheal,    treat- 
ment of,  1358 
tuberculous,  252 
Endoscope,  Marks's,  1298 
Endothelial  cancer,  370 
Endothelioma,  370 
of  brain,  826 
of  breast,  1427 
Endotracheal  goiter,  1233 
Endspore,  23 

End-to-side    intestinal    anastomo- 
sis, 1093 
English  catheter,  1309 
Enterectomy,  1092 
Enteritis,  rest  in,  97 
Enterocele,  1124 

partial,  1148,  1158 
Enteroclysis  in  shock,  264,  265 
Entero-epiplocele,  1124 
Enteroptosis,  1001 
Enterorrhaphy,  106 1 

circular,  1092 
Enterostenosis,      969.     See     also 

Intestinal  obstruction. 
Enterostomy,  mo 

Stewart's  method,  977 
Enucleation  in  goiter,  1233 

of  thyroid  gland,  1238 
Enzymes,  36 
Epidermization,  125 
Epididymectomy    in    tuberculosis 

of  testicle,  1391 
Epididymis,  encysted  hydrocele  of, 
1304 
tuberculosis  of.  1389.  '391 
Epididymitis,  1391 
compression  in,  103 
in  gonorrhea,  1341 
treatment,  1350 
Epiglottis,  burns  and  scalds,  1220 
closure  of,  in  anesthesia,  treat- 
ment, 1 1 99 
Epilepsy,  essential,  operative  treat- 
ment, 837 
focal,  operative  treatment,  837 
following  infantile  cerebral  palsy, 
operative  treatment,  839 


Epilepsy,     idiopathic,     operative 
treatment,  837 
with   local   onset  of   attacks, 
operative  treatment,  837 
Jacksonian,  830 

due   to   grc»s   brain   disease, 

oijerative  treatment,  839 
operative  treatment,  837 
operative  treatment,  836 
pleural,  906 

post-hemiplegic,  operative  treat- 
ment, 839 
reflex,  operative  treatment,  837 
traumatic,  operative  treatment, 
83S 
Epileptic  insanity,  operative  treat- 
ment, 840 
Epiphyseal  separation,  521 
Epiphysitis,  acute,  512 
Epiplocele,  1124 
Epiploic  abscess,  949 
Epiplopexy,  1108 
Epispadias,  1365 
Epistaxis,  control  of,  454 
Epithelial  cystoma,  traunuitic,  392 
cysts,  traumatic,  394 
odontoma,  35s 
tumors,  innocent,  375 
malignant,  378 
Epithelioid  cells,  229 
Epithelioma,  387 

cylindrical-celled,  387 
exedens,  388 
of  nipple,  1424 
squamous-celled,  387 
jc-rays  in,  1457 
Epsom  salt,  saturated  watery  solu- 
tion  of,    in    inflammation, 
103 
solution  of,   for  spinal  anal- 
gesia, 1217 
Epulides,  fibrous,  350 
Epulis,  fibrous,  350 
Equinia,  308 
Erasion,  709 

of  knee-joint,  709 
Erb's  sign,  1243 
Erectile  tumors,  359 
Erector  spinas  muscle,  strain  of, 

869 
Ergot  in  pulmonary  hemorrhage, 

457 
Ergotism,  gangrene  from,  191 
Erichsen's  ligature,  method  of  ap- 
plying, 361 
signs  in  dislocation  of  shoulder- 
joint,  674,  67s 
Erysipelas,  215 
ambulant,  215 
bullous,  215 
cellulocutaneous,  217 
clinical  forms,  216 
compression  in,  103 
cutaneous,  215,  216 
diffused,  215 
edematous,  215 
effect  of,  on  sarcoma,  375 
erratic,  215 
erythematous,  215 
faucial,  215 
forms  of,  215 
lead-water    and    laudanum    in, 

103 
lymphatic,  215 
metastatic,  216 
migratory,  215 
mucous,  215 
neonatorum,  215 
phlegmonous,  215,  217 
puerperal,  215 
serum  in  sarcoma,  374 
simplex,  215 
streptococcus  of,  48.  49 
typhoid,  215 
universal,  215 
venous,  215 
wandering,  215 
Erysipele  salutaire,  216 
Erysipeloid,  214 


1478 


Index 


Erythema  serpens,  214 

syphilitic,  319 
Escherich's  bacillus,  52 
Esmarch's  elastic  bandage,  1306 
method    of    preventing   hemor- 
rhage in  amputation  at  hip- 
joint,  141 5 
splint,  713,  714 
Esophageal  bougie,  928 
forceps,  Q28 
instruments,  928 
Esophagismus,  931 
Esophagotomy,  external,   for  for- 
eign bodies,  934 
external,  in  stricture,  928 
internal,  in  stricture,  928 
Esophagus,  bums  and  scalds,  932, 
1220 
cancer  of,  930 

treatment,  390 
diverticula  of,  932 
foreign  bodies  in,  933 
injuries  and  diseases,  908 
from  within,  932 
from  without,  932 
spasm  of,  931 
stricture     of,     926.     See     also 

Slriclure  of  esopliagus. 
wounds  of,  932 
Estlander's    method    of    thoraco- 
plasty, 906 
Ether,  administration  of,  1193 
drop  method,  11 94 
and  chloroform  anesthesia,  1204 
and  oxygen  anesthesia,  1195 
anesthesia,  1190,  1106 

followed  by  chloroform,  1208 
Ether-inhaler,  AUis's,  1193 

Clover's,  1 104 
Etherization,  rect;il,  1195 
Ether-pneumonia,  1201 
Ether-spray  anesthesia,  12 11 
Ethyl  bromid  anesthesia,  1205 
chlorid  anesthesia,  1205 

for  freezing  anesthesia,  12 11 
Eucain  hydrochlorate  anesthesia, 

1212 
Europhen,  31 

Eventration  of  diaphragm,  11 59 
Evulsion  of  brachial  plexus,  766 
Ewald's  method  of  testing  motor 
power  of  stomach,  966 
test-breakfast     in     cancer     of 
stomach,  951 
Excision  of  ankle-joint,  717 
Hancock's  method,  718 
of  bones,  708 
of  cla%'icle,  719 
of  elbow-joint,  712 
of  half  of  lower  jaw,  722 

of  upper  jaw,  720 
of  hemorrhoids,  11 77 
of  hip- joint,  715 

Barker's  method,  715 
by  anterior  incision,  715 
by  lateral  incision,  716 
Gross'  method,  716 
Langcnbeck's  or«ration,  716 
of  joints,  708 
of  knee-joint,  716 

Ashhurst's  method,  717 
by    anterior    semilunar    flap, 
716 
of  metacarpal  bones,  715 
of  metatarsal  bone  of  great  toe, 
710 
Butcher's  method,  719 
of   metatarsophalangeal   articu- 
lation of  great  toe,  719 
of  OS  calcis,  718 

by    subijeriosteal     method, 
718 
of  phalanges,  715 
of  pylorus,  1067 
of  rib,  720 
in  caries,  720 
in  empyema,  720 
of  scapula,  719 

Syme's  method,  720 


Excision     of     scapula,     Treves's 
method,  720 
of  shoulder-joint,  711 
by  anterior  incision,  712 
by  deltoid  flap,  712 
Senn's  method,  712 
of  testicle,  1391 
of  wrist-joint.  713 
Lister's  method,  714 
radial  incision,  714 
ulnar  incision,  714 
Exclusion,  local  intestinal,  1107 
Exfoliation,  507 
Exhaustion   theorv   of   immunity, 

38 
Exophthalmic  goiter,  1230,  1234 
exophthalmus  in,  1235 
Moebius's  sign  in,  1235 
partial      thyroidectomy      in, 

1237 
Stellwag's  sign  in,  1235 
tachycardia  in,  1235 
thvToidectin  in,  1236 
treatment,  1236 
von  Graefe's  sign  in,  1235 
.Y-rays  in,  1458 
Exophthalmus,  1235 
Exostosis,  355 

of  retrocalcaneal  bursa,  355 
subungual,  355 
ExothjTopexy,  1233 
Expectoration,  albuminous,  904 
Explosive  bullets,  290 
Exstrophy  of  bladder,  1309 
Extensor  tendon,  rupture  of,  756 
Extirpation  in  goiter,  1233 

intracapsular,  of  thjToid  gland, 

1241 
of  sac  in  treatment  of  aneurysm, 

422 
of  thyroid  gland,  1239 
Extracapsular  fracture,  522 
Extradural  abscess,  823 
hemorrhage,  804 
control  of,  453 
Extravasation,  260 
Exudation,  lymph,  83 

of  fluids  in  inflammation,  82 
plastic,  83 
Eyes,  Borsch's  bandage,  1253 
crossed  bandage,  1253 
figure-of-eight  bandage,  1253 
foreign   bodies   in.  Sweet's  ap- 
paratus for  locating,  1455 
inflammation  of,  pain  in,  91 

rest  in,  97 
symptoms,   in  hereditary  syph- 
ilis, 338 
syphilitic  affections,  323 

Fabricics's  operation  for  femoral 

hernia,  1144 
Face,  injuries  and  diseases,  908 
Facial  artery,  ligation  of,  486 

paralysis,  operation  for,  784 
Facio-accessory  anastomosis,  784 
Faciohypoglossal         anastomosis, 

784 
Fallopian   tubes,   tuberculosis   of. 

255 
Farcy,  308 

acute.  308 

chronic,  308 
Fascia,  plantar,  subcutaneous  fas- 
ciotomy  of,  749 

tuberculous  disease  of,  252 
Fasciotomy, subcutaneous, of  plan- 
tar fascia,  749 
Fat-embolism,  205 
Fat-hernia,  348,  11 24 
Fat-necrosis  of  pancreas,  1040 
Faucial  erysipelas,  215 
Fecal  abscess,  144 

accumulation,      intestinal      ob- 
struction from,  971 

fistula,  978 

Senn's  operation  for,  11 10 

impaction,  treatment,  1308 


Fecal  incontinence  after  oj^ration 
for  tistula  in  ano,  treatment, 
1171 
vomiting  in  strangulated  hernia, 
1148 
Fehleisen's  coccus,  49 
Fell-O'Dwyer  apparatus,  894 
Fell's  method  of  artificial  respira- 
tion in  cyanosis  in  anesthesia, 
1198 
Felon,  149,  738 
bone,  739 
deep,  739 
painless,  738 
superficial.  739 
White's  treatment,  740 
Femoral    artery,   compression   of, 
446 
ligation,  492 
condyles,   amputation   through, 

1412 
vein,  hemorrhage  from,  control 
of,  453 
P'cmur,  fractures  of,  588.     See  also 
Fractures  oj  femur. 
incurvation  of  neck,  762 
osteotomy  of  shaft   below   tro- 
chanters, 701 
Gant's  operation,  701 
through  neck,  700 

Adams's  operation,  700 
with  osteotome,  701 
traumatic  dislocation,  687.     See 
also  Dislocation,  traumatic,  of 
femur. 
Ferguson's  operation  for  inguinal 

hernia,  11 39 
Fergusson's    operation    for    cleft 
palate,  918 
for  varix  of  leg,  462 
Fetus,  parasitic,  393 

suppressed,  393 
Fever,  94 

inflammatory,  94 

symptomatic,  94 

Fibro-adenoma,  377 

of  breast,  1424 
Fibroblasts  of  inflammation,  85 
Fibrocystadenoma  of  breast,  1425 
Fibrofatty  tumor,  347 
Fibroid  tumor,  recurrent,  370 

uterine,  357 
Fibroma,  349 

cystic,  of  breast,  1426 
hard,  349 

nasopharjTigeal,  3so 
of  brain,  827 
of  breast,  1424 
soft,  350 
treatment,  353 
Fibromyxoma  of  breast,  1425 
Fibrosarcoma,  367,  370 
Fibrosis,  arteriocapillary,  412 
Fibrospindle-cell  sarcoma,  368 
Fibrous  epulides,  350 
epulis,  350 
tissue,  124 
Fibula,  fractures  of,  620.     See  also 
Fractures  of  fibula. 
traumatic  dislocation,  69.!; 
Fifth    nerve,    neuralgia    of,    779. 
See    also    Neuralgia    of    fiflh 
nerve. 
Figure-of-eight  bandage,  1250 
of  breast,  1257 
of  elbow,  1255 
of  eyes,  1253 
of  jaw  and  occiput,  1253 
of  neck  and  axilla,  1256 
of  shoulders,  1255 
of  thigh  and  pelvis,  1255 
Filarial  worms,  1246 
Fingers,  amputation  of,  1401 
drop-,  756 
jerk-,  755 
lock-,  755 
mallet-,  756 
sarcoma  of,  367 
snapping-,  755 


Index 


1479 


Finders,  spiral  bandage,  1251 

trigger-,  755 
webbed,  754 
Finney's    method    of    Kastroduo- 
denostomy,  1066 
in  cicatricial  stenosis,  962 
Finsen  light,  1450 

in  tuberculosis,  249 
F"irst  intention,  healing  by,  120 
Fish-mouth  meatus  in  gonorrhea, 

1340 
Fission,  bacteria  in,  21 
Fissure,  intrajiarietal,  788 
of  anus,  1 1 72 
of  Bichat,  786 
of  bone,  519 
of  breast,  1420 

prevention,  1420 
of  Rolando,  786 
of  Sylvius,  787 
Fistula,  178 
accidental,  978 
biliary,    after    cholecystostomy, 

1116 
branchial,  395 
complete,  395 
incomplete,  395 
cervical,    complete    congenital, 
395 
median,  922 
incomplete  congenital  lateral, 

395 
median,  922 
fecal,  078 

Senn's  operation  for,  mo 
horseshoe,  1 1 70 
in  ano,  1169 

fecal  incontinence  after  oper- 
ation for,  treatment,  1171 
in  tuberculous  arthritis.  Beck's 

treatment,  631 
intentional,  978 
of  Steno's  duct,  909 
perineal,   in   urethral    stricture, 

treatment,  1362 
pleural,  890,  892 
salivary,  908 

De  Guise's  operation  for,  909 
Flagella,  19 
Flail-joints,  763 

Flap  method  of  amputation,  1400 
Flat  condyloma,  321 
Flat-foot,  758 

Gleich's  treatment,  760 
Golding-Bird  and  Davy's  oper- 
ation for,  760 
inflammatory,  758 
Miiller's  treatment,  760 
Ogston's  operation  for,  760 
paralytic,  758 
spurious,  758 
static,  758 

Stokes's  operation  for,  760 
Trendelenburg's  operation  for, 

760 
Wilson's   correction   screw   for, 
759 
Flesh,  proud,  125 
Floating  cartilages,  663 
hepatic  lobe,  1022 
kidney,  1273 
liver,  102 1 
patella,  625 
Floss,  silk,  73 
Fluhrer's  probe,  283 
Fluoroscope,  1447,  1448 
Edison's,  1447 
in  locating  bullet,  283 
Folliculitis    in    gonorrhea,    treat- 
ment, 1350 
Fomentations,    antiseptic,    in    in- 
flammation, 105 
in  inflammation,  105 
Foot,  American  bandage,  1252 
amputation  of,  1407 
bandage  of,  covering  heel,  1252 

not  covering  heel,  1252 
fractures  of,  623 
French  bandage,  1252 


Foot,  Madura-,  19 
spiral    bandage,   covering   heel, 
1252 
Foramen  of  Winslow,  hernia  into, 

1157 
Forbes's    amputation    at    tarsus, 
1409 
lithotrite,  1327 
Forceps,  bullet-,  284 
esophageal,  928 
Halsted's,  437 
hemostatic,  437 
Hudson's  moditied  De   Vilbiss, 

844 
Laplace's,  for  intestinal  anasto- 
mosis, 1 100 
lateral  intestinal  anastomosis 
with,  1105 
O'Hara's,  for  intestinal  anasto- 
mosis, IIOI 
Thompson's  vesical,  1330 
Ford's  suture,  272,  1062 

treatment  of  acute  arteritis,  412 
Forearm,  amputation  at,  1403 
and  hand,  sterilization  of,  62 
Furbringer's  method,  62 
mechanical,  61 
sublimate-alcohol    method, 

63 
Weir-Stimson  method,  63 
Welch-Kelly  method,  63 
Foreign    bodies    in    air-passages, 
883 
in  bronchi,  884 
in  esophagus,  933 
in  eye.  Sweet's  apparatus  for 

locating,  1455 
in  intestine,  949 
in  larynx,  883 
in  nose,  881 
in  pharynx,  883 
in  rectum,  1166 
in  stomach,  949 
in  urethra,  1335 
in  wounds,  removal  of,  268 
intestinal    obstruction    from, 

970 
x-rays  in  localizing,  1450 
Formaldehyd,  3$ 
Formalin,  33 

method  of  preparing  catgut  71 
Formalin-gelatin,  33 
Formic  aldehyd,  i^ 
Fort's    treatment    of    stricture    of 

urethra,  1362 
Fossa,  intersigmoid,   hernia   into, 
1157 
retrocecal,  hernia  into,  1157 
retrod uodenal,  hernia  into,  1157 
Foudroyant  gangrene,  185 
Fourth  of  July  tetanus,  279 
Fowler's  method  of  gastro-enter- 
ostomy,  1077,  1083 
of    pulmonary    decortication, 
907 
operation    for   inguinal   hernia, 

1138 
position  in  peritonitis,  1006 
Fox's   apparatus    for    fracture    of 

clavicle,  555 
Fractures,  517 

ambulatory,  treatment,  534 

Barton's,  582 

Bennett's,  587 

bent,  519 

by  contrecoup,  521 

capillary,  519 

causes,  522 

CoUes's,  581 

Bond's  splint  in,  583 
Levis's  treatment,  583 
Maisonneuve's   symptom   in, 

583 
Moore's  treatment,  584 
Pilcher's  treatment,  584 
Roberts's  splint  in,  584 
Storp's  treatment,  585 
comminuted,  520,  521 
complete,  518 


Fractures,  complications,  518,  528 

[jrevention  and  treatment,  535 
composite,  520 
compound,  517 

of  patella,  treatment,  538 

primary,  51X 

repair  of,  531 

secondary,  518 

treatment  of,  536 
compression  in,  103 

consequences,  528 
crepitus  in,  526 
cuneated,  520 
cuneiform,  520 
definition,  517 
delayed  union,  531 
treatment,  538 
dentate,  520 
depression-,  519 
designation   according   to   seat, 

522 
diagnosis,  527 

by  x-rays,  528 
direct,  521 

dislocations  occurring  with,  535 
Dupuytren's,  696 
edema  in,  535 
en  coin,  520 
en  rave,  519 
en  V,  520 
extracapsular,  522 
extravasation  of  blood,  525 
false  joint  in,  531 
faulty  union,  531 
fibrous  union,  531 
fissured,  519 

from  muscular  action,  522 
from  violence,  direct,  522 

indirect,  522 
Gosselin's,  520 
green-stick,  519 
gutter-,  of  skull,  813,  814 
hair,  519 

Harting's  apparatus  for,  534 
helicoidal,  521 
hickory-stick,  519 
impacted,  521 
inconi]  lete,  518 
indirect,  521 
inflammation  in,  536 
intra-articular,  522 
intracapsular,  522 
intra-uterine,  522 
ligamentous  union,  531 
linear,  519 
lipuria  after,  206 
longitudinal,  519 
loss  of  function,  525 
massage  in,  534 
membranous  union,  531 
multiple,  520 
muscular  spasm  in,  536 
non-union,  531 
oblique,  519 

spiroide,  520 
of  acetabulum,  552 
of  acromion,  558 
of  both  bones  of  leg,  622 

compound,  623 
of  brim  of  acetabulum,  592 
of  carpal  scaphoid,  586 
of  carpus,  585 
of  clavicle,  554 

at  acromial  end,  557 

at  shaft,  554 

at  sternal  end,  557 

Fox's  apparatus,  555 

Moore's  dressing  in,  556 

Sayre's  dressing  for,  556 

Velpeau's  bandage  in,  556 
of  coccyx,  554 
of  coracoid  process,  558 
of  costal  cartilages,  549 

Malgaigne's  treatment,  550 
of  false  pelvis,  551 
of  femur,  588 

at  base  of  neck,  597 

at  lower  part  of  lower  third, 
60s 


1480 


Index 


Fractures    of    femur     at    middle 
third,  604 
at  neck,  in  children,  590 

operative  treatment,  509 
at  shaft,  602 
in  children,  605 

Bryant's     extension     in, 

606 
Dunham's        treatment, 

606 
Van  Arsdale's  splint  in, 

606 
Ware's  splint  in,  608 
Wyeth's  dressing  for,  607 
at  upper  extremity,  588 
part  of  lower  third,  604 
third,  603 

Agnew's  treatment,  603 
Smith's  sjilint  in,  603 
examination  of  hip  in,  588 
extracapsular,  597 
impacted,  598 
Southam's  treatment,  599 
Hodgen's  splint  for,  604 
intracapsular,  588 
Allis's  sign  in,  591 
Buck's  apparatus  in.  593 
Desault's  sign  in,  591 
diagnosis  of,  591 
Lagoria's  sign  in,  591 
Morris's    measurement   in, 

591 
prognosis  of,  503 
Senn's  treatment,  594 
symptoms  of,  590 
Thomas's  splint  in,  596 
Whitman's  treatment,  597 
just  above  contlyles,  609 

Bryant's  treatment,  609 
longitudinal,  609 
Mclntyre's  splint  in,  605 
near  knee-joint,  605 
separating  either  condyle,  609 
separation  of  lower  epiphysis, 
610 
ef  upper  epiphysis,  601 
of  fibula,  620 

at  lower  third,  620 
at  upper  two-thirds,  620 
of  foot,  623 
of  glenoid  cavity,  558 
of  great  trochanter,  601 
of  humerus,  558 

at  anatomical  neck,  559 

Scudder's     bandage    in, 
560 
at  base  of  condyles,  568 
at  external  condyle,  566 
at  head,  562 
at  inner  epicondyle,  567 
at  internal  condyle,  567 
at  lower  extremity,  566 

Gerster's  method  of  re- 
ducing swelling  in,  566 
at  outer  epicondyle,  567 
at  shaft,  563 

injury     of     musculospiral 

nerve  in,  563 
Scudder's  bandage  in,  564 
at  surgical  neck,  561 
carrying  angle  in,  566 
in  or  near  elbow-joint,  prog- 
nosis, 569 
treatment,  569 
intracapsular,  559 
separation   at   lower   epiphy- 
sis, 572 
at  upper  epiphysis,  563 
T-fractures,  569 
of  hyoid  bone,  546 
of  inferior  maxilLary  bone,  545 
of  inner  malleolus,  619 
of  innominate  bone,  552 
of  lachrymal  bone,  541 
of  laryngeal  cartilages,  547 
of  leg,  617 
of  malar  bone,  543 
of  metacarpal  bones,  587 
Russ's  splint  in,  588 


Fractures  of  metatarsal  bones,  624 
of  nasal  bones,  539 
Asch  tube  in,  540 
Jones's  splint  in,  541 
Nason's  pin  in,  540 
of  patella,  610 

by  direct  force,  616 

compound,  616 

recent    transverse,    operative 

treatment,  704 
transverse,  6 1 1 

Agnew's  spilint  in,  613 
Barker's  operation  in,  615 
treatment  of,  612 
wiring  in,  615 
ununited   and    badly   united, 
617 
operative  treatment,  706 
of  pelvis,  55 1 
of  penis,  1368 
of  phalanges,  588 

of  toes,  625 
of  radius,  577 

and  ulna  near  wrist,  585 

at  both  forearms,  581 

at  head,  577 

at  lower  extremity,  581 

at  neck,  579 

at  shaft,  580 

above  insertion  of  pronator 

radii  teres  musde,  580 
below  insertion  of  pronator 
radii  teres  muscle,  =;Ri 
separation     of    lower    radial 
epiphysis,  585 
of  ribs,  547 
of  sacrum,  553 
of  scapula,  557 
of  body,  557 
of  neck,  558 
of  spine,  558 
of  skull,  807 

by  contre-coup,  807 
of  base,  809 

Battle's  sign  in,  811 
of  vault,  80S 
trephining  for,  842 
of  spine,  871 
of  sternum,  550 

of  superior  maxillary  bone,  541 
of  tibia,  617 

at  lower  end,  619 
at  shaft,  618 
at  upper  end,  617 
separation  of  lower  epiphysis, 
619 
of  tubercle  of,  6t8 
of  upper  epiphysis,  618 
of  true  pelvis,  552 

Wood's  rule  in,  552 
of  tuberosity  of  ischium,  552 
of  ulna,  572 

and  radius  near  wrist,  585 
at  coronoid  pirocess,  572 
at  olecranon  process,  573 
Murphy's  operation  for, 

575 
Pick's  treatment,  574 
at  shaft,  576 
at  styloid  process,  577 
of  vertebra,  871 
of  zygomatic  arch,  544 

Matas'  operation  for,  544 
par  iiTadiation,  521 
pathological,  521 
Pilcher's  dressing  for,  534 
Pott's,     620,     696.     See     also 

Poll's  jrarhtre. 
preternatural  mobility,  525 
pseudo-arthrosis  in,  531 
radish-,  519 
recent,  operative  treatment,  538, 

703 
repair,  528 
rest  in,  97 
rupture  in,  536 
secondary,  521 
simple,  517 
repair  of,  528 


Fractures,  spiral,  521 
splinter-,  519 
spontaneous,  521 
sprain-,  519 
starred,  521 
stellate,  521 
strain-,  519 
symptoms,  524 
toothed,  520 
torsion,  521 
transverse,  519 
treatment,  532 
T-shaped,  520 
ununited,  521 

Menard    and    Lannelongue's 

treatment,  705 
of   femoral   neck,   Freeman's 
treatment,  705 
oferative  treatment,  705 
operative  treatment,  704 
Senn's  treatment,  70s 
treatment  of,  538 
varieties,  517 

of  displacement,  524 
vicious  union,  531 

osteotomy  for,  702 
treatment,  539 
V-shaped,  520 
wedge-shafed,  520 
willow,  519 

w-ith  crushing  or  penetration,  521 
Fracture-box,  619 
Fracture-dislocation  of  spine,  871 

treatment,  874 
Fracture-hook,     McBumey     and 

Dowd's,  536 
Fragilitas  ossium,  523 
Frankel's  bacillus,  52 
Frank's   coupler,   intestinal  anas- 
tomosis with,  1096 
Franks's  method   of  examination 

in  movable  kidney,  1275 
Frazier's   modification   of  Jones's 
dressing  for  injuries  of  elbow- 
joint,  571 
Frazier-S[iller  operation  of  intra- 
cranial neurotomy,  784 
Freeman's  clamp,  705 

method    of    treatment    in    un- 
united   fractures   of    femoral 
neck,  705 
Freezing  for  anesthesia,  1211 
French  bandage  of  foot,  1252 

catheter,  1308 
Freyer's    method    of    suprapubic 

prostatectomy,  1378 
Frieclrich's  operation  in  pulmon- 
ary tuberculosis,  901 
Frontal  cephalocele,  793 
lobe,  tumors  of,  831 
sinus,  distention  and  abscess,  882 
trephining,  845 
Frost-bite,  191 

gangrene  from,  191 
Fuller's  method  of  milking  semi- 
nal ducts,  1369 
of  suprapubic  prostatectomy, 
1379 
Fulminating  appendicitis,  987 
Fungus  as  cause  of  skin  diseases, 
18 
budding,  18 
cerebri,  8i6 
filamentous,  18 
of  testicle,  255 
ray-,  18,  310 

as  cause  of  actinomycosis,  18 
Funicular  hydrocele,  1394 

[irocess,  hernia  into,  11 54 
Fiirbringer's   method  of  steriliza- 
tion of  hands  and  forearms,  62 
Furuncle,     149,    1222.     See    also 

Boil. 
Furunculosis,   1223 


Galactocele,  1426 
Galeazzi's  treatment  of  coxa  valga, 
763 


Index 


1481 


(lallant's    Irt-atnient    of    movable 

kidney,  1276 
Gall-bladder,  1014 
cancer  of,  1037 
catarrhal  inllainination,  1024 
congenital  absence,  1 1 13 
crouiious  inllaiiimation,  1025 
ernpyenia  of,  102.3,  1026,  1035 
acute,  1027 
recurrent,  1027 
healthy,  11 13 
hydrops  of,  1023,  1035 
incision    for    operations    upon, 

1113 
inflammation  of,  1022 
mucous  membrane  of,  removal, 

1118 
rupture  of,  945 
suppurative  catarrh,  1026 

inflammation,  1025 
Gall-stones,  1030 
ball-valve,  1034 
colic  in,  1033 
Coiu-voisier's  law  in,  1035 
Hamel's   test   for   jaundice   in, 

1034 
McBumey's  operation  for,  1121 
prodromal  state,  1032 
symptoms,  1032 
treatment,  1036 
Gait's  trephine,  842 
Gamma-rays,  1459 
Ganglion,  737 

compound,  737,  738 
Gasserian,  removal  of,  781 
Cushing's  method,  783 
Hartley's  method,  782 
Horsley's  method,  7S3 
Gangrene,  179 
acute,  1S4 

amputation  for,  rules,  ig8 
carbolic  acid,  197 
chronic,  181 
classification,  179 
cold,  180 
congenital,  180 
constitutional,  180 
cutaneous,  180 
decubital,  180,  195 
diabetic,  180,  188 
dry,  179,  180 

non-senile,  180 
embolic,  180 

emphysematous,  180,  185 
foudroyante,  185 
from  ergotism,  191 
from  frost-bites,  igi 
fulminating,  185 
gaseous,  180 
glycemic,  180 
hospital,  180,  i86 

treatment  of,  187 
hot,  180 
idiopathic,  180 

symmetrical,  180 
in  strangulated  hernia,  1148 
line  of  demarcation,  181,  182 
microbic,  179 

acute,  i8s 
mixed,  180 
moist,  179,  184 

from  inflammation,  185 

of  leg,  184 

treatment  of,  185 
multiple,  180 
of  penis,  1368 
post-febrile,  198 
Pott's,  18 1 
pressure,  180 
primary,  180 
purpuric,  180 
Raynaud's,  180,  187,  188 
secondary,  180 
scorbutic,  180 
senile,  180,  181 

prevention  of,  in  predisposed, 
183 

treatment  of,  183 
static,  180 


Gangrene,  symmetrical,  187 
thrombotic,  180 
traumatic  spreading,  185 
trophic,  180 
venous,  180 

white,  from  .x-rays,  1446 
Gangrenous  appendicitis,  988 
cellulitis,  2ig 
ecthyma,  180 
emphysema,  185,  297 
induration  of  neik,  196 
inflammation,  88 
masses,  194 
Gant's  osteotomy  of  shaft  of  femur 

below  trochanters,  701 
Garel's  sign  in  abscess  of  antrum 

of  Highmore,  148 
Gaseous  phlegmon,  185 
Gasolene,  commercial,  33 
Gasserian  ganglion,  removal,  781 
Cushing's  method,  783 
Hartley's  method,  782 
Horsley's  method,  783 
Gastrectomy,   complete,   for   can- 
cer, 953 
partial,  1070 

for  cancer,  953 
subtotal,  for  cancer,  953 
Gastro-anastomosis,  1089 
Gastro-duodenostomy,     Finney's, 
1066 
Jaboulay's,  1079 
Gastroenterostomy,  1073 
anterior,  1077 

Kocher's  method,  1078 
Mayo's  method,  1078 
Scnn's  method,  1077 
Billroth's  method,  1076 
Braun's  method,  1081 
by  Murphy  button,  1082 
complications  after,  1074 
for  cancer,  953 
Fowler's  method,  1077,  1083 
Jaboulay's  method,  1081 
Lucke's  method,  1077 
Mayo's  method,  1086 
McGraw's  method,  1077,  1079 
Moynihan's  method,  1083 
peptic  ulcer  of   jejunum   after, 

1075 
posterior,  108 1 
treatment  after,  1074 
vicious  circle  and  regurgitation 

after,  1075 
vomiting  after,  1075,  1076 

treatment,  1077 
von  Hacker's  method,  1077 
with  entero-anastomosis,   1077 
Wolfler-Liicke  method,  1077 
Wolfler's  method,  1077 
Gastrogastrostomy,  1089 
Gastrojejunostomy,  1073 
Gastropexy,  logo 
Gastroplication,  1090 

Bircher's  method,  1089 
Gastroptosis,  968 

Beyea's  operation  for,  1091 

Duret's  operation  for,  1090 

Gastrorrhagia  in  ulcer  of  stomach, 

operation  for,  959 
Gastrostomy,  1070 
for  cancer,  953 
Kader's  method,  1072 
Senn's  method,  1072 
Ssabanejew-Frank  method,  1072 
Witzel's  method,  1072 
Gastrotomy,  1070 
Gauze,  antiseptic,  preparation  of, 

aseptic,  preparation  01,  75 
cyanid,  preparation  of,  75 
iodoform,  preparation  of,  75 
sterilized,  preparation  of,  75 

Gebauer's  ethyl-chlorid  tube,  1209 

Gelatin  in  hemorrhage,  448 
treatment  of  aneurysm,  420 

Gelatiniform       degeneration       in 
tuberuclous  arthritis,  629 

Gelsemium  in  inflammation,   no 


Genito-urinary  diseases,   pain  in, 
12O0 
ojjerations  in  insanity,  841 
organs,    diseases    and    injuries, 
1264 
Genu  valgum,  756 

.Macewen's  operation  for,  699 
Ogston's  operation  for,  700 
osteotomy  for,  699 

varum,  756 
Germicides,  25 
Gerster's  method  of  reducingswell- 

ing  in  fracture  of  lower  e.xtrem- 

ity  of  humerus,  566 
Giant-cell  sarcoma,  368 
Gibbon's   method   of   ureterolith- 
otomy, 1296 
Giljney's      method      of      treating 

sprains  of  ankle,  656 
Gibson's  bandage,  1253 
Gila  monster,  bite  of,  301 
Girdle  pain  in  tetanus,  223 
Girdner's     telephonic     probe     in 

locating  bullet,  283 
Glabella,  786 
Glanders,  308 

acute,  308 

bacillus  of,  52 

chronic,  308 

treatment  of,  309 
Gleet,  1342 
Gleich's    treatment    of     flat-foot, 

760 
Glenard's  disease,  looi 

sign,  1022 
Glenoid  cavity,  fractures,  558 
Glioma,  350 

of  brain,  826 
Gliosarcoma,  370 
Glottis,  bums  and  scalds,  1220 

edema  of,  882 
Glovers'  stitch,  74 
Gloves  for  operation,  preparation, 

6s 
Gluck's  method  of  circular  arte- 

riorrhaphy,  443 
Gluteal  artery,  ligation  of,  496 

bursitis,  742 
Glutol,  33 

Goelet's  method  of  palpation  for 
detection  of  prolapsed  kidney, 
1276 

operation  for  movable  kidney, 
1278 
Goiter,  1228 

acute,  1227,  1230 

adenomatous,  1229 

Basedowified,  1230 

causes,  1230 

colloid,  1230 

cystic,  1229 

diver,  1230 

endemic,  1230 

endotracheal,  1233 

enucleation  in,  1233 

epidemic,  1230 

exophthalmic,  1230,  1234.     See 
also  Exophthalmic  goiter. 

extirpation  in,  1233 

fibrous,  1229 

hemorrhagic,  1230 

inflammatory,  1227 

intrathoracic,  1230 

malignant,  1229 

non-malignant,     metastasis    of, 
1232 

operations,  dangers  in,  1241 

parenchymatous,  1229 

pulsating,  1234 

retro-esophageal,  1230 

retrosternal.  1230 

retrotracheal,  1230 

sporadic,  1230 

substernal,  1230 

suffocating,  1230 

symptoms,  1231 

thyroidectomy  in,  1233 

treatment,  1233 

wandering,  1230 


1482 


Index 


Gold-beaters'   skin  as  protective, 

76 
Golding-Bird  and  Davy's  opera- 
tion for  flat-foot,  760 
Gonococcus,  49 
Gonorrhea,  1339 
abortive,  1341 

acute   inflammatory,   complica- 
tions in  treatment,  1349 
symptoms,  1340 
treatment,  1342 
black,  1339 
catarrhal,  1341 

treatment  of,  1346 
chronic,  treatment  of,  1351 
urethritis     following,     treat- 
ment, 1 35 1 
in  children,  1356 
in  female,  1355 
children,  1357 
irritative,  1341 

treatment  of,  1346 
micrococcus  of,  49 
of  anus  and  rectum,  1354 
of  mouth,  1355 
of  nose,  I3S5 
of  uterus,  treatment,  1356 
subacute,  1341 
when  cured,  1351 
Gonorrheal  arthritis,  645 
treatment,  1358 
endocarditis,  treatment,  1358 
ophthalmia,  1340 
treatment,  1350 
peritonitis,  1340 
rheumatism,  643 
Gordon's  reflex,  S54 
Gosselin's  fracture,  520 
Gouley's  catheter,  1307 

divulsor,  1362 
Gout,  chronic,  650 
partial  rheumatic,  651 
progressive  rheumatic,  651 
rheumatic,  650 
of  hip-joint,  651 
Gouty  arthritis,  650 

urethritis,  1337 
Graft,  omental,  1063 
Grafting,  bone-,  704 
for  bone-cavities,  510 
nerve-,  777 
skin-,   1260.     See     also     Skin- 

grajling. 
tendon-,  751 
thyroid,  1227 
Graham's     treatment     of     meta- 

tarsalgia,  762 
Granny-knot,  438 
Grant's  clamp,  11 13 

operation  in  cancer  of  lip,  390, 
919 
Granulation,  exuberant,  125 
repair  by,  123 
tissue,  143 

in  inflammation,  86 
Gravel,  1281 
Graves's  disease,  1234 
Gravity,  influence  of,  on  projec- 
tiles, 2S8 
Green-stick  fracture,  519 
Gritti's    supracondyloid    amputa- 
tion, 1413 
Groin,  abscess  of,  149 
spica  bandage,  1255 
Gross'  method  of  excision  of  hip)- 
joint.  716 
urethral  dilator,  1361 
urethrotome,  1361 
Grynfelt  and  Lesshaft's  triangle, 

1 1 57 
Gum-boil,  148 
Gumma,  325 
of  clavicle.  325 
tuberculous,  250 
of  brain.  826 
Gummatous  inflammation,  325 
tumors  of  brain,  826 
ulcer,  325 
Gummy  pus,  140 


Gunpowder,  black,  as  compared 

with  smokeless  powder,  285 
Gunshot-wounds,  277 

amputation  in,  284 

contour,  281 

from  shot-gun,  279 

from  sporting  rifle,  279 

hemorrhage    from,    control    of, 
455 

in  civil  life,  278 

of  abdomen,  947 
>  of  arteries,  434 

of  pregnant  uterus,  948 

penetrating,  2S0 

perforating,  280 

symptoms,  282 

tattooing  in.  281 

tissue  track,  280 

treatment,  282 

wound  of  entrance,  280 
of  exit,  280 
Gussenbauer's  clamp  in  ununited 
fractures,  539 

operation  for  stricture  of  esoph- 
agus, 92S 

suture,  1063 
Guthrie's  rule  in  hemorrhage,  450 
Gutta-percha  tissue  as  protective, 

76 
Gutter-fracture     of     skull,     813, 

814 
GjTiecological    operations    in    in- 

s;mity,  841 


Habit  fits,  840 
Hagedom's  needles,  439 
Hair,  syphilitic  affections,  322 
Hallus  valgus,  761 

osteotomy  for,  702 
Wilson's  treatment,  761 
varus,  761 
Halsted's  band  roller,  428 
forceps,  437 

method  of  arteriorrhaphy,  444 
of      intestinal      anastomosis, 

HOC 

of   lateral    intestinal    anasto- 
mosis, 1 104 
operation  for  aneurysm,  426 
for  cancer  of  breast,  1433 
for  inguinal  hernia,  1134 
modified,  1137 
stitch,  75 

suture,  56,  273,  1062 
Hamel's  test  for  jaimdice  in  gall- 
stones, 1034 
Hamilton's  bandage,  S45 

bone-drills,  704 
Hammer-toe,  761 

Ferrier's  treatment,  761 
Hancock's  method  of  excision  of 

ankle-joint,  718 
Handkerchief  bandage,   1257 
Hands,  amputation  of,  1401 
and    forearm,    sterilization    of, 
62 
Furbringer's  method,  62 
mechanical,  61 
sublimate-alcohol    methcxl, 

63 
Weir-Stimson  method,  63 
Welch-Kelly  method,  63 
spiral  bandage  of  palm  or  dor- 
sura,  1251 
sterilization  of,  60 
Hare-lip,  910 

double,  operation  for.  912 

Owen's  operation  for,  912 
Malgaigne's  operation  for,  911 
operation  for,  911 
single,  Mirault's  operation  for, 
912 
operation  for,  911 
suture,  274 
Harrington     and     Gould's     seg- 
mented ring,  anastomosis  with, 
ioqO 
Harrison's  renipuncture,  1293 


Harris's  method  of  intestinal  an- 
astomosis, 1098 
urine  segregator,  1267 
Harting's  apparatus  for  fractures, 

534 
Hartley's    method   of  removal   of 

Gasserian  ganglion,  782 
Hayden's    treatment   of   bubo   in 

chancroid,  1368 
Head,  contusions  of,  797 
diseases  and  injuries,  786 
injuries  of,  797 

during  labor,  790 
recurrent  bandage,  1257 
tetanus,  223 
Headache,  elevation  in,  97 
Healing,  120.     See  also  Repair. 
Heart,  diseases  and  injuries,  401 
in  inflammation. '116 
massage  in   chloroform-poison- 
ing, 1 1 98 
muscle,  tuberculosis  of,  252 
rupture  of.  401 
wounds  of,  401 
operation  for.  459 
Potter's  incision  in,  459 
sutiu'e,  459 
Heart-cavity,  tapping,  439 
Heat,  34 

effect  on  bacteria,  24 
in  inflammation.  90,   102,   104, 
106 
Heath   and   Selby's  treatment  of 

Pott's  fracture,  622 
Heberden's  nodosities,  651 
Hectic  fever,  135,  145 
Heineke-Mikulicz's     methcxl     of 
pyloroplasty,  1065 
operation   for   cicatricial  steno- 
sis of  stomach,  962 
Helferich's   treatment  of  delayed 

union  in  fractures,  539 
Heller's  test  for  hematuria,  1264 
Hemangeiosarcoma,  369 
Hemangioma,  359 
Hematemesis,  control  of,  457 
Hematocele,  1394 

diffused,  of  spermatic  cord,  1394 
encysted,    of    spermatic    cord, 
I3Q4 
of  testicle,  1394 
of  tunica  vaginalis,  1395 
parenchymatous,  1394 
vaginal,  1394 
Hematoma,  260 

of  dura  mater  of  brain,  817 
of  scalp,  797 
of  stemomastoid,  752 
Hematomyelia,  869 
Hematuria,  1264 
Almen's  test.  1265 
Heller's  test.  1264 
in  appendicitis,  994 
microscopic  test,  1265 
renal,  1263 
Rosenthal's  test.  1264 
Struve's  test,  1265 
Hemianopsia,  831 
Hemoglobinuria,  1265 
Hemolysin,  48 
Hemophilia,  467 
Hemophilic  arthritis,  469 
Hemoptysis,  control  of,  457 
Hemorrhage,  434 

actual  cautery  in,  449 

acupressure  in,  445 

after  lateral  lithotomy,  control 

of,  456 
after    operation    in    obstructive 

jaundice,  43s 
arterial,  rules  for  arresting,  430 
arteriorrhaphy  in,  440 
calcium  chlorid  in,  449 
capillary,  control  of,  434 
cerebral,  806 
compression  in,  443 
consecutive,  437 
Downes's  method  of  controlling, 
450 


Index 


1483 


Hemorrhage,  elevation  in,  445 
extradural,  804 

control  of,  453 
extramedullary,  870 
forced  flexion  in,  447 
from  bladder,  1268 

control  of,  456 
from  cerebral  sinus,  control  of, 

453  ,     , 

from  ear,  control  of,  455 
from  femoral  vein,   control  of, 

from   gunshot-wounds,    control 

°^'  455  ,  ^  , 

from  intercostal  artery,  control 

of,  452 
from  internal  mammary  artery, 

control  of,  452 
from  intestines,  control  of,  457 
from  kidney,  control  of,  456 
from  leech-bite,  control  of,  455 
from  lung,  control  of,  457 
from    palmar    arch,    rules    for 

arresting,  45° 
from  prostate.  1268 

control  of,  456 
from  rectum,  control  of,  455 
from  stomach,  control  of,  457 
from  tooth-socket,  treatment  of, 

453 
from  urethra,  1209 

control  of,  45S 
from  uterus,  control  of,  456 
gelatin  in,  448 
Guthrie's  rule  in,  450 
Horsley's    wax    in    controUmg, 

in  aMominal  section,  control  of, 

454  . 

in  amputation,  13QO 
in  pancreatitis,  1040 
in  ulcer  of  stomach,  operation 

for,  959 
intercurrent,  457 
intermediate,  457 
intra-abdominal,  435,  937 

control  of,  453 
intracranial,  804 

in  newborn,  806 
intramedullary,  870 
ligature  for,  436 
meningeal,  traumatic,  804 
of  wounds,  261 

arrest.  268 
phleborrhaphy  in.  439 
jMimary.  rules  for  arresting,  450 
reactionary,  457 
recurrent,  457 
secondary,  458 
Sken's   method   of    controlhng, 

450  ,    . 

spinal,  control  ot,  453 
styptics  in,  447 
subcutaneous,  435 

treatment  of,  455 
subdural,  805 
suprarenal  extract  in,  449 
torsion  in.  444 
treatment,  436 

hemostatic  agents,  436 
umbilical,  control  of,  455 
Xaughn's  method  of  controlling, 

452 
venous,  rules  for  arresnng,  450 
Hemorrhagic  diathesis.  467 
disease,  467 
goiter.  1230 
infarction,  204 
inflammation,  85,  88 
sarcoma,  369 
ulcers,  174 
Hemorrhoids,  409.  1173 

Allingham's  operation  for,  1177 

arterial,  11 75 

cajMUary,  11 73 

clamp    and    cautery    operation 

for,  1177 
excision  for,  11 77 
external,  11 73 


Hemorrhoids,    external,    connec- 
tive-tissue, 1 1 74 
thrombotic,  1173 
varicose,  1174 
inflammatory,  1174 
internal,  1175 

ligature  operation  for,  1177 
treatment  of,  11 75 
operative,  11 76 
venous,  11 75 

Whitehead's  operation  for,  11 77 
Hemostatic  forceps,  437 
Hepatic  duct,  drainage  of,  1 1 18 
fever.  136,  1034 

intermittent,  1028 
infection  after  appendicitis,  992 
lobe,  floating,  1022 
Hepaticostomy,  11 20 
Hepaticotomy,  1120 
Hepatitis,  pain  of,  91 
Hepatopexy,  1022 
Hepatoptosis,  102 1 
hepatopexy  in,  1022 
laparectomy  in,  1022 
]5artial,  1022 
Hepatotomy,  transthoracic,  102 1 
Heredity  as  cause  of  cancer,  383 
Hernia,  1123 

abdominal,  1123 
causes.  1124 
cecal,  1 1 35 
cerebri,  816 
diaphragmatic,  1158 
director,  1130 
epigastric,  11 55 
fat-,  348,  1 124 
femoral,  1155 

Fabricius's  operation  for,  1 144 
herniotomy  in,  115 1 
radical  cure,  1144 
gluteal.  1 1 57 
hydrocele  of,  1394 
in  childhood.  1152 
incarcerated,  1145 
infantile,  11 54 

encysted,  1153 
inflamed,  1145 
inguinal  congenital,  11 54 
direct,  1154 

radical  cure,  1141 
Ferguson's      operation      for, 

"39  .       , 

i  Fowler's  operation  for,  1 138 

Halsted's  operation  for,  1134 
moditied,  1137 
'  plus  Bloodgood's  method 

of  transplanting  rectus 
muscle,  1 1 38 
indirect,  11 54 
injury  to  bladder  in  operating 

for,  1127 
interparietal,  11 56 
interstitial,  11 56 
Kocher's  operation  for.  1138 
Macewen's      operation      for, 

1 130 
oblique,    Bassini's    operation 
for,  1131 
Coley's  dressing  in.  1133 
herniotomy  in.  11 50 
superficial,  11 56 
internal,  1157 

into  foramen  of  Winslow,  1157 
into  funicular  process.  1154 
into  intersigmoid  fossa,  1157 
into  retrocecal  fossa,  1157 
into  retroduodenal  fossae,  1157 
intra-abdominal.  1157 
irreducible,  1145 
labial.  II 54 
Littre's,  1148.  11 58 
lumbar,  1157 
mortality  from,  11 52 
needles,  11 30 
obstructed,  1145 
obturator,  1156 
of  bladder,  11 58 
of  brain,  815 
of  intestinal  wall,  11 58 


Hernia  of  linea  alba,  11 55 
of  Meckel's  diverticulum,  1158 
of  muscles,  734 
of  ovary,  11 59 
of  uterus,  11 59 
of  vermiform  appendix,  1155 
p.erineal,  11 57 
pjroi-«ritoneal,  1156 
pudendal,  11 57 
reducible,  1125 

Lannelongue's         treatment, 

1 130 
treatment  of,  11 26 
rest  in,  97 

retroperitoneal,  11 57 
Richter's,  1148,  1157 
Rokitansky's  diverticular,  11 58 
sciatic,  1 157 
scrotal,  1 134 

sliding,   of   ascending   and   de- 
scending colon,  operative 
treatment,  1145 
colon,  1 153 
of  descending  colon,  11 36 
strangulated,  1146 
delusive  calm  in,  1148 
elastic,  1 1 46 
fecal,  1 147 

vomiting  in,  1148 
gangrene  in,  1148 
herniotomy  in,  11 30 
reduction  en  bissac,  1149 

en  masse,  11 49 
taxis  in,  1148 
treatment  of,  1148 
traumatic,  1125 
tuberculosis  of,  11 24 
umbilical,  11 55 

herniotomy  in,  11 31 
Mayo's  operation  for,  1141 
radical  cure,  1141 
vaginal,  11 37 
varieties  of,  11 54 
ventral,  1155 
Hemiotome,  Cooper's,  1150 
Herniotomy,  11 50 
Heurteloup's  artificial  leech,  99 
Hewitt's  nitrous  oxid  and  oxygen 
apparatus,  1207 
apparatus,  1206 
Hey's  amputation  of  foot,  1408 

internal  derangement,  694 
Hibbs's  method  of  tendon-length- 
ening, 750 
Highmore,    antrum    of,    abscess, 
148,  881 
treatment,  132 
inflammation.  881 
Hilton's  method  of  opening  deep 

abscess.  154 
Hip,  abscess  of.  634 

congenitiil    dislocation.  Hoffa's 
op'cration.  724 
Lorenz's  bloodless  method 
of  reduction.  723 
operation,  725 
operation  for,  723 
disease,  633 

examination  of,  in  fractures  of 
femur,  588 
Hip-joint,  disarticulation  at,  1414 
disease,  633 

excision,     713-     %«    also    Ex- 
cision oj  hip- joint. 
faulty  ankylosis,  osteotomy  for, 

700 
osteo-arthritis  of,  651 
rheumatic  gout.  631 
traumatic  dislocation,  687.     See 
also  Dislocation,  traumatic,  of 
femur. 
tuberculosis  of,  633.     See  also 
Tuberculosis  of  hip-joint. 
Hirschsprung's  disease,  1000 
Hodgen's  splint  for  fractures  of 

femur,  604 
Hodgkin's  disease,  1247 
Hoffa's   operation   for   congenital 
dislocation  of  hip,  724 


1484 


Index 


Hoffmann's  sign,  1243 
Hollow  foot,  760 
Home's  lobf,  1373 
Horsehair,  73 

preparation  of,  73 
probang,  928 
Horseshoe  fistula,  11 70 
Horsley's  cyrtometer,  789 

method    of    finding    Rolando's 
fissure,  7S7 
of  lateral  intestinal  anastomo- 
sis, 1 105 
of  removal  of  Gasserian  gan- 
glion, 783 
operation     for     chronic     spinal 

meningitis,  880 
wax  in  controlling  hemorrhage, 
452 
Horwitz's  treatment  of  acute  gon- 
orrhea, 1347 
Hospital  gangrene,  180,  186 

treatment,  187 
Hot-water  bath  in  inflammation, 

106 
Hour-glass  stomach,  964,  1090 
Housemaid's  knee,  747 
Hudson's  burrs,  843 

modified  De  Vilbiss  forceps,  844 
Hugier  and  Murphy's  treatment  of 

ankylosis,  662 
Humerus,  fractures  of,  558.     See 
also  Fractures  oj  humerus. 
subluxation  of,  734 
traumatic  dislocation,  672 
axillary,  674 
Cock's  reduction,  678 
Cooper's  reduction,  677 
diagnosis,  67s 
Dugas's  sign  in,  674 
Erichsen's    signs    in,    674, 

675 
habitual,  680 

capsulorrhaphy  in,  680 
Thomas's  operation  for, 
6S0 
irreducible,  679 
Keetley's  reduction,  676 
Kocher's  reduction,  676 
La  Mothe's  reduction,  678 
partial,  675 
recurrent,  680 
reduction  by  extension,  677 
Smith's  reduction,  676 
subclavicular,  673 
subcoracoid,  673 
subglenoid,  674 
subspinous,  674 
supracoracoid,  674 
symptoms,  674 
treatment,  676 
unreduced,  679 

McBumey's     treatment, 
679 
Humoral  theory  of  immunity,  38 
Hunger  pain  in  ulcer  of  stomach, 

955 
Hunterian  chancre,  315 
Hunter's  canal,  492 

operation  for  aneurysm,  422 
Huntington's  treatment  of  tuber- 
culosis of  hip-joint,  639 
Hutchinson's  splint,  640 

teeth,  339 
Hater's  sign,  733 
Hyaline  tubercle,  230 
Hydatid  cysts,  399 
of  breast,  1426 
of  liver,  1016 
moles  of  pregnancy,  356 
toxemia,  400,  1016 
Hydrartlirosis    in    osteo-arthritis, 

651 
Hydrencephalic  cry,  819 
Hydrencephalocele,  793 
Hydrocele,  acute,  1391 
chronic,  1392 
congenital,  1394 
diffused,  of  spermatic  cord,  1394 
en  bissac,  1393 


Hydrocele,  encysted,   of   epididy- 
mis, 1394 
of  spermatic  cord,  1394 
of  testicle,  1394 
funicular,  1394 
infantile,  1394 
of  hernia,  1394 
of  neck,  392 

of  tunica  vaginalis,  1392 
vaginal,  1392 
Hydrocephalus,  795 
acute,  795,  819 
chronic,  795 
Hydrogen  peroxid,  29 

rectal  insufllation  of,  940 
Hydronephrosis,  398,  1286 
Hydrophobia,  304 

and  tetanus,  differentiation,  225 
Pasteur  treatment,  307 
spurious,  306 
Hydrophobic  tetanus,  223 
Hydrops,  398 
articuli,  626 

of  gall-l)ladder,  1023,  1035 
Hydrosalpinx,  397 
Hyoid  bone,  fractures,  546 
Hyperchlorhydria,  954 
Hyperemia,  active,  79 
clinical  signs,  80 
Bier's,  in  tuberculosis,  249 
of  testicle,  1390 
Hypernepliroma,  374 

of  kidney,  1271 
Hyperth>Toidism,  1234,  1241 
Hypertrophy,  congenital,  of    thy- 
roid gland,  1226 
of  bone,  500 
of  breast,  1419 
of  muscles,  727 
of  prostate,  1372 

catheterization  in.  1374 
cystoscopic   examination   be- 
fore operation  in,  1376 
middle  lobe,  1373 
operafions  for,  1376 
results,  1384 
symptoms,  1374 
treatment,  1374 
Hypochondriacal  delusions,  opera- 
tive treatment,  840 
Hypodermoclysis   in   shock,    264, 

265 
Hypophysis    cerebri,    tumors    of, 

832 
Hypospadias,  1365 

Beck's  operation  for,  1365 
Hysteria  and  tetanus,  differentia- 
tion, 224 
stigmata  of,  869 
traumatic,  868 
Hysterical  coma,  803 
fever,  136 
joint,  653 
stricture,  931 


Ice  and  salt  anesthesia,  12 11 
Ice-bag,  loi 

Ichthyol  in  inflammation,  104 
Ileus,    969.     See    also    Intestinal 

obstruction. 
Iliac  abscess,  tuberculous.  162 
artery,  common,  ligation  of,  494 
external,  ligation  of,  405 
internal,  ligation  of,  495 
ligation,  493 

after     abdominal     section, 
494 
bursitis,  742 
Iliopsoas  bursitis,  742 
Immunity,  37,  42 
acquired,  37 
active,  37 

CoUes's,  in  syphilis,  313 
Ehrlich's  theory,  39 
exhaustion  theory,  38 
humoral  theory,  38 
natural,  37 
passive,  37 


Immunity,    Profeta's,  in  syphilis, 
313 
retention  theory,  38 
to  cancer,  342 
Imperforate  anus,  1169 
Impetigo,  syphilitic,  321 
Implantation,  intestinal,  of  ureters, 
1297 
of  nerves,  776 
Incisive  glancl,  cysts  of,  922 
Incontinence,  fecal,  after  operation 
for  fistula  in  ano,  treatment, 
1171 
of  retention  of  urine,  1306 
Incurvation  of  neck  of  femur,  762 
Index,  opsonic,  41 
Indian     method    of     rhinoplasty, 

1264 
Indifferent  tissue  in  inflammation, 

86 
Indolent  buboes,  317 
Induction  balante  in  locating  bul- 
let, 283 
Infarction,  hemorrhagic,  204 
red,  204 
white,  204 
Infection,  intra-uterine,  25 
mixed,  25 
placental,  25 

treatment  of,  by  bacterial  vac- 
cines, 45 
vital  resistance  to.  42 
Infiltration,  purulent,  141,  142 
Infiltration -anesthesia,  12 13 

with  sterile  water.  1214 
Inflammation,  79 
aconite  in,  log 
acute,  88 

symptoms  of,  90 
treatment,  96 
adhesive,  88 
adynamic,  88 
alcohol  in,  113 
alkaline  iodids  in,  113 
anodynes  in.  iii 
antiphlogistic  regimen,  J14 
antipjTetics  in,  11 1 
antiseptic  fomentation  in,  105 
arterial  sedatives  in,  109 
asthenic,  88 
astringents  in,  103 
Bier's     hyperemic      treatment, 

116 
bleeding  in,  97,  108 
blisters  in,  108 
blood  plaques,  85 
blue  ointment  in,  104 
buffy  coat,  94 
cataplasm  in,  106 
catarrhal,  87,  88 

of  gall-bladder  and  bile-ducts, 
1024 
cathartics  in,  no 
causes,  89 

cauterization  in,  108 
cell-proliferation,  85 
changes  in  perivascular  tissues, 

85 
chronic,  88,  95 
causes,  95 
symptoms,  96 
tissue-changes,  95 
treatment  of,  1 16 
circulatory  changes,  79 
classification,  87 
cleanliness  in,  116 
cold  in,  99 
common,  87 
compression  in,  103 
contagious,  88 
Corrigan  cautery  in,  108 
counterirritants  in,  107 
croupous,  87,  88 

of  gall-blaclder  and  bile-ducts,, 
102  s 
cupping  in,  98 
cutting  off  blood -supply  in,  09 

definition,  79 
delitescence,  89 


Index 


1485 


Inflammation,  depletion  in,  97 
derangement  of  absorbents,  94 

of  secretions,  04 
diapedesis  and  migration,  84 
diaphoretics  in,  no 
diet  in,  114 
diphtheritic,  87,  88 
discoloration,  92 
disordered  function,  93 
diuretics  in,  no 
douche  in,  104 
drv,  H8 

elevation  in  treatment,  97 
embryonic  tissue,  86 
emetics  in,  112 
extension,  38 
exudation  of  fluids,  82 

fibrinous,  88 
fibroblasts,  85 
fomentations  in,  105 
gangrenous,  88 
gelsemium  in,  no 
gouty,  elevation  in,  97 
granulation  tissue,  86 
gummatous,  325 
healthy,  88 
heart  in,  116 
heat  in,  90,  102,  104,  106 
hemorrhagic,  85,  88 
hot-water  bath  in,  106 
hypnotics  in,  ni 
hypostatic,  88 
ichthyol  in,  104 
idiopathic,  88  . 

impairment  of  special  function, 

in  fractures,  530  . 
in  non-vascular  tssue,  86 
incision  in,  98 
increased  irritability,  93 

tenderness,  93 
indifferent  tissue,  86 
infective,  88 
interstitial,  88 
iodids  in,  112 
irritants  in,  107 
juvenile  tissue,  86 
latent,  88,  gi 
lead-water  in,  103 
leeching  in,  98 
leukocytosis,  85,  94 
malignant,  88 
massage  in,  104 
mercurials  in,  104 
mercury  in,  112 
migration  and  diapedesis,  84 
moist  gangrene  from,  185 
multiple  puncture  in,  98 
muscular  relaxation  in,  97 

rigidity,  94 
neuropathic,  88 
new  growth,  89 

obstructive  hyperemia  by  means 
of  cupping  glass  in,  1 18 
of  elastic  bandage  in,  116 
of  antrum  of  Highmore,  881 
of  artery,  411 
of     bladder,     13 16.     See     also 

Cyslilis. 
of  bone,  501 
of  breast,  1421 
of  cartil  ige,  87 
of  cornea,  86 

of  crypts  of  Morgagni,  1181 
of  epididymis,  1391 
of  eve,  rest  in,  97 
of  gall-l)ladder,  1022 
of  hernia,  Ii45 
of  joint,  compression  in,  103 

rest  in,  97 
of  mucous  membrane,  87 

rest  in,  97 
of  nerves,  763 
of  nipple,  1420 
of  prostate  gland,  137°.  i37i 
of  rectum,  1167 
of  semilunar  cartilages,  626 
of  seminal  vesicles,  1369 
of  sigmoid,  1167 


Inflammation  of  testicle,  1388 
of  thyroid  gland,  1227 
of     urethra,      1336-     See     also 

Urethritis. 
of  vein,  406 

oscillation  and  stagnation,  81 
pain,  90 

parenchymatous,  88 
peri-anal,  1168 
perirectal,  1168 
phlebotomy  in,  108 
phlegmonous,  88 
plastic,  83,  88 
fioultice  in,  106 
pulse  in,  116 
punctiu-e  in,  98 
purgation  in,  no 
purulent,  88 
redness  as  sign,  92 
reflex,  88 
relaxation  in,  97 
remedies  directed  against  spe- 
cial morbid  states,  113 
resolution,  89 
rest  in  treatment,  96 
retardation  of  circulation,  81 
rouleaux  formation,  82 
saturated    watery    solution    of 

Epsom  salt  in,  103 
scarification  in,  98 
Scotch  douche  in,  104 
serous,  82,  88 
silver  nitrate  in,  104 
simple,  87 

sorbefacients  in,  103 
specific,  88 

stagnation  and  oscillation,  8i 
stasis,  82 
sthenic,  88 
stimulants  in,  113 
strychnin  in,  114 
stupe  in,  104 
subacute,  88 
suppurative,  87,  88 
of     gall-bladder 
ducts,  1025 
swelling  or  tumefaction,  93 
sympathetic,  88 
pain,  91 

tartar  emetic  in,  no 
ointment  in,  108 
temi-erature  in,  116 
tenderness,  90 
terminations,  89 
third  corpuscles,  85 
tincture  of  iodin  in,  103 
tonics  in,  114 
traumatic,  88 

of  brain,  817 
treatment,  constitutional,  108 

local,  96 
turpentine  stupe  in,  105 
unhealthy,  88 
urine  in,  116 
vascular  changes,  79 

resume  of,  82 
venesection  in,  loS 
ventilation  in,  116 
veratrum  \-iride  in,  109 
Vienna  paste  in,  108 
Wright's  views  on,  119 
Inflammatory  new  formation,  86 
Infra-orbital  nerve,  neurectomy  of, 

"^  •,  A 

Ingrowing  toe-nail,  173.  1220 

Inhibition,  death  by,  262 

Inion,  786 

Injection  Brue  in  acute  gonorrhea 

Innominate    artery,    ligation     ol 


and     bile- 


bone,  fractures  of,  552 
Inoculation  tuberculosis,  233 
Inoculations,  preventive,  42 

protective,  42 
Insanity,  abdominal  operations  in 


Insanity,  genito-urinary  operations 
in,  841 
gynecological      operations     in, 

841 
non-traumatic,  operative  treat- 
ment, 840 
operative  treatment,  840 
traumatic,  operations  for,  840 
Insects,  bites  and  stings,  298 
Instep,  spica  bandage,  1252 
Instruments,  sterilization  of,  65 
Insusceptibility,  42 
Intercostal     artery,     hemorrhage 
from,  control  of,  452 
neuralgia,  726 
Interilio-abdominal     amputition, 

InterpolaUon   in    plastic   surgery, 

1260 
Interrupted  suture,  272 
Intersigmoid    fossa,    hernia    into, 

1157 
Intertarsal    disarticulation,    ante- 
rior, 1409 
posterior,  1409 
Inlerureteral    bar    in    cystoscopy, 

1301  .  c         ( 

Intestinal  anastomosis.      See  Ati- 
I  astomosis,  intestinal. 

exclusion,  local,  1107 
implantation  of  ureters,  1297 
obstruction,  969 
acute,  969 

by  foreign  bodies,  970 
by  tumors,  970 

outside  bowel,  971 
cluronic,  969 
differentiation,     from     other 

diseases,  974 
for  embolism   or   tlirombosis 

of  mesenteric  vessels,  971 
from  fecal  accumulation,  071 
from  intussusception,  970 
from  Meckel's  diverticulum, 

from  strangulation,  969 

from  stricture,  970 

from  volvulus,  970 
post-operative,  971 

treatment,  974 
tuberculosis,  251 

primary,  9S2 
wall,  hernia  of,  11 58 
Intestine,  949 
cancer  of,  983 

treatment,  390 
foreign  bodies  in,  949 
hemorrhage    from,    control    of, 

457  .^       .  , 

large,  identification  ot,  941 
malignant  tumors,  9S3 
resection   of,   with   circular  en- 

terorrhaphy,  1092 
rupture    of,    without    external 

wound,  939 
sarcoma  of,  983 
small,  identification  of,  941 

location  of  loop,  942 
strangulation  of,  intestinal  ob- 
struction from,  969 
suture  of,  106 1 
ulcer  of,  979  , 

Intoxication,  acid,  after  anesthe- 
sia, 1202 
putrid,  209 

septic,  209  .        ,. 

Intra-abdc)minal  emergencies,  di- 
agnosis, 936 
hemorrhage,  43S.  937 
control  of,  453 
Intra-articular  fracture,  522 
Intracapsular  fracture,  522 
Intramammary  abscess,  1422 
Intraparietal  fissure,  788 
Intrathoracic     operations     under 
positive  or  negative  air-pressure. 


epileptic,    operative    treatment, 
840 


Intra-uterine  fractures,  522 
infection,  25 


I486 


Index 


Intravenous    infusion     of    saline 
fluid,  465 
in  shock,  264 
Intubation  of  larynx,  888 
Intussusception,  570 

cecal,  970 

colic,  970 

diverticular,  970 

ileal,  970 

ileo-aprendiceal,  970 

ileocecal,  970 

ileocolic,  970 

Maunsell's  operation  for,  1109 

operation  for,  1109 

retrogade,  970 
Involucrum,  507 
lodid,  lithiomercuric,  27 
lodin,  33         .    . 

tincture  of,  in  inflammation,  103 
lodism,  113 
Iodoform,  30 

absorption,  fever  of,  135 

collodion,  76 

gauze,  preparation,  75 
lodoform-poisoning,  31 
lodol,  32 

Iritis,  syphilitic,  323 
Irrigation  of  septic  wounds,  68 

of  ureter,  1304 

treatment  of  gonorrhea,  1345 
Ischiorectal  abscess,  148,  1168 

treatment,  152 
Ischium,  tuberosity  of,  fractures, 

552 
Isohemolysins,  380 
Italian    method    of    rhinoplasty, 

1264 
Itrol,  32 


Jaboulay's     method    of    gastro- 
duodenostomy,  1079 
of  gastro-enterostomy,  1081 
Jacksonian  epilepsy,  830 

due   to   gross   brain   disease, 

operative  treatment,  839 
operative  treatment,  837 
Jackson's  operation  for  cancer  of 
breast,  1436 
tracheobronchoscope,  886 
Jacobs'    treatment   in   dislocation 
of    semilunar     cartilages    of 
knee,  695 
ulcer,  175,  388 
Jacobson's     treatment     of     chil- 
blain, 122 1 
Janet's  treatment  of  acute  gonor- 
rhea, 1344 
Jaundice,      obstructive,      hemor- 
rhage after  operation  in,  435 
Jaw   and   occiput,   figure-of-eight 
bandage,  1253 
crossed  bandage  of  angle,  1254 
injuries  and  diseases,  goS 
lower,  excision  of  half,  722 
lumpy,  310 
oblique  bandage,  1254 
sarcoma  of,  366 
traumatic  dislocations,  668 
Cooper's  treatment,  669 
Kelaton's  treatment,  669 
upfser,  excision  of  half,  720 
Jejunostomy,  1091 
Jejunum,      peptic      ulcer,      after 

gastro-enterostomy,  1075 
Jerk-finger,  755 
Johnston's   method    of    preparing 

catgut,  72 
Joints,  abscess  of.  tuberculous,  162 
aspiration  of.  707 
Brodie's.  653 
Charcot's,  652 
diseases  of,  625 
excision  of,  708 
false,  in  fracture.  531 
hysterical,  653 

inflammation    of,    compression 
in,  103 
Test  in,  97 


Joints,  loose  bodies  in,  663 
neuralgia  of,  654 
operations  on,  698 
strumous,  628 
syphilitic  affections,  322 
tertiary  syphilis  of,  327 
tuberculous  disease  of.  253 
wounds  and  injuries,  655 

Jones's    dressing    for    injuries   of 
elbow-joint,  571 
splint     in     fracture     of     nasal 

bones,  541 
treatment   of   Volkmann's  con- 
tracture, 730 

Jonnesco's     method     of     sympa- 
thectomy, 777 

Jordan's      amputation      of     hip- 
joint,  1419 
treatment  of  spinal  caries,  864 

Junker's  inhaler,  1192 

Justus's  test  for  syphilis,  328 

Jute  as  dressing,  76 

Juvenile   tissue   in   inflammation, 
86 


Kader's  method  of  gastrostomy. 

1072 
Kangaroo-tendon,  72 
preparation  of,  72 
Marcy's  method,  72 
Truax's  method,  72 
Karyokinesis,  127 
Keen's  method  of  diagnosing  rup- 
ture of  bladder,  13 12 
operation  for  Dupuytren's  con- 
traction, 754 
siphonage  apparatus,  1324 
Keedey's     method     of     reducing 
dislocated  humerus,  676 
treatment  of  dislocation  of  meta- 
carpophalangeal      joint       of 
thumb,  686 
Keith's  method  of  lithotrity,  1330 
Kelly's  method  of  differentiating 
between  appendicular  pain 
and  pain  of  movable  kid- 
ney, 1275 
of  examining  rectum,  11 64 
operation  for  movable  kidney, 

1278 
speculum,  1163 
Keloid,  351 
following  bum,  350 
spontaneous,  351 
true,  351 
Kidney,  abscess  of,  1284 
calculus  in,  pain  of,  91 
chronic  tuberculosis,  1287 
complications   after   anesthesia, 

1202 
determination  of  excretory   ca- 
pacity, 1270 
diseases  and  injuries,  1271 
dislocated,  1273 

hemorrhage  from,  control  of,  456 
hypernephroma  of,  1271 
injuries  of,  1278 
laceration  of,  1278 
mobile,  1273 
movable,  1273 

treatment  of,  1276 
operations  on.  12S8 
pehis  of,  bleeding  from,  1265 

irrigation,  1304 
perforating  wounds,  1280 
prolapse  of,  1273 
puncture  of,  1293 
repair  of,  133 
rupture  of,  1278 
sarcoma  of,  1272 
stone  in,  1281 

operation  for,  1291 
surgical,  1287 
tuberculosis  of,  25s 
tumors  of,  1271 
wandering,  1273 
Kidney-substance,  bleeding  from, 
1265 


Kissing  ulcer,  954 

Klemperer's    method    of    testing 

motor  ix>wer  of  stomach,  965 
Knee,   crucial   ligaments,   rupture 
of,  658 
disarticulation  of,  1412 
housemaids',  747 
semilunar  cartilages,  dislocation. 
Barker's  operation.  723 
traumatic  dislocation.  694 
subluxation  of,  694 
traumatic  dislocation.  692.    See 
also  Dislocalion,  traumatk,  0} 
knee. 
Knee-joint  disease,  639 
crasion  of,  709 
excision  of.  716 

Ashhurst's  method,  717 
by    anterior    semilunar    flap, 
716 
faulty  ankylosis,  osteotomy  for, 

701 
fractures  of  femur  near,  605 
tuberculosis  of,  639 
Knock-knee,     756.  See    also 

Genu  valgum. 
Kocher's  amputation  at  shoulder- 
joint.  1405 
of  knee,  1412 
of  upper  extremity.  1406 
incision  for  nephrotomy,  1290 
for  surgery  of  bile-tracts.  1 1 13 
in  nephrectomy,  1292 
method     of     anterior     gastro- 
enterostomy, 1078 
of    disarticulation    at    wrist- 
joint,  1403 
of      intestinal      anastomosis, 

1098 
of    reducing    dislocated    hu- 
merus, 676 
of  thjToidectomy,  1239.  1240 
operation  for  cancer  of  tongue, 
925     .     , 
for  inguinal  hernia.  11 38 
Koch's  bacillus,  51,  231 

circuit  as  proof  of  microbe  'is 
cause  of  disease,  35 
Koenig's  tracheotomy  tube.  1233 
KoUmann's  dilators.  1353 

gland  sjTinge,  1354 
Konig's  incision  for  nephrectomy. 

1292 
Koranyi's   method   of   cryoscopy, 

1271 
Krag-Jorgensen  bullet,  287 
Kraske's    method    of    preventing 
spread     of     cutaneous     ery- 
sipelas, 216 
operation        for        imperforate 
anus,  1 169 
for  rectal  cancer,  11S5 
Kronig's     method    of     preparing 

catgut,  70 
Kronlein's    method    of    locating 

brain-areas,  789 
Kyphosis,  861 


La  Mothe's  method  of  reducing 
dislocated  humerus,  67S 

Labial  hernia,  1154 

Labor,  head  injuries  during,  790 

Laborde's    method    of    artificial 
respiration,  11 99 

Lacerated  wounds,  274 

Laceration  of  brain,  797 
of  kidney,  12  78 
palsy,  767 

Lachrymal  bone  fractures,  541 

Lacteal  cysts,  397 
of  breast,  1426 

Lagoria's    sign    in    intracapsular 
fracture  of  femur,  591 

Lambotte's  operation  for  enterop- 
tosis,  1002 

Laminectomy,  866,  878 

Landerer's  dry   method   of  oper- 
ating, 69 


Index 


1487 


Langenbeck's     inrision     in     ne- 
phrectomy, 1 29  J 
method  of  excision  of  hip-joint, 

treatment  of  ununited  fractures, 
539 
Langenbuch's    plan    of    reaching 

liver.  1014 
Lannclongue  and  Meniird's  treat- 
ment of  ununited  fractures,  705 
lannelongue's   plan   of   reaching 
liver,  10 1 4 

treatment  of  reducible   hernia, 
1130 
Laparectomy      in      hepatoptosis, 

1022 
Laparotomy,  1048 
Laplace's    forceps    for    intestinal 

anastomosis,  iioo,  1105 
Lardaceous  disease  from  tubercu- 
lous abscess,  160 
Larrey's  amputation  at  shoulder- 
joint,  1405 
of  hip-joint,  1419 
Laryngeal     cartilages,     fractures, 

547 
LarjTigotomy,  quick,  888 
Laryngotracheotomy.  888 
Larynx,  abscess  of,  148 
treatment,  153 

diseases  and  injuries,  882 

edema  of,  882 

foreign  bodies  in,  883 

intubation  of,  888 

operations  on,  886 

wounds  and  injuries,  882 
Latissimus   dorsi,   dislocation   of, 

734 
Laudable  pus,  139,  140 
Lautenschlager's  sterilizer,  75 
Lavage  of  ureter.  1304 
Law,  Courvoisier's,  in  gull-stones, 
1035 

Miiller's,  of  tumors,  341 

Virchow's,  of  tumors,  341 
Lawn-tennis  arm,  732 

leg,  733 
Le  Conte's  amputation  of   upf)er 

extremity,  1407 
Le  Dentu's  tendon-suture,  750 
Le  Fort's  tendon-suture,  750 
Lead-water     and     laudanum     in 
erysipelas,  103 

in  inflammation,  103 
Leather-botde  stomach,  950 
Leech,  artificial.  99 
Leech-bite,  hemorrhage  from,  con- 
trol of,  45; 
Leeching  in  inflammation,  98 
Leg,  amputation  of.    14:0.      See 
also  Amputation  of  leg. 

fractures  of,  617 
of  both  bones.  622 
compoimd,  623 

lawn-tennis,  733 

milk,  201 

moist  gangrene  of.  184 

rider's,  732 

ulcer  of,  acute.  16S 
chronic,  169 
treatment,  170 

varLx  of,  operation  for.  461.   See 
also  Varix  oj  leg. 
Lejar's  tendon-suture,  750 
Lembert's  suture,  1061,  1064 
Leontiasis  ossium,  515 
Leptomeningitis,  817 

acute.  817 

chronic,  818 

primary,  818 

secondary,  818 
Letievant's  method   of  implanta- 
tion of  nerves,  776 
Leukemia,  .r-rays  in,  1458 
Leukocytosis  in  inflammation,  85, 

94 
Leukolysin,  46 
Leukomains,  37 
Levis's  splint,  583,  685 


'    Levis's  treatment  of  Colles's  frac- 
I  ture,  583 

ureter-cystoscof*,  1267 
Lexer's  method  of  arteriorrhaphy, 
444 
operation  for  Dupuytren's  con- 
traction, 754 
treatment  of  ankylosis,  661 
Lichen,  syphilitic,  321 
Ligament,  Bigelow's,  689 
crucial,  of  knee,  rupture,  658 
of  Treitz,  1087 
spinal,  injuries  of,  867 
Ligation  in  tabaticre,  472 
of  abdominal  aorta,  498 
of  anterior  tibial  artery,  488 
of  arteries  in  continuity,  469 
of  axillary  artery,  476 
of  brachial  artery,  475 
of  common  carotid  artery,  483 

iliac  artery,  494 
of  dorsalis  pedis  artery,  488 
of  external  carotid  artery,  484 
iliac  artery,  495 
I         of  facial  artery,  486 

of  femoral  artery,  492 
!        of  gluteal  artery,  496 
of  iliac  aileries,  493 

after  abdominal  section,  494 
of  inferior  thryoid  artery,  480 
of  innominate  artery,  480 
of  internal  carotid  artery,  485 
iliac  artery,  495 
pudic  artery,  498 
of  lingual  artery,  486 
of  occipital  artery.  487 
I        of  popliteal  artery,  490 
■        of  posterior  tibial  artery.  490 
I        of  radial  artery,  472 
j        of  sciatic  artery,  497 
'        of  subcla\-ian  artery,  478 

of  superior  thyxoid  artery,  486 
of  temporal  artery,  487 
of  ulnar  artery,  474 
of  vertebral  artery,  479 
Ligature  and  suture,  69 

Enchsen's  method  of  applying, 

361 
for  hemorrhage,  436 
operation  for  piles,  1177 
subcutaneous,     for     varicocele, 

462 
suture-,  438 
Lightning,    effects    produced    by, 

1461 
Ligneus  phlegmon,  141 
Lilienthal's  operating  table.  61 

probe,  2S3 
Line,  Crampton's,  495 
McKees',  495 
Xela ton's,  591 
of  demarcation,  181,  182 
Linea  alba,  hernia  of,  1155 
Lingual  artery,  ligation  of,  486 
Linguiform  lobe  of  liver,  1022 
Liomyoma,  357 
Lip,  cancer  of,  919 

Grant's    operation    for,    390, 
919 
carbuncle  of,  921 
Lipoma,  347 
cavernous,  348 
diffuse,  348 
nevoid,  360 
of  breast,  1426 
telangiectodes,  348 
treatment  of,  349 
Lipuria  after  fractures,  206 
Lisfranc's  amputation  at  shoulder- 
joint,  1406 
of  foot,  1407 
Lister's  cyanid  gauze,  preparation, 
75 
method    of    excision    of    wrist- 
joint,  714 
protective,  76 

tourniquet  in  aneurysm,  421 
treatment  of  old  traumatic  dis- 
locations, 668 


Listen's  amputation  of  hip-joint, 
1419 
modification  of  modified  circular 
method  of  amputation,  1400 
Lithiasis,  apj^ndicular,  986 
Lithiomercuric  iodid,  27 
Litholopaxy,  1325 
after-treatment,  1329 
in  male  children,  1329 
Lithotomy,  1322 
lateral,  1322 

hemorrhage  after,  control  of, 
456 
median,  1330 
suprapubic,  1323 
Lithotrite,  Bigelow's,  1327 
Forbes's,  1327 
Thompson's.  1327 
Lithotrity,  jjerineal,  1330 

rapid,  1325 
Litigation  backs,  869 
Littre's  follicles,  inflammation,  in 
gonorrhea,  1341 
hernia,  1148,  1158 
Liver,  1014 

abscess  of,  146,  1017.     See  also 

Abscess  oj  liver. 
cancer  of,  1015 
cancerous  cirrhosis,  1015 
cysts  of,  1015 
floating,  102 1 
hydatid  cysts,  1016 
linguiform  lobe  of,  1022 
lobe  of  floating,  1022 

linguiform,  1022 
movable,  102 1 
repair  of,  133 
rupture  of,  1014 
syphilis  of,  1016 
tuberculosis  of,  251 
tumors  of,  1015 
wounds  of,  1014 
Lizard,  poisonous,  bite  of,  301 
Lock-finger,  755 

Lockjaw,  219.     See  also  Tetanus. 
Locus  minoris  resistentise,  35 
Longuet's    operation    for    hydro- 
cele, 1394 
Loose  bodies  in  joints,  663 

cartilages  in  osteo-arthritis,  651 
Lordosis,  861 

Lorenz's '   bloodless     method     of 
reduction   of    congenital   dis- 
location of  hip,  723 
method  of  treating  tuberculosis 

of  hif)-joint.  63S 
operation    for    congenital    dis- 
location of  hip,  725 
Loreta's  operation  for  cicatricial 
stenosis  of  stomach,  962 
of   digital    dilatation    of    py- 
lorus, 1063 
Loretin,  31 
Liicke's   method   of  gastro-enter- 

ostomy,  1077 
Ludwig's  angina,  196 
Lumbago,  726 

Lumbar  abscess,  tuberculous,  162 
•  treatment  of,  167 
and  last  dorsal  vertebra,  caries 
of,  Treves's  operation  for,  707 
colostomy,  1112 
hernia,  1157 
nephrectomy,  1292 
puncture,  878 

in  hydrocephalus,  796 
triangle,  superior,  1157 
Lumpy  jaw,  310 
Lund's     treatment     of     iliopsoas 

abscess,  747 
Lung,  abscess  of,  147,  898 
pneumotomy  for,  908 
treatment,  151 

Tuffier's   method   of   explor- 
ing for,  908 
contusion  of,  895 
diseases  and  injuries,  888 
edema  of,  in  anesthesia,  treat- 
ment, 1 1 99 


1488 


Index 


Lung,  hemorrhage  from,   control 
of,  457 

operations  on,  901 

protrusion  of,  896 

rupture  of,  895 
Lupus,  250 

exedens,  250 

hypertrophirus,  250 

syphilitic,  325 

vulgaris,  250 
Luxation,  664.     See  also  Disloca- 
tion. 
Luxatio  erecta,  674 
Luys's  urine  separator,  1268 
Lymph,  aplastic,  88 

coagulable,  121 

exudation,  83 

scrotum,  362 
Lymphadenitis,  acute,  1245 

cervical,  tuberculous,  253 

chronic,  1246 

compression  in,  103 

infective,  1245 

septic,  1245 
Lymphadenoid  tissue,  1248 
Lyraphadenoma,  1247 
Lymphangiectasis,  362,  1246 
Lymphangioma,  362,  1247 

cavernous,  363 

circumscriptum,  1246 
Lymphangitis,  124 

capillary,  1245 

reticular,  214,  1245 

tubular,  1245 
Lymphatic  abscess,  144,  155 

constitution,  240 

erysipelas,  215 

glands,  atjscess  of,  tuberculous, 
treatment,  165 
cervical,  tuberculosis  of,  253 
diseases  and  injuries,  1244 
involvement    of,    in    cancer, 

384-  385 
tuberculosis  of,  253 
varicose,  1246 

infection  after  appendicitis,  992 

nevus,  362 

scrofula,  239 

thrombosis,  201 

tissue,  repair  of,  133 

warts,  1246 
Lymphatism,  240 
Lymphoma,  malignant,  1247 
Lymphorrhea,  1247 
Lymphosarcoma,  365 
Lysins,  38 
Lysol,  is 
Lyssa,  304 
Lytic  antibodies,  38 


MacCokmac's  method  of  measur- 
ing for  truss,  1126 
Macewen's  method  of  preventing 
hemorrhage  in  amjiutation  at 
hip-joint,  1415 
operation     for     genu     valgum, 
690 
for  inguinal  hernia,  1130 
treatment     in     contractions    of 

muscles,  734 
triangle,  789,  848 
ackenzie-Davidson        localizer, 
1452 
Mackintosh  as  protective,  76 
Macroglossia,  362 
Maculae,  syphilitic,  319 
Madelung's  operation  for  varix  of 

leg,  461 
Madura-foot,  19 
Magazine  rifles  of  small  caliber, 

286 
Magnesium   sulphate   in   tetanus, 

228 
Maisonneuve's  symptom  in   Col- 
les's  fracture,  583 
urethrotome,  1360 
Malar  bone,  fracture,  543 
Malaria,  136 


Malgaigne's  operation  for  liarclip, 
911 
pads,  643 

treatment  of  fractures  of  costal 
cartilages,  550 
Malingering    in    spinal    diseases, 

869 
Mallein,  309 
Malleolus,     inner,     fracture     of, 

619 
Mallet,  rawhide,  699 
Mallet-fmger,  756 
Malleus,  308 
Malplaced  testicle,  1387 
Mammary  artery,  internal,  hemor- 
rhage from,  control  of,  452 
gland,  1419.     See  also  Breast. 
Mammillitis,  1420 
Maragliano's   serum    in    tubercu- 
losis, 248 
Marchant's    operation    for    mov- 
able liver,  1022 
Marcy's     method     of     preparing 

kangaroo-tendon,  72 
Marie's  disease,  653 
Marine  sponges,  preparation,  78 
Mar  John's  ulcer,  175,  387 
Marks's  endoscope,  1298 
Marriage  in  syphilis,  336 
Marsupialization,  400,  1016 
Martin's  bandage  in  ulcer,  172 
method  of  proctoscopy,  1166 
speculum,  1162 
Marwedel's  incision  for  nephrot- 
omy, 1291 
Mask,  ecchymotic,  888 

Skinner's,  1192 
Mason's  ijin  in  fracture  of  nasal 

bones,  540 
Massage,     heart,     in     chloroform 
poisoning,  1198 
in  fractures,  534 
in  inflammation,  104 
of  tuberculous  focus  in  diagnosis 
of  tuberculosis,  243 
Mastitis,  acute,  1421 
carcinomata,  1429 
chronic,  1422 
lobular,  1422 
Mastoid,  empyema  of,  822 
suppuration,  operation  for,  848 
trephining  of,  845 
Matas's  operation  for  aneurysm, 
424 
for    fractures    of    zygomatic 
arch,  544 
Mathews's  speculum,  1162 

treatment     of     tlirombotic     ex- 
ternal hemorrhoids,  11 74 
Maunsell's    method    of    intestinal 
anastomosis,  1096 
operation    for    intussusception, 
1109 
Maxillary   antrum,    inflammation 
and  abscess,  881 
bone,  inferior,  fractures  of,  545 
superior,  fracture  of,  541 
Maydl's  method  of  inguinal  col- 
ostomy, 1 1 10 
method  of  intestinal   implanta- 
tion of  ureters,  1297 
operation     for     exstrophy     of 
bladder.  13 10 
Mayer's  dressing    for    Thiersch's 

method  of  skin-grafting,  1262 
Mayo-Quenu  operation  for  rectal 

cancer,  11 86 
Mayo's  method  of  anterior  gastro- 
enterostomy, 1078 
of  gastro-enterostomy,  1086 
of  pylorectomy,  1068 
operation  for  bunion,  748 
for  uml)ilical  hernia,  1141 
McBumey  and  Dowd's  fracture- 
hook,  536 
McBurney's  incision  in  appendi- 
citis, 1053 
interval   operation   in   appendi- 
citis, 1059 


McBurney's  method  of    prevent- 
ing   hemorrhage  in  ampu- 
tation of  hip- joint,  141 5 
of  treating  unreduced  disloca- 
tions of  shoulder,  679 
operation  for  gall-stones,  1121 
point  in  appendicitis,  984,  990 
rule  in  ajipendicitis,  999 
McGill's    method    of    suprapubic 

prostatectomy,  1379 
McGraw's   method   of   gastro-en- 
terostomy, 1077,  1079 
Mclntyre's  splint  in  fractures  of 
femur,  605 
in  fractures  of  leg,  623 
McKee's  line,  495 
Meatus,  fish-mouth,  in  gonorrhea, 
1340 
occluded,    of    new-bom,    treat- 
ment, 1308 
urinarius,     stricture    of,     treat 
ment,  1361 
Meckel's  diverticulum,  070 
hernia  of,  1158 
intestinal    obstruction    from, 
969 
Mediastinum,  abscess  of,  147 
treatment,  131 
tuberculous,  162 
treatment,  166 
surgical  invasion,  935 
Medulla,  tumors  of,  832 
Medullary  cancer,  389 
Melanosis,  389 

Menard  and  Lannelongue's  treat- 
ment of  ununited  fractures,  705 
Meningeal  hemorrhage,  traumat- 
ic, 803 
Meninges,  spinal,  puncture  of,  878 
Meningitis,  817 

spinal,  chronic,  Horsley's  opera- 
tion for,  880 
tuberculous,  819 
diagnosis  of,  241 
Meningocele,  794,  852 
Robson's  treatment,  794 
spurious,  795 
Meningomyelocele,  852 
Mercier's  catheter,  1308 
Mercurial  fever,  135 
Mercurials  in  inflammation,  104 
Mercury  in  syphilis,  331 
Mesenteric  arteries,  embolism  of, 
205 
rupture,  945 
cysts,  948 

gland,  tuberculosis  of,  253 
vessels,   embolism  or  thrombo- 
sis,   intestinal    otistruction 
from,  971 
thrombosis  of,  201 
Metacarpal  bones,  excision,  71s 
fractures,  587 
traumatic  dislocations,  685 
Metacarpophalangeal        articula- 
tions,   traumatic    dislocations 
at,  685 
joint,  disarticulation  at,  1402 
of  thumb,  traumatic  disloca- 
tion at,  68s 
Metachromatic  bodies,  19 
Metatarsal  bones,  fractures,  624 
of  great  toe,  excision,  719 

Butcher's  method,  719 
traumatic  dslocation,  698 
Metatarsalgia,  761 

Graham's  treatment,  762 
Metatarsophalangeal    articulation 

of  great  toe,  excision  of,  719 
Methylene-bluc    in    acute   gonor- 
rhea, 1347 
test    for   excretory    capacity   of 
kidneys,  12  71 
Meyer's   operation   for   cancer  of 

breast,   1437 
Microbes,  17 
Microcephalus,  792 
Micrococcus,  20 
gonorrhoeje,  49 


Index 


1489 


Mirrococciis  pyogenes,  46 
tcnius,  47 
IctraHcnus,  47 
Miiro-organisnis,  17 
MiiTophyta,  17 
Microscopic    lest    for    hematuria, 

1265 
Microzoaria,  17 
Micturition,  frequency  of,  i26<) 

slowness  of,  1269 
Middle  lobe,  357 

Mikulicz-Heinckc    operation    for 
cicatricial   stenosis  of  stomach, 
p62 
Mikulicz's  bag,  76 

method   of   operating   for  gan- 
grene   in    intestinal    obstruc- 
tion, 977 
Miliary  aneurysm.  416 
Milk  abscess,  144 
cysts,  307 
leg,  201 
Milzbrand,  301 
Miners'  elbow,  747 
Mirault's     operation     for     single 

harelip,  012 
Mixed  infection,  25 
thrombus,  200 
tumors,  370 
Mixter's     apparatus     for     skin- 
grafting,  1261 
Mobile  kidney,  1273 
Moebius's   sign   in    exophthalmic 

goiter,  1235 
Mole,  350 

congenital     pigmented,     malig- 
nant growth  from,  391 
hydatid,  of  iiregnancy,  356 
Moliities  ossium,  514 
MoUuscum  fibrosum,  351,  358 
Monk's  method  of  locating  loop  of 
small  intestine,  042 
treatment  of  subacromial  bursi- 
tis, 746 
Monococci,  20 
Monteggia's  dislocation,  691 
Moore's   dressing   in    fracture   of 
clavicle,  556 
treatment  of   Colles's  fracture, 
584 
Moorhof-Mosetig's    treatment    of 

bone-cavities,  509 
Moose  pappe  as  dressing,  76 
Morbid  growths,  340 
Morbus  coxae,  633 
senilis,  651 
coxarius,  633 
Morgagni,    crypts    of,    inflamma- 
tion, iiSi 
Moro's   cutaneous   tuberculin   re- 
action in  tuberculosis,  243 
Morphea,  351 
Morphinism,  fever  of,  135 
Morris's  measurement  in  fractures 
of  femur,  591 
method  of  palpating  vermiform 

appendix,  991 
rule  in  operations  on  tumors  of 
bladder,  1322 
Mortification,  179 
Morton's  disease,  761 

method  of  spinal  analgesia,  12 14 
Morvan's  disease,  739 
Mother's  marks,  359 
Motor  aphasia,  831 

power  of  stomach,  testing,  965 
Ewald's  method,  966 
Klemperer's  method,  965 
Moulds,  18 
Mouse  cancer,  382 
Mouth,  gonorrhea  of,  1355 
injuries  and  diseases,  908 
mucous  cysts,  922 
preparation  of,  for  operation,  68 
Movable  kidney,  1273 
treatment,  1276 
liver,  102 1 
pancreas,  1039 
Moynihan's  clamp,  1084 

94 


Moynihan's    method    of    gastro- 
enterostomy, 1083 
of      intestinal      anastomosis, 

1099 
of  lateral  intestinal  anastomo- 
sis, 1 106 
Muco-pus,  140 
Mucous  cystoma,  392 
cysts,  397 

of  mouth,  922 
erosions  of  stomach,  955 
glands  of   Nuhn   and   Blandin, 

922 
membrane,  adenoma  of,  377 
disinfection  of,  68 
inllanimation,  87 

rest  in,  97 
of      gall-bladder,      removal, 

1118 
syphilitic  affections,  321 
wounds  of,  274 
patches,  syphilitic,  321 
polypi,  356 
Mulberry     calculus    in    bladder, 

1313 
Miiller's  law  of  tumors,  341 
treatment  of  flat-foot,  760 
Mummification,  182 
Mumps,  909 
Murphy  and   Hugier's  treatment 

of  ankylosis,  662 
Murphy's  button,  anastomosis  by, 
1095 
gastro-enterostomy  by,  1082 
method  of  arteriorrhaphy,  443 

of  cholecystenterostomy,  11 17 
operation  for  fractures  of  olec- 
ranon process  of  ulna,  575 
plan  to  protect  nerves  from  scar 

invasion  after  suture,  776 
treatment  of  peritonitis,  1006 
of     pulmonary     tuberculosis, 
900 
Murray's    operation    for    ligating 

abdominal  aorta,  498 
Muscles,  atrophy  of,  727 
ischemic,  72S 
contractions  of,  734 
contusions  of,  731 
degeneration  of,  727 
diseases  and  injuries,  726 
dislocation  of,  734 
hernia  of,  734 
hypertrophy  of,  727 
operations  on,  748 
ossification  of,  727 
repair  of,  130 
rupture  of,  732 
spinal,  injuries  of,  867 
strains  of,  731 
syphilis  of,  728 
trichinosis  of,  728 
tuberculosis  of,  252 
tumors  of,  727 
wounds  of,  731 
Muscular    inflammation,    relaxa- 
tion in,  97 
rheumatism,  726 
rupture  from  abdominal  contu- 
sion, 937 
spasm  in  fractures,  536 
Musculospiral    nerve,    injury    of, 
in  fractures  of  shaft  of  humerus, 

563 
Musculus  sardonicus,  222 
Mushroom  abscess,  820 

bullet,  290 
Mustard,  33 
Myalgia,  726 
Mycelial  threads,  18 
Mycetoma,  19 
Mycosis  fungoides,  371 
Myelocele,  852 
Myoma,  357 

uterine,  357 
Myositis,  727 

infective,  727 

ischemia,  728 

ossificans,  727 


Myxedema,  1226 

operative,  1226 
Myxoma,  356 

of  breast,  1426 
Myxosarcoma,  356,  370 

of  orbit,  369 


Nails,  diseases  of,  1222 

syphilitic  affections,  322 
Narcosis  palsy,  1203 
Nasal  bones,  fracture,  539 
Asch  tube  in,  540 
Jones's  splint  in,  541 
Mason's  pin  in,  540 
Nasopharyngeal  fibroma,  350 
Natiform  skull,  338 
Neck,  abscess  of,  deep,  146 
tuberculous,  162 
and  axilla,  figure-of-eight  band- 
age, 1256 
anterior  triangle,  482 
gangrenous  induration  of,  196 
hydrocele  of,  392 
region  of  anatomy,  482 
sarcoma  of,  364,  365,  367 
triangles  of,  482 
posterior,  483 
Necrosis,  167 

fat-,  of  pancreas,  1040 
of  bone,  502,  506 
acute,  502 
central,  507 
postfebrile,  508 
quiet,  507,  508 
Necrotomy,  508 
Negri  bodies,  305 
Neisser's  bacillus,  49 
Nelaton's  bullet  probe,  283 
catheter,  1307 
dislocation,  696 
line,  591 

treatment  of  traumatic  disloca- 
tions of  lower  jaw,  669 
Neoplasms,  340 
Nephrectomy,  1291 
abdominal,  1293 
for  movable  kidney,  1277 
in  children,  1293 
lumbar,  1292 
partial,  1293 
Nephritic  colic,  1282 
Nephritis,  chronic,  operation  for, 

12SS 
Nephrolithotomy,  1291 
Nephropexy,  1277,  1293 
Nephroptosis,  1273 
Neplirorrhaphy,  1293 
Nephrostomy,  1290 
Nephrotomy,  1290 

for  calculus,  1291 
Nerve-grafting,  777 
Nerves,  anastomosis  of,  776 
contusions  of,  775 
diseases  of,  763 
implantation  of,  776 
inflammation  of,  763 
operations  on,  77s 
pressure  on,  774 
punctured  wounds,  775 
repair  of,  127 
section  of,  764 
symptoms,  765 

in  anterior  crural,  77T 

in  brachial  plexus,  766 

in  circumflex,  767 

in  external  popliteal,  772 

in  facial,  773 

in  great  sciatic,  772 

in  internal  popliteal,  773 

in  lumbar  plexus,  771 

in  median  nerve,  768 

in  musculocutaneous,  767 

in  musculospiral,  768 

in  obturator,  772 

in  plantar,  773 

in  posterior  thoracic,  767 

in  radial,  768 

in  sacral  plexus,  771 


I4QO 


Index 


Nerves,  section  of,  symptoms,  in 
small  sciatic,  772 
in  superior  gluteal,  772 
in  suprascapular,  767 
in  ulnar,  769 
treatment,  773 
Nerve-stretching,  777 
Nerve-suture,  775 
primary,  77s 
secondary,  775 
Nerve-trunk,      cocainization     of, 
1212 
tuberculosis  of,  251 
tubulization  of,  776 
wounds  and  injuries,  764 
Nervous  syphilis,  32S 
Nervousness,  bladder,  1269 
Neuber's  treatment  of  bone-cavi- 
ties, 509 
of  knee-joint  disease,  640 
Neuralgia,  764 
intercostal,  726 
of  fifth  nerve,  alcohol  in,  780 
extracranial  operation  for, 

779 
osmic  acid  in,  779 
removal  of  Gasserian  gan- 
glion   for,    781.  See 
also  Gasserian  ganglion. 
Rose's   method  of  neurec- 
tomy in,  780 
of  joints,  654 

of  stumps,  Senn's  treatment,  764 
treatment,  764 
Neurasthenia,  traumatic,  868 
Neurectasy,  777 
Neurectomy,  777 

intracranial,  Abbe's  operation, 

784 
of  inferior  dental  nerve,  779 
of  infra-orbital  nerve,  77S 
of  supra-orbital  nerve,  779 
Rose's  method,  in  neuralgia  of 
fifth  nerve,  780 
Neuritis,  763 

multiple,  763 
Neurofibroma,  358 
Neuroma,  358 
false,  358 
malignant,  358 
of  brain,  827 
plexiform,  358 
traumatic,  358 
true,  358 
Neuropathic  arthritis,  652 
Neuroplasty  by  flap  method,  776 
Neurotomy,  777 

intracranial,  Frazier-Spiller 

method,  784 
Neurorrhafihy,  775 
Nevoid  lipoma,  360 
Nevolipoma,  348 
Nevus,  359,  411 
lymphatic,  362 
venous,  360 
Nicolaier's  bacillus,  50 
Nicoll's  method  of  perineal  prosta- 
tectomy, 13S0 
Nipple,  cancer  of,  1423 
cysts  of,  1423 
ei  itlielioma  of,  1424 
inflammation  of,  1420 
malignant  dermatitis,  1424 
Paget's  disease,  1424 
tumors  of,  1423 
Nitrous   oxid    gas    as    anesthetic, 
1206 
followed  by  ether,  1208 
Nitze's     instrument     for     ureter- 

catheterism,  1266 
Nodes  of  bone,  503 
Nodosities,  Heberden's,  651 
Noli  me  tangere,  175,  388 
Noma,  192 
pudendi,  192 
streptococci  in,  50 
treatment,  194 
Nose  and  antrum,  diseases  and  in- 
juries, 881 


Nose,  foreign  bcxlies  in,  881 
gonorrhea  of,  1355 
injuries  and  diseases,  008 
saddle-,  correction  of,  by  inser- 
tion of  plate,  1263 
syphilis  of,  324 

Nosophen,  31 

Nucleinic  acid,  34 

Nucleins,  33 

Xuhn     and     Blandin's     mucous 
glands,  922 

Nussbaum's    incision    in    chronic 
ulcer  of  leg,  170 


Oakum  as  dressing,  76 
Oberlander's  dilators,    1353 
Obliterative  appendicitis,  988 
endarteritis,  413 

arteriovenous        anastomosis 
for,  414 
Occipital  artery,  ligation,  487 
cephalocele,  793 
lobe,  tumors  of,  831 
triangle,  483 
Ochsner's   operation   for    esopha- 
geal stricture,  930 
Odontoma,  355 
composite,  356 
epithelial,  355 
fibrous,  355 
follicular,  355 

compound,  35s 
radicular,  356 
O'Dwyer's    operation    of    intuba- 
tion of  larynx,  SSS 
Ogston's   operation   for    fl.it-foot, 
760 
for  genu  valgxim,  700 
O'Hara's    forceps    for    intestinal 

anastomosis,  iioi 
Oidium  albicans,  18 
Oil  cysts,  397 

Ollier-Thiersch's  method  of  skin- 
grafting,  1 26 1 
Omental  cysts,  948 

graft,  1063 
Omphalectomy,  1141 
Onychia,  1226 
malignant,  1226 
syphilitic,  322 
06:^horectomy  in  cancer  of  breast, 

391,  1442 
Operating  table,  Boldt's,  59,  60 

Lilienthal's,  61 
Operation,  gloves  for,  63 
p.reparation,  65 
Landerer's  dry  method,  69 
preparation,  57 
of  moutli,  68 
of  patient,  66 
of  rectum,  68 
of  urethra,  68 
sterilization  of  hands,  60 
and  forearm,  62 
mechanical,  61 
time  of  day  for,  68 
Ophthalmia,  gonorrheal,  1340 

treatment  of,  1350 
Ophthalmo-tuberculin  reaction  in 

tuberculosis,  242 
Opisthotonos,  222 
Opium-poisoning,  coma  of,  804 
Oppenheim's  reflex,  S54 
Opsonic  index,  41 
Opsonins,  39,  40 
Orange  pus,  140 
Orbital  al)scess,  149 

treatment,  152 
Orchidectomy,  1391 

for  prostatic  hypertrophy,  1383 
in  tuberculosis,  1391 
Orchitis,  1388 
Orrhotherapy,  43 
Orthopedic  surgery,  752 
Orthotonos,  222 
Os  calcis,  excisjion  of,  718 

by     superiosteal     method, 
718 


Oscillation  and  stagnation  in  in- 
flammation, 81 
Osmic  acid  in  neuralgia  of  ffth 

nerve,  779 
Ossification  of  muscles,  727 
Osteitis,  501 
caseous,  505 
deformans,  515 
pearl  workers',  501 
Osteo-arthritis,  650 
of  hip- joint,  651 
treatment,  652 
Osteo-arthropatliie      hypertrophi- 

ante  pneumique,  653 
Osteoma,  354 
cancellous,  355 
of  brain,  827 
Osteomalacia,  514 
Osteomyelitis,  acute,  of  vertebrae, 
856 
pyogenic,  510 
chronic,  514 
tuberculous,  252,  501 
Osteoperiostitis,  501 

diffuse,  503 
Osteoplastic  periostitis,  503 
Osteopsa-thjTosis,  523 
Osteosarcoma,  36S,  370 

of  superior  maxilla,  366 
Osteotome,  699 
Osteotomy,  69S 
•    cuneiform,  698 
for  bent  tibia,  700 
for    faulty     ajikylosis    of    hip- 
joint,  700 
of  knee-joint,  701 
for  genu  valgum,  699 
for  hallux  valgus,  702 
for  talipes  equinovarus,  702 
Barker's  method,  702 
equinus,  702 

Davy's  method,  702 
for  vicious  union  of  fractures, 

702 
linear,  698 

of   shaft   of    femur   below    tro- 
chanters, 701 
Gant's  o]jeration,  701 
through  neck  of  femur,  700 

Adams's  operation,  700 
with  osteotome,  701 
Oval  amf)Utation,  1400 
Ovary,  hernia  of,  1159 

tuberculosis  of,  255 
Owen's     operation     for     double 

harelip,  912 
Ozena,  syphilitic,  325 


Pachymeningitis,  817 
externa,  817 
intema,  817 

ha;morrhagica,  817 
Pads  of  Malgaigne,  643 
Paget's  abscess,  144 
disease,  387,  515 

of  nipple,  1424 
residual  abscess,  253 
Pain,  expression  in,  92 
in  fractures,  524 
in  genito-urinary  diseases,  1269 
in  wounds,  261 

from  rifle  bullets,  294 
of  coxalgia,  91 
of  hepatitis,  91 
of  inflammation,  90 

of  eye,  91 

of  neck  of  bladder,  91 

of  testicle,  91 
of  jjyelitis,  91 
of  renal  calculus,  91 
Palate,  cleft,  910.      See  also  CleU 

palate. 
hard,  closure  of  clefts  in,  917 
soft,  suture  of,  operation  for,  915 
Palmar  abscess,  149,  735 

arch,  hemorrhage  from,  rules  for 

arresting,  450 
psoriasis,  320 


Index 


149 1 


Pancoast's  tourniquet,  1414 
Pancreas,  fat-necrosis  of,  1040 
movalile,  lojp 
tumors  of,  1045 
wounds  and  injuries,  1038 
Pancreatic  calculi,  1044 

cysts,  1044 
Pancreatitis,  1039 
acute,  1041 
chronic,  1043 
forms  of,  1041 
hemorrhage  in,  1040 
subacute,  1042 
Pantophobia,  305 
Papilloma,  375.      See  also  Warls. 
Papular  syphilides,  320 
Papules,  humid,  321 

moist,  321 
Pacjuelin  cautery,  440 
Paracentesis  auriculi,  450 
pericardii,  459 
tlioracis,  903 
Paraffin  paper  as  protective,  76 
subcutaneous  injection,  for  pros- 
thetic purposes,  1262 
workers'  cancer,  386 
Paralysis,  brachial  birth,  767 
operation  for,  786 
crossed,  832 

facial,  operation  for,  784 
in  Pott's  disease,  865 
in  spinal  injury,  872 
ischemic,  728 
laceration,  767 
narcosis,  1203 
postanesthetic,  1203 
pseudohypertrophic,  727 
\'olkmann's,  728 
Paralytic  rabies,  306 
Paranoia,  operative  treatment,  840 
Paraphimosis  in  gonorrhea,  1341 

treatment,  1349 
Paraphlebitis,  406 
Parasites,  potential,  67 
Parasitic  bacteria,  19 
cysts,  399 
fetus,  393 

theory  of  cancer,  381 

of  tumors,  343 

ParathyToid  glands,  1242 

tetany  after  removal,  1243 
transplantaion,  1243 
Paratrimma,  105 
Paresis,  operative  treatment,  S40 
Parietal  lobe,  tumors  of,  S31 
Parker's  incision  in  appendicitis, 

IOS9 
Parkhill's     clump     for    ununited 

fracture,  538 
Paronychia,  739,  1226 

syphilitic,  322 
Parotitis,  909 
epidemic,  909 
sympathetic,  910 
Pasteur  treatment  of  hydrophobia, 

307 
Patella,  compound  fracture,  treat- 
ment, 538 
floating,  625 
fractures    of,    610.        See    also 

Fractures  of  patella. 
traumatic  dislocation,  693.    See 
also     Dislocation,    traumatic, 
oj  patella. 
Patient,  preparation  of,  for  opera- 
tion, 66 
Pearl  tumor,  352 
of  brain,  827 
workers'  osteitis,  501 
Peat  as  dressing,  76 
Pehnrectal  abscess,  1168 
Peh-is,  false,  fractures  of,  551 
fractures  of,  ssi 
traumatic  dislocation,  686 
true,  fractures  of,  552 
Wood's  rule  in,  552 
Penis,  amputation  of,  1369 
cancer  of,  1368 
treatment,  390 


Penis,  diseases  ;md  injuries,  1332 
fracture  of,  1368 
gangrene  of,  1368 
Peptic  ulcers,  954 

of  duodenum,  979 
of  jejunum  after  gastro-enter- 
ostomy,  107s 
Perforation  in  gastric  ulcer,  957 

operation  for,  960 
Perforative  jieritonitis,  1004 
Perhydrol,  29 

Peri-anal  inflammation,  1168 
Periarteritis,  413 

Pericardial  effusion,  operation  for, 
459 
sac,  tapping,  459 
suppuration,  operation  for,  459 
Peric;irditis,  404 

Pericardium,     diseases     and     in- 
juries, 401 
tuberculosis  of,  252 
wounds  of,  401 
Pericystic  abscess,  1028 
Perier's  treatment  of  burns,  1219 
Perigastric  abscess,  957 

adhesions,  963 
Perineal  bruises,  1332 

fistula   in   stricture   of   urethra, 

treatment,  1362 
lithotomy,  lateral,  1322 

median,  1332 
lithotrity,  1330 
section,  1364 

Cock's  operation,  1365 
Syme's  operation,  1364 
Wheelhouse's  operation,  1364 
Perinepliric  abscess,  147,  1285 

treatment,  152 
Perinephritis,  1285 
Perineum,  T-bandage  of,  1257 
Periosteal  bridge,  528 
Periostitis,  501 
chronic,  503 
diffuse,  502 

in  tertiary  syphilis,  326 
osteoplastic,  503 
simple  acute,  502 
Perirectal  inflammation,  1168 
Peritoneal  hernia,  1157 
shock,  937 
tuberculosis,  251 
Peritoneum,  1002 
rupture  of,  937 

toilet  of,   after   abdominal  sec- 
tion, 105 1 
Peritonism,  937 
Peritonitis,  acute,  1002 
ascitic,  1009 
aseptic,  1002 
caseous,  1009 
circumscribed  suppurative,  1004 

treatment,  1008 
diffuse  septic,  1004 
suppurative,  1005 
fibrinoplastic,  1009 
forms,  1004 

Fowler's  position  in,  1006 
gonorrheal,  1340 
Murphy's  treatment,  1006 
perforative,  1004 
pneumococcus,  ion 
treatment,  1005 
tuberculous,  1008 
acute  form,  loio 
chronic  form,  1009 
Perivascular   tissues,   changes   in, 

in  inflammation,  85 
Permanganate    of     potassium    in 

acute  gonorrhea,  1344 
Pernio,  122 1 

Peroneus    brevis    muscle,    subcu- 
taneous tenotomy  of  tendon 
of,  749 
longus     muscle,     subcutaneous 
tenotomy  of  tendon  of,  740 
Peroxid  of  hydrogen,  29 
Pes  ca\'us,  760 

planus,  758.     See  also  Flat-joot. 
Petechia,  260 


Peterson's    method    of    intestinal 

implantation  of  ureters,  1297 
Petit's  triangle,  1157 

tourniquet,  1397 
Phagedena,  194,  317,  1367 
Phagocytes,  40,  41 
Phagocytosis,  38,  41 

artificial  stimulation,  42 
Phalanges,  excision  of,  715 

fractures  of,  588 

of  toes,  fractures,  625 

traumatic  dislocation,  686,  698 
PharjTigeal  diverticulum,  395 
Ph.arynx,  bums  and  scalds,  1220 

foreign  bodies  in,  883 
Phelps's  operation  for  talipes,  758 

for  varix  of  leg,  462 
Phimosis,  1368 

complete,  treatment  of,  1308 

in  gonorrhea,  1341 
treatment,  1349 
Phlebectasia,  408 
Phlebectasis,  408 
Phlebitis,  406 

acute,  406 

chronic,  407 

infective,  406 

pListic,  406 

post-operative,  406 
Phlebolith,  200,  410 
Phleborrhaphy,  439 
Phlebosclerosis,  407 
Phlebotomy,  463 

in  inflammation,  io8 
Phlegmasia  alba  dolens,  201 
Phlegmon,  gaseous,  185 

ligneus,  141 

of  tendon-sheaths,  73s 

peri-urethral,      in      gonorrhea, 
1 341 

wooden,  141 
Phloridzin  test  for  excretory  ca- 
pacity of  kidneys,  1270 
Physiological  block,  262,  263 
Pick's   treatment   of   fractures  of 

olecranon  process  of  ulna,  574 

Picric    acid   in   acute   gonorrhe;i, 

1347 

treatment  of  bums,  12 19 

Pilcher's    dressing    for    fractures, 

534 
treatment  of   CoUes's  fracture, 

584 
Piles,  409,  1 1 73.      See  also  Hem- 
orrhoids. 
Pirogoff's    amputation   at   ankle- 
joint,  1410 
Pitchblende,  1459 
Placental  infection,  25 
Plantar       fascia,       subcutaneous 
fasciotomy  of,  749 

psoriasis,  320 
Plantaris  muscle,  rupture  of,  733 
Plaster-of -Paris  bandage,  1258 
Plastic  exudation,  83 

inflammation,  83,  88 

phlebitis,  406 

resection    of    breast    for    fibro- 
myxoma,  1425 

surgery,  1259 
Pleura,     diseases     and     injuries, 
888 

operations  on,  001 

parietal,     decoUement     of,     in 
abscess,  908 

pulmonary,  discission  of,  Ran- 
sohoff's  operation,  908 

tuberculosis  of,  252 
Pleural  epilepsy,  906 

fistula,  890,  892 

sac,  exploratory  puncture,  903 
Pleurectomy,  total,  907 
Pleuritic  effusion,  889 
Pleuritis,  rest  in,  97 

traumatic,  895 
Pleurodynia,  726 
Pleuropneumolysis,         thoracico- 

plastic,    with    subcostal    apico- 

lysis,  901 


1492 


Index 


Pleurosthotonos,  222 
Plexus,  brachial,  evulsion  of,  766 
Pneumatocele,  cranial,  702 
Pneumectomy       in        pulmonary 

tuberculosis,  900 
Pneumococcus,  52 
arthritis,  647 
peritonitis,  1012 
Pneumonia,  ether-,  1201 

traumatic,  895 
Pneumothorax,    acute    traumatic, 
§93. 
artificial,  in  treatment  of  pul- 
monary tuberculosis,  900 
non-traumatic,  892 
Pneumotomy  for  abscess  of  lung, 
908 
in  abscess  of  lung,  809 
in  pulmonary  tuberculosis,  goo 
Point,  Barker's,  789 

of  least  resistance,  35 
Pointing  of  abscess,  140,  143 
Points  douloureux,  92 
Poisoned  wounds,  296 
Poisoning,  carbolic  acid,  28 
cocain-,  fever  of,  136 
corrosive  sublimate,  27 
delayed,  after  anesthesia,  1202 
iodoform-,  31 
opium-,  coma  of,  804 
ptomai'n-,  37 

strychnin-,  and  tetanus,  differ- 
entiation, 224 
Polydactylism,  755 
Polyps,  fleshy,  357 
gelatinous,  356 
mucous,  356 
Poncet's  method  of  tendon-length- 
ening, 750 
Pons,  tumors  of,  832 
Popliteal  artery,  ligation,  490 

space,  abscess  of,  149 
Portal  pyemia,  10 18 
Port-wine  stains,  360 
Position,  Trendelenburg,  1049 
Positive  pressure  apparatus,  902 
Post-anal  gut,  11 60 
Postanesthetic   paralysis,   1203 
Post-epileptic  coma,  803 
Post-febrile  gangrene,  198 
Post -operative  phlebitis,  406 

rise  of  temperature,  134 
Postpharyngeal   abscess,   tubercu- 
lous, 161 
treatment  of,  167 
Potential  parasites,  67 
Pott's  aneurysm,  431 
disease,  861 

paralysis  in,  865 
fracture,  620,  696 

Bryant's  splint  in,  622 
compound,  622 
Dupuytren's  s^int  in,  621 
Heath  and  Selby's  treatment, 

622 
Stimson's  splint  in,  622 
gangrene,  iSi 
Poultice,  antiseptic,  in  inflamma- 
tion, 105 
in  inflammation,  106 
Pox,  312.     See  also  Syphilis. 
Precentral  sulcus,  788 
Precipitins,  38 

Prefront'l  region,  tumors  of,  831 
Pregnancy,  appendicitis  in,  996 
tre-itment,  1000 
hydatid  moles  of,  31:6 
Pregnant  uterus,  gunshot-wounds. 

048 
Pressure  apparatus,  positive,  902 
on  nerves,  774 
stasis,  888 
Preventive  trenhining,  800 
Probmg,  horsehair,  928 
Proctitis,  1 167 

Proctoclysis  apparatus,  1008 
Proctoscooe,  Tuttle's,  1165 
Proctoscopy,     Martin's     method, 
1 166 


Proctotomy     in     rectal     stricture, 

1 182 
Profeta's  immunity  in  syphilis,  313 
Projectiles,  285 

culminating  point,  289 
danger-zone,  289 
explosive  effect,  293 
influence    of    air  resistance    on, 
288 
of  gravity  on,  288 
mechanics  of,  287 
motion  of  translation,  287 
mo\-ement  cjf  rotation,  288 
muzzle  velocity  of,  288 
point  of  first  catch  for  cavalry, 
2S9 
for  infantry,  289 
power  of,  to  wound,  290 
remaining  velocity  of,  288 
sectional  density.  288 
smdl,     nature    of    wound     in- 
flicted by,  291 
spin  of,  288 
trajectory  of,  288 
velocity  of,  288 
wind  contusions  from,  294 
Prolapse  of  anus,  1178 
of  brain,  815 
of  kidney,  1273 
of  rectum,  11 78 
Prostate,  abscess  of,  148 

in  gonorrhea,  treatment,  1350 
treatment,  153 
adenoma  of,  377 
cancer  of,  1385 
diseases  and  injuries,  1332 
enlarged,  treatment  of,  1308 

inflammation  of,  1370,  1371 
hemorrhage  from,  1268 

control  of,  456 
hypertrophy  of,  1372.     See  also 

Hypertrophy  of  prostate. 
malignant  disease,  1385 
sarcoma  of,  1385 
tuberculosis  of,  1386 
latent,  1389 
Prostatectomy,  perineal,  1380 
Alexander's  methcxl,  1380 
Bryson's  method,  1380 
Nicoll's  method,  1380 
Young's  method,  1381 
suprapubic,    Bel  field's   method, 
1380 
Freyer's  method,  1378 
Fuller's  method,  1379 
AIcGiU's  method,  1379 
Prostatitis,  acute,  1370 
chronic,  1342,  1371 
in  gonorrhea,  treatment,  1350 
Prostatorrhea,  1342,  1371 
Prostatotomy,    Bottini's    galvano- 
caustic,  13S1 
Young's  modification,  1382 
for  hypertrophy,  1377 
Protargol,  32 

in  acute  gonorrhea,  1346 
Protective,  76 
Lister's,  76 
Proteid,  defensive,  38 
Protonuclein,  34 
Protozoa,  infections  with,  54 
Proud  flesh,  125 
Pruritus  of  anus,  1171 
Psammoma,  352,  370 

of  brain,  826 
Pseudo-arthrosis  in  fracture,  531 
Pseudodichotomy  of  bacilli,  21 
Pseudoleukemia,  1247 
Psoas  abscess,  144 
tuberculous,  162 
treatment,  166 
muscle,  strains  of,  732 
Psoriasis,  palmar,  320 

plantar,  320 
Psorosperm,  34s 
Pterion,  786 
Ptoma'in-poisoning,  37 
Ptomai'ns,  37 
Ptyalism,  fever  of,  135 


Ptyalism    mercurial,    in     syphilis, 

3,34 
Pudic  artery,  internal,  ligation  of, 

498 
Puerperal  erysipelas,  215 
Pulmonary  decortication.  Fowler's 
operation,  907 

embolism,  205 
occluding,  897 

pleura,     discission     of,     Ranso- 
hoff's  operation,  908 

tuberculosis,  251 

surgical  treatment,  899 
Pulpy    degeneration    of    sjTiovial 

membrane,  253 
Pulse  in  inflammation,  ti6 
Puncture,   exploratory,  of  pleural 
sac,  903 

in  inflammation,  98 

lumbar,  878 

in  hydrocephalus,  796 

of  kidney,  1293 

of  spinal  meninges,  878 
Purulent  effusion,  142 

infiltration,  141,  142 
Pus,  aseptic,  138 

blue,  140 

caseous,  140 

concrete,  140 

curdy,  140 

drainage  of,  77 

fibrinous,  140 

forms  of,  139 

gummy,  140 

healtliy,  139 

ichorous,  140 

in  general,  139 

laudable,  139 

malignant,  140 

microbes,  46 

muco-,  140 

orange,  140 

red,  140 

sanious,  140 

scrofulous,  146 

serous,  140 

spurious,  138 

stinking,  140 

tuberculous,  140,  230 

watery,  140 
Pustular  syphilides,  321 
Pustule,  malignant,  301,  302 
Putrefaction,  34 
Putrid  intoxication,  209 
Pyelitis,  1285 

in  gonorrhea,  treatment,  13^0 

pain  of,  91 
Pyelonephritis,  1285 
Pyelotomy  for  renal  calculus,  1291 
Pyemia,  212 

arterial,  213 

idiopathic,  213 

portal,  1018 

streptococcus  of,  48 

symptoms  of,  213 

treatment  of,  214 
Pylephlebitis,  septic,  203 
Pylorectomy,  1067 

Billroth's  method,  1067 

for  cancer,  953 

Mayo's  method,  1068 
Pylorodiosis,   1063 
Pyloroplasty,  Finney's,  1066 

Heineke-Mikulicz,  1065 
Pylorus,  cancer  of,  treatment,  390 

congenital    hypertrophic   steno- 
sis, 962 
digital  dilatation,  for  cicatrici.il 

stenosis,  1063 

excision  of,  1067 

Pyonephrosis,  1287 


Quadriceps  extensor  femoris  ten- 
don, rupture  of,  733 

Quenu-Mayo  operation  for  rect.il 
cancer,  1186 

Quilled  suture,  273 

Quincke's  lumbar  puncture,  878 


Index 


1493 


Rabic  tuljercle,  .^05 
Rabies,  304 

paralytic,  .506 
Rachischisis,  852 
partial,  &^2 
total,  852 
kadiitic.-  beails,  256 
Raihilis,  255-     See  also  Rickets. 
Racket  amputation,  1400 
Radial  artery,  ligation,  472 

epiphysis,  lower,  separation  of, 
585 
Radio-ulnar  articulation,  inferior, 

traumatic  dislocation  at,  684 
Radish-fracture,  519 
Radium,  1459 

effect  on  bacteria,  24 
rays,  1459 
therapy,  1460 
working  unit,  1461 
Radius   and    ulna,    fracture    near 
wrist,  585 
traumatic  dislocation,  681 
fractures  of,   577.  See  also 

Fractures  of  radius. 
traumatic  dislocation,  682 
Railway  spine,  867,  868 
Ransohoff's  method   of  discission 

of  pulmonary  pleura,  908 
Ranula,  921 

Rattlesnake,  bite  of,  300 
Rawhide  mallet,  699 
Ray-fungus,  18,  310 

as  cause  of  actinomycosis,  i8 
Raynaud's  disease,  187,  188 

gangrene,  180,  187,  188 
Reclus's  treatment  of  burns,  T219 
Rectal  etherization,  1195 

insufHation  of  hydrogen,  940 
speculum,  Brinkerhoff's,  1162 
Cook's,  1163 
Kelly's,  1 163 
Martin's,  1162 
Mathews's,  1162 
Sims's,  1 163 
tubes,  pass  ige  of,  1 166 
Rectum,  ballooning  of,  1164 
cancer  of,    1182.  See   also 

Cancer  of  rectum. 
diseases  and  injuries,  1160 
examination  of,  1161 
foreign  bodies  in,  1166 
gonorrhea  of,  1354 
hemorrhage    from,    control    of, 
4S5 
y     inflammation  of,  1167 

Kelly's   method   of   examining, 

1164 
preparation  of,  for  operation,  68 
prolapse  of,  11 78 
stricture  of ,  non-cancerous,  n8i 
tumors  of,  benign,  1180 
ulcer  of,  1 1  So 
dysenteric,  1180 
simple,  1 180 
syphilitic,  1180 
tuberculous,  1 180 
varicose  tumors  of,  409 
wounds  and  injuries,  1167 
Red  pus,  140 
Reef-knot,  438,  471 
Reflex,  Babinski's,  854 
Gordon's,  854 
Oppenheim's,  8s4 
Regurgitation    after   gastro-enter- 

ostomy,  1075 
jxeid's  treatment  of  aneurysm,  421 
Reminders,  syphilitic,  313,  323 
Renipuncture,  1293 
Repair,  120 

albuminuria  obstructing,  120 

by  blood-clot,  123 

by  first  intention,  120 

by  granulation,  123 

by  second  intention,  123 

by  third  intention,  125 

diabetes  obstructing,  120 

in  cartilage,  127 

of  abscess,  143 


Repair  of  blrxxl-vessels,  132 
of  bone,  132 
of  brain,  129 

of  comiX)und  fractures,  531 
of  fractures,  528 
of  kidney,  133 
of  liver,  133 
of  lymphatic  tissue,  133 
of  muscles,  130 
of  nerve,  127 
of  simple   fractures,    528 
of  skin,  133 
of  spinal  cord,  129 
of  spleen,  133 

of  subcutaneous  wounds,  126 
of  tendon,  132 
of  testicle,  133 

of  wounds  in  non-vascular  tis- 
sues, 126 
Reptiles,  bites  of,  299 
Resection    of    intestine   with    ap- 
proximation  by   circular  en- 
terorrhaphy,  1092 
of  rib,  720 

osteoplastic,  of  skull,  843 
Cushing's  method,  843 
with  Hudson's  burrs,  843 
with  Stellwagen's  trephine, 
S44 
plastic,  of  breast,  for  fibroma, 
1425 
Residual  abscess,  157 
of  Paget,  253 
urine,  1306 

in  prostatic  hypertrophy,  1373 
Resistance,  vital,  to  infection,  42 
Respiration,  artificial,  1199.     See 

also  Artificial  respiration. 
Respiratory  disorders  after  anes- 
thesia, 1201 
organs,  surgery,  881 
Rest  bacillus,  236 
Rests,  adrenal.  375 
Retained  testicle,  1387 
Retention  of  urine,  1306 

from  expulsive  defect,  treat- 
ment, 1308 
in  gonorrhea,  treatment,  1350 
incontinence  of,  1306 
theory  of  immunity,  38 
Retention-cysts,  396 
Retrenchment,  1260 
Retrocalcaneai  bursa,  exostoses  of, 
355. 
bursitis,  741 
Retrocecal  fossa,  hernia  into,  1157 
Retroduodenal      choledochotomy, 
1121 
fossae,  hernia  into,  1157 
Retromammary  abscess,  1422 
Retropharyngeal    abscess,    acute, 
147 
treatment,  152 
tuberculous,  161 
Retrorectal  abscess,  1168 
Reverdin's  method  of  skin-graft- 
ing, 1261 
Revolver  bullets,  wounds  of  brain 
from,  814 
wounds  from,  280 
Rhabdomyoma,  357,  367 
Rheumatic  arthritis,  acute,  648 
chronic,  648 
fever,  648 
gout,  650 

of  hip- joint,  651 
partial,  651 
progressive,  651 
torticollis,  726 
Rheumatism,  acute,  648 
chronic,  648 
gonorrheal,  645 
muscular,  726 
syphilitic,  323 
Rheumatoid  arthritis,  650 
Rhigolene  anesthesia,  121 1 
Rhinoplisty,  1264 
Indian  method,  1264 
Italian  method,  1264 


Rhinoplasty,  Tagliacotian  method, 

1264 
Rhoads's     a[)paratus     for     dislo- 
cated clavicle,  670 
niethcKl   of   tendon-lengthening, 
750 
Rib,  abscess  of,  tuberculous,  162 
treatment  of,  166 
and  costal   cartilage,   traumatic 

dislocation,  686 
cervical,  857 

method  of  removing,  720 
excision  of,  720 
in  caries,  720 
in  empyema,  720 
fractures  of,  547 
resection  of,  720 
Ribbail's  bandage,  1252 
Richter's  hernia,  1148,  '  157 
Rickets,  255 
acute,  257 
congenital,  256 
evidences  of,  256 
late,  257 
scurvy,  256,  259 
treatment  of,  257 
Rider's  bone,  727 

leg,  732 
Rifle,  magazine,  of  small  caliber, 

286 
Rifle-bullets,  wounds  in  war  from, 
2S4 
symptoms,  294 
treatment,  294 
Ring  around,  739 
Risus  sardonicus,  222 
Roberts's  splint  in  CoUes's  frac- 
ture, 584 
treatment  of  injuries  of  elbow- 
joint,  572 
Robson's  incision  for  surgery  of 
bile-tracts,  1114 
method  of  intestinal  anastomo- 
sis, 1098 
of  preventing  hemorrhage  in 
choledochotomy,  11 19 
operation  for  fecal  incontinence 
after  operation  for  fistula  in 
ano,  1 1 7 1 
treatment    of    cephalocele    and 
meningocele,  795 
Rodent  ulcer,  175,  388 
Rogers    and    Torrey's    antigono- 

coccic  serum,  1358 
Rogers's   serum   in   exophthalmic 

goiter,  1236 
Rokitansky's   diverticular  hernia, 

1158 
Rolando's  fissure,  786 
Rontgen  rays,    1443.        See  also 

X-rays. 
Rontgenography,  1443.      See  also 

X-rays. 
Rosenberger's  method  of  detecting 

tubercle  bacillus  in  blood,  243 
Rosenthal's    test    for    hematuria, 

1264 
Roseola,  syphilitic,  319 
Rose's  method  of  neurectomy  in 

neuralgia  of  fifth  nerve,  780 
Rotter's    incision    in    wounds    of 

heart,  459 
Rouge's    operation    in     myxoma, 

357 
Rouleaux  formation,  82 
Round-cell  sarcoma,  365,  368 
Rubber  dam,  76 

drainage-tubes,  76,  77 

suit,  Crile's,  in  shock,  264 
Rubor,  90 
Rugh's     splint     for     Volkmann's 

contracture,  730 
Run-around,  1226 
Rupia,  syphilitic,  321,  324 
Rujjture,  abdominal,    1123 

in  fractures,  536 

muscular,  from  abdominal  con- 
tusion, 937 
I        of  aneurysm,  416 


1494 


Index 


Rupture  of  biceps  flexor  cubiti  or 

tendon,  732 
of  bile-ducts,  945 
of  bladder,  13 10 
of  crucial  ligaments  of  knee,  658 
of  diaphragm.  895 
of  extensor  tendon,  756 
of  gall-bladder,  945 
of  heart,  401 
of    intestine     without    external 

wound,  930 
of  kidney,  1278 
of  left  thoracic  ducts,  1244 
of  liver,  1014 

of  long  head  of  biceps,  733 
of  lung,  895 

of  mesenteric  arteries,  945 
of  muscles,  732 
of  peritoneum,  937 
of  plantaris  muscle,  733 
of  quadriceps  extensor  femoris 

tendon,  733 
of  sinus  of  brain,  806 
of  spleen,  1046 
of  stomach     without     external 

wound,  938 
of  tendons,  732,  735 
of  ureters,  1280 
of  urethra,  1333 
of  varicose  veins,  control  of,  454 
Russ's  splint,  5S7 


Sabanejeff's  amputation  through 

femoral  condyles,  1413 
Sacrococcygeal    region,    teratoids 
and  dermoids  associated  with, 
1 160 

tumors,  853 
Sacro-iliac  ciisease,  632 

joint,  sprains  of,  658 
tuberculosis  of,  632 

relaxation,  658 
Sacrum,  fractures  of,  553 
Saddle-back,  861 
Saddle-nose,     correction     of,     by 

insertion  of  plate,  1263 
Saline   fluid,    arterial    transfusion 
and  infusion,  467 
intravenous  infusion,  465 
in  shock,  264 

solution,  29 
Salivary  concretions,  910 

cysts,  397 

fistula,  908 

De  Guise's  operation  for,  909 

glands,    injuries    and    diseases, 
908 
wounds  of,  908 
Salivation  in  syphilis,  334 
Salkindsohn's      modification      of 

Claudius'  method  of  preparing 

catgut.  71 
Salomoni  and  Tomaselli's  method 

of  arteriorrhaphy,  443 
Salzer's  local  intestinal  exclusion, 

1 107 
Sapremia,  200 
Saprophytes,  19 

facultative.  19 

obligate,  19 
Saprophytic  microbes,  19 
Sarcinje,  20,  22 
Sarcocele,  syphilitic,  323 
Sarcoma.  363 

alveolar.  368 

black,  360 

cachexia  in,  346 

Coley's  fluid  in,  373 

effect  of  erysipelas  on,  373 
of  suppuration  on,  373 

erysipelas  serum  in,  374 

fibrospindle-cell,  368 

giant-cell,  368 

hemorrhagic,  369 

medullary,  368 

melanotic,  369 

metastasis,  363 

mixed  spindle-cell,  368 


Sarcoma,  myeloid,  368 

of  antrum,  363,  366 

of  brain,  826 

of  breast,  1427 

of  finger,  367 

of  intestine,  983 

of  kidney,  1272 

of  neck,  364,  363,  367 

of  prostate,  1385 

of  sternum,  370 

of  stomach,  953 

of  thyToid  gland,  1227,  1228 

of  tonsil,  Dawbam's  operation 
in.  372 

plexiform,  370 

round-cell,  365,  368 

spindle-celled,  367 

telangiectatic,  369 

treatment  of,  371 

varieites  of,  365 

-v-rays  in.  374.  1457 
Sarcomatosis.  363 
Sardonic  smile.  222 
Sauerbruch  chamber.  901 
Saviard's  aneurysm  needle,  470 
Saw,  Adams's.  60S 
Sawdust  as  dressing.  76 
Sayre's    dressing    for    fracture   of 
clavicle.  556 

plaster -of-Paris  jacket  and  jury- 
mast.  863 

solint.  637,  640 
Scalds,    12 1 7.         See   also   Burns 

and  scalds. 
Scalp,  abscess  of,  791 

a^-ulsion  of,  275 

diseases  of,  791 

hematoma  of,  797 

wounds  of,  707 
Scaphoid,  carpal  fractures  of,  s86 
Scapula,  excision  of,  719 
Syme's  method,  720 
Treves's  method.  720 

fractures   of,    537.         See   also 
Fractures  of  scapula. 

traumatic  dislocation,  672 

wing-like,  767 
Scar-tissue,  124 

Scarification  in  inflammation,  98 
Scarificator,  99 
Scarlet  fever,  surgical,  136 
Scarpa's  triangle,  492 
Scars,  125 

Schede's  methcxl  of  thoracoplasty, 
907  _ 

operation  for  varix  of  leg,  461 

treatment  of  bone-ca^nties,  509 
Schimmelbusch's   gas-heated   ap- 
paratus, 65 
Schizomycetes,  19 
Schleich's     infiltration-anesthesia, 
1213 

mixture  for  general  anesthesia, 
1204 

treatment  of  bone-cavities,  509 
Schlosser's    alcohol     injection    in 

neuralgia  of  fifth  nerve,  780 
Sciatic  artery,  ligation,  497 

nerve,  stretching  of,  778 
Scirrhus  of  breast,  1428 

atrophic  or  withering,  143 1 
Sclavo's  serum  in  anthrax.  304 
Scoliosis,  858 
Scopolamin-morphin     anesthesia, 

1210 
Scorbutic  gangrene,  180 

ulcer,  177 
Scorbutus,  257.     See  also  Scurvy: 
Scorpion,  bite  of,  298 
Scotch   douche    in    inflammation, 

104 
Scrofula,  230 

angelic,  240 

lymphatic.  239 

phlegmatic.  239 

sanguine,  240 
Scrofuloderma ta,  250 
Scrofulous  abscess,  155 

pus,  140 


Scrotal  hernia,  1154 
Scrotum,  lymph,  362 
Scudder's  bandage  in  fractures  of 
anatomical    neck   of  hu- 
merus, 560 
of  shaft  of  humerus,  564 
Scurvy,  257 
infantile,  259 
rickets,  256,  259 
Sebaceous  cysts.  396 
Second  intention,  healing  by,  123 
Sedillot's  leg-amputation.   141 1 
Segmentation,  bacteria  in,  21 
Segmented     ring,     intestinal    an- 
astomosis with,  1096 
Selby   and   Heath's   treatment   of 

Pott's  fracture,  622 
Selva's  thumb  bandage,  1251 
Semilunar    carfilages,    inflamma- 
tion of,  626 
of      knee-joint,      dislocation. 
Barker's  operation,  723 
traumatic  dislocation.  694 
Seminal   vesicle,   diseases  and  in- 
juries, 1332 
inflammation,  1369 
tuberculosis  of,  1369 
vesiculitis,  1369 
Senkungsabscess,  155 
Serm's    amputation    of    hip-joint, 
1418 
bullet  probe,  283,  8x5 
decalcified  bone-chips,  78 
injection  s>Tinge,  164 
method   of    anterior   gastro-en- 
terostomy,  1077 
of  cystotomy,  1331 
of  excision  of  shoulder-joint, 

712 
of     fixing      kidney     without 
sutures.  Da  Costa's  modi- 
fication, 1293 
of  gastrostomy,  1072 
of      intestinal      anastomosis, 

1093,  1 100 
of  preparing  catgut,  71 
operation  for  cancer  of  breast, 
1436 
for  fecal  fistula,  11 10 
powder  in  bums,  12 18 
silver  tube,  1331 
treatment  in  intracapsular  frac- 
ture of  femur,  594 
of  bone-cavities,  509 
of  fecal  fistula,  979 
of  hydrocephalus,  796 
of  stump  neiu-algia,  764 
of  ununited  fractures,  705 
Sepsis,  209 

Septic  wounds,  irrigation  in,  68 
Septicemia,  209 

streptococcus  of,  48 
true,  210 
Sequestrectomy,  508 
Sequestrum,  507 
Serum,  antigono(  occic,  1358 
antito.xin,  in  tetanus,  225,  227 
Calmette's  antivenene,  301 
diagnosis  of  syphilis,  328 
disease,  45 

erysipelas,  in  sarcoma,  374 
hypersusceptibility  to,  45 
injections,  untoward  effects  of, 

Maragliano's,    in     tuberculosis, 
248 

reaction  in  cancer,  380 

Rogers  and  Torrey's  antigono- 
coccic,  1358 

Sclavo's,  in  anthrax,  304 
Serum-therapy,  43 
Sheldon's  amputation  of  hip-joint, 

1419 
Shelkelton's  aneury.sm,  415 
Shirt-stud  abscess,  154.  159 

treatment,  163 
Shock,  261 

adrenalin  chlorid  in,  264 

apathetic,  262 


Index 


1495 


Shock,  atropin  in,  265 
autotransfusion  in,  266 
centripetal    arterial    transfusion 

in,  265 
Crile's  rubber  suit  in,  264 
delayed,  263 
flelirions,  263 
diagnosis  of,  263 
enteroilysis  in,  264,  265 
erethistic,  263 

hypodermoclysis  in,  264,  265 
in  anesthesia,  treatment,  1107 
in  wounds  from  rifle-bullets,  294 
intravenous  s;dt  infusion  in,  264 
operation  during,  267 
peritoneal,  937 

prevention  of,  in  operations,  263 
resuscitation  in,  265 
secondary,  263 
strychnin  in,  265 
symptoms  of,  262 
torpid,  262 

transfusion  of  blood  in,  265 
treiitment  of.  264 
urethral,  1362 
Shot-gun,  wounds  from,  279 
Shoulder,  figure-of-eight  bandage, 
1255 
spica  bandage,  1255 
Shoulder-blade,  fractures  of,  557. 

See  also  Fractures  oj  scapula. 
Shoulder-joint,   disarticulation  ;•.!, 
1404 
disease,  641 
excision  of,  711.      See  also  £.v- 

cision  nj  shoulder-jninl. 
traumatic  dislocation,  672.     See 
also  Humerus,  traumatic  dis- 
location. 
tuberculosis  of,  641 
Sigmoid,  inflammation  of,  1167 
Sigmoiditis,  1167 
Sigmoidopexy  in  rectal  prolapse, 

1180 
Sign,  AUis's,  in  intracapsular  frac- 
ture of  femur,  591 
in    traumatic    dislocation    of 
femur,  688 
Battle's,  in  fractures  of  base  of 

skull,  811 
Chvostek's,  1243 
Dawbam's,  in  subacromial  bur- 
sitis, 745 
Desault's,  in  intracapsular  frac- 
ture of  femur,  591 
Dugas's,  in  dislocation  of  shoul- 
der-joint, 674 
Erb's,  1243 
Erichsen's,     in     dislocation    of 

shoulder-joint,  674,  675 
Garel's,  in  abscess  of  antrum  of 

High  more,  148 
Glenard's,  1022 
Hoffmann's,  1243 
Hater's,  733 
.  Lagoria's,  in  intracapsular  frac- 
ture of  femur,  591 
Moebius's,      in      exophthalmic 

goiter,  1235 
Stellwag's,      in      exophthalmic 

goiter,  1235 
Stiller's,  1002 
Trousseau's,  1243 
V'irchow's,   in  hereditary  syph- 
ilis, 339 
von   Graefe's,    in   exophthalmic 
goiter,  1235 
Sihcate  of  sodium  dressing,  1258 
Silk,  braided,  73 
floss,  73 

for  ligatures  and  sutures,  73 
preparation  of,  73 
Tait's,  73 
Silkworm-gut,  73 

preparation  of,  74 
Silver,  32 
citrate,  32 
colloidal,  32 
Crede's  ointment  of,  32  j 


Silver  foil  as  protective,  76 
for  dressmgs,  76 
lactate,  i2 

nitrate  in  infl;immation,  104 
vitellin,  in  acute  gonorrhea,  1347 
wire,  preparation,  74 
Silver-fork  deformity,  582 
Silverizcd  citgut,  Blake's  method 

of  prcp;iring,  71 
Sims's  speculum,  1 163 
Sinus,  178 
branchial,  395 
cavernous,  infective  tlirombosis 

of,  824 
cerebral  hemorrhage  from,  con- 
trol of,  453 
frontal,  distention  and  abscess, 
882 
trephining  of,  845 
lateral,  infective  thrombosis  of, 

823 
of  brain,  rupture,  806 
petrosal,  infective  thrombosis  of, 

824 
pocularis,    cyst    of,    treatment, 

1308 
post-anal,  853 
thjToglossal,  922 
thjTolingual,  922 
.r-rays  in,  1458 
Sinus-thrombosis,  infective,  823 
Siphon,  102 
Skene's    method    of    electrohemo- 

stasis,  450 
Skiagraph  in  locating  bullet,  284 
Skiagraphy,  1443 
Skin,  actinomycosis  of,  310 
blastomycosis  of,  312 
diseases  of,  1222 
fungi  as  cause,  18 
in  tertiary  syphilis,  324 
syphilitic,  318 
.r-rays  in,  1456,  1457 
gold-beaters',  as  protective,  76 
repair  of,  133 
tabs,  1 1 74 
tuberculosis  of.  249 
Skin-grafting.  1260 
Amot's  method,  1261 
Mixter's  apparatus  for,  1261 
Ollier-Thiersch's  method,  1261 
Reverdin's  method,  126 1 
Wolfe's  method,  1262 
Skinner's  mask,  1192 
Skull,  bones  of,  diseases  and  mal- 
formations, 792 
fractures   of,    807.         See   also 

Fractures  oj  skull. 
gutter-fracture  of,  813,  814 
natiform,  338 
operations  on,  842 
osteoplastic  resection,  843 
Cushing's  method,  843 
with  Hudson's  burrs,  843 
with  Stellwagec's  trephine, 
844 
Sleeping-sweats  in  tropical  abscess 

of  liver,  1019 
Sloughing,  194   • 
Smith's  dressing  basin,  77 

methixl   of  reducing  dislocated 

humerus,  676 
pile  clamp,  1177 
splint  in  fracture  of  femur  ut 
upper  third,  603 
of  leg,  623 
Smokeless    powder   as   compared 

with  black  gunpowder,  285 
Snake-bites,  299 
Snapping-finger,  755 
Snook's      Rontgen      transformer, 

1444 
Snuff-box,  anatomical,  472 
Socin's  operation  on  th\Toid,  1238 
Solitary  cyst,  354 
Sonnenberg's    operation    for    ex- 
strophy of  bladder,  1309 
Sorbefacients  in  inflammation,  103 
Sores,  splint-,  195,  729  ' 


Souchon's  inhaler,  1 192 
Sound,   Thomj^son's,    1314 
Soulham's  treatment  in  Charcot's 
disease,  653 
of   extracapsular   fracture   of 
femur,  509 
Spangaro's  incision  in  wounds  of 

heart,  403 
Spasm,  muscular,  in  fractures,  536 

of  esor)hagus,  931 
Speculum,  Cook's,  1163 
Kelly's,  1 163 
Martin's,  1162 
Mathew.s's,  1162 
Sims's,  1 163 
Spencer's  apparatus  for  salt  solu- 
tion, 467 
Spermatic  cord,  difl'used  hemato- 
cele of,  1394 
hydrocele  of,  1394 
diseases  and  injuries,  1332 
encysted  hematocele  of,  1394 

hydrocele,  1394 
strangulation,  1392 
torsion,  1392 
varix  of,  409 
Spermatorrhea,  defecation-,   137 1 
Sphacelus,  179 

Spider,  poisonous,  bites  of,  298 
Spina  bifida,  852 

occulta,  852,  853 
operation  for,  877 
ventrosa,  253 
Spinal  analgesia,  12 14 
caries,  861 

treatment,  864 
cord,  cocainization  of,  12 14 
compression  of,  870 
concussion  of,  869 
contusion  of,  869 
repair  of,  129 
tuberculosis  of,  252 
tumors  of,  854 

e.xtramedullary,  854 
intramedullary,  855 
wounds  of,  870 
curvature,  858 
angular,  861 

forcible  correction,  865 
gradual  correction,  865 
anterior,  861 
anteroposterior,  861 
posterior,  861 
excurvation,  861 
hemorrhage,  control  of,  453 
ligaments  and  muscles,  injuries 

of,  867 
meninges,  puncture  of,  878 
meningitis,    chronic,    Horsley's 

operation  for,  880 
syphilis,  328 
Spindle-celled  sarcoma,  367 

mixed,  368 
Spine,  abscess  of,  864 

congenital  deformities,  852 
ciu^'es  of,  858 
dislocations  of,  871 
fracture-dislocation  of,  871 

tre;itment,  874 
fractures  of,  871 
operations  on,  877 
railway,  867,  868 
surgery  of,  S52 
typhoid,  856 
Spirillum,  20 
Spirochaeta  p-allida,  54,  312 

in  diagnosis  of  syphilis,  330 
Splanchnoptosis,  looi 
Spleen,  abscess  of.  1047 
enl-.irgement  of,  1047 
injuries  and  diseases,  1046 
removal  of,  1122 
repair  of.  133 
rupture  of,  1046 
tumors  of.  1047 
wandering,  1048 
wounds  of,  1046 
Splenectomy,  changes  after,  1123 
total,  1 122 


1496 


Index 


Splenic  fever,  301 
Splenopexy,  1048.  1123 
Splenojitosis,  1048 
Splenorrhaphy,  1047 
Splint,     Agnew's,     in     transverse 
fracture  of  patella,  613 
anterior  angular,  570 
Bond's,  in  Colles's  fracture,  584 
bracketed,  537 

Bryant's,  in  Pott's  fracture,  622 
Charrifere's,  686 
Dupuytren's,  in  Pott's  fracture, 

621 
Esmarch's,  713,  714 
fenestrated,  537 
hard-rubber,  542 
Hodgen's,  in  fractures  of  femur, 

604 
Hutchinson's,  640 
interdental,  546 
internal  angular,  561,  56s 
Jones's  nasal,  541 
Levis's,  583,  68s 
Mclntyre's,  in  fracture  of  femur, 
60s 
of  leg,  623 
Roberts's,   in  Colles's  fracture, 

584 
Rugh's,  for  \'olkmann's  contrac- 
ture, 730 
Russ's,  587 
SajTe's,  637,  640 
Smith's,  in  fracture  of  femur  at 
upper  third,  603 
of  leg,  623 
Stimson's,  in  Pott's  fracture,  622 
Stromeyer,  571,  642 
Thomas's,  636 

in    intracapsular   fracture   of 
femur,  S96 
\'an   Arsdale's,   in  fractures  of 
shaft  of  femur  in  children,  606 
Volkmann's,  718 
vulcanite,  546 
Ware's,  in  fractures  of  shaft  of 

femur  in  children,  608 
Watson's,  717 
Wyeth's,  637 
Splint-sores,  105,  729 
Splinter-fracture,  519 
Spondylitis,  861 

deformans,  652,  659,  866 
rhizomelique,  867 
Sponges,  artificial,  78 

marine,  preparation  of,  78 
Spores,  22 

Spots,  syphilitic,  319 
Sprague  hot  dry-air  apparatus,  627 
Sprain-fracture,  519 
Sprains,  655 

of  sacroiliac  joint,  658 
Springfield  bullet,  287 
Spurious  hyflrophobia,  306 
Squamous-celled  epithelioma,  387 
Square-knot,  438 
Ssabanejew-Frank  method  of  gas- 
trostomy, 1072 
St.  Anthony's  fire,  215 
Stab-wounds,  276 
Stagnation  and  oscillation  in  in- 
flammation, 81 
Stains,  claret,  360 

port-wine,  360 
Stammering  of  urine,  132 1 
Staphylococcus,  20 
cereus  flavus,  47 
epidermidis  albus,  47 
fiavescens,  47 
pyogenes  albus,  47 
aureus,  21,  47 
citreus,  47 
Staphylorrhaphy,  915 
Stasis  in  inflammation,  82 

pressure,  888 
Stave  of  thumb,  587 
Stay-knot,  471 
Steam-pressure  sterilizer,  74 
Steeple  chart  of  Charcot's  fever, 
103s 


Stellwag's   sign    in    exophthalmic 

goiter,  1 23s 
Stellvvagen's  trephine,  S44 
Steno's  duct,  fistula  of,  909 

wound  of,  900 
Stenosis,  cicatricial,  of  oritices  of 
stomach,  961 
of  pylorus,  digital  dilatation 
for,  1063 
congenit;il       hyijertropliic,       of 
pylorus,  962 
Stercoral  appendicitis.  986 
Sterility  from  a;-rays,   1447 
Sterilization,  26 
of  cystoscope,  1300 
of  hands,  60 
and  forearm,  62 

Fiirbringer's  method,  62 
mechanical,  61 
sublimate-alcohol    methwl, 

63 
Weir-Stimson  method,  63 
Welch-Kelly  method,  63 
of  instruments,  6s 
of  ureteral  catheters,   1300 
of  urethral  catheters,  1305 
Sterilized  gauze,  preparation,  75 
Sterilizer,  Lautenschlager's,  75 
portable,  66 
Schimmelbusch's,  65 
steam-pressure,  74 
Sternocleidomastoid  muscle,  open 

division,  for  wTy-neck,  748 
Sternomastoid,  hematoma  of,  752 
Sternum,  fractures  of,  550 
sarcoma  of,  370 
traumatic  dislocation,  686 
Stevenson's   bag  for  inguinal  co-. 
lostomy,  iiii 
suprapubic  drainage-tube,  1332, 
13.53 
Stewart's  method  of  enterostomy, 

977 
Stigmata  of  hysteria,  869 
Stiller's  sign,  1002 
Stimson's  splint  in  Pott's  fracture, 

622 
Stimulation,   artificial,  of    phago- 
cytosis, 42 
Stings  and  bites  of  insects,  298 
of  bees,  298 
of  wasps,  298 
Stinking  pus,  140 
Stokes's    operation    for    flat-foot, 

760 
Stomach,  949 

absorptive  power  of,  testing,  966 

bilocular,  9O4 

cancer  of,  9so.    See  also  Cancer 

of  stomach. 
cardiac  oritice,  constJiction  of, 

961 
cicatricial    stenosis    of    oritices, 

961 
dilatation  of,  acute,  966 

Brandt's  operation  for,  1090 
chronic,  965 
diseases   of,  syphilis   as   cause, 

327 
foreign  bcxlies  in,  949 
hemorrhage    from,    control    of, 
457 
in  ulcer,  operation  for,  959 
hour-glass,  964,  1090 
leather-bottle,  9S0 
motor  power  of,  testing,  965 
Ewald's  methcxi,  966 
KJemperer's         method, 
96s 
mucous  erosions,  gss 
operations  on,  1063 
pyloric  orifice,  constriction   of, 

961 
rupture  of,  with  external  wound, 

938 
sarcoma  of,  953 
tuberculosis  of,  251 
ulcer  of,  954.     See  also  Ulcer  of 
stomach. 


Stomach,  volvulus  of,  950 
Stomach-reefing,  Brandt's  opera- 
tion for  dilatation.  1090 
Stone,  vein-,  410 
Storp's      treatment      of      Colles's 

fracture,  585 
Stovain  anesthesia,  1212 
Strain,  muscular,  731 
of  back.  732 

of  erector  spinas  muscle,  869 
of  psoas  muscle,  732 
of  vertebral  lig.iments,  869 
Strain-fracture,  519 
Strangulation     of     intestine,     in- 
testinal obstruction  from,  969 
of  spermatic  cord,  1392 
Streptobacillus,  21 
Streptococcus,  20 
articulorum,  48 
in  noma,  50 
lanceolatus,  52 
of  erysipelas,  48,  49 
of  pyemia,  48 
of  septicemia,  48 
pyogenes,  48 

malignus,  48 
septicus,  48 
Streptothrix  Madurae,  19 
Stricture,  hysterical,  931 

intestinal  obstruction  from,  070 
of  esophagus,  926 

Abbe's  operation  for.  929 
cicatricial,  926 
fibrous,  926 
Gussenbauer's  operation  for, 

928 
Ochsner's  operation  for,  930 
spasmodic,  931 
Symonds's   treatment,   92S 
of  meatus  urinarius,  treatment, 

1361 
of  rectum,  non-cancerous,  1181 
of  ureter,  1286 
of  urethra,  1358 
congenital,  1359 
inflammatory,  1358 
organic,  1359 

treatment,  1307 
perineal  fistula  in,  treatment, 

1362 
spasmodic,  1358 

treatment,  1308 
symptoms  and  results,  13S9 
treatment,  1360 
Stromeyer  spjlint,  571,  642 
Strongylus    armatus   as   cause   f>f 

aneurysm,  417 
Strumous  joint,  628 
Struve's  test  for  hematuria,  1265 
Strychnin  in  shock,  265 
Strychnin-poisoning  and   tetanus, 

differentiation,  224 
Stxunp    neuralgia,    Senn's    treat- 
ment, 764 
treatment,  764 
recurrent  bandage,  1257 
Stupe  in  inflammation,  104 

turpentine,  in  inflammation,  io> 
Stupor,  802 

Styptics  in  hemorrhage,  447 
Subacromial  bursitis,  744 
Dawbam's  sign  in,  745 
Codman's  treatment,  747 
Monks's  treatment,  746 
Subastragaloid         disarticulation, 
1409 
dislocation,  traumatic,  697 
Subclavian  artery,  compression  of, 
.  446 

ligation  of,  478 
-triangle,  483 
Subdiaphragmatic  abscess,  147 
Subdural  hemorrhage,  S05 
Subhyoid  cyst,  922 
Sublimate-alcohol  method  of  ster- 
ilization   of    hands    and    fore- 
arms, 63 
Sublingual  dermoid,  922 
Subluxation,  664 


Index 


1497 


Subluxation  of  head  of  radius,  683 

of  humerus,  734 

of  knee-joint.  604 
SubmaxilLiry  triangle,  482 
Submental  triangle,  482 
Subphrenic  abscess,  147,890,  1012 

treatment,  151 
Subungual  exostosis,  355 
Suffusion,  260 
Sulcus,  precentral,  788 
Sulphur  grains,  310 
Sunlight,  effect  on  bacteria,  24 
Sui:)emumerary  digits,  755 
Suppression  of  urine,  post-opera- 
tive, 267 
Suppuration,  46,  137 

effect  of,  on  sarcoma.  373 

mastoid,  operation  for,  848 

pericardial,  operation  for,  459 

phlegmonous.  141 

signs  of,  14D 

symptoms  of.  140 

threatened,  treatment  of.  107 
Suppurative  fever,  135,  145 

inflammation,  87 
Suprameatal  triangle,  789,  848 
Supra-orbital    nerve,    neurectomy 

of,  779 
Suprarenal  extract  in  hemorrhage, 

449 
Surgeon's  knot,  438 
Siu-gical  fevers,  133 

essential  phenomena,  133 
genuine,  134 

kidney,  1287 

scarlet  fever,  136 
Sutherland    and    Cheyne's    treat- 
ment of  hydrocephalus,  796 
Suture  i  distance,  776 

button.  274 

Connell's,  1063 

continuous,  272 

Cushing's  right-angled,   1062 

Czemy-Lembert,  1062 

Downes's,  1062 

Dupuytren's,  1062 

Erichsen's.  361 

Ford's,  272,  1062 

Glovers',  74 

Gussenbauer's,  1063 

Halsted's,  56,  75,  273,  1062 

hare-lip,  274 

interrupted,  272 

Lembert's,  1061,  1064 

ligature  and,  69 

nerve-,  775.       See  also  Nerve- 
suture. 

of  artery,  440 

of  heart  wounds,  459 

of  intestine,  106 1 

of  soft  palate,  operation  for,  915 

of  vein,  439 

of  wound  after  abdominal  sec- 
tion, 1052 

quilled,  273 

removal,  77 

tendon-,  750.    See  also  Tendon- 
sultire. 

twisted,  274 

Wolfler's,  1063 
Suture-ligature,  438 
Suturing,  secondary,  125 
Sweats,  sleeping-,  in  tropical  ab- 
scess of  liver,  10 19 
Sweet's    apparatus    for    locating 

foreign  bodies  in  eye,  1455 
Swelling,  white,  253,  628,  639 
Sylvester's    method    of    artificial 

respiration,  1200 
Syhius's  fissure,  7S7 
Syme's  amputation  at  ankle-joint, 
1410 
through     femoral     condyles. 
1412 

method  of  excision  of  scapula, 
720 

operation  for  aneurysm.  422 
of  perineal  section.  1364 

staff,  1360 


Symonds's   treatment   of  esopha- 
geal stricture,  928 
Sympathectomy,  777. 

Jonnesco's  metliod,  777 
Sympathetic  parotitis,  910 
Synchondroseotomy  for  exstrophy 

of  bladder,  1309 
Syncope  in  anesthesia,  treatment, 

1197 
Syncytioma  malignum,  389 
SjTidactylism,  754 

Agnew's  operation  for,  75s 
Diday's  operation  for,  75s 
SjTiovial  fringes,  inflamed,  643 
membrane,  pulpy  degeneration, 

253,  626,  628 
S)Tio\'itis,  625 
acute,  62s 
chronic,  626 
pannous,  629 
relaxation  in,  97 
Syphilides,  318 
nummular,  320 
papular,  320 
pustular,  321 

secondary  and  tertiary,  differ- 
entiation, 321 
tubercular,  321 
Syphilis,  312 
acquired,  313 
and     tuberculosis,    coexistence. 

314 
as  cause  of  disease  of  stomach, 

327  , 
calomel  ointment  m,  330 
Chinese.  314 
CoUes's  law  in.  313 
definition  of,  312 
duality  theory,  315 
effect  of,  upon  longevity,  314 
general,  318 
hereditary,  313,  337 

dactj-litis  in,  338 

diagnosis,  339 

evidences  of,  337 

eye  symptoms  in,  338 

treatment  of,  339 
Hutchinson's  teeth  in,  339 
initial  lesions,  315 
intermediate  period,  314,  323 
Justus's  test  for,  328 
marriage  in,  336 
mercury  in,  331 
nervous,  328 
of  bone,  322 
of  brain,  328 
of  innocent,  313 
of  liver,  1016 
of  muscles,  728 
of  nose,  324 
of  thjToid  gland,  1227 
osteocopic  pains  in,  322 
period,  314 

of  primary  incubation,  314 
symptoms,  314 

of  secondary  incubation,  314 
symptoms,  3r4 

of  tertiary  symptoms,  314 
Prof  eta's  immunity  in,  313 
primary,  314,  315' 

treatment  of,  330 
ptj'alism  in,  334 
reminders,  313,  323 
salivation  in,  334 
secondary,  314,  318 

albuminuria  of.  323 

comphcations  in  treatment  of, 

335 

treatment  of,  33r 
serum  diagnosis,  328 
spinal,  328 
spirochaeta  pallida  in  diagnosis 

of,  330 
stages  of,  314 
tertiary,  314,  324 

albuminuria  in,  327 

lesions  of,  326 

of  bones,  326 

of  joints,  327 


Syphilis,  tertiary,  periostitis  in,  326 

serpiginous  ulcer  in,  324 

skin  diseases  in,  324 

treatment  of,  335 
transmission  of,  313 
transmitted  congenital,  337 
unity  theory,  315 
visceral,  327 
Wassermann's  test  for  diagnosis 

of,  328 
Syphilitic  abscess,  144 
acne,  321 

affections  of  bones  and  joints, 
322 

of  ear,  322 

of  eye,  323 

of  hair,  322 

of  mucous  membranes,  321 

of  nails,  322 

of  testes.  323 
alopecia,  322 
arthritis,  322 
bubo,  317 
ecthyma,  321 
erythema,  319 
fever,  318 
impetigo,  321 
iritis,  323 
lichen,  321 
lupus,  32  s 
maculas,  319 
mucous  patches,  321 
onychia,  322 
ozcena,  325 
paronychia,  322 
rheumatism,  323 
roseola,  319 
rupia,  321,  324 
sarcocele,  323 
skin  diseases,  318 
spots,  319 
ulcer,  169 
warts,  322 
Syphiloderm.  318 
annular,  320 
circinate,  320 
Syphiloma  of  brain,  826 
SyTingomyelocele,  852 
Szumann's  solution,  466 


Tabatiere         anatomique        of 
Cloquet,  472 
ligation  in,  472 
Tabes  mesenterica,  253 
Tabetic  arthropathy,  652 
Table,  Brown's  cystoscopic,  1301 
Tache  cerebrale,  819 
Tachycardia  in  exophthalmic  goi- 
ter, 123s 
Tagliacotian    method    of    rhino- 
plasty, 1264 
Tait's  silk,  73 
Talipes,  737 

astragalectomy  in.  758 
calcaneo-valgus,  757 
calcaneo-varus,  757 
calcaneus,  757 
equino-valgus,  737 
equinovarus,  757 
osteotomy  for,  702 
Barker's  method.  702 
equinus,  757 

osteotomy  for.  702 
Da\-y's  method,  702 
Phelps's  operation  for,  758 
subcutaneous  tenotomy  of  tendo 

Achillis  for,  749 
valgus,  757 
varus,  757 
Talma's  opyeration  for  ascites,  1108 
T-amputation  of  hip-joint,  r4i8 
Tarantula,  bites  of,  298 
Tarsal  bones,   traumatic  disloca- 
tion, 698 
joint,  middle,  disarticulation  at, 
1409 
Tarsometatarsal  articulation,  dis- 
articulation at,  1407 


1498 


Index- 


Tarsus,  amputation  ^t,  1409 

Tartar  emetic    in    inflammation, 
1:0 

Tartar-emetic     ointment     in     in- 
flammation, 108 

Tattooing  in  gunshot-wounds,  281 

Taylor's  treatment  of  hydroceph- 
alus, 796 

T-bandage  of  perineum,  1257 

T.  C,  236 

Teale's  amputation  of  leg,  141 1 
method  of  amputation  through 

forearm,  1403 
probe  gorget,  1364 

Teeth,  Hutchinson's,  339 

Telangiectasis,  360 

Telangiectatic  sarcoma,  369 

Telephonic  probe,  283 

Temperature     in     inflammation, 
116 
post-operative  rise,  134 

Temporal  artery,  ligation,  487 

Temporosphenoidal  lobe,  tumors 
of,  831 

Tenaculum,  438 

Tenderness  of  inflammation,  90 

Tendo  Achillis,  subcutaneous  ten- 
otomy of,  749 

Tendon,  diseases  and  injuries,  726 
dislocation  of,  734 
operations  on,  748 
repair  of,  132 
rupture  of,  732,  735 
wounds  of,  735 

Tendon -grafting,  751 

Tendon-lengthening,  750 
Anderson's  method,  750 
Czerny's  method,  750 
Hibbs's  method,  750 
Poncet's  method,  750 
Rhoads's  method,  750 

Tendon-sheaths,  phlegmon  of,  735 
tuberculosis  of,  255 

Tendon-suture,  750 
Le  Dentu's,  750 
Le  Fort's,  750 
Lejar's,  750 

Tendon-transplantation,  751 

Tenosynovitis,  735 
tuberculous,  255 

Tenotomy,  748 
open,  748 
subcutaneous,  748 
of  tendo  Achillis,  749 
of  tendon  of  peroneus  longus 
and  brevis  muscle,  749 
of   tibialis  anticus  muscle, 
749 
posticus  muscle,  749 

Tension,  fever  of,  135 

Teratoids   associated   with   sacro- 
coccygeal region,  11 60 

Teratoma,  303 
external,  393 
internal,  393 

Terrier's    treatment   of   hammer- 
toe, 761 

Test,  .\rchard  and  Castaign's,  for 
excretory  capacity  of  kidneys, 
1271 
agglutination,    in    tuberculosis, 

Almen's,  for  hematuna,  1265 
Buerger's,  of   patency  of   deep 

veins,  413 
Ewald's,    for    motor    power    of 

stomach,  966 
Hamel's,  for   jaundice   in   gall- 
stones, 1034 
Heller's,  for  hematuria,  1264 
Justus's,  for  syphilis,  32S 
Klemperer's,   for   motor   power 

of  stomach,  965 
methylene-blue,     for    excretory 

capacity  of  kidneys,  12  71 
microscopic,      for      hematuria, 

1265 
Moro's    cutaneous    tuberculin, 

in  tuberculosis,  243 


Test,    ophthalmo-tuberculin,     in 
tuberculosis,  242 

phloridzin,  for  excretory  capacity 
of  kidneys,  1270 

Rosenthal's,  for  hematuria,  1264 

Struve's,  for  hematuria,  1265 

three-glass,     of     urethral     dis- 
charge, 1338 

tuberculin,  in  tuberculosis,  241 

von  Pirquet's  cutaneous  tuber- 
culin, in  tuberculosis,  243 

Wassermann's,  for  diagnosis  of 
syphilis,  328 
Testicle,    diseases    and    injuries, 
1332 

ectopia  of,  1387 

encysted  hematocele  of,  1394 
hydrocele  of,  1394 

excision  of,  1391 

extraserous  transposition,  1394 

fungus  of,  255 

inflammation  of,  1388 
pain  in,  91 

malplaced,  1387 

repair  of,  133 

retained,  1387 

syphilitic  afiections,  323 

tuberculosis  of,  255,  1389 

undescended,  1387 
Tetanus,  219 

acute,  symptoms  of,  222 

antitoxin  serum  in,  225,  227 

Bacelli's  treatment,  228 

bacillus,  50,  221 

brain-matter  in,  228 

carbolic  acid  in,  228 

Cephalic,  223 

cerebral,  223 

chronic,  223 

diagnosis  of,  224 
differential,  225 

dolorosa,  223 

following  vaccination,  220 

Fourth  of  July,  279 

girdle  pain  in,  223 

head,  223 

hydrophobic,  223 

local,  222 

magnesium  sulphate  in,  228 

of  newborn,  223 

symptoms  of,  222 

treatment  of,  225 
Tetany  after  removal  of  parathy- 
roids, 1243 

and  tetanus,  differentiation,  224 

from  removal  of  th>Toid  gland, 
1226 
Tetracoccus,  20,  22 
T-fractures  of  humerus,  569 
Theca,  1401 

Thecal  abscess,  144,  735,  739 
Thecitis,  735 

acute,  735 

chronic,  736 

suppurative,  149 

traumatic,  737 

tuberculous,  737 
Thiersch's  fluid,  29 

hypothesis  of  cancer,  381 
Thiery's  treatment  of  bums,  12 19 
Thigh,  amputation  of,  1413 
by  transfixion,  1401 

and  peh-is,  figure-of-eight  band- 
age, 1255 
Third  corpuscles  in  inflammation, 
85  _ 

intention,  healing  by,  125 
Thomas's   operation   for  habitual 
dislocation  of  humerus,  680 

splint,  636 

in    intracapsular   fracture   of 
femur,  596 
Thompson's  calculus  sound,  1314 

diagnostic    questions    on    mic- 
turition, 1270 

divulsor,  1362 

evacuator,  1328 

lithotrite,  1327 

method  of  litholapaxy,  1328 


Thompson's  vesical  forceps,  1330 
Thoracic  ducts,  left,  wounds,  rup- 
tures, and  occlusions,  1244 
Thoracicoplastic    pleuropneumol- 
ysis   with   subcostal   apicolysis, 
901 
Thoracoplasty,  906 

Esdander's  operation,  906 
Schede's  operation,  907 
Thoracotomy.  904 
Thorax.     See  Chest. 
Thorium,  1459 
Threads,  mycelial,  18 
Three-glass   test  of  urethral  dis- 
charge, 1338 
Throat,  cut,  S82 
Thrombo-arteritis,  201 
Thrombophlebitis,  infective,  201, 

406 
Thrombosis,  199 

after  abdominal  operations.  202 
causes,  199 
in  appendicitis,  202 
in  general  infections,  202 
in  typhoid  fever.  202 
infective,    of    cavernous    sinus, 
824 
of  lateral  sinus,  823 
of  petrosal  sinus,  824 
lymphatic,  201 
of  jugular  vein.  201 
of  mesenteric  vessels,  201 

intestinal  obstruction  from, 
971 
sinus-,  infective,  823 
symptoms  of,  201 
treatment  of,  203 
Thrombus,  199 
antemortem.  200 
asepdc,  190 
bland,  199 
infectious,  199 
mixed,  200 
primary,  200 
propagating,  200 
red,  200 
secondary,  200 
simple,  199 
spreading,  200 
white,  200 
Thrush,  18 

Thumb,  amputation  of,  1402 
metacarpophalangeal    joint    of, 

traumadc  dislocation,  685 
Selva's  bandage,  1251 
spica  bandage,  1251 
stave  of,  5S7 
ThjToglossal  cysts,  922 

sinus,  922 
Thyroid  artery,  inferior,  ligation 
of,  480 
superior,  ligation  of,  486 
extract  in  hemophilia,  469 
fever,  1242 

gland,  aberrant,  1230 
absence  of,  1226 
accessory,  1230 
adenoma  of,  377 
atrophy  of,  1226 
cancer  of,  1227,  1228 
congenitiil     hypertrophy    of, 

1226 
congestion  of,  1227 
diseases  and  injuries,  1226 
effect   of    complete   removal, 

1226 
enucleation  of,  1238 
extirpation  of.  1239 
grafting  of,  1227 
inflammation  of,  1227 
intracapsular         extirpation, 

1241 
operations  on,  1238 
sarcoma  of.  1227.  1228 
Socin's  operation  on,  1258 
syphilis  of,  1227 
tuberculosis  of.  1227 
tumors  of.  1227 
wounds  of,  1226 


Index 


1499 


Thyroitlectin  in  exophthalmic  goi- 
ter, 1236 
Thyroidectomy,  lomijlete,  1239 
for  goiter,  1233 
Koihcr's  method,  1239,  1240 
partial,  1239 

in  exophthalmic  goiter,  1237 
Thyroidism,  atule,  1241 
Thyrolinijual  cysts,  922 

sinus,  022 
Tibia,  Ijent,  osteotomy  for,  700 
fractures   of,    617.         See    also 

Fractures  oj  tUtia. 
spine  of,  avulsion,  618 
Tibial  artery,  anterior,  ligation  of, 
48S 
posterior,  ligation  of,  490 
Tibialis    anticus    muscle,    subcu- 
taneous tenotomy  of  tendon 
of,  749 
posticus    muscle,   subcutaneous 
tenotomy  of,  749 
Tibiofibular      articulation,      trau- 
matic dislocation,  695 
Tic  douloureux,  764 
Tincture    of    iodin    in    inflamma- 
tion, 103 
Tinnitus     aurium,     division     of 

auditory  nerve  for,  784 
Toe,  amputation  of,  1407 

great,  metatarsal  bone,  excision 
of,  719 
met;Uarsophalangeal  articula- 
tion, excision  of,  719 
phalanges  of,  fractures,  625 
Toe-nail,  ingrowing,  173,  1226 
Tongue,  adherent,  921 
burns  and  scalds,  1220 
cancer  of,  923.     See  also  Cancer 

of  tongue. 
injuries  and  diseases,  908 
swallowing    of,    in    anesthesia, 
1197 
treatment,  1199 
Tongue-tie,  921 
Tonsil,    sarcoma    of,    Dawbarn's 

operation  for,  372 
Toothache,  elevation  in,  97 
Tooth-socket,    hemorrhage    from, 

treatment  of,  453 
Torpid  shocl<-,  262 
Torsion  in  hemorrhage,  444 

of  spermatic  cord,  1392 
Torticollis,  752 
congenital,  753 

open    division    of    sternocleido- 
mastoid muscle  for,  748 
rheumatic,  726 
spasmodic,  753 
Tourniquet,  application  of,  1396 
Charriere's,  1397 
Esmarch's,  1415 
impromptu,  446 
Lister's,  in  aneurysm,  421 
Pancoast's,  1414 
Petit's,  1397 
Toxalbumins,  36 
Toxemia,  hydatid,  400,   1016 
Toxins,  36 
Trachea,  diseases  and  injuries,  882 

operations  on,  886 
Tracheobronclioscopy,  886 
Tracheotomy,  886 

high,  887 
Trajectory  of  projectiles,  288 
Transfusion,    arterial,    of    saline 
fluid,  467 
of  blood,  463 

Brewer's  method,  465 
Crile's  operation,  464 
shock,  265 
Transplantation  of  bone,  704 
of  parath\Toids,  1243 
tendon-,  751 
with  a  pedicle,  1260 
without  a  pedicle,  1260 
Traumatic  fevers,  133 
aseptic,  134 
benign,  134 


Traumatic  fevers,  septic,  134 

true,  134 
Treitz's  ligament,  1087 
Trendelenburg's     operation     for 
exstrophy  of  bladder,  1309 
for  flat-foot,  760 
for  varix  of  leg,  461 
position,  1049 
Trephine,  Gait's,  842 

Stellwagen's,  844 
Trephining,  842 
decompressive,  850 
frontal  sinus,  845 
mastoid,  845 
palliative,   in   tumors  of  brain, 

835    . 
preventive,  8og 
Treves's    method   of    excision    of 

scapula,  720 
operation  for  caries  of  lumbar 
and  last  dorsal  vertebrae,  707 
treatment  for  perforating  ulcer, 
177 
Triangle,  Bryant's,  591 
carotid,  inferior,  482 

superior,  482 
Macewen's,  789,  848 
occipital,  483 
of  election,  4S2 
of  necessity,  482 
of  neck,  482 
anterior,  482 
posterior,  483 
Petit's,  1157 
Scarpa's,  492 
subclavian,  483 
submaxillary,  482 
submental,  4S2 
superior  lumbar,  1157 
Trichinosis  of  muscles,  728 
Trigeminal  neuralgia,   779.       See 

also  Neuralgia  of  fifth  nerve. 
Trigeminus,      sensory      root     of, 
Frazier-Spiller  operation  of  in- 
tracranial neurotomy  of,  784 
Trigger-finger,  755 
Tripper,  1339 
Trismus,  222 
nascentium,  223 
neonatorum,  223 
Trochanter,    great,    fractures    of, 
601 
separation  of  epiphysis,  601 
of  hver,  144,  1018.      See  also 
Abscess  of  liver,  tropical. 
Trousseau's  sign,  1243 
Truax's     method     of     preparing 

kangaroo-tendon,  72 
Tubercle,  229 
anatomical,  250 
librous,  230 
hyaline,  230 

painful,  subcutaneous,  350 
primitive,  229 
rabic,  305 
reticulated,  230 
Tuberculin,  23s 
B.  E.,  235 

test  in  tuberculous,  241 
T.O.,  235 
T.  R.,  235 

treatment  of  tuberculosis,  247 
Tuberculoma  of  brain,  826 
Tuberculosis,  229 

and  syphilis,  coexistence,  314 
agglutination  lest  in,  243 
animal     inoculations     in    diag- 
nosis of,  243 
bacillus  of,  51,  231 
distribution,  232 
extracellular  poisons,  235 
in  blood,  in  diagnosis,  243 
intracellular  poisons,  23s 
products,  235 
resistance,  237 
Bier's  treatment,  249 
blistering  in  diagnosis,  243 
bovine,  232 
caseation  in,  230 


Tuberculosis,  chronic,  of  kidney, 

1287^ 
congenital,  237 
conglomerate,  982 
diagnosis  of,  240 
disseminata,  250 
l-'inscn  light  in,  249 
hyperplastic,  982 
immunity  to,  237 
incidence  of,  230 
ingesticjn,  233 
inhalation,  233 
inoculation,  233 
intestinal,  251 

primary,  982 
Maragliano's  serum  in,  248 
massage  of  focus  in  diagnosis 

of,  243 
Moro's     cutaneous     tubercuhn 

reaction  in,  243 
of  alimentary  canal,  251 
of  ankle-joint,  640 
of  blood-vessels,  251 
of  bone,  252,  501 
of  brain,  252 
of  breast,  1422 

confluent,  1423 

nodular,  1423 
of  cervical  lymph -glands,  253 
of  elbow-joint,  642 
of  epididymis,  1389 
of  Fallopian  tubes,  255 
of  fascia,  252 
of  heart  muscle,  252 
of  hernia,  1124 
of  hip-joint,  633 

by   weight-bearing    and     fix 
ation,  638 

complications,  636 

Huntington's  treatment,  639 

intra-articular  injections  and 
operation  in,  638 

Lorenz's  treatment,  638 

treatment,  636 
of  joints,  253 
of  kidney,  255 
of  knee-joint,  639 
of  liver,  251 

of  lymphatic  glands,  253 
of  mesenteric  gland,  253 
of  muscle,  252 
of  nerve,  251 
of  ovaries,  255 
of  pericardium,  252 
of  peritoneum,  1008 
of  pleura,  252 
of  prostate,  1386 

latent,  1389 
of  sacro-iliac  joint,  632 
of  seminal  vesicles,  1369 
of  shoulder-joint,  642 
of  skin,  249 
of  spinal  cord,  252 
of  stomach,  251 

of  subcutaneous  connective  tis- 
sue, 250 
of  tendon-sheaths,  255 
of  testicle,  255,  1389 
of  thyroid  gland,  1227 
of  uterus,  255 
of  wrist-joint,  642 
ophthalmo-tuberculin    test    in, 

242 
peritoneal,  251 
predisposition  to,  237 
prognosis  of,  244 
pulmonary,  251 

surgical  treatment,  899 
routes  of  infection,  233 
treatment  of,  24s 

local,  248 

surgical,  special  methods,  248 
tuberculin  test  in,  241 

treatment,  247 
ulcerosa,  249 
verrucosa,  250 

von  Pirquet's  cutaneous  tuber- 
culin reaction  in,  243 
x-Ta.ys  in  diagnosis  of,  241 


I500 


Index 


Tuberculosis,  a;-rays  in  treatment 

of,  249 
Tubulization  of  nerves,  776 
Tubulo-cysts,  398 
Tubulo-dermoid,  394 
Tuffier's  method  of  exploring  for 

abscess  of  lung,  908 
Tuffnell's  compress  in  aneurysm, 
421 
treatment  of  aneurysm,  419 
Tumors,  340 
causes  of,  341 
classes  of,  340 
classification  of,  346 
connective-tissue,       malignant, 

363 
cystic,  multilocular,  355 
di\-ision  of,  340 
erectile,  359 
fibrofatty,  347 
heredity  as  cause.  342 
heterologous,  341 
inclusion  theory  of  Cohnheim. 

341 
injury    and     infLimmation     as 

causes,  342 
innocent,  346 

connective-tissue,  347 
epithelial,  375 
maHgnant,  346 
epithelial.  378 

from    congenital     pigmented 
mole,  391 
mixed.  370 
Miiller's  law,  341 
parasitic  theory.  343 
pearl,  352 

physiologic    activity    as    cause, 
343 
decline  as  cause,  343 
Virchow's  law  of,  341 
Tunica  vaginalis,  diseases  and  in- 
juries, 1332 
hematocele  of,  1395 
hydrocele  of,  1392 
Turpentine    stupe    in    inflamma- 
tion, 105 
Tuttle's  proctoscope,  1165 
Twisted  suture.  274 
Typhoid  arthritis,  645 
bacillus,  S3 
bone  disease,  508 
cholecystitis,  1029 
erysipelas,  215 
fever,  dislocation  in,  665 

thrombosis  in,  202 
spine,  856 
ulcer,  perforated,  981 


Ulcer,  167 
callous,  174 
cancerous,  true,  387 
cancroid,  175 
classifications,  168 
complications,  treatment  of,  171 
compression  in,  103 
Curling's,  177,  979,  1218 
cystoscopicum,  1297 
edematous,  174 
erethistic,  173 
exuberant,  173 
fungous,  173 
gummatous,  325 
healthy,  173 
hemorrhagic,  174 
indolent,  174 
irritable,  173 
Jacob's,  175,  388 
kissing,  954 
Marjolin's,  175,  387 
Martin's  bandage  in,  172 
neuropandytic,  176 
of  bladder,  1320 
of  intestine,  979 
of  leg,  acute,  168 

chronic,  169 
of  rectum,  1180.     See  also  Ra- 

tum,  ulcer  oj. 


Ulcer  of  stomach,  954 
acute,  955 
chronic,  955 
hemorrhage  in,  operation  for, 

959 
hunger  pain  in,  955 
indurated,  954 
latent,  955 
non-indurated,  954 
perforation  in,  957 

operation  for,  960 
treatment,  958 
painful,  173 
peptic,  955 

of  duodenum,  979 
of   jejunum    after    gastro-en- 
terostomy,  1075 
perforating.  176 

of  abdomen.  979 
phagedenic.  168,  174,  317 
rodent,  17s,  388 
scorbutic,  177 
serpiginous,  in  tertiary  syphilis,, 

324 
syphilitic,  169 
trophic,  176 
tuberculous,  169,  250 
typhoid,  perforated,  981 
varicose,  173 
Ulna    and    radius,    fracture    near 
wrist,  585 
traumatic  dislocation,  681 
fractures   of,    572.         See   also 

Fractures  of  ulna. 
traumatic  dislocation.  6S2 
Ulnar  artery,  ligation.  474 

ner\e  at  elbow,  dislocation,  774 
Undescended  testicle,  1387 
Unna's  dressing  in  chronic  ulcer 

of  leg, 1 70 
Urachal  cysts,  394 
Uranium,  1459 
Uranoplasty,  gry 
Uremia,  coma  of,  803 
Ureter,  bleeding  from,  1265 
calculus  in,  1283 
catheterization  of.  1265 
diseases  and  injuries.  12  71 
intestinal  implantation,   1297 
irrigation  of,  1304 
lavage  of.  1304 
operations  on,  1288 
rupture  of,  1280 
stricture  of,  1286 
wounds  of,  1280 
Ureteral  catheterization,  practic;il 
value,  1304 
catheters,  sterilization,  1300 
orifices,  location,  in  cystoscopy, 
1302 
Ureter-cystoscope,  Lewis's,  1267 
Ureterolithotomy,  1295 

for  stone  in  ureter,  1283 
Uretero-ureterostomy,  1296 
Urethra,    diseases    and    injuries, 
1332 
divulsion  of,  for  stricture,  1361 
foreign  bodies  in,  1335 
hemorrhage  from,  1269 

treatment.  455 
inflammation  of,  1336.    See  also 

Urclhrilis. 
preparation  of,  for  operation,  68 
ruptiire  of,  1333 
stricture    of,     1358.      See  also 
Stricture  oj  urethra. 
Urethral  calculus,  treatment,  1308 
catarrh,  chronic,  1342 
catheters,  disinfection,  1305 
discharge,  chronic,  1342 
examination  in,  1338 
three-glass  test  of.  1338 
fever,  1362 
shock,  1362 
Urethritis,  1336 

acute   posterior,    in   gonorrhea, 

treatment,  1350 
anteroposterior,     treatment    of, 
1349 


Urethritis,  chronic,  following  gon- 
orrhea, treatment,  1351 
eczematous,  1338 
gouty,  1337 
non-specific,  1337 
simple,  1337 
specific,  1337,  1339 
traumatic,  1337 
treatment,  1308 
tuberculous,  1338 
Urethrorrhea,  1336 
Urethroscope,  Valentine's.  1352 
Urethrotome.  Gross's,  1361 

Maisonneuve's,  1360 
Urethrotomy,    external    perineal, 
1364 
internal,  136 1 
Urinary  abscess,  144 

fever,  1363 
Urination,  frequency  of,  1269 

slon-ness  of,  1269 
Urine  after  anesthesia,  1202 
bloody,  1264 
collection    of,    by    cystoscofje, 

1303 
otoscopy  of,  1271 
defective  expulsion,  1306 
examination    of,    in   inflamma- 
tion, 116 
post-operative    suppression    of, 

267 
residual,  1306 

in  prostatic  hypertrophy,  1373 
retention  of.  1306 

from  expulsive  defect,  treat- 
ment, 1308 
in  gonorrhea,  treatment,  1350 
incontinence  of.  1306 
segregation  of,  1267 
segregator,  Harris's,  1267 
separator,  Luys's,  1268 
stammering  of,  132 1 
Uropyknometer,  1304 
Urotropin    in    acute    gonorrhea, 

1347 
Uterine  fibroid,  357 

myoma,  357 
Uterus,   gonorrhea  of,   treatment, 
1356 
hemorrhage    from,    control    of, 

456 
hernia  of,  11 59 

pregnant,  gunshot  wounds,  948 
tuberculosis  of,  255 


\'accination,    tetanus   following, 

220 
\"accines,  autogenous,  45 
bacterial,  treatment  of  infection 
by,  45 
\agina,    hemorrhage    from,    con- 
trol of,  456 
\  aginK  tendinum,  737 
\'aginal  hematocele,  1394 
hernia,  1157 
hydrocele,  1392 
\'alen tine's  irrigator,  1344 
light  carrier,  1352 
method      of      examination      in 

urethral  discharge,  1338 
obturator,  1352 
rules  for  dilatation   in  chronic 

gonorrhea,  13-4 
treatment  of   acute   gonorrhea, 

1344.  1345 
urethroscope,  1352 
urethroscopic  tube,  1352 
Valleix's  points  douloureux,  92 
Valsalva's  treatment  of  aneuiysm, 

419 
Van  Arsdale's  method  of  treafing 
sprains,  657 
splint  in  ifractures  of  shaft  of 
femur  in  children,  606 
Van  Hook's  of)eration  of  uretero- 
ureterostomy, 1206 
Varicocele,  409,  1394 

Bloodgcxjd's  operation  for,  462 


Index 


I^OI 


Varicocele,  o|)en  operation  for,  462 

subcutaneous  ligature  for,  462 
Naricose  aneurysm,  431 
lymphatics,  124O 
tumors  of  rectum,  409 
ulcer,  173 

veins.  40S.     See  also  Varix. 
Varix,  408 

aneurysmal,  431 

complicating    ulcer,    treatment, 

171 
of  leg.  Bennett's  operation  for, 
462 
Fergusson's     operation     for, 

462 
Madelung's     operation     for, 

461 
operation  for,  461 
Phelps's  operation  for,  462 
Schede's  opjeration  for,  461 
I'rendelenburg's       operation 
for,  461 
of  spermatic  cord,  400 
rupture  of,  control,  454 
treatment  of,  410 
Vascular   system,    operations   on, 

459 
Vasectomy    for    hypertrophy    of 

prostate,  1383 
Vasotribe,  440 
Doyen's,  440 
N'aughan's  method  of  controlling 

hemorrhage,  452 
\'eins,  femoral,  hemorrhage  from, 
control  of,  453 
inflammation  of,  406 
suture  of,  439 

varicose,  408.    See  also  Varix. 
wounds  of.  434 
Vein-stone.  410 
Velpeau's  bandage,  1255 

in  fracture  of  cla\icle,  556 
cancer  en  cuirasse,  143 1 
Venae  comites.  4-0 
Venereal  catarrh,  1339 
sore,  local,  1366 
warts.  376 
Venesection,  463 

in  inflammation,  108 
Venom,  colubrine,  299 

viperine.  299 
\'enous  circle.  409 
\ncious,  409 
hemorrhage,  rules  for  arresting, 

450 
hemorrhoids,  11 73 
neW,  360 
Veratrum  viride  in  inflammation, 

109 
Vermiform  appendix,  constipation 
of.  987 
hernia  of,  1155 
malignant  disease  of,  997 
Morris's  method  of  palpating, 
991 
Verruca  necrogenica,  250 
Vertebrae,  acute  osteomyelitis  of, 
836 
fractures  of,  554 
\ertebral  artery,  ligation,  479 

ligaments,  strain  of,  869 
Vesiculitis,    acute,    in   gonorrhea, 
treatment  of,  1350 
seminal,  1369 
tuberculous.  1369 
Vibrio,  20 

Vibrione  septique,  52 
\lcious  cicatrix,  126 

circle  after  gastro-enterostomy. 

1075 
venous  circle,  409 
\'ienna  paste  in  inflammation,  108 
\'iperine  venom.  299 
Virchow's  disease,  515 
law  of  tumors.  341 
sign  in  hereditary  syphilis,  339 
Visceral  syphilis,  327 
\'ischer's  ca.se  for  carrying  culture- 
tubes,  i^o 


Vitello-intestinal    duct,    cysts    of. 

308 
Volkmann's  contracture,  72S 
CoUey's  o|jeration  in,  731 
Jones's  treatment,  730 
membrane,  157 
of)eration  for  hydrocele,  1393 
p;iralysis,  728 
splint,  718 
VoKtiIus,  970 

of  stomach,  950 
Vomiting       after    gastro-enteros- 
tomy, 1075,  1076 
treatment,  1077 
fecal,    in    strangulated    hernia, 

1 148 
in  anesthesia,  1201 
treatment,  1197 
stercoraceous,  971 
von  Bezold's  abscess,  149 
von  Graefe's  sign  in  exophthalmic 

goiter,  1235 
von  Hackter"s  method   of   gastro- 
enterostomy. 1077 
von  Mosetig-Moorhof's  treatment 

of  bone-cjnnties,  509 
von  Pirquet's  cutaneous  tubercu- 
lin reaction  in  tuberculosis,  243 


Waxdering  abscess,  144,  155 
erysipelas,  215 
goiter,  1230 
kidney,  1273 
spleen,  1048 

War,  wounds  of  brain  in,  813 

Wardrop's    operation    for    aneur- 
ysm, 424 

Ware's  splint  in  fractures  of  shaft 
of  femur  in  children,  608 

Warren's  operation  for  cancer  of 
breast,  1436 
for  tibroma  of  breast,  1425 

Wart-horn,  376 

Warts,  375 

lymphatic,  1246 
syphilitic,  322 
venereal,  376 
\illous,  376 

Wash-stand,  58 

Wasps,  stings  of,  298 

Wassermann's   test  for   diagnosis 
of  syphilis,  328 

Water,  boiled,  29 
boiling,  34 
on  brain,  819 

Watson's  splint.  717 

Wax,     Horsley's,     in    controlling 
hemorrhage,  452 

Waxed  pajser  as  protective,  76 

Waxy    disease    from    tuberculous 
abscess.  160 

Weavers'  bottom,  747 

Webbed  fingers,  754 

Webster's  operation  for  enterop- 
tosis,  1002 

Weglowski's     treatment     of     an- 
kylosis, 661 

Weir's  appendicostomy,  1061 
operation  for  rectal  cancer,  1186 

Weir-Stimson  method  of  steriliza- 
tion of  hand  and  forearms.  63 

Welander's  treatment  of  bubo  in 
chancroid,  1367 

Welch-Kelly  method  of  steriliza- 
tion of  hand  and  forearms,  63 

Welch's   bacillus   aerogenes   cap- 
sulatus,  53 

Wens,  396 

West's   rules  as   to  treatment   in 
pneumothorax,  893 

Wheelhouse's  operation  of  perineal 
I  section,  1364 

i         staff,  1364 

I    WTiite  and  Nfartin's  treatment  of 
i        acute  gonorrhea,  1343 
I    \\'hite  gangrene  from  .v-rays.  1446 
.         infarction.  204 
I        swelling,  253,  628,  639 


White  thrombus,  200 
Whitehead's  operation  for  cancer 
of  tongue,  926 
for  hemorrhoids,  1177 
White's  treiitment  of  acute  gonor- 
rhea, 1348 
of  catarrhal  gonorrhea,  1346 
of  felon  and  whitlow,  740 
Whitlow,  738 

White's  treatment,  740 
Whitman's    treatment    of    intra- 
capsular fracture  of  femur,  597 
Wilson's  flat-foot  correction  screw, 
759 
treatment  of  hallus  valgus,  761 
Wind  contusion  from  projectiles, 

294 
Wing-like  scapula,  767 
Winslow,  foramen  of,  hernia  into, 

1 157 
Wire,  brass,  preparation  of,  74 
bronze,  preparation  of,  74 
copper,  preparation  of,  74 
in  treatment  of  aneurysm,  420 
silver,  preparation  of,  74 
Witzel's   method  of  gastrostomy, 

1072 
Wolfe's   method  of  skin-grafting, 

1262 
Wolfler-Liicke  method  of  gastro- 
enterostomy. :o77 
Wolfler's  method  of  gastro-enter- 
ostomy, 1077 
suture,  1063 
Wood  wool  as  dressing.  76 
Wooden  phlegmon,  141 
Wood's  rule  in  fractures  of  true 

pehis,  552 
Wool,  absorbent,  as  dressing,  76 

wood,  as  dressing,  76 
Wool-sac  cocci,  20 
Wool-sorters'  disease,  301 
Word-deafness,  832 
Worms,  filarial,  1246 
Wounds,  261 
arrow-,  277 
blank -cartridge,  279 
bringing  about  reaction,  268 
by  cannon-balls,  284 
cleansing  of,  268 
constitutional    condition    after. 

261 
contused,  274 
dissection-,  297 
drainage  of,  26S 
dressing  of,  268 
exuberant  granulations,  125 
foreign  bodies  in,  removal,  268 
from  revolver,  280 
gaping  or  retraction  of  edges. 

261 
gunshot-,  277.  See  also  Gunshot- 
wounds. 
hemorrhage  of,  261 

arrest,  268 
immediate  union.  121 
in  non-vascular  tissues,  healing 

of,  126 
in  war  from  rifle-bullets,  284 
symptoms,  294 
treatment,  294 
incised.  270 
infected,  297 
lacerated,  274 
local  phenomena.  261 
loss  of  function  in,  261 
of  abdominal  wall,  945 
of  arteries.  433 
contused,  433 
gunshot,  434 
incised.  433 
lacerated.  434 
pimctured,  434 
of  bladder.  1310 
of  brain,  812 

from  revolver  bullets,  814 
in  war.  813 
of  chest.  894,  896 
of  esophagus,  932 


1502 


Index 


Wounds  of  heart,  401 
operation  for,  459 
Rotter's  incision  in,  459 
suture,  459 

of  joints,  655 

of  larjTLX,  882 

of  left  thoracic  ducts,  1244 

of  liver,  1014 

of  mucous  membranes,  274 

of  muscles,  731 

of  ner\es,  764 

of  pancreas.  103.S 

of  pericardium,  401 

of  rectum,  1167 

of  salivary  glands,  908 

of  scalp,  797 

of  spinal  cord,  870 

of  spleen,  1046 

of  Steno's  duct,  909 

of  tendons,  735 

of  th>Toid  gland,  1226 

of  ureters,  1280 

of  veins,  434 

pain  in,  261 

perforating,  of  kidney.  1280 

poisoned.  296 

primarj-  union,  120 

punctured.  275 

rest  in,  269 

septic,  297 

irrigation  in,  68 

stab-,  275 

subcutaneous,  repair  of,  126 

treatment  of,  267 
constitutional,  270 
Wright's    views    upon   inflamma- 
tion and  its  treatment.  119 
Wrist,  traumatic  dislocation,  683 


Wrist-joint,      disarticulation      at, 
1402 

disease,  642 

excision  of,  713.  See  also  Ex- 
cision of  urisl- joint. 

tuberculosis  of,  642 
Wry-neck,  752.      See  also  Torti- 
collis. 
Wyeth's  amputation  of  hip-joint, 
1415 

dressing  for  fractures  of  shaft  of 
femur  in  children,  607 

method  of  preventing  hemor- 
rhage in  amputation  of  hip- 
joint,  1415 

pins  in  amputation  at  shoulder- 
joint,  1404 

splint,  637 


X.\NTHOMA,  349 

X-rays,  1443 

apparatus,      Mackenzie-David- 
son, 1452 
Sweet's,  for  locating  foreign 
bodies.  1455 
bum  from.  1445,  1446,  1447 
death  from,  1447 
dermatitis  from,  1445,  1446, 1447 
diagnosis  of  fractures  by,  528 
effect  on  bacteria,  24 
gangrene  from,  1446 
in  aincer,  391,  1457 
in  diagnosis   of  disease  of   ali- 
mentary' canal,  1449 
of  urinary  organs,  1449 
of  tuberculosis,  241 
in  diseases  of  skin,  1456,  1457 


X-rays  in  epithelioma,  1457 
in  exophthalmic  goiter,  1458 
in  leukemia,  145a 
in  localizing  foreign  bodies,  1450 
in  locating  bullet,  283 
in  malignant  growths,  1457 
in  sarcoma,  374,  1457 
sinuses,  1458 
in  treatment  of  diseases,  1456 

of  tuberculosis.  249 
malignant  changes  from,  1447 
physiologic  effects,  1445 
reaction  from,  1446 
sterility  from,  1447 
uses  of,  1447 
white  gangrene  from,  1446 

Yeasts,  18 

Young's     method      of      perineal 
prostatectomy,  1381 
modification    of    Bottini's    gal- 
vanocaustic     pirostatotomy, 
1382 
of  Freudenberg"s  instrument 
for    prostatotomy    by    gal- 
vanocautery,  1382 
operation  for  tuberculous  vesic- 
ulitis, 1370 


ZoN*E  of  election   of  pathological 
processes,  512 

Zofiglea  masses,  20 

Zuckerkandl's   incision   in   tuber- 
culous  vesiculitis.    1370 

Zygomatic  arch,  fractures,  544 
Matas'  operation  for,  544 


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has  seen  them  during  an  experience  of  nearly  twenty-five  years.  In  it  are 
answered  in  detail  those  questions  regarding  the  course  and  outcome  of  diseases 
which  cause  the  less  experienced  observer  the  most  anxiety  in  an  individual  case. 
Topographic  anatomy  has  been  accorded  liberal  space. 

Pennsylvania  Medical  Journal 

"This  is  the  most  practical  volume  on  the  nose,  pharynx,  and  ear  that  has  appeared 
recently.  ...  It  is  exactly  what  the  less  experienced  observer  needs,  as  it  avoids  the  confusion 
incident  to  a  categorical  statement  of  everybody's  opinion." 

Kyle's 
Diseases  of  Nose  am)  Throat 


Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  797  pages;  with  219  illustrations,  26  in  colors. 
Cloth,  ;^4.oo  net;  Half  Morocco,  ^5.50  net. 

THE    NEW   (4th)    EDITION 

Four  large  editions  of  this  excellent  work  fully  testify  to  its  practical  value. 
In  this  edition  the  author  has  revised  the  text  thoroughly,  bringing  it  absolutely 
down  to  date.  With  the  practical  purpose  of  the  book  in  mind,  extended  con- 
sideration has  been  given  to  treatment,  each  disease  being  considered  in  full,  and 
definite  courses  being  laid  down  to  ineet  special  conditions  and  symptoms. 
Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book.  The  practical  man,  be  he  special  or  general,  will  not  search  in  vain 
for  anything  he  needs." 


EYE,    EAR,    NOSE,    AND    THROAT. 


GET  /k  •  THE  NEW 

THE    BEST  t\  HI  6  r  1  C  2lll  STANDARD 

Illustrated   Dictionary 

Just    Ready— The    New    (5th)     Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches;  with  over  loo  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  876  pages,  bound  in  full  flexible  leather. 
Price,  ^4.50  net;  with  thumb  index,  $5.00  net. 

A   KEY  TO   MEDICAL  LITERATURE— WITH  2000   NEW  TERMS 

In  this  edition  the  book  has  been  subjected  to  a  thorough  revision.  The 
author  has  also  added  upward  of  two  thousand  important  new  terms  that  have 
appeared  in  medical  literature  during  the  past  few  months. 

Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecologic  Surgery,  fohus  Hopkins  University,  Baltimore 
"Dr.  Dorland's  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  suck  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

Theobald's  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald,  M.  D., 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  550pages,  with  219  text-cuts  and  several  colored 
plates.     Cloth,  t^.'^O  net ;   Half  Morocco,  ^6.00  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye,  although  written 
ostensibly  for  the  general  practitioner,  are  in  reality  adapted  only  to  the  specialist  ; 
but  Dr.  Theobald  in  his  book  has  described  very  clearly  and  in  detail  those  condi- 
tions, the  diagnosis  and  treatment  of  which  come  withm  the  province  of  the  general 
practitioner.  The  therapeutic  suggestions  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  Eye  written  particularly  for  the  general  practitioner, 

Charles  A.  Oliver.  M.D.. 

Clinical  Professor  of  Ophthalmology,   Woman  s  Medical  College  of  Pennsylvania. 

"  I  feel  I  can  conscientiously  recommend  it,  not  only  to  the  general  physician  and  medical 
student,  for  whom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist.  Most 
surely  Dr.  Theobald  has  accomplished  his  purpose." 


8  EYE,    EAR,    NOSE,    AND    THROAT. 

deSchweinitz   and    HoUoway   on   Pulsating*    Exoph- 
thalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  HoLLOWAY,  M.  D.     Octavo  of  125  pages.     Cloth,  JS2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
to  determine  from  these  analyses  which  procedures  seem  likely  to  prove  of 
the  greatest  value.  It  is  the  most  valuable  contribution  to  ophthalmic  liter- 
ature within  recent  years. 

British  Medical  Journal 

"  The  book  deals  very  thoroughly  with  the  whole  subject  and  in  it  the  most  complete  account  of 
the  disease  will  be  found." 

Jackson     on    the     Eye  The  New  (2d)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Colorado.  i2mo  volume  of  615  pages,  with  1S4  beautiful 
illustrations.     Cloth,  ^2.50  net. 

The  Medical  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence  of  the 
author's  comprehensive  grasp  of  the  subject.  The  term  '  multum  in  parvo  '  is  an  appropriate  one  to 
apply  to  this  work." 

Grant  on   Face,   Mouth,   and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Diseases 
OF  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages,  with 
68  illustrations.     Cloth,  ^2.50  net. 

Friedrich  and   Curtis   on  Nose,   Larynx,   and   Ear 

RhINOLOGY,    LARYNGOLOGy,  AND    OtOLOGY,    AND    ThEIR    SIGNIFICANCE 

IN  General  Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited 
by  H.  HoLBROOK  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York 
Nose  and  Throat  Hospital.  Octavo  volume  of  350  pages.  Cloth, 
^2.50  net. 


GENITO-URINARY  AND    NOSE,     THROAT,     ETC.  9 

Greene  and  Brooks* 
Genito-Urinary  Diseases 

Diseases  of    the   Genito=Urinary  Organs  and  the   Kidney.      By 

Robert  H.  Greene,  M.  D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medical 
School.  Octavo  of  605  pages,  illustrated.  Cloth,  $5.00  net;  Half 
Morocco,  $6.50  net. 

THE  NEW     (2d)     EDITION 

This  new  work  presents  both  the  inedical  atid  surgical  sides.  Designed  as  a 
work  of  quick  reference,  it  has  been  written  in  a  clear,  condensed  style,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidney  diseases  are  very 
elaborately  detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito-urinary 
diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and  students." 

Gleason  on  Nose,  Throat, 
and  Ear 

A   Manual   of    Diseases  of   the    Nose,  Throat,  and    Ear.     By  E. 

Baldwin  Gleason,  M.  D.,  LL.  D.,  Clinical  Professor  of  Otology, 
Medico-Chirurgical  College,  Philadelphia.  i2mo  of  556  pages,  pro- 
fusely illustrated.     Flexible  leather,  $2.50  net. 

FOR    PRACTITIONERS 

Methods  ot  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  beneficial.  A  valuable  feature  consists  of  the  collection  of 
formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  are  few 
books  which  can  be  more  heartily  commended." 


American  Text=Book  of  Qenito=Urinary  Diseases,  Syphilis,  and 
Diseases  of  the  Skin.  Edited  by  L.  Bolton  Bangs,  M.  D.,  and 
W.  A.  Haruaway,  M.  D.  Octavo,  1229  pages,  300  engravings,  20 
colored  plates.     Cloth,  $'j.oo  net. 


SAUNDERS'    BOOKS    ON 


StelwagonV 
Diseases  of  the  Skin 


A  Treatise  on  Diseases  of  the  5kin.  By  Henry  W.  Stelwagon, 
M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Octavo  of  1135  pages,  with  258  text-cuts  and 
32  plates.     Cloth,  ;$6.oo  net ;   Half  Morocco,  $7.^0  net. 

THE    NEW    (5th)    EDITION 

The  demand  for  five  editions  of  this  work  in  a  period  of  five  years  indicates 
the  practical  character  of  the  book.  In  this  edition  the  articles  on  Frambesia, 
Oriental  Sore,  and  other  tropical  diseases  have  been  entirely  rewritten.  The  new 
subjects  include  Verruga  Peruana,  Leukemia  Cutis,  Meralgia  Paraesthetica,  Dhobie 
Itch,  and  Uncinarial  Dermatitis. 

George  T.  Elliot,  M.  D.,   Professor  of  Dermatology,  Cornell  University. 

"  It  is  a  book  that  I  recommend  to  my  class  at  Cornell,  because  for  conservative  judgment, 
for  accurate  observation,  and  for  a  thorough  appreciation  of  the  essential  position  of  derma- 
tology, I  thinlc  it  holds  first  place." 


Schamber^'s  Diseases  qf  the  Skin 
and  E^ruptive  Fevers 


Diseases  of  the  Skin  and  the  Eruptive  Fevers.  By  Jay  F.  Schamberg, 
M.  D.,  Professor  of  Dermatology  and  the  Infectious  Eruptive  Diseases,  Philadel- 
phia Polyclinic.     Octavo  of  534  pages,  illustrated.      Cloth,  #3.00  net. 

THE   CUTANEOUS    MANIFESTATIONS   OF  ALL   DISEASES 

"  The  acute  eruptive  fevers  constitute  a  valuable  contribution,  the  statements  made 
emanating  from  one  who  has  studied  these  diseases  in  a  practical  and  thorough  manner  from 
the  standpoint  of  cutaneous  medicine.  .  .  .  The  views  expressed  on  all  topics  are  con- 
servative, safe  to  follow,  and  practical,  and  are  well  abreast  of  the  knowledge  of  the  present 
time,  both  as  to  general  and  special  pathology,  etiology,  and  treatment." — American  Journal 
of  Medical  Sciences. 


DISEASES   OF   THE  SKIN. 


Mracek  and  Stelwa^on*s 
Diseases  of  the  Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof.  Dr.  Franz 
Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry  W.  Stelwagon, 
M.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical  College, 
Philadelphia.  With  yj  colored  plates,  50  half-tone  illustrations,  and 
280  pages  of  text.     In  Saunders'  Hand- Atlas  Series.  Clo.,;^4.oonet. 

THE    NEW    (2d)    EDITION 

This  volume,  the  outcome  of  years  of  scientific  and  artistic  work,  contains, 
together  with  colored  plates  of  unusual  beauty,  numerous  illustrations  in  black, 
and  a  text  comprehending  the  entire  field  of  dermatology.  The  illustrations  are 
all  original  and  prepared  from  actual  cases  in  Mracek' s  clinic,  and  the  execution 
of  the  plates  is  superior  to  that  of  any,  even  the  most  expensive,  dermatologic 
atlas  hitherto  published. 

American  Journal  of  the  Medical  Sciences 

"  The  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  are: 
First,  its  handiness;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color,  and  the 
diagnostic  points  which  they  bring  out." 

Mracek  anb  Bang's* 
Syphilis  and  Venereal 

Atlas    and    Epitome   of    Syphilis    and    the    Venereal    Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by 
L.  Bolton  Bangs,  M.  D.,  late  Prof,  of  Genito-Urinary  Surgery,  Univer- 
sity and  Bellevue  Hospital  Medical  College,  New  York.  With  71 
colored  plates  and  122  pages  of  text.  Cloth,  $'^.^0  net.  ///  Saunders' 
Hand- Ad  as  Series. 

CONTAINING  n   COLORED  PLATES 

According  to  the  unanimous  opinion  of  numerous  authorities,  to  whom  the 
original  illustrations  of  this  book  were  presented,  they  surpass  in  beauty  anything 
of  the  kind  that  has  been  produced  in  this  field,  not  only  in  Germany,  but 
throughout  the  literature  of  the  world. 

Robert  L.  Dickinson,  M.  D., 

Art  Editor  of  "  The  American  Text-Book  of  Obstetrics." 
"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  valuable,  and  graphic 
character  of  its  illustrations  is  the  '  Atlas  of  Syphilis  and  the  Venereal  Diseases."     I  know  of 
nothing  in  this  country  that  can  compare  with  it." 


I*  SAUNDERS'  BOOKS   ON 


Holland's  Medical 
Chemistry  and  Toxicology 

A  Text=Book  of  Medical  Chemistry  and  Toxicology.  By  James 
W.  Holland,  M.D.,  Professor  of  Medical  Chemistry  and  Toxicology, 
and  Dean,  Jefferson  Medical  College,  Philadelphia.  Octavo  of  655 
pages,  fully  illustrated.     Cloth,  $3.00  net. 

THE  NEW  (2d)   EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years' 
practical  experience  in  teaching  chemistry  and  medicine.  It  has  been  subjected  to 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
to  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  equilib- 
rium, Kjeldahl's  method  for  determining  nitrogen,  chemistry  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.      More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry. 

American  Medicine 

"  Its  statements  are  clear  and  terse  ;  its  illustrations  well  chosen  ;  its  development  logical, 
systematic,  and  comparatively  easy  to  follow.  .  .  .  We  heartily  commend  the  work." 

Grtinwald  and  Newcomb*s 
Mouth,  Pharynx,  and  Nose 

Atlas  and  Epitome  of  Diseases  of  the  Mouth,  Pharynx,  and 
Nose.  By  Ur.  L.  Grunwald,  of  Munich.  From  the  Second  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by  James  E. 
Newcomb,  M.  D.,  Instructor  in  Lar>aigology,  Cornell  University  Medical 
School.  With  102  illustrations  on  42  colored  lithographic  plates,  41 
text-cuts,  and  219  pages  of  text.  Cloth,  ;^3.oo  net.  In  Sautiders' 
Hand-Atlas  Series. 

INCLUDING   ANATOMY   AND    PHYSIOLOGY 

In  designing  this  atlas  the  needs  of  both  student  and  practitioner  were  kept 
constantly  in  mind,  and  as  far  as  possible  typical  cases  of  the  various  diseases 
•were  selected.  The  illustrations  are  described  in  the  text  in  exactly  the  same  way 
as  a  practised  examiner  would  demonstrate  the  objective  findings  to  his  class. 
The  illustrations  themselves  are  numerous  and  exceedingly  well  executed.  The 
editor  has  incorporated  his  own  valuable  experience,  and  has  also  included  exten- 
sive notes  on  the  use  of  the  active  principle  of  the  suprarenal  bodies. 

American  Medicine 

"  Its  conciseness  without  sacrifice  of  clearness  and  thoroughness,  as  well  as  the  excellence 
of  text  and  illustrations,  are  commendable." 


URLYE  AND   IMPOTENCE.  13 

O^den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  New  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  ;$3.00  net. 

JUST   READY -THE   NEW   (3d)    EDITION 

In  this  edition  the  work  has  been  brought  absokitely  down  to  the  present  day. 
Urinary  examinations  for  purposes  of  hfe  insurance  have  been  incorporated,  because 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinary  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  ;  and  the  peculiarities  of  the  urine 
in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own  experience, 
so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

Vecki*s  Sexual  Impotence 


The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
G.  Vecki,  M.  D.  From  the  Second  Revised  and  Enlarged  German 
Edition.      i2mo  volume  of  329  pages.     Cloth,.  ;^2. 00  net. 

THIRD   EDITION,  REVISED   AND   ENLARGED 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  countr)'  in  the 
truly  scientific  spirit  that  its  pre-eminent  importance  deserves,  and  this  volume  will 
come  to  many  as  a  revelation  of  the  possibilities  of  therapeutics  in  this  important 
field.  The  reading  part  of  the  English-speaking  medical  profession  has  passed 
judgment  on  this  monograph.  The  whole  subject  of  sexual  impotence  and  its 
treatment  is  discussed  by  the  author  in  an  exhaustive  and  thoroughly  scientific 
manner.  In  this  edition  the  book  has  been  thoroughly  revised,  and  new  matter 
has  been  added,  especially  to  the  portion  dealing  with  treatment. 

Johns  Hopkins  Hospital  Bulletin 

"  A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The  treatment 
of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and  judicious." 


14  SAUNDERS'    BOOKS   ON 

Wells'   Chemical  Pathology 

Chemical  Pathology.  Being  a  discussion  of  General  Path- 
ology from  the  Standpoint  of  the  Chemical  Processes  Involved. 
By  H.  Gideon  Wells,  Ph.  D.,  M.  D.,  Assistant  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  549  pages. 
Cloth,  $2).2$  net;  Half  Morocco,  $4.7$  "et. 

Dr.  Wells  here  concisely  presents  the  latest  work  systematically  con- 
sidering the  subject  of  general  pathology  from  the  standpoint  of  the  chemical 
processes  involved.  Special  chapters  are  devoted  to  Diabetes  and  to  Uric- 
acid  Metabolism  and  Gout. 

Wm.   H.  Welch,  M.  D.,  Professor  of  Pathology,  Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and 
I  shall  be  glad  to  recommend  it  to  my  students." 


Just  Ready 
The  New   (2d)   Edition 


Saxe*s  Urinalysis 

Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe,  M.  D., 
Instructor  in  Gcnito-Urinary  Surgery,  York  Post-graduate  Medical 
School  and  Hospital.  i2mo  of  448  pages,  fully  illustrated. 
Cloth,  ^1.75  net. 

This  work  is  intended  as  an  aid  in  diagnosis,  by  interpreting  the  clinical 
significance  of  the  chemic  and  microscopic  urinary  findings. 

Francit  Cz^rter  Wood,   M.  D.,    Adjunct  Professor  of  Clinical  Pathology,   Columbia    Uni- 
versity. 

"  It  seems  to  me  to  be  one  of  the  best  of  the  smaller  works  on  this  subject ;  it  is, 
indeed,  better  than  a  good  many  of  the  larger  ones." 

deSchweinitz  and  Randall   on  the  Eye,  Ear, 
Nose,  and  Throat 

American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of 
Ophthalmology  in  the  University  of  Penn.sylvania ;  and  B.  Alex- 
ander Randall,  M.  D.,  Clinical  Professor  of  Di.seases  of  the  Ear 
in  the  University  of  Pennsylvania.  Imperial  octavo,  1251  pages, 
with  766  illustrations,  59  of  them  in  colors.  Cloth,  ^7.00  net; 
Half  Morocco,  $8.50  net. 

Grtinwald  and  Grayson  on  the  Larynx 

Atlas  and    Epitome  of  Diseases  of  the   Larynx.     By  Dr.  L. 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.  D.,  Clinical  Professor  of  Laryngology  and  Rhinology, 
University  of  Pennsylvania.  With  107  colored  figures  on  44 
plates,  25  text-cuts,  and  103  pages  of  text.  Cloth,  $2. so  net. 
In  Saunders'  Hajid-Atlas  Series. 


CHEMISTRY,   SKIN,  AND   VENEREAL   DISEASES.  15 

American  Pocket  Dictionary        sixth  Edition— Recently  issued 

The  American  Pocket  Medical  Dictionakv.    Edited  by  W.  A. 

Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to  the  Hosj^ital 

of  the  University  of  Pennsylvania.     Containini^  the  pronunciation 

and  definition  of  the  principal  words  used  in  medicine  and  kindred 

sciences.      598  pages,      F'lexible   leather,  with   gold  edges,   ^i.oo 

net;  with  thumb  index,  ;$i.25  net. 

James  W.  Holland,  M.  D.. 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 
Philadelphia, 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  ] 
can  recommend  it  to  our  students  without  reserve." 

Stel wagon's  Essentials  of  Skin  ;ust  Ready— 7th  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
wagon,  M.  D.,  Ph.D.,  Professor  of  Dermatology  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  29 1  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  ^i.oo  net.  In 
Saunders'  Question-  Compcnd  Series. 
The  Medical  News 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  eompends  have  been  noted." 

Wolffs  Medical  Chemistry  New  (7th)  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson 
Medical  College.  Revised  by  A.  Ferree  Witmer,  Ph.  G.,  M.  D., 
Formerly  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  ^i.oo  net.  In 
Saunders'  Question-  Coinpend  Series. 

Martin's  Minor  Surgery,  Bandaging,  and  the  Venereal 

Diseases  second  Edition,  Revised 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.  M.,  M.  D.,  Professor  of  Clin- 
ical Surgery,  University  of  Pennsylvania,  etc.  Post-octavo,  166 
pages,  with  78  illustrations.  Cloth,  ;^i.oo  net.  In  Saunders' 
Question-  Coinpend  Series. 


l6  URINE,  EYE,  EAR,  NOSE,  AND    THROAT. 

Wolfs  Examination  of  Urine 

A  Laboratory  Handbook  of  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.  Wolf,  M,  D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  University  Medical  College,  New- 
York.  1 2mo  volume  of  204  pages,  fully  illustrated.  Cloth,  ^1.25  net, 
British  Medical  Journal 

"  The  methods  of  examining  the  urine  are  very  fully  described,  and  there  are  at  the 
end  of  the  book  some   extensive   tables  drawn  up  to  assist  in  urinary  diagnosis." 

Jackson's  Essentials  of  Eye  Third  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eye.  By 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illus- 
trations. Cloth,  $1.00  net.  ///  Sa7{?iders'  Question- Compend  Series. 
Johns  Hopkins  Hospital  Bulletin 

"  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." 

Gleason's  Nose  and  Throat  Fourth  Edition.  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia,  etc.  Post-octavo,  241  pages,  1 12 
illustrations.  Cloth,  $1.00  net.  Jn  Saunders'  Question  Compends, 
The  Lancet,  London 

"  The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  avernge  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." 

Gleason*s  Diseases  of  the  Ear  Third  Edition,  Revised 

Essentials  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Phila.,  etc.     Post-octavo   volume  of  214  pages,  with    114  illustra- 
tions.    Cloth,  ^ I. GO  net.      In  Saunders'  Question-Contpend  Series. 
Bristol  Medico-Chirurgical  Journal 

"We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  this,  either  in 
freshness  of  style  or  completeness  of  information." 

Wilcox  on  Genito- Urinary  and  Venereal  Diseases 

Just  Ready— The  New  (2d)  Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinary  Diseases 
and  Syphilology,  Starling-Ohio  Medical  College,  Columbus.  i2mo 
of  321  pages,  illustrated.     Cloth,  *&i. 00  net.     Saunders'  Compends. 

Stevenson's  Photoscopy 

Photoscofy  (Skiascopy  or  Retinoscopy).  By  Mark  D.  Stev- 
enson, M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital. 
i2mo  of  126  pages,  illustrated.  Cloth,  ^1.25  net. 

Edward  Jackson,  M.  D.,  University  of  Colorado. 

"  It  is  well  written  and  will  prove  a  valuable  help.  Your  treatment  of  the  emergent 
pencil  of  rays,  and  the  part  falling  on  the  examiner's  eye,  is  decidedly  better  than  any 
previous  account." 


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